quality strategy and improvement plan...3 part one – quality strategy 1. introduction: north west...
TRANSCRIPT
Quality Strategy and Improvement Plan2015-2018
2
STRATEGY DOCUMENT DETAILS
Status: FINAL
Originating Date: October 2015
Date Ratified: 4 November 2015 (Quality Committee)
Next Review Date: April 2018
Accountable Director: Gail Briers, Chief Nurse and Executive Director of Clinical
Operational Services
Strategy Authors: Julie Chadwick, Assistant Director of Integrated Governance
Jackie Hughes, Head of Compliance
CONTENTS PAGE
PART ONE: QUALITY STRATEGY
3
3
4
4
5
Introduction
What does quality mean to North West Boroughs Healthcare?
Why have a quality strategy?
What quality means to our staff
How the quality strategy was developed
How we monitor and report progress and achievement of quality 6
PART TWO: QUALITY IMPROVEMENT PLAN
Culture of Care 10
Sign up to Safety 11
CQUIN 12
Quality Priorities 13
Quality Improvement Cycle 16
Quality Big Dots 17
Lessons Learned 18
3
PART ONE – QUALITY STRATEGY
1. Introduction:
North West Boroughs Healthcare NHS Foundation Trust provides mental health, learning disability and
community health services to people in Halton, Knowsley, Sefton, St Helens, Warrington and Wigan, as well as criminal justice liaison services across Greater Manchester. The Trust has a turnover of
approximately £140m a year (covering alongside GPs, providing primary care support to patients and a
number of independent sector providers population of approximately 700,000). The Trust is the primary
public sector provider of mental health services on this footprint.
We are committed to providing the highest quality services possible for the patients we serve. This quality
strategy incorporates the listening from our patients, carers, families and stakeholders into a framework
where we can identify quality initiatives and goals, take action and not only meet but exceed their
expectations for what matters most to them.
In conjunction with the Quality Strategy the Trust has developed the Living Life Well strategy that ensures
our approach to peoples care is equitable, inclusive and reflects strong social values for anyone who
requires our services at any point in their lives, based on the following set of principles.
We commit to the users of our service having their basic needs identified and addressed
Compassion in practice will be evidenced by all users of our service having their goals identified and addressed
Our care quality is underpinned by all our teams providing personalised services
We will courageously ensure that all services are strengths based, concentrating on what can be done rather than what the problem may be.
The way that we communicate across organisational boundaries will promote social inclusion
We are committed to working in partnership with patients and carers as equals
We recognise carers as partners in what we do.
The competencies of our staff enable promotion and encouragement of advanced planning and self-management.
We support and value our staff
We are committed to evidencing the above principles in the way we deliver our services and work with our partners
Our strategic intentions reflect our commitment to supporting our communities to live their lives well.
Further details about our Living Life Well Strategy and approach are available on the Trust’s internet site.
http://www.5boroughspartnership.nhs.uk/
2. What does quality mean to North West Boroughs Healthcare?
Good quality healthcare depends on getting the basics right; safe, effective harm free care, at home or in a clean and
pleasant environment, where people feel welcome, and are treated with dignity and respect. We believe that it is
every patient’s right to receive high quality care by a well-trained and supported workforce.
4
Quality is at the heart of everything we do at North West Boroughs Healthcare, this strategy is linked directly to
the Trust’s Purpose, high level objectives, values and with the quality definition at its heart.
Quality Definition
“The users of our services are the first priority in everything we do, ensuring that they receive effective care
from caring, compassionate, and committed people, working within a common culture and protected from
harm.”
