The Hillingdon Hospitals NHS Foundation Trust · 4 The Hillingdon and North West London Health Economy ... It provides a structure for delivering the ... The Hillingdon Hospitals

The Hillingdon Hospitals NHS Foundation Trust

Clinical Quality Strategy 2013 / 16

November 2013

Version 1.0

PUTTING COMPASSIONATE CARE, SAFETY AND QUALITY AT THE HEART OF EVERYTHING WE DO

Hillingdon Hospitals NHS Foundation Trust Clinical Strategy 2013-16

2

CLINICAL QUALITY STRATEGY

INDEX

1 Introduction 3

2 Strategic Aims 4

3 Objectives 4

4 The Hillingdon and North West London Health Economy Context 4

5 National Context 6

6 How Do We Perform on Measures of Quality 8

7 Our Quality Priorities 11

8 Enablers to improve the quality of care we deliver 14

9 Improving our Governance of Clinical Quality 16

10 Delivering our Strategy 17

11 Regular Review of our Strategy 18

12 Equality Impact Assessment 18

13 Other Trust Referenced and Related Documents 18

Annex A NHS Outcomes Framework 2013/14 ‘at a glance’ 19

Annex B Pre-Visit Safety Indicators from the Keogh Review 20 - Application to The Hillingdon Hospitals

Annex C Key Clinical Quality Indicators 21

Annex D Governance and leadership of Clinical Quality 26

Annex E Clinical Governance & Quality & Risk 30 Reporting Structure

Annex F Equality Impact Assessment 31


3

1 Introduction: Quality at the Heart of Everything We Do

This document sets out the trust’s Clinical Quality Strategy that will help us to achieve our vision ‘To put compassionate care, safety and quality at the heart of everything we do’. It provides a structure for delivering the clinical quality governance agenda to ensure on-going improvement in the quality and safety of patient care over the next three years. It outlines the responsibilities of its staff and it is supported by our culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety)1which embraces a culture that empowers staff to report incidents and raise concerns about quality in an open, blame-free working environment. The Strategy provides a framework so that we can be assured that our services are safe and effective. It builds on the local and national context of service change that so critically affects quality of care for all our patients. Nationally there is an increasing focus to make quality the organising principle for the NHS and to ensure consistently high levels of quality, provided 24 hours, seven days per week, across all organisations. In line with this the Trust Board is determined to put clinical quality at the heart of all our work and activity. The NHS however is working under considerable pressure to meet the rising demand for health services and raise clinical quality standards within increasingly constrained resources. The trust, along with local health and social care partners, continues to strive for clinical quality improvements despite these challenging economic circumstances. The trust embraces the three key components of ‘High Quality Care for All’2where quality is placed as the organising principle in the NHS. Quality is defined in relation to three domains: Patient safety Treating and caring for people in a safe environment and protecting them from avoidable harm, for example, ensuring that medicines are managed safely, reducing the number of patient falls and hospital acquired pressure ulcers. Clinical effectiveness Clinical effectiveness is about whether or not a patient’s care or treatment was successful. In other words, did it have the impact that it was supposed to have? And did it achieve the best possible result for the patient? This may include improvement in specific medical or health conditions and treatments or working with our community colleagues to ensure there is a stronger focus on improving quality of life and prevention of disease. Patient and carer experience Patient experience is about ensuring patients, relatives and carers have as positive experience as possible at every stage of the care or treatment that is

1http://www.thh.nhs.uk/about/values.php 2 www.official-documents.gov.uk/document/cm74/7432/7432.asp


4

being provided. Patient experience refers to the overall experience throughout the course of treatment, and not just the results that were achieved at the end. Quality care is not achieved by focusing on one or two aspects of this definition; rather, high quality care encompasses all three aspects with equal importance. This strategy is driven by our commitment to ensure that quality as defined in ‘High Quality Care for All’ is at the core of everything we do; it supports our overall Trust strategy and is aligned with our key strategic priorities. 2 Strategic Aim The aims of this Strategy are to: • Ensure that the Trust’s approach and commitment to clinical quality

governance is clearly defined so that all trust staff are clear on their role and the drive to continually improve the quality of care.

• Ensure that clinical quality governance and risk management are integrated

into the Trust’s culture and everyday management practice. 3 Objectives • For the Trust to fulfil its legal and governance responsibilities in order to:

– Achieve and maintain the standards outlined by the Care Quality

Commission3 (CQC)and our CQC registration – Achieve the requirements of the Monitor Quality Governance Framework4

• Make sure that the best possible hospital care is afforded to our patients and their families so that the interests of staff, stakeholders, patients and the public are protected

• Strengthen the ethos of a clinically led, quality and patient-focused organisation and to ensure this is embedded into the day-to-day working practices of the Trust

• Ensure that the Trust Board is provided with the right evidence which is timely so that it can be assured that the clinical quality agenda is being appropriately identified, assessed, addressed and monitored

• To ensure there is an honest, open and blame-free culture where clinical quality risks are identified and addressed at every level of the organisation.

4 The Hillingdon and North West London Health Economy Context

3http://www.cqc.org.uk/organisations-we-regulate 4 www.monitor-nhsft.gov.uk/sites/default/files/publications


5

The Hillingdon Hospitals NHS Foundation Trust provides health services at two hospitals in North West London: Hillingdon and Mount Vernon. Hillingdon Hospital is the only general hospital in the London Borough of Hillingdon and offers a wide range of services including accident and emergency, inpatient care, day surgery, outpatient clinics and maternity services. The Trust’s services at Mount Vernon Hospital include routine inpatient and day surgery at a modern treatment centre, a minor injuries unit, and outpatient clinics. The Trust also acts as a landlord to a number of other organisations that provide health services at Mount Vernon, including East & North Hertfordshire NHS Trust’s Cancer Centre. The Trust’s turnover in 2012/13 was over £190m and we employ over 2,500 staff. The majority of our patients live in the London Borough of Hillingdon but we also provide healthcare to people living in the surrounding areas of Ealing, Harrow, Buckinghamshire and Hertfordshire, giving us a total catchment population of over 350,000 people. In 2012/13: • 110,354 attendances were made to our accident & emergency department

and minor injuries unit (108,719 in 2011/12) • 4,205 babies were born in our maternity unit (4,218 in 2011/12) • 289,041 attendances were made as outpatients (296,606 in 2011/12) • 24,271 admissions were made for emergency treatment across all parts of

the Trust (25,267 in 2011/12) Within North West London the ‘Shaping a Healthier Future’5 programme has been approved by the Secretary of State for Health. This programme outlines a 5 year strategy which places The Hillingdon Hospitals NHS Foundation Trust as one of the five major hospitals for providing a full range of 24/7 emergency care in the region. The programme is based on implementing the London Health Programmes (LHP) standards for emergency care across all the major hospitals and in all specialties that take part in the provision of this service. The programme also places an emphasis on the provision of a wider range of out-of-hours primary and urgent care, and we are working closely with our GP commissioners and other providers to ensure that across the healthcare community patient care is provided in the right place at the right time. North West London has also recently been awarded “Pioneer status”, one of fourteen areas in the country which will develop closer integration of health and social care. However the Hillingdon Clinical Commissioning Group (CCG) is facing a significant financial deficit and the resources available for investment in acute care are increasingly constrained. This combined with reduced tariff income from NHS England means that the hospital has to deliver £8M of cost improvements in 2013/14 to 'standstill'. Managing this process while maintaining and improving clinical quality is the key 5 http://www.healthiernorthwestlondon.nhs.uk/


6

strategic challenge.The national concerns over poor patient care, exemplified in the Public Inquiry on Mid Staffordshire NHS Trust are a salutary reminder to all hospitals that clinical quality, patient safety and patient experience are of paramount importance and must never be placed secondary to achieving financial balance. 5 National Context There is an increased political and public awareness of the importance of quality of care in the NHS and our strategy endeavours to reflect the changing requirements from our local commissioners, our regulator Monitor and the CQC which is revising its methodology for assessing care standards in hospitals in the light of recent poor practice. There are a number of publications and investigation reports that have influenced our thinking on clinical quality.

• NHS Outcomes Framework Our goal is that we should systematically measure, analyse and improve quality, focussing on patient outcomes using the 'NHS Outcomes Framework'6. The five domains of the framework were derived from the three part definition of high quality care comprising effectiveness, patient experience and safety. The framework supports us in driving up quality improvement across the organisation. Our aim, with our community colleagues, is to achieve the key quality indicators across all of the domains (see below).See Annex 1 for The NHS Outcomes Framework 2013/14 and overarching indicators ‘at a glance’.

In building this Strategy we have made reference to key NHS investigations and reviews in order that the learning and recommendations from these underpin our principles and our governance structure for quality improvement:

• The Francis Report The ‘Francis Report’7 into the failings at Mid Staffordshire NHS Foundation Trust where the standard of services put patients at risk is a salutary reminder that things can go wrong when quality is not put at the heart of what we do.The report

6http://www.nhsconfed.org/Publications/Pages/NHS-outcomes-framework-2013-14.aspx 7http://www.midstaffspublicinquiry.com/report


7

made numerous recommendations that can be grouped into the following themes and that are fundamental to the delivery of this strategy: – Emphasis on and commitment to common values throughout the system by

all within it – Readily accessible fundamental standards and means of compliance – No tolerance of non-compliance and the rigorous policing of fundamental

standards – Openness, transparency and candour in all the system’s business – Strong leadership in nursing and other professional values – Strong support for leadership roles – A level playing field for accountability – Information accessible and useable by all allowing effective comparison of

performance by individuals, services and organisation An intrinsic part of our Strategy over the next three years will be the implementation of the recommendations of the Francis report. We are currently reviewing our nursing and midwifery workforce, in particular to improve nursing/midwifery care at the bedside, and we will monitor the quality of care through our patient surveys, detailed and patient focussed nursing templates and establish further mechanisms for measuring compassionate care. The Trust has developed a series of pledges that will be embedded within the Trust and against which we will track progress and produce a public annual report discussed at the Board. • The 6 Cs National Nursing and Midwifery Strategy December 2012saw the launch of the Chief Nursing Officer’s Vision, referred to as the 6Cs8. The 6Cs (Care, Compassion, Courage, Competence, Communication and Commitment) is a national strategy for quality which sets out a shared purpose for nurses, midwives and healthcare staff to deliver high quality, compassionate care, and to achieve excellent health and wellbeing outcomes. Our Clinical Quality Strategy embraces the delivery of the 6 Cs so that the fundamental values that are outlined in the 6 Cs and that resonate strongly with both staff and people who use our services are delivered across the organisation. • The Keogh Review Professor Sir Bruce Keogh, Medical Director of NHS England, published a report in July of this year which outlined a review on the quality of care and treatment provided by 14 NHS trusts and NHS foundation trusts that were persistent outliers on mortality indicators.

The Keogh Review9 measured trusts against a variety of indicators, many of which are now incorporated into the new CQC intelligent monitoring report for acute trusts. The review identified some common challenges facing the wider

8 http://www.england.nhs.uk/nursingvision/ 99http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx


8

NHS and Keogh identifies 8 ambitions for tackling some of the underlying causes of poor care. Improvement across these areas is expected within two years. The Keogh Report has informed our Strategy and forms an integral part of our ambition to ensure that we continue our work on reducing hospital mortality, and will report through to the public board our progress on this key safety standard. • The Berwick Report The Berwick Report10, published in August 2013 clearly identifies the importance of constant vigilance, monitoring and learning to make sure our patients do not come to any kind of avoidable harm. We need to actively seek out the views of patients and staff, and work hard to build a culture of openness, honesty and support so that no stone is left unturned in the pursuit of patient safety. Professor Berwick’s excellent report shows us all how much more can be done with a united, concerted and sustained effort across all our services. His four key aims for the whole of the NHS system are: • Placing the quality of patient care, especially patient safety, above all

other aims; • Engaging, empowering, and hearing patients and carers at all times; • Fostering whole-heartedly the growth and development of all staff,

including their ability and support to improve the processes in which they work; and

• Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

A culture of learning and transparency is a key theme running through both the Berwick Report and the Keogh Review; this is an underpinning element of our Strategy. In addition, analysing and understanding data and information on our own performance in relation to a broad spectrum of quality indicators is critical to making sure we identify risks to patient safety and that these are resolved at the first available opportunity 6 How Do We Perform On Measures of Quality?

The measures of clinical quality are complex, multifarious and currently under review. Over and above our own clinical performance targets we have to meet the standards and targets set by the CQC, our local commissioners and Monitor, our statutory regulator. Much of this regulation is in flux in light of the reorganisation of the CQC and the Keogh and Berwick reviews.

Our current performance, key risks and issues and the local drivers for improvement in quality that are to be embraced are set out below:

• Clinical Effectiveness

– Patient Reported Outcome Measures

10 http://www.england.nhs.uk/tag/berwick-report/


9

Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys. In 2012/13 we performed well against national and London-wide performance; we performed better than average for groin hernia surgery, but worse than average for hip and knee replacements for some of the key indicators.We were better than average however for all three procedures from the patient’s perspective of the outcome of surgery. Patient response rates need to improve so that we are in line with the national average for the key procedures. This is work that is currently being taken forward.

- Stroke - TIA treated in 24hrs NICE guideline 68 specifies that people who have had a suspected TIA should have specialist assessment and investigation within 24 hours of onset of symptoms. The trust is achieving 100% on this quality indicator against a target of 75%. – Maternity The trust’s maternity unit performs well on many of its key quality indicators. The trust consistently offers 95% of patients a booking appointment within 12+6 weeks gestation. The trust has dropped its Caesarean Section rate by 3% with considerable effort, including a Vaginal Birth after Caesarean (VBAC) clinic. Our admission of babies to our Neonatal Unit is very low, which is an indication of the high quality care provided to women in labour. Our breastfeeding target has improved but is an area we feel that we can strengthen. The trust is working with our public health colleagues to put forward a case for achieving Baby Friendly Status (initiative set up by UNICEF and the World Health Organisation).