Trust Governance Principles:
We deliver our services safety
We have sufficient, highly motivated and skilled staff
We deliver to our patients and users
We are financially viable
We are delivering our strategy
Our stakeholders support what we do
Trust Purpose:
We will take a lead in improving the wellbeing of our communities in order to make a positive difference
throughout people’s lives
Our Values:
We value people as individuals ensuring we are
all treated with dignity and respect
We value quality and strive for excellence in
everything we do
We value, encourage, and recognise everyone’s
contribution and feedback
We value open, two-way communication, to
promote a listening and learning culture
We value and deliver on the commitments we
make
3. Why have a quality strategy?
This quality strategy is available publically. It
demonstrates how the Trust identifies and makes
continuous improvements to the quality of care we
provide. It outlines the key drivers to identifying our
quality improvement work and how we engage with
our staff, patients, their families and stakeholders in
identifying what is important to them. It also outlines
the strategy, using objectives and different quality
initiatives that form our Quality Improvement Plan, as
well as how we will achieve measure and monitor
them. The Quality Improvement Plan is included in
Part 2 of this strategy; it contains details of each
quality improvement initiative in more detail and is
updated annually to reflect the current work being
undertaken.
4. What quality means to our staff
The Trust recognises the connection between the
quality of care our patients receive, and the values,
aspirations, and skills of our staff. We believe staff
that are better engaged deliver better care. There is
compelling evidence that staff wellbeing, and staff
experience, correlate with patient experience and
outcome. We therefore strive to develop and make
best use of the potential and expertise of all those
who work for the Trust to provide the highest
standards of care to patients. This is why we have
developed our own Culture of Care based on the Chief
Nursing Officer of England’s 6C’s initiative.
5
5. How the quality strategy was developed
In 2010 Lord Darzi released a report commissioned by
the Department of Health to look at the way in which
healthcare was delivered across the country. His
report, ‘High Quality Care For All, the next stage
review’, identified the three domains of quality
essential to provide a high quality service, based on
patients’ needs. These three domains, shown below,
have shaped and underpin this strategy and the way
we provide high quality care.
Safety (Patient and Health and Safety) – ensuring
service users come to no harm within our services
Effectiveness – ensuring service users receive the
right treatments, delivering the right results
Patient Experience – we listen to service users
and carers and their experience of being in our
Trust
In addition, subsequent publications including Francis,
Keogh, Berwick, and the five year forward view
continue to be drivers within the Trust to improve
quality, using the findings and recommendations to
shape our Trust Objectives and Quality Improvement
Plan.
The quality strategy is made up of all the elements
below;
Quality Objectives –all quality initiatives are
categorised into these objectives.
Quality Big Dots – Longer term aspirational goals
with yearly quality initiatives
Quality Account Priorities – yearly quality
initiatives developed in partnership with our
service users, carers and stakeholders
Quality Improvement Cycle –measurement of
quality to inform future quality improvement
Sign Up to Safety - National safety campaign
Lessons Learned – continual learning and
improvement from experience
CQUIN – Commissioning for Quality and
Innovation – yearly improvement initiatives
We have given a brief description of these below and
in Part 2 of the Strategy you can see our high level
plans to implement them.
5.1 Quality Objectives
The Trust has established a set of Quality Objectives,
which follow the 3 domains of Safety; they set out the
Trust’s long term objectives, by which all quality
improvement is categorised.
Safety – our goal is to improve safety and reduce
harm to patients
Objective 1 – To improve safety and reduce harm to
patients
Objective 2 – To promote a patient safety culture,
encourage incident reporting and learning from
adverse events.
Objective 3 – To reduce avoidable harm to service
users and staff by 20% year on year
Objective 4 – To aspire to reduce service user suicide
to zero in 5 years (2013/14 – 2017/18)
Objective 5 – To review and monitor the management
of the serious incident process across the Trust
Effectiveness – Our goal is to demonstrate success in
our outcomes
Objective 1 – To improve care and outcomes for our
service users
Objective 2 – To ensure compliance against
appropriate NICE guidelines
Objective 3 – To ensure compliance and frontline
understanding of Care Quality Commission standards
Objective 4 – To promote quality at an operational
level
Experience – Our aim is to ensure that people using
our services have the best possible experience.