– Orthopaedics - Fractured Neck of Femur The trust performs well on key quality indicators in relation to the pathway for patients who experience a Fractured Neck of Femur; in particular we are in the top decile on the time taken for patients to be transferred to theatres, and we have lower than expected mortality rates. This results in the trust performing considerably better to other NHS Trusts both in London and nationally. – Cancer performance The cancer waiting time standards are set out to ensure that cancer services are delivered to patients in atimely manner. The trust achieved compliance against all standards in 2012/13 and is consistently one of the top performing hospitals when benchmarking performance against other provider trusts in the London Cancer Alliance (LCA). The results of the National Cancer Patient Experience Survey 2012/13 are significantly better than the majority of other trusts in the LCA with the trust achieving the highest score in England for two questions. – 18 week elective pathway 18 week elective pathway targets for both admitted and non-admitted patients were achieved and exceeded in 2012/13. The strong performance across elective (planned treatment) waiting time standards continues to ensure that the


10

Trust remains one of the top performing hospitals in North West London on these targets which seek to minimize patients’ waiting time for treatment. • Patient Safety

The Keogh Report has measured Acute Trusts against a variety of safety indicators, we rate as follows: – Mortality rates are below the national average (HSMR & SHMI) and currently

there is no difference between weekend and weekday mortality – Pressure ulcer rates are lower than the national average over the last three

years – MRSA rates dropped significantly over the last two years but are still

historically at or slightly above the national and regional average – C diff rates have reduced dramatically over the last two years and are at

below the national average – The trust faces a significant challenge to maintain the downward trend in

infections and the targets of 0 for MRSA and 14 for C difficile will be challenging

– Reporting of incidents(under reporting is a sign that the organisation does not have an open reporting culture) is at the national average

– Medical error rates per 1000 admissions is 5.88 compared to the national average of 7.7

Annex B presents our detailed gap analysis against the Keogh Review standards. The Keogh analysis of “Failing Trusts” also highlighted the importance of well embedded Early Warning Scoring Systems, sepsis care bundles and an effective complaints procedure. • Patient Experience

Our above average performance on clinical effectiveness is not matched by our feedback on the National Patient Survey. There are areas of care identified within the survey which need further focussed attention, for example, ‘trust responsiveness to patient need’ and ‘overall experience of care’ are slightly below the national average.

Our recent Patient Led Assessment of the Care Environment (PLACE)11showed the Mount Vernon site as performing well. However the Hillingdon site performed below the national average with a number of concerns many related to the aging estate and poor maintenance. This undoubtedly affects patients’ experience adversely.

We have made significant improvements in relation to key essential nursing quality care standards and the outcome of this is reflected in our local patient

11 http://www.england.nhs.uk/2013/02/19/place/


11

experience survey and in our Friends and Family test responses, where 93% of patients were satisfied with the responsiveness to their needs. Responsiveness to need consists of a cluster of questions related to fundamental needs such as pain control, help with feeding or visiting the toilet, response to the call bell. 96% of patients felt they were being treated with kindness and respect and in response to the question, ‘overall were you treated with kindness and understanding’, 96% of those patients surveyed replied ‘yes, all of the time’.

Through our First Contact Project we have worked hard to improve the Outpatient Experience by implementing the Call Management System (CMS), initiating the centralisation of bookings, and introducing a document scanning referral system for all cancer and symptomatic breast referrals. However we need to complete the appointments project and complete the introduction of the electronic letters from the hospital clinics to the GP which is currently being piloted in four specialties.

Through the Leaving Hospital Project we have made considerable progress in increased positive patient experience by ensuring patients have the appropriate discharge documentation and keeping the Visual Management System (our colour coded system for where a patient is on their pathway) up to date. Several of the other standards are close to their target such as receiving a copy of ‘Your Patient Journey’ and 90% of our patients are now going home with their medication at the time of discharge. However, we need to work harder to increase the proportion of patients being discharged home earlier in the day. We aim to discharge patients before 6pm wherever possible, but they may be discharged later where it is clinically appropriate and safe to do so, taking the patient’s home circumstances into consideration.

• Commissioning for Quality and Innovation (CQUIN)

Our CQUINs are stretching targets that are set by our commissioner to ensure an improved performance in relation to key quality improvement initiatives.

Of the nine CQUIN schemes that were identified for 2012/13 we fully achieved four; 'Preventing Blood Clots', 'Using the North West London Drug Formulary', 'Improving Care for Patients with Diabetes', and 'Collecting Data for the Patient Safety Thermometer' (a national improvement tool for measuring, monitoring, and analysing patient harm and 'harm-free' care which includes assessment for blood clots, urinary catheter related infections, falls and pressure ulcers). We also fully achieved four out of five elements of the 'End of Life Care' scheme, and 2 out of 4 elements of the 'Providing Real Time Information About our Patients to GPs' scheme, and we partially achieved the CQUIN for 'Responsiveness to the Personal Needs of Patients'. We did not achieve two of the CQUINs for 2012/13; 'Ensuring Patients are Seen by a Consultant Within 12 hours of Admission to Hospital' and 'Dementia Screening, Assessment and Onward Referral'. 7 Our Quality Priorities


12

In developing both our objectives and quality priorities we have referred, in Sections 5 and 6, to national best practice, findings from the various recent reviews and quality initiatives, reviewed our current quality performance and referenced local feedback from staff and patients. An analysis of these sections, as well as Annex B, and our recent award of a ‘Band 6’ Trust as part of the new CQC Hospital Intelligent Monitoring Band Ratings12 confirm the importance of strong quality performance across a range of indicators, and Annex C lays out a comprehensive list of our quality objectives going forward over the next 3 years. A further analysis of our performance against the indicators in Sections 5 and 6, allows us to clearly identify a smaller number of key strategic quality objectives which will need greater focus with regard to our current position to ensure we improve our performance alongside other providers within London and nationally. These can be grouped under the three domains as follows: 7.1 Improving clinical effectiveness: • Improve Patient Reported Outcome Measures (PROMs) – the trust will

improve the key hip and knee PROM indicators to be in line with the national average and it will aim to increase the response rate to the PROM questionnaires from patients.

• Improve the Initiation of Breastfeeding– the trust aims to improve the

uptake of breastfeeding amongst women to achieve >88% by increasing women’s awareness of the value of breastfeeding and working with our GP commissioners to raise awareness across the local community.

• Reduce Caesarean Section Rates–the aim is to achieve a reduction which

is in line with the London average through learning from the best performing trusts and reviewing our existing systems and processes.

• Achieve Accident and Emergency Access Targets – it is important that

patients are seen as quickly as possible when they attend the A&E department, especially those patients who are more seriously unwell (Type 1). The trust aims to achieve the expected target of >95% of Type 1 patients seen within four hours.

7.2 Improving Patient Safety • Reduce mortality rates – the trust aims to improve the Hospital

Standardised Mortality Ratio (HSMR) and reduce the variation between weekend and weekday mortality rates so that it is in line with the best performing trusts in the London region.

• Preventing avoidable deaths – the trust aims to achieve a year on year reduction in avoidable deaths through surveillance of all specialty mortality and open Multi-Disciplinary Team mortality meetings led by a Mortality Lead. The trust will share the learning from all identified preventable deaths.

12 http://www.cqc.org.uk/public/hospital-intelligent-monitoring


13

• Reduce avoidable infections – the trust’s aim is to reduce avoidable

healthcare associated infections to zero. The trust has a robust annual action plan based on its three year infection prevention and control strategy. The trust will aim to achieve the targets set by its regulator Monitor for MRSA & Clostridium difficile infections for each forthcoming year.