Objective 1 – To fully engage service users and carers
where indicated in their care
Objective 2 – To continue to improve the collaborative
participation and engagement of service users
Objective 3 – To listen and engage with our service
users to continue to improve quality of care
6
All quality initiatives undertaken by the Trust fit within
the objectives set out above, and these include the
Trust’s established Quality Big Dots and Quality
Priorities as defined below.
5.2 Quality Big Dots 2013/14 – 2017/18
The Trust has established three ‘Quality Big Dots’
which cover a five year period. These big dots were
established by the Trust Board, Senior Leadership
Team and Council of Members, supported by AQuA
(Advancing Quality Alliance). The following big dots
are supported by programmes of work;
We will demonstrate a year on year
improvement in the collaborative
participation with, and engagement of, service
users. This will result in improved
collaboration and engagement of service
users with a long term condition, thus
achieving the Quality Big Dot.
We will implement our suicide reduction
strategy with the aim to reduce service user
suicide to zero in five years. This will be
achieved by the implementation of a suicide
reduction strategy that will be informed by a
suicide audit scheduled which we completed
at the end of 2013/14.
We will aim to reduce avoidable harm to
service users and staff by 20% year on year.
To reduce avoidable harm to service users and
staff by 20% year on year. This will be
achieved by an initial scoping of the harms
that the trust will focus on and the
development of a five year trajectory.
5.3 Quality Account Priorities
To demonstrate the Trust’s continual commitment to
quality improvement each year we engaged with our
five Health watch organisations, five Local Authorities,
and five Clinical Commissioning groups, as well as our
service users and carers and the Council of Members
to establish the Trust’s Quality Priorities for the
coming year. These Quality Priorities follow the same
domains of safety, experience and effectiveness and
are monitored throughout the year. Themes for each
area have now been identified as;
Safety – Sign up to Safety - During 2015/16
the Trust will expand on previous Quality
Priorities by supporting the national Sign up to
Safety Campaign, launched by NHS England in
2014.
Effectiveness – Care Planning - During
2015/16, we will build on work of the 2014/15
Quality Priority and make care
plans/statements of care, simple and formed
in partnership with service users and/or their
carer’s.
Experience – Using patient and staff feedback
to shape improvements in services. During
2015/16 we will bring together feedback from
patients, carers and staff into one place to
inform the development and continual
improvement of services.
5.4 Quality Improvement Cycle
The Trust will continue to assess itself monthly against
the Fundamental Standards of Care, CQC intelligent
Monitoring and internal assessments of compliance;
reporting monthly to the Trust Board. Assurances will
be provided using the Clinical Quality Assurance cycle
that incorporates the following three areas:
Team Quality Assessment An internal team-
led self-assessment of the services they
provide. Measured against specific prompts
created to reflect the standards of quality and
safety and Trust policy. The prompts are
considered by the team from three points of
view; staff and observations, documentation
and service user and carer feedback.
Internal Quality Reviews A programme of
unannounced inspections of teams
undertaken by staff, service user / carer
volunteers and Non-Executive Directors,
against the standards of quality and safety
and Trust policy.
Quality and Safety Walk-abouts A
programme of visits by Trust Board Members,
designed by the Trust and AQuA, to have a
7
structured conversation about safety with
frontline staff and patients. These visits are
instrumental in developing our open culture
where the safety of patients is seen as an
organisational priority. The resulting reports
feedback into the quality and safety
governance arrangements at the Trust and
directly at the Board Meetings.
Continuous Clinical Improvement A review
of outcomes from the above elements that
identify areas for improvement. These are
either carried out at a local level within teams,
or on a Trust wide basis informing the quality
agenda for the Trust.
5.5 Sign up to Safety
In June 2014 a national Sign Up to Safety Campaign
was launched, with the mission to strengthen patient
safety in the NHS and make it the safest healthcare
system in the world. The ambition was to reduce
avoidable harm by half in the NHS over three years,
saving 6000 lives.
In November 2014 the Trust adopted the sign up to
safety campaign, and we submitted our pledges and
Safety Improvement Plan to NHS England in January
2015.
Sign up to Safety became a Trust high level objective
for 2015/16 under the theme ‘Are we delivering our
services safely?’ It has also been agreed by the Trust
Board as a quality priority for safety for 2015/16 and is
set out as a trust intention in the Quality Account.
5.6 Lessons Learned
A learning organisation has been defined by Senge
(1992) as “a place where people continually expand
their capacity to create the results they truly desire,
where new and expansive patterns of thinking are
nurtured, where collective aspiration is set free, and
where people are continually learning to see the
whole (reality) together."
The Trust is driven to becoming an organisation that
rigorously and consistently utilises and develops the
collective knowledge and experiences of its people,
and through this we learn and develop.
The Trust is putting in place a number of additional
methods to enhance the lessons learned within the
Trust, as we believe this learning is powerful in the
pursuit of continuous improvement. The Trust is a
high reporter of incidents, which we believe
demonstrates an open safety culture. By examining
and learning from incidents and sharing the things we
do well we constantly improve the quality of care we
deliver. This helps to deliver a better service user
experience. The Lessons Learned programme within
the Trust is driving how we do this.
5.7 CQUIN (Commissioning for Quality and
Improvement)
CQUINS are agreed yearly, with the organisations that
commission our services; they are made up of both
national and local goals, with the aim to incentivise
quality and efficiency. We use CQUIN targets within
our quality measures to provide further information
on Trust performance.
These measures cover in-patient and community
mental health and learning disabilities and community
health services provided across our boroughs; they fit
into the same quality domains of safety, experience
and effectiveness.
6. How we monitor and report progress
and achievement of quality
The measurement, monitoring and reporting of
quality within the Trust is an important part of the
Quality Strategy and requires the following robust
governance arrangements we have in place.
6.1 Governance Arrangements
The Quality Committee is a sub-committee of the
Trust Board with delegated powers to provide
leadership and assurance to the Trust Board on the
effectiveness of Trust arrangement’s for quality,
ensuring there is a consistent approach throughout
the Trust, specifically in the domain areas of:
8
Safety (Patient and Health and Safety)
Effectiveness
Patient Experience
The Quality Committee agree and oversee the Quality
Strategy, with a scheduled work plan in place to
ensure that all the elements of the Strategy are
regularly reviewed and monitored; reporting monthly
to the Trust Board.
Each element of the Quality Strategy has an
accountable Executive Director and identified Trust
Leads with responsibility for the implementation of
the Quality Initiatives, supported by groups of
experienced staff to drive improvement and change
within service delivery.
6.2 Quality Accounts
Each year the Trust publishes the Quality Accounts,
this is a report on the quality of our services; focusing
on patient experience, clinical effectiveness and
patient safety. The report provides updates on quality
initiatives undertaken throughout the previous year
and details of the quality improvement priorities for
the year ahead.
The quality account process is the opportunity to
engage with patients, their families, staff, local
commissioners, partner organisations, and Foundation
Trust members to determine future priorities.
9
PART TWO – QUALITY IMPROVEMENT PLAN
2015-2016
The Quality Improvement Plan 2015-2016 is
surrounded by the use of tried and tested
Service Improvement Methodology which is
underpinned by the Trusts Culture of Care. The
third circle of the Quality Strategy Wheel
contains the six elements which bring our
Quality Definition to life.
This part of the Strategy provides the high level
plans for implementation of the 2015/16
initiatives for;
Sign Up to Safety
CQUIN (Commissioning for Quality andInnovation)
Quality Priorities
Quality Improvement Cycle
Quality Big Dots
Lessons Learned
10
Our Culture of Care
Our Culture of Care underpins the Quality
Strategy. It brings learning and improvement
from external reports (notably, Francis,
Berwick and Cavendish) that identified a need
for quality improvement in healthcare.