• Patient Safety Thermometer (PST) and Delivering Harm Free Care - the

trust aims to reduce the level of hospital acquired harms as measured by the PST and reduce the overall incidence of pressure ulcers and patient falls with harm. The aim is to ensure that at least 95% of patients consistently receive harm free care in line with national targets.

• Implementation of the national Early Warning Scoring (EWS) System -

implementation of the national EWS system which supports early identification of any deterioration in a patient’s vital signs and medical condition is a priority for the trust. Roll out of this system across the trust will support identification of those patients who may need more intensive care and treatment at the earliest stage. The trust needs to ensure it is in line with this national initiative and with other acute care providers.

• Reduce the number of patient safety incidents that are graded as

moderate and severe – learning from incidents in relation to patient safety is an important part of our clinical governance process. Ensuring staff report incidents and near misses helps us in taking actions to prevent reoccurrence and to avoid more serious incidents from occurring. Organisations that report fewer incidents may have a weaker and less effective safety culture. Our aim is to ensure we are above the national average in incident reporting, particularly for no/low harm incidents.

7.3 Improving the Patient and Carer Experience • Achieve year-on-year improvement in the National Patient Survey – our

aim is to ensure we are amongst the best performing trusts for the patient experience of care. We particularly want to ensure that we achieve high scores in relation to how patients rate their care overall and how responsive we have been in meeting their needs in relation to communication and compassion.

• Improve our Management of Patient Complaints – responding effectively

to patient feedback is a key priority for our staff. We want to ensure that we learn from our patients and their families with regard to their experience of care they have received and where we can make improvements to ensure patients and their families receive the highest possible quality of care. We aim to ensure that >90% of complaints are responded to within agreed time frames and that there is effective resolution at the earliest stage.

• Improve Patient Experience of the Out-Patient Pathway– the trust aims to

ensure that the patient experience is positive for all patients attending the hospital; improving arrangements in relation to out-patient appointments is a


14

key priority. This will assist the trust to deliver a more efficient and effective service, which will reduce cancellations and non-attendances and improve communication with patients, GPs and other healthcare providers.

• Improve Patient Experience of Leaving Hospital – the trust has already

undertaken work on improving the inpatient care pathway and reducing the length of stay in hospital for patients in response to the results of the National Patient Survey. The trust aims to ensure that the discharge from hospital process is managed efficiently and effectively and that patients report this via the National Patient Survey and via the Friends and Family Test survey. Improved integrated pathways of care and working closely with our health and social care partners will support an improved experience for patients in them returning to primary care at the earliest opportunity. We will aim to evidence the introduction of integrated care pathways, improved communication between the trust and our partners and reduction in length of stay.

8. Strategic Enablers to improve the quality of care we deliver In line with emerging best practice and national quality improvement initiatives there are several key strategic enablers that will truly support the trust in driving forward the quality agenda and are central to the delivery of this strategy. These are outlined below: 8.1 Implementing improvements in relation to the London Health

Programme Emergency and Maternity Care Standards - to include seven day working and earlier review, presence and decision-making by senior clinicians

8.2 Review of nurse to patient ratios – this is in line with Royal College and

key investigation reports and recommendations (Francis, Safe Staffing Alliance)

8.3 Meeting increased expectations from our regulators (Care Quality

Commission and Monitor) – this is an expected improved quality governance and patient safety culture in response to Francis, Keogh and Berwick reports

8.4 Increasing and improving our understanding of patient reports of

clinical outcome and staff views / recommendations – to meet the expectation that we are listening to patient feedback via a variety of sources and that we listen carefully to what our staff tell us about the setting within which they work and the culture and behaviours which are critical to the delivery of high quality care.

In order to achieve our quality priorities we need to ensure that we have the following key elements well organised and resourced: Accurate data collection and analysis


15

The accuracy of our data collection continues to be of a high quality but we need to develop more analytical capacity to collect and analyse the intelligence mentioned, scan databases such as Dr Foster and HSCIC, and collating staff and patient feedback. We also need to ensure that our clinical coding is of the highest possible quality so that the Trust Board can be assured that any data that is submitted for reporting purposes is accurate. More effective coordination, interpretation and presentation of quality information at all levels of the organisation Over the last year there has been a systematic and steady improvement in the quality and depth of quality information presented to the Board particularly in respect to the interpretation of trends and more information from teams and wards. The new quality dashboard presented to the monthly Board needs to be supplemented by

• Greater feedback on the observations of care on the ward visits by Executives / NEDS and Governors

• Presentations from Clinical Divisions or specific teams on performance and good practice

• More systematic analysis of complaints and trends • Greater review of patient pathways and understanding the impediments to

improving the patient experience • Increased focus on performance at ward and speciality level e.g. nursing

heat map, balanced scorecard • Seeking greater assurance on the links between board level quality

objectives through to team outcomes

Effective risk management and clinical audit Risk Management and clinical audit are key components of the Trust’s approach to continuous quality improvement and patient safety. Engagement of all staff in this work is essential to ensure that opportunities are not missed to recognise and manage risks and to learn from outcomes of clinical audit. To support staff the Trust seeks to provide a fair, consistent, open environment where the culture is one of learning and that supports us in achieving an integrated approach to risk management and quality improvement. Systematically assessing the impact of service changes on quality Undertaking a quality impact assessment with any anticipated service change or scheme under our Quality, Innovation, Prevention and Productivity (QIPP) programme is a key requisite in ensuring quality of care and patient safety is at the centre of our decision-making. The Clinical Assurance Panel (CAP),which is multi-professional and chaired by the medical director, assesses all service changes for their impact on the delivery of quality care, modifying or rejecting them before they are given the go-ahead. Stricter adherence to standards The Board is practising a culture of “no tolerance of non-compliance and the rigorous policing of fundamental standards” which requires the use of our CARES framework by all staff with additional assurance being provided by the use of Clinical Fridays, deep dives, and Board visits to the wards.


16

Greater patient and carer involvement in improving services Involving patients and carers in the review of the quality of services and engaging with them in ensuring they are truly empowered to work with healthcare professionals to reshape services and care pathways. Safe Staffing levels The trust has a responsibility in ensuring it has the right numbers of staff with the right skills to deliver a safe and effective service to its patients; this is a regulatory requirement. The trust will ensure that it reviews its front-line clinical staffing levels in line with best practice requirements and that there is regular reporting at board level. Strong clinical leadership Involving clinicians and staff in transforming the way we deliver services and listening to their views on the improvement of clinical quality and being clear about what high quality care looks like in all specialties and reflecting this in a coherent approach to the setting of standards. Delivering compassionate care It is essential that we recruit, retain and develop the aptitude and behaviours of staff involved in delivering improvements in quality. The trust has already integrated the CARES values within its appraisal, talent management and performance management processes and is delivering a programme of customer care training over the next two years. Recognising and rewarding improvement in the quality of care and service Ensuring that every member of staff that has contact with a patient, or whose actions directly impact on patient care, is motivated and enabled to deliver effective, safe and person centred care. Modernising and reconfiguring our hospital and facilities to enhance clinical quality and the patient experience Our estate needs robust maintenance and modernisation to ensure it delivers an appropriate care environment for patients and their families and carers moving forward. We need to ensure that we use capital resources to best effect and that clinical staff are at the forefront of environmental improvement. Progress against our quality priorities needs to be monitored from ward to board with appropriate granularity at each level. Clear actions must be identified if performance is not on track and progress monitored subsequently. Review of our priorities will be undertaken on an annual basis as a minimum and more frequently if necessary for those which are highest level priority; in addition our strategy will need to be responsive to a changing operating environment. 9 Improving our Governance and Leadership of Clinical Quality In order for the trust to achieve high quality care we need to ensure that we have the right structures and processes in place allied to an appropriate culture with supporting values and behaviours and staff who are appropriately trained. The collective term used for these areas is ‘quality governance’. The information provided in Annex D and E outline the structure that we have in place to support


17

a robust approach to quality governance. Improving quality and healthcare outcomes is the responsibility of everyone working in the NHS, no matter what their position or level of authority; this is the culture that all of our staff must adopt to ensure patients are kept safe and are well-looked after. The key elements to achieving an effective quality governance structure are outlined by the National Quality Board in its document, ‘Quality in the New Health System’13 and principally these are: • Individual health and care professionals, their ethos, behaviours and actions,

are the first line of defence in maintaining quality • The leadership within provider organisations is ultimately responsible for the

quality of care being provided by that organisation • Commissioners are responsible for commissioning services that meet the

needs of their local populations and for driving improvements in quality. The leadership within the organisation must see their fundamental role as ensuring high quality care for patients. As part of this, the trust board will ensure that: • The quality of care being provided is routinely monitored across all services • Poor performance or variation in quality is challenged • High quality care and quality improvement is incentivised and rewarded • The trust works with other health and social care organisations to ensure that

care is centred on people’s needs • A culture of openness and transparency is fostered throughout the

organisation • If significant problems arise that concerns are raised and help is sought 10 Delivering Our Strategy The key priorities outlined in Section 7 and Annex C have been presented as a result of analysis of the trust’s current performance against each of the indicators / metrics / standards outlined in both our strategic priorities and our Annual Quality Report and are in line with local and national priorities. Benchmarking against local and London-wide providers has also been undertaken and informs the trust’s quality drive to achieve improved performance on quality targets in line with local, regional and national best performance. The priorities will focus on those areas which are the most important (based on a balance of greatest impact on patient care, national profile and public profile), as well as those where performance is below expected. For each priority, we will identify the actions we will take and what success looks like. Robustly tracking performance and adapting to changing local, regional and national priorities will inevitably lead to a changing of the quality priorities over the three-year cycle of this strategy. 13 http://www.england.nhs.uk/2013/01/24/nqb/


18

We are committed to working with our key stakeholders and supporting both internal and external surveillance of our performance on quality. Above all we will ensure that we remain open and transparent, that we listen to and engage with our staff and that we increasingly value the patient voice via the different sources of patient feedback. 11 Regular review of our strategy Our priorities will be monitored by the individual teams, through their quarterly divisional reviews and quarterly via the Quality and Risk Committee, a Board Committee. Bi-annual reports will be presented to the Trust Board. The results will be reported in the 2013/2014 Trust Annual Report.

12 Equality Impact Assessment The Trust is legally required to ensure that all new policies and documents are assessed for their impact both positive and negative on equality target groups: race/nationality; ethnic origins; religion/beliefs; disability; age; gender, sexual orientation and transgender. This Strategy provides an effective framework for meeting the needs of different equality groups. An impact assessment for this document can be found in Annex F. 13 Other Trust Referenced and Related Documents

- Trust ‘Strategy on a Page’ - Annual Report and Accounts - Annual Business Plan - Annual Quality Report - Clinical Quality Plan - Divisional Business Plans - Equality Objectives Report - Information Management and Technology Strategy - Carers Strategy - Patient Experience and Engagement Strategy - Leadership Strategy - Infection Prevention and Control Strategy - Dementia Strategy - Trust Culture and Values - Trust Policies

Annex B – Pre-Visit Safety Indicators from Keogh Review of 14 Trusts: Application to THHFT

The following table shows how THHFT would have been RAG Rated had the Keogh Review applied the Pre-Visit Safety Indicators to the Trust. Category Indicator RAG

Rating Comments

1. Number of harm incidents reported as ‘moderate, severe or death’

93

2. Number of ‘Never Events’ (2009 – 2013)

6

Keogh Report does not RAG Rate these (Provided for

context only)

General

3. Reporting of Patient Safety Incidents

Organisations that report fewer incidents may have a weaker and less effective

safety culture THHFT Rate = 6.6 compare to

National Rate = 6.7 4. Medical Error

THHFT Rate per 1,000 admissions (5.88) is below

National Rate (7.23) 5. MRSA

Trust MRSA rates per 100,000 beddays have historically been

higher compared to London/national Providers.

6. CDiff

Trust C.diff rates per 100,000 beddays have been at or below

national and regional levels over the last 3 years.

7. Pressure Ulcers

Pressure Ulcer rates over last 12 months are generally lower than national pressure ulcer

rates.

Specific Safety

Measures

8. ‘Harm’ for all four Safety Thermometer Indicators

The THHFT Harm Free Rate exceeds the National rate over

the last 12 months 9. Clinical Negligence Scheme Payments

THHFT is a net contributor Litigation And

Coroner 10. Rule 43 coroner Reports

No Rule 43 Reports received by THHFT

Notes: 1. These indicators are based on the Final Keogh Report available from the NHS Choices website14. 2. There is more detailed information available on how the RAG rating for each indicator has been

derived. The rationale for the ratings is taken from the data packs for each of the 14 Trusts under review which are also available at the NHS Choices Website15.

14http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf, table 4.2.1 on page 20 15 http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx


21

Annex C

Key Clinical Quality Indicators Patients who use our hospitals may be on different pathways, principally emergency, elective, outpatient or maternity. Some of the selected indicators apply to all patients, others to one of these pathways. All Inpatients (emergency, elective, day case, maternity) Quality Indicator Objective

Success criteria Key Actions

1. Mortality Indicators HSMR and SHMI

Reduce overall HSMR / SHMI and weekday versus weekend variability

To achieve London average HSMR with no variability.

To ensure: - Accurate coding - Weekend working in Medicine/Emergency Care - Implementation of LHP standards / 7 day working

Avoidable mortality

To identify preventable deaths and share learning including examining specialty mortality as per new CQC template

-Year on year reduction in avoidable deaths -Below average medical error rates.

-Standardised proforma for completion for all deaths, completed by consultant -Open Multi-Disciplinary Team mortality meetings, led by specialty mortality lead -Surveillance of all specialty mortality with audit of outliers.

2. Infection Control Rates of MRSA, C diff, MSSA, E Coli

Reduce avoidable infection and achieve Monitor mandated targets for MRSA & C diff

HCAI reduction targets achieved. Ensure delivery of IP&C Strategy and robust implementation of the HCAI annual action plan.