Our Culture of Care recognises and translates
the Chief Nursing Officer’s call to action to
embed the 6Cs into everyday practice across
all health care organisations.
Care
Compassion
Competence
Communication
Courage
Commitment
Culture of Care, has a three year plan.
2013-2014 – Branding
2014-2015 – Publicity and Promotion
2015-2016 – Embedding in Practice
2013/14
When the 6 Cs were launched by the Chief
Nursing Officer it was very much aimed at
nursing staff. At the Trust we believe that the
ethos and principles of the 6 Cs applied to
everyone so we developed our own Culture of
Care Initiative. We encouraged all staff to sign
up to be ‘Care Makers’, and were the first trust
to include Doctors, Allied Health Professionals,
Communication Professionals and Estates
Professionals in this initiative. In doing so, this
assisted us to realise the 6 Cs and put these
into action.
In 2014/15
Culture of Care became a Trust Quality Priority,
with a number of events held to publicise and
promote the Culture of Care within the Trust.
This included a launch event attended by the
Chief Nursing Officer for England, who was
delighted with the way the Trust had
embraced the 6 Cs for all. Staff were invited
to speak at prestigious events and we
received positive feedback about what the
Trust has undertaken to promote the 6 Cs.
During 2015-2016
This year we want to find out if the Culture of
Care Campaign has been successful and has
truly become the ‘way we do things here’. To
do this we are;
Developing a set of questions to test the culture of the organisation, this together with the Friends and Family Test will provide a measure against the implementation of the 6 Cs
Looking at how we further embed
these values by developing further
communications to set expectations
11
Sign up to Safety
In June 2014 a national Sign Up to Safety
Campaign was launched, with the mission to
strengthen patient safety in the NHS and make
it the safest healthcare system in the world.
The ambition was to halve avoidable harm in
the NHS over three years, saving 6000 lives.
In November 2014, the Trust adopted the sign
to safety campaign, and we submitted our
pledges and Safety Improvement Plan to NHS
England in January 2015.
Sign up to Safety became a Trust high level
objective for 2015/16 under the theme ‘Are we
delivering our services safely?
We will establish targets for the reduction in
avoidable harm for the following areas
Self-harm
Suicide
Falls
Violence and Aggression
Physical Health
By collaborating with other Trusts, we will
develop learning networks in order to
determine harm reduction priorities and
develop and implement these solutions locally.
By monitoring these projects appropriately we
will measure their overall effectiveness in
reducing harm during 2015-2016.
Quarter 1
Develop and agree the Trust’s Safety
Improvement Strategy which will include a
year one work plan and communication
plan.
Establish how we will define and identify
avoidable harm, to ensure accurate
reporting of progress.
Utilise existing strategic groups to
implement the Safety Improvement
Strategy.
Develop bespoke training for Matrons and
Quality Leads.
Develop indicators for the reduction of
avoidable harm including % target
reduction in years 1, 2 and 3.
Develop and design the role of the Safety
Ambassador.
Quarter 2
Deliver bespoke training to Matrons and
Quality Leads.
Develop a cohort of Safety Ambassadors,
along with roles and responsibilities and
training required to fulfil role
Quarter 3
Safety Ambassadors in place to identify
safety initiatives within their own areas of
work and produce Safety Improvement
Plans.
Quarter 4
Safety Ambassadors present the outcomes
of safety improvement plans to the Quality
Committee.
Evaluate the Trust’s Safety Culture using a
questionnaire that will be used to shape
work plan for year 2.