3. Harm Free Care Patient Safety Thermometer (PST) and the Incidence of Pressure Ulcers and Patient Falls with Harm

Reduce the level of hospital acquired harms as measured by the PST and reduce the overall incidence of pressure ulcers and falls with harm

At least 95% of patients receive harm free care; Achieve annual reduction targets: Pressure ulcers – 25% (2013/14) Falls – 20% (2013/14) Achieve 90% reliability in Pressure Ulcers and Falls Measures of Care Assessments

-Consistent data collection and validation -Accurate incident reporting and monitoring -Root cause analysis and shared learning -Implementation of Nursing and Midwifery Quality and Accreditation Framework -Implement evidence-based /best practice interventions

4. Failure to Rescue Care of the acutely unwell patient

To identify and manage the “acutely unwell” patient

-Below average cardiac arrests as measured by the NCAA -Notes audit (using GTT) looking for avoidable deterioration. -Reduced patient safety incidents -

-Implementation of National Early Warning Scoring (NEWS) system in year 1 in all areas using NEWS, PEWS (Paediatrics), MEWS (Maternity) -7 day senior review for all “acutely unwell” patients -Effective use of Critical care Outreach team


23

Below average medical error rates. -Implementation of LHP standards 5. Safeguarding Prevention / early detection of child / adult abuse

To ensure staff are aware of indicators and know the processes to follow to raise a concern

-Safeguarding training for adults and children to be >80% at all levels of training -Robust child and adult protection processes in place

-Robust and effective electronic monitoring of training data -Performance management of individuals and managers in relation to training requirements -Annual review of policy and procedures in line with updated guidance

6. Patient Experience National Patient Survey (NPS) and Friends and Family Test (FFT)

Our patients will be safe, comfortable, informed and involved whilst receiving care within our hospitals

-Achieve year-on-year improvement in the NPS: Overall how would you rate your care and responsiveness to need -Achieve annual trust target in patient experience priority areas in the local patient experience survey: -Communication -Responsiveness to need -Compassionate care

-Achieve target response rates in local patient experience survey and FFT -Triangulate data from all sources of feedback -Embed never events framework to support identification of themes emerging across feedback -Work in partnership with patients and carers involving them in identifying improvements -Develop a realistic and achievable annual programme of improvement/initiatives at ward/department and trust level -Shared learning from feedback

Complaints

Transform complaints handling to ensure there is improved responsiveness and organisational learning

-Response rate targets achieved >90% -Improved complainant experience with better complaint resolution

-Implement recommendations from: Designing Good Together: Transforming Hospital Complaint Handling (2013) -Ensure open culture/shared learning/continuousimprovement

7. Dementia Care Dementia friendly hospital To ensure that our dementia

strategy is delivered -Improved pathways of care linked to achievement of CQUIN -Improved environment of care linked to dementia bid -Improvement in results in carers survey

-Ensure delivery of annual action plan -Review strategy annually against metrics -Ensure uptake of training across the organisation

8. Integrated Care Patient focussed integrated care pathways

To plan, design and provide service models where different organisations providing certain elements of people’s care are joined up in approach and delivery.

-Integrated care pathways which place patients and their carers at the centre of services and that deliver high quality, well-coordinated care. -Enhanced patient experience and outcomes, avoiding where possible hospital based activity and improved

-Participate in the NWL pioneer whole systems plan -Continue to develop and embed current integrated care projects - Falls project, frail elderly and diabetes -Work collaboratively with HCCG, Hillingdon borough council and community health to implement the requirements of the integration transformation agenda -Align our endeavours with the national voices principles for


24

efficiencies for the health economy. integrated care 9. Admission Avoidance and Leaving Hospital

Innovative approaches to the acute/emergency care pathway

As key members of the Hillingdon Partners Intermediate Care Committee, continue to work collaboratively with Admission avoidance projects and Early Supported Discharge programme.

-Improved patient experience via NPS and FFT. -Evidence of ambulatory pathways. -Reduction in length of stay. -Evidence of improved communication between partners.

-Continue to develop and evolve ambulatory services supporting innovation -Continue with the Leaving Hospital improvement project work as part of Improving Inpatient Care -Work proactively to achieve 7 day working, re designing working patterns within the trust and working collaboratively with Hillingdon social services and community health to enable a whole system infrastructure is in place to support 7 day health care delivery.

10. Cancer Care 70% full cancer staging To ensure that our patients

diagnosed with cancer have full staging.

-Achieve target. -Review staging at MDT meeting -Collaborative working with Thames Cancer Registry -Monthly review of performance -Procurement of new Cancer Data Management system

80% Peer review compliance To ensure all tumour groups achieve > 80% compliance against Peer Review measures.

-Improve overall compliance against peer review measure. -Improve patient experience.

-Ensure action plans and work programmes are robust to achieve compliance against measures. -Monitor action plans at quarterly service meetings -Assess services against Best Practice Commissioning - Pathways and implement actions as necessary

11. Emergency Care 95% 4 hour A&E target

To meet 95% A&E access target including type.

-Target achieved. -Improved patient experience.

-Clear pathways for triage and UCC/ED working. -Implement RAT -Review of patient flow and bed capacity including re-modelled MAU -Deliver IIPC project -Implement LHP standards / 7 day working

Clinical pathways

Developing shared clinical pathways of care for ambulatory care, elderly care and mental health groups.

-Improved patient experience. -Develop specific PROMs. -Reduced admission rate year on year. -Reduced re-admission rate

-Collaborative working with primary and social care (e.g. Pioneer project / equivalent) -Capacity within MAU -Implementation of LHP standards

Early discharge

Year 1 > 40% of patients discharged by midday, 7 days per week.

-Reduced length of stay year on year. -Improved patient experience.

-IIPC project -Implementation of LHP standards


25

12. Elective and day case pathways Patient Reported Outcome Measures

Improve performance on current PROMs (Hip and Knee) and consider implementing other PROMs

-Improved performance for hip and knee PROMs performance – better than national average -Improve the post-operative response rate from patients -Agreement on other conditions for PROMs implementation

-Monthly review of performance against key PROMs indicators for knee and hip replacements -Increase the awareness of patients through relevant media and discussions at clinic to increase response rate -Explore with clinicians the scope to look at other conditions to monitor PROMs

Early supported discharge (ESD)

Develop early supported discharge for a variety of conditions.

-Improved patient experience -Shorter lengths of stay -Prompt discharge (> 40% by midday for non-day case)

-Identify surgical procedures amenable to Early Supported Discharge and agree implementation plan -Deliver action plan to improve patient experience of discharge from hospital

Surgical Site Infections (SSIs) Reduce the rate of SSIs - SSI rate in line with national average -Invest in electronic information system to support improved surveillance of SSIs -Agree with clinicians which conditions are to be prioritized for closer inspection and review e.g. orthopaedics -Implement quality improvement actions based on analysis of surveillance data

13. Maternity Care Caesarean Section rates

Reduce Caesarean Section rates (elective and emergency)

-To achieve London average rate -LHP standards -Share learning and best practice

Maternal and perinatal mortality rates

Prevent all avoidable maternal, stillbirths and neonatal deaths

-Below London average for all maternity-related mortality indicators / SIs

-LHP standards -Mortality reviews with shared learning -Participate in annual stillbirth audit

Breastfeeding initiation Increase breast-feeding initiation to >88%

>88% target achieved -Implement all measures to support increased breastfeeding rate -Increase women’s awareness of the value of breastfeeding -Work with our GP commissioners to raise awareness across the local community

14. Outpatient Pathway Clinical Pathways of Care Develop clinical pathways of

care with primary care for a variety of conditions (year 1- gynaecology, urology)

-Improved patient experience --Develop PROMs

-Ensure clinician engagement in work streams -Identify and share external and internal best practice

First contact project

Improve patient experience and reduce DNA rates

-Indicators from First contact project, e.g. calls answered in < 1 min >95%,

-Improve communication with GPs, patients and other providers


26

calls abandoned <10%. -Reduced complaints related to outpatients and reduced DNA rate <8%

-Revision of letter templates -Further centralisation of bookings -Action plan to further reduce DNAs and hospital cancellations

All Inpatients (emergency, elective, day case, maternity) 10.Safe Staffing Nursing staff establishments Ensure all wards (including

escalation) have safe staffing ratios and staff with the right skills.

-Improved patient and staff experience -Improved nursing quality indicators -Reduced patient safety incidents

-Staffing ratios to meet best practice recommendations and acuity and dependency demands - Engage with our staff (open forums, feedback from sources other than staff survey e.g. GMC, Deanery). - Skills profiles completed; improved STaM training compliance

Supervisory status for the Ward Sister/Charge Nurse

All inpatient wards to have a supervisory sister/charge nurse in position

-Improved patient and staff experience -Improved nursing quality indicators -Reduced patient safety incidents

-Supervisory status for sister/charge nurse for inpatient wards to be rolled out across the Trust -Clear expectations of role to be defined -Performance to be closely monitored in line with Nursing and Midwifery Nursing Quality & Accreditation Framework

11. Clinical Leadership Clinically led divisions Leaders of Clinical Divisions to

be effective Clinical Directors supported closely by NSM / equivalent and ADO working closely as a “triumvirate” and that are high performing

-Improved patient and staff experience -Improved performance in relation to quality governance and resource management -Innovative approaches to patient care

-Provide adequate time in job plans -Provide development support -Identify ACDs and senior nurses for development with succession planning

12. Culture and Values Responsive, high quality services

To ensure a learning organisation with a transparent and open culture

-Positive experience of staff reporting errors (staff survey) -Duty of candour contractual requirements achieved -Improved patient experience results (FFT and NPS)

-Ensure a culture of shared learning and ownership, of complaints / incidents -Instil a no blame culture -Ensure CARES is truly embedded – continue with trust wide action plans -Integrate into all areas of human resource management

13. Environment of Care Safe and comfortable wards / departments

Wards and departments to meet needs of patients and staff in relation to safety and comfort requirements

- Cleaning scores above agreed targets -Positive PLACE assessment results -Minor works to clinical areas completed as per maintenance schedule -Patient equipment and furniture of acceptable quality and in good working order

-Adequate funding to be allocated for preventative maintenance programme for clinical areas -Culture of zero tolerance to poor care environments to be embedded across the organisation -Annual review of patient equipment and furniture -Quarterly review of clinical care environments with E&F and Nursing

Annex D The Governance and Leadership of Clinical Quality

The leadership of the trust must ensure that the right systems and processes are in place across the organisation to support staff in driving quality improvement and to allow them to raise any concerns about quality that they may have. The following outlines the role and responsibilities of key individuals, teams and committees that support the governance and leadership of clinical quality at the trust. The Trust Board The Trust Board is responsible for setting the culture and overseeing the quality of care being delivered across all the services within the Trust and assuring itself through relevant evidence that quality and good health outcomes are being achieved throughout the Trust. Effective governance means that the Board pays as much attention to the quality of care as they do to the management of the Trust’s finances.The Trust has recently reviewed its quality governance to ensure that it has in place a robust framework that is meeting best practice and that the quality of care is continually improved. The Chief Executive The Chief Executive has overall accountability for Quality Governance, delegating the executive responsibility to the Director of Nursing and Patient Experience and the Medical Director who in turn are responsible for reporting to the Trust Board on the quality governance agenda and ensuring that any supporting strategy documents are implemented and evaluated effectively. The Medical Director The Medical Director, working with the Director of Nursing and Patient Experience, has delegated responsibility to drive forward the quality agenda, ensuring that the safety of patients and the priority of a harm free culture are explicit within divisional business plans and within clinical working practices. The Medical Director will positively influence the medical workforce to ensure that clinical leadership has a strong voice within divisions and that the clinical governance agenda is seen as a business critical priority. The Director of Nursing and Patient Experience The Director of Nursing and Patient Experience, working with the Medical Director, has delegated responsibility for managing the strategic development and implementation of effective clinical quality governance and organisational risk management, ensuring that clinical and corporate teams are demonstrating a real commitment to the quality agenda and its assurance process. Executive Directors Every Executive Director has a responsibility to uphold the Trust’s vision and to ensure that clinical quality is a priority for the trust. The Executive Directors are pivotal in influencing senior operational management teams, corporate services and support teams, and in ensuring that the quality of patient care is always considered in business discussions and strategic and operational decision-making.


28

The Quality and Risk Committee The Quality and Risk Committee(QRC) is the key Board Committee that monitors and reviews on behalf of the Board, the Trust’s clinical and quality governance arrangements, which includes coordinating and prioritising clinical and non-clinical risk management issues. It ensures there are clear and robust accountability arrangements at all levels of the Trust for quality governance. The committee ensures that there is rigorous review of the high-level risk register, the Board Assurance Framework and quarterly clinical governance and quality reports which include Patient Safety, Patient Experience, Patient Outcomes and Clinical Effectiveness, and Regulatory Assurance. The Committee also reviews and implements recommendations from external reports from the Care Quality Commission andtheNHSLA Risk Management Standards. The QRC ensures that intelligent information is available to support decision-making and through its reporting arrangements that there is effective operation of the Trust quality governance framework at all levels and that organisational learning takes place. The Audit & Assurance Committee The Audit and Assurance Committee is authorised by the Trust Board to investigate any activity or seek any information required, within its terms of reference. It has responsibility for overseeing and providing an independent review of the systems of internal control. The AAC reviews the establishment and maintenance of integrated governance, risk management and internal control across the whole of the Trust’s activities both clinical and non-clinical. The Committee Chair is responsible for ensuring the Board is provided with independent and objective review of the assurances available on the adequacy of governance arrangements, financial systems and compliance with legislation and codes of conduct; this includes reviewing and challenging the BAF. The Clinical Governance Committee The Clinical Governance Committee (CGC) ensures that there is clear responsibility for divisional clinical leads and managersfor clinical governance and quality to assist the trust in working towards clinical excellence and high quality care. It sets clear performance standards and provides a level of scrutiny regarding clinical governance holding the Clinical Divisions, and where relevant other Trust wide groups and departments, to account for the delivery of the clinical governance agenda. The CGC escalates any areas of concern to the Quality and Risk Committee as appropriate. Patient Safety and Quality Team Whilst the main delivery of clinical governance and quality occurs within each of the Clinical Divisions and corporate departments, the Patient Safety and Quality Team (PS&QT) has a crucial role in providing direction and impetus for action, interpreting and acting on national guidance and facilitating change within divisions, providing the divisions with the tools, skills and methodologies. The PS&QT consists of the Clinical Governance Facilitators and the Audit and Effectiveness Team. The teams provide intelligent information on incidents/near misses, investigation outcomes and requirements in relation to national and local clinical audit; the teams ensure that Trust policy is followed in relation to clinical governance and audit requirements and they support the sharing of learning, ensuring consistency of approach to patient safety and