12
CQUIN (Commissioning for Quality
and Innovation)
The CQUIN framework is a national framework
for locally-agreed schemes, set by Clinical
Commissioning Groups (CCGs) to improve
quality and efficiency. The aim of the
framework is to help the NHS to improve
patient experiences and outcomes. The
2015/16 Trust CQUINs are in the following
quality and clinical areas:
Child and Adolescent Mental Health
Services (CAMHS)
Improving care pathway journeys
Assuring the appropriateness of
unplanned CAMHS admissions
Single Point of Access (St Helens)
Eating Disorders Children and Young
People (Wigan)
Mental Health and Learning
Disabilities:
Physical Health of Mental Health
Patients
Urgent Emergency Care
Employment and Mental Health
Mental Health First Aid
Smoking Cessation
Single Point of Access (Warrington)
Care Home Support (Warrington)
MH Safety Thermometer (Warrington)
Secure Services
Physical Health of Mental Health
Patients
Risk Assessment
Carer Involvement
Community Health Services:
Urgent Emergency Care and
Integrating care for patients with LTC
Frail Elderly
Health Inequalities
Each CQUIN target has an allocated Assistant
Clinical Director lead, and progress is
monitored via monthly CQUIN Update
Meetings with leads which is chaired by the
Deputy Director of Nursing and Quality.
13
To demonstrate the Trust’s continual
commitment to quality improvement each
year we engaged with our five Health watch
organisations, five Local Authorities, and five
Clinical Commissioning groups, as well as our
service users and carers and the Council of
Members to establish the Trust’s Quality
Priorities for the coming year. These Quality
Priorities follow the same domains of safety,
experience and effectiveness, and are
monitored throughout the year. Themes for
each area have now been identified as;
1. Care Planning
We will ensure that the care planning module
in RiO (new electronic records system) is
aligned to ensure that care plans are Specific,
Measurable, Achievable, Realistic and Timed
(SMART)
The Trust will develop mechanisms to monitor
care plans/statements of care for
effectiveness.
We will continue to use those people already
trained from the Involvement Scheme to
conduct on-going audits which were developed
as part of the care planning priority from last
year.
Quarter 1
The care planning module in RiO will use
the SMART for care planning/statements
of care.
We will develop an audit tool to reflect this
format.
Quarter 2
We will audit 50 care plans using the new
audit tool.
We will report the findings of the audits to
the Quality Committee.
Quarter 3
Action plans will be developed and
implemented for any improvement areas
from the audits results.
Quarter 4
Re-audits will take place to ensure
improvements have been made and are
embedded in practice.
2. Using patient and staff feedback
to shape improvements in
services
PATIENT LIAISON SERVICE (PALS)
We will improve our systems to ensure that all
PALS activity is recorded sufficiently. This will
allow us to analyse concerns raised and
incorporate PALS into existing mechanisms
currently used for complaints that we use to
shape improvements in our services.
We want to ensure that the service PALS
provides is appropriate and effective. We will
introduce a method to evaluate the service
provided and use the feedback as an
opportunity to shape and develop the service
to ensure that it meets the needs of those who
use it.
Quarter 1
PALS activity will be recorded using the
Trust’s Risk Management System, Datix; it
will identify both the borough, and themes
14
of concerns together with outcomes and
actions.
PALS feedback and evaluation methods
will be developed and agreed. These will
comprise of methods for both people
contacting the service and staff.
Quarter 2
Develop and agree robust reporting
mechanisms for PALS activity, to align fully
with existing processes used for the
evaluation of themes and feedback for
complaints.
Roll out the agreed evaluation methods to
gain patient and staff feedback of the
service provided by PALS.
Quarter 3
Implement the agreed reporting methods
to aggregate the PALS activity from the
Datix system, and communicate these
within our services and teams to establish
actions for improvements.
Review and report on the feedback
received from the evaluation of the PALS
service; and agree improvements and
actions to achieve this.
Quarter 4
Receive and report on actions taken within
services to address PALS concerns within
our services, to ensure that further
learning is disseminated throughout the
Trust.
Implement actions and report against
progress and changes made as a result of
the evaluation exercises.
Family and Friends Test (FFT)
FFT was introduced to all areas of the Trust
from January 2015. Outcomes from the FFT
will be published nationally on a quarterly
basis from April 2015. The Trust will establish
a working group that will develop a process for
measuring the impact of and sharing the
intelligence and learning from FFT.
Quarter 1
Membership of the Friends and Family
Working Group will be established. The
Group will meet and agree their Terms of
Reference.
Quarter 2
The Group will identify and agree methods
of data collection for the whole Trust, and
decide on a system to measure
improvements from actions implemented
as a result of FFT.
Quarter 3
Collect and collate information on
improvements.
Identify opportunities to utilise other
patient experience intelligence to form an
overall picture of patient satisfaction.
Quarter 4
Provide a report to the Trust’s Quality and
Safety Meeting that incorporates collated
PALS information with other patient
experience sources identifying where
improvements are needed and been made
within services. Incorporate PALS
information to Patient Experience Reports
for each borough.
Values Based Recruitment
The Trust is committed to ensuring we have
the right staff, with the right values in our
services. By recruiting the right people who
are caring, compassionate and committed, we
will in turn increase the quality of care we
provide.
To support this commitment, we have
introduced a series of Values Based Interview
tools aligned to both the Trust Values and the
15
Nursing Six C’s. Each value contains a series of
interview questions, enabling managers to
select from a range of options. In addition, the
tool requires managers to create their own
technical competency-based questions,
resulting in candidates having a two-part
interview consisting of five values questions
and a number of technical ones.
The Trust has also introduced other values
based recruitment selection tools which we
would like to develop further as below.
Quarter 1
Continue to actively promote the values
based interviewing tools across Nursing
and seek on going feedback from
managers.
Trial the Admin and Clerical values based
interviewing tools across the Trust,
proactively involving managers in the
development of questions.
Implement Values Based Application
questions on NHS Jobs for all posts that are
advertised.
Train a further 25-30 recruiting managers
and service users and carers in Values and
Behavioural Based Interview Training,
evaluating feedback regularly.
Continue to develop the pool of service
user and carer values based interview
questions.
Further extend the service user and carer
interview involvement scheme to band 6
posts and above.
Quarter 2
Involve Domestic Managers in the
introduction of values based interview
questions for both substantive and bank
posts. This will include on-going evaluation
from recruiting managers.
Create a values based interviews
assessment centre / recruitment event
tool kit incorporating role play materials
and scenario based exercises for volume
posts.
Train a further 25-30 recruiting managers
and service users and carers in Values and
Behavioural Based Interview Training,
evaluating feedback regularly.
Start work on the values based interview
tool for Psychological Therapies, engaging
recruiting managers in the design of the
questions and subsequent piloting.
Further extend the service user and carer
interview involvement scheme to band 5
posts and above.
Quarter 3:
Commence working on values based
interview questions for Medical and
Consultant recruitment, engaging senior
medical leaders in the design of questions.
Start work on the design of AHP values
based interview questions involving
recruiting managers throughout.
Train a further 25-30 recruiting managers
and service users and carers in Values and
Behavioural Based Interview Training,
evaluating feedback regularly.
Further extend the service user and carer
interview involvement scheme to band 4
posts and above.
16
The Trust will continue to assess itself monthly,
against the Fundamental Standards of Care,
CQC intelligent Monitoring and internal
assessments of compliance; reporting monthly
to the Trust Board. Assurances will be provided
by via the Clinical Quality Assurance cycle that
incorporates the following three areas:
1. Team Quality Assessment
A team led review of the services they provide,
against specific prompts created to reflect the
standards of quality and safety and Trust
policy, against the domains of; staff and
observations, documentation and service user
and carer feedback.
We will update the team quality
assessment tool to reflect the framework
of the CQC Fundamental Standard.
We will collate and report and report
against progress of Caring, Responsive,
Effective, Well-led and Safe to identify ‘hot
spots’ for further trust-wide and local
learning and improvement.