29

quality strategies and work-streams, encouraging linkages between divisions and corporate departments. Other corporate teams that support this strategy comprise of the following:

The Corporate Governance Team Corporate Governance ensures specific elements of governance are sufficiently and efficiently carried out to timescales. This provides assurance to the Trust Board and the whole Trust that the highest standards of healthcare is carried out (based upon evidence-based best practice in a safe working environment). The Corporate Governance Team also ensures the Board Assurance Framework is up to date and interlinks with the Corporate Risk Register and the Critical Success Factors of the Trust’s main objectives. The Health and Safety Team The Assistant Director Health & Safety who oversees the Health and Safety (H&S) Team makes a quarterly report to the Trust Board on matters relating to H&S. It can be informed by the H&S Committee whose remit includes reviewing all identified H&S risks within the Trust and ensuring risk management processes are monitored and reviewed. The Complaints Department is responsible for the effective management of complaints, liaising with PALS, Claims and the Divisions and providing intelligent information on patient experiences to aid organisational learning.

Divisional Responsibility and Accountability The Senior Divisional Management Teamsare accountable for the delivery of the quality governance agenda within their Divisions. It is the responsibility of Divisional Management Teams to ensure that quality governance values are embedded in their Divisions and this means: • Awareness All staff should know that quality improvement is a key priority for the Trust and understand how they can contribute to the agenda. All staff should be aware of what CQC compliance is and the purpose of the Essential Standards of Quality and Safety. All staff should be aware of the key Trust policies and processes and should comply with them. • Compliance Each Division should use the standards to plan a programme of quality governance work to ensure improvement year on year (and build this into their business plan) and ensure the CQC registration and compliance requirements applicable to them are met. • Assurance Each Divisional Management Team should be ‘assured’ (i.e. by evidence collation, walkabouts, surveys, audits etc.) of, and able to demonstrate, compliance with the standards and other relevant accreditation requirements.


30

• Sharing and learning Divisions should be sharing areas of good practice and learning across the Trust, both when things go well and when things could be improved. • Clinical Leadership With the publication of recent reports, there is an increasing emphasis on clinical leadership, staff skills and cultures. Each Division needs to support the Trust vision, ‘To put compassionate care, safety and quality at the heart of everything we do’by continually striving to deliver high quality care in the most efficient way. Leadership is a key element that underpins divisional goals to make year on year improvements in the quality of patient care. Divisional Governance Boards Each Division is required to have a Divisional Governance Board which meets regularly to discuss and oversee all governance issues within the Division. To ensure accountability, the Divisions are required to submit a summary of their meetings to the CGC on a bi-monthly basis. Care groups also have their own governance groups which report into the Divisional Governance Boards. Divisions are required to ensure there is sufficient clinical representation within the Divisional and Care Groups Governance groups. All Trust employees The first line of defence in the battle against any serious quality failures in healthcare is frontline professionals, both clinical and managerial, who deal directly with patients, carers and the public and are responsible for their own professional conduct and competence and for the quality of the care that they provide. Trust employees are expected to: – Support and participate in the delivery of the quality agenda thus ensuring that the

clinical quality assurance process is delivered from ‘Board to floor’ – Comply with all Trust Policies and Procedures – Work professionally in accordance with the Trust and where appropriate,

professional Code(s) of Conduct – Provide safe clinical practice in diagnosis and treatment in accordance with

protocols – Report any concerns that they may have regarding the quality of patient care, and

any evidence of malpractice or mistreatment of patients by colleagues.

Annex E Clinical Governance & Quality & Risk Reporting Structure Board

- Report from Quality & Risk Committee - Report from Audit & Assurance Committee - Quality Dashboard & Exception Report - Approve SI reports & monitor action plans

Quality & Risk Committee – Providing Assurance

Agenda items Reports / Minutes from Patient Safety /Quality Indicators &CQUINS Clinical Governance Committee Complaints, Litigation, Incidents & PALS Mount Vernon Governance Board Dr Foster – HSMR/Readmissions/LoS Safeguarding Committee Investigations and clinical audits Experience & Engagement Committee Trust Risk Register Dementia Steering Group NHSLA /CNST Progress Cancer Board Internal/External Clinical Audit Medical Education Committee People & Workforce Infection Control Committee CQC Compliance/Alerts Clinical Records Committee Assurance Framework Organ Donation Committee Annual Quality Report Hillingdon Medicines Management Committee MDA/NPSA alert monitoring Clinical Audit & Effectiveness Committee

Clinical Governance Committee – Driving Improvements Agenda Items Reports / Minutes from Clinical Risk Register, Safeguarding Committee Clinical Audit, NICE, NCEPOD Research & Development Committee Policy ratification Experience & Engagement Committee Directorate reports Clinical Audit & Effectiveness Committee MDA and NPSA alert monitoring Blood Transfusion Committee NHSLA/CNST Hillingdon Medicines Management Committee Patient Safety & Quality Report Directorate Governance Boards Complaints/Litigation/Incidents/PALS Resuscitation Committee Action plans from CQC reports & Organ Donation Committee Enquiries (e.g. Mid Staffs) Infection Control Divisional balanced score card

QIPP - Service Improvement

Projects - Productivity, Quality

Improvement & Innovation reporting

Infection Control Committee Monitoring IC performance & assurance framework – Health & Social Care Act Infection Control Risks Decontamination reporting Monitoring Antibiotic Prescribing Infection Control Audits Infection Control initiatives – e.g. Matching Michigan Liaison with HPA – outbreaks Occupational Health issues Antimicrobial Committee All Root Cause Analyses Water Hygiene

Audit & Assurance Committee – Assurance Framework – Challenge on adequacy of

governance arrangements, financial systems and compliance with legislation

– Internal audits – clinical and non-clinical


32

Annex F Standard Equality Impact Assessment Tool

Name of Policy or Document Clinical Quality Strategy 2013 - 2016

Name of Author Abbas Khakoo, Medical Director Theresa Murphy, Director of Nursing Jacqueline Walker, Deputy Director of Nursing

Who is this Strategy or service aimed at: (Staff, Patients/Carers, Visitors/General Public

Staff, Patients and Carers

Description and aims of the Strategy This Strategy provides a framework for meeting the needs of different equality groups. There is no evidence that any discrimination to any particular group will occur as a result of the Strategy. The Strategy has been developed in accordance with the Equality Act 2010 and Equality Delivery System 2010.

Date EIA Completed 15th November 2013

Nature of the Change Yes/No Details of adverse impact identified

Does the policy/Service change affect one group less or more favourably than another on the basis of:

If yes to any of the following a full EIA must be completed

Race or Ethnicity No Nationality No Gender, Marital Status, Pregnancy and maternity

No

Culture or Heritage No Religion, Faith or belief No Sexual orientation, transgender Gender Reassignment

No

Age No Mental Health No Physical, sensory or Learning Disabilities No

Homelessness, Gypsy/Travellers, Refugees/Asylum Seekers

No

I declare that in assessing the proposed documentation/change I have identified that there is unlikely to be an adverse impact on different minority groups.

Name Jacqueline Walker Deputy Director of Nursing

Signature

Contact Number 01895 279840