2. Internal Quality Reviews
A programme of inspections of teams
undertaken by staff, service user / carer
volunteers and Non-Executive Directors;
against the standards of quality and safety and
Trust policy.
We will provide support our clinical teams
in the completion of the Team Quality
Assessment and review the evidence
gathered for their self-declarations.
We will review action plans for the team
quality assessment and Quality and safety
walk-rounds and support teams to achieve
improvements.
We will gather information from the
internal quality reviews to identify Trust
wide improvements that will shape future
quality initiatives.
3. Quality and safety Walk-rounds
These walk-rounds are instrumental in
developing our open culture where the safety
of patients is seen as an organisational priority.
We will continue with the programme of
weekly walk-rounds by Trust Board
Members and Senior Managers, designed
to have a structured conversation around
safety with frontline staff and patients.
We will produce comprehensive reports to
feedback into the quality and safety
governance arrangements at the Trust and
directly at the Board Meetings.
4. Continuous Clinical Improvement
We will review the outcomes from the above
elements to identify areas for improvement,
either at a local level or on a Trust wide basis
that informs the quality agenda for the Trust.
17
Quality Big Dots
The Trust has established three ‘Quality Big
Dots’ which cover a five year period 2013-2014
to 2017-2018.
These big dots were established by the Trust
Board, Senior Leadership Team and Council of
Governors, supported by AQuA.
Each quality big dot is shown here; they mirror
the three Quality Priorities for 2014-2015 and
have joint work plans and monitoring
arrangements with the Trust’s Quality
Committee.
As the Quality Big Dots have longer term goals
than the in-year Quality Priorities, the
measurement of achievement differs to reflect
both goals.
Big Dot One
We will demonstrate a year on year
improvement in the collaborative participation
with, and engagement of, service users.
This will result in improved collaboration
and engagement of service users with a
long term condition, thus achieving the
Quality Big Dot.
Big Dot Two
We will implement our suicide reduction
strategy with the aim to reduce service user
suicide to zero in five years.
This will be achieved by the
implementation of a suicide reduction
strategy that will be informed by a suicide
audit scheduled for completion by the end
of 2013/14.
This quality big dot aligns to the 2015-2016
high level objective under the theme of
Are we delivering our services safely?
Big Dot Three
We will aim to reduce avoidable harm to
service users and staff by 20% year on year.
To reduce avoidable harm to service users
and staff by 20% year on year. - This will be
achieved by an initial scoping of the harms
that the trust will focus on and the
development of a five year trajectory.
This quality big dot aligns to the 2015-2016
high level objective under the theme of
Are we delivering our services safely?
18
Lessons Learned
The Trust is driven to becoming an
organisation that rigorously and consistently
utilises and develops the collective knowledge
and experiences of its people.
Through each experience we learn and
develop as individuals, so learning often feels
quite natural. Yet learning is much like an art
and a skill in that it can be developed and
perfected. When considered carefully,
learning can be very powerful for individuals
and organisations in the pursuit of continuous
improvement.
To support the Trust as a learning organisation
we have established a Lessons Learned Forum
chaired by the Medical Director. The aims of
the forum are;
1. To provide assurance to the Trust that
lessons are learned from Serious
Incidents.
2. To prevent reoccurrence of Serious
Incidents, by holding to account, strategic
and operational groups to deliver on
actions from Serious Incidents linked to
rapid improvement.
3. To monitor and test improvements made
are sustained and embedded.
The group identify themes from serious
incidents and commission work to address
these issues. This is then presented back to
the Organisation in a variety of ways through
the Trusts internal communications and by
holding events to share the outcomes of
incidents, promote best practice and improve
patient safety.
As part of the Trusts Transformation agenda
we are developing a standard approach to
learning lessons which can be applied to
broader areas of learning such as
organisational change projects and
improvement initiatives in addition to
individual areas such as serious incidents.