Examples of Indicators and Evidence

Transcription

1 Examples of Indicators and Evidence

2 Quality Area 1 Service User Experience Quality Area 1 explores how your organisation puts the user at the heart of planning services through gathering feedback from users, their families and significant others. The key to excellent planning and the gathering of outcome-focused evidence is through the placing of the service user at the centre of all decisions regarding the services they receive together with excellent two-way communication. As part of this Quality Area, we also require you to demonstrate that service your users are encouraged to become involved in local engagement and consultation. The delivery of person-centred support and services Service users involved in the planning of their service programme Tailoring of individual service plans Information of service delivery options shared with users The caring treatment of users, families and significant others Excellent two-way feedback mechanisms, including complaints Involvement of the governing body in feedback processes Examples of how services users are welcomed to the organisation Documents used to support service users in making choice and being involved in planning their service package Examples of how service user (and others) feedback is gathered and how learning is analysed and implemented Examples of how complaints are managed in a pro-active manner Examples of supporting service users in engagement and consultation Examples of tools and analysis made regarding service user choice and adaptation of service delivery Evidence of the review of the information and the tools used to help make person-centred choice Examples of surveys used to gather information from service users and others together with reports on the feedback to the governing body Evidence that planning meetings are used to reflect on feedback and adapt services Evidence of service users engaging with external bodies Evidence that training and supervision contribute to improving user experience Evidence of regular review meetings of individual user plans 2 P a g e

3 Evidence of internal consultation with users, families and significant others Evidence of implementing change as a result of surveys and/or complaints Evidence of organisational horizon-scanning to improve service experience / longer term health benefits through engagement and consultation activities Quality Area 2 Safety and Safeguarding Quality Area 2 requires you to demonstrate that the practices and principles of safety and safeguarding are key to the delivery of a quality health service. As with Quality Area one the focus is not just on the supply of policies and procedures but the ability to demonstrate the difference made by the work carried to both service users and the organisation. The evidence you supply will demonstrate that safety and safeguarding practices are implemented pro-actively within your organisation and that all members of the team from the governing body downwards share responsibility for both areas. This Quality Area also covers your requirement to comply with data protection and other appropriate legalisation regarding the safe management of service user records. Commitment to both safety and safeguarding as pro-active principles of service delivery Evidence of clear understanding of health and safety and safeguarding regulations and legalisation Implementation and regular review of underpinning policies and procedures Service user feedback forms part of the review process On-going development for all members of the team from induction onwards Clear and accessible record keeping Evidence of learning and adaption based on feedback and incidents Demonstration of appropriate storage of service user records and other sensitive records The appointment of persons to take organisational lead in these areas Evidence of appropriate use of the DBS system Organisational links with the appropriate local safeguarding boards And for those providing services to children, evidence of compliance with Section 11 Copies of appropriate policies and procedures Copies of tools used to assess and manage risk Evidence of training and development for all Evidence of compliance with HSE requirements for the workplace Evidence of records of compliance with fire regulations 3 P a g e

4 Indicators and Evidence Evidence that resources used to support and manage a safeguarding disclosure is accessible to team members Evidence of compliance with DBS and work checking requirements Evidence of compliance with Section 11 Demonstration that training is evaluated and learning implemented Records of training and development Evidence of development of review of health and safety policies and procedures Evidence of compliance with apparatus testing regulations/requirements Evidence of safe data storage Evidence review and updating Evidence of implementing actions plans to deliver any required learning from reviews Evidence of de-brief processes for safeguarding incidents Quality Area 3 Effectiveness This Quality Area seeks to identify evidence that will support you to demonstrate that the services you deliver are effective both in terms of bringing about positive health benefits for service users and also demonstrating cost effectiveness to those that commission the service you deliver. Elements of this section will also allow you demonstrate the effectiveness of your team through exploring their qualifications, skills, and experience, the linkage your organisation makes in its service planning to the strategic plans of those commissioning services and the impact of your service in tackling local health inequalities Evidence of service users being equal partners in the service delivery planning process Evidence of clearly set health benefits/outcomes supported by rigorous measurement Evidence of training and development for the team to support and enable the delivery of planned services Evidence that service delivery is linked to both service user need and local strategic priorities Demonstration of promoting healthier lifestyles, and the prevention of ill-health Evidence of innovation and creativity in the planning and delivery of services 4 P a g e

5 Evidence of measuring baseline health and well being and using results to set health outcomes with service users Evidence of the use of evidence based interventions to deliver planned outcomes Evidence of developing and adapting interventions to meet individual need Evidence of achieving and measuring outcomes Evidence of training and development including records of qualifications Evidence that services received contribute to a healthier life style and increased self care Evidence of delivering health benefits through service delivery Evidence of linking service delivery to local strategic priorities Evidence of delivering value for money Evidence of review and adaption of service delivery plans to meet needs Evidence of on-going development for all members of the team Evidence of reduction in the need for primary care interventions as a result of improved health and wellbeing Evidence of review of evidence-based interventions Evidence of innovative and creative development of interventions, Evidence of the governing body supporting innovation and creativity Evidence of sharing innovation with cross-sector providers Evidence of working with or referring to other providers to help unmet needs Quality Area 4 Health Promotion This Quality Area explores how your organisation supports its service users to improve their lifestyle and overall health though proactive health promotion. The indicators and evidence require your organisation not only to provide a range of support but also to consider how the use of effective health promotion can be used as tool to fight against local health inequalities. 5 P a g e

6 Evidence of proactive health promotion, tailored to individual need Evidence of making health promotion accessible Evidence of both understanding and using health promotion to tackle health inequalities Evidence of using a range of resources and support materials Evidence of team development in health promotion Evidence of signposting to other providers to meet individual needs Evidence of health promotion and the use of a range of resources based on best practice Evidence of health promotion forming part of individual health promotion plans Evidence of using health promotion to support those suffering health inequalities Evidence using external, health promotion resources Evidence of health promotion as part of the team member induction programme Evidence of reviewing and updating health promotion materials and activities Evidence of measuring health promotion outcomes Evidence of targeted health promotion to tackle health inequalities Evidence of linking health promotion to local strategic plans Evidence of health promotion being included in communications Evidence of external training to support health promotion activity Evidence of impact of health promotion Evidence of innovation in developing internal health promotion resources Evidence of health promotion forming part of the discussion with statutory partners Evidence of linking health promotion into equalities monitoring 6 P a g e

7 Quality Area 5 Equality and Diversity The Equality and Diversity Quality Area looks at how you mange not just the principles and practices of equality and diversity but also how your organisation implements a positive working framework for the benefit of all, whilst seeking to prevent discriminatory behaviour from both service users and members of your team. Demonstrate an understanding of equality legislation and guidance Evidence of implementation of accessible policies and procedures covering equality, diversity and anti-discriminatory practice Evidence of shared ownership across the organisation of good equality and diversity practice Evidence of training and development for all members of the team Evidence of and commitment to robust equality monitoring of services, service delivery and workforce Evidence of fair recruitment process that meet the current equality and diversity requirements Commitment to keeping equality and diversity on the agenda for all supervision and staff meetings Copies of policies relating to equality and diversity Evidence of training and development Evidence of equality monitoring, including meeting equality outcomes Evidence of good practice in relation to recruitment at all levels Evidence of review and implementation of equality and diversity policies Evidence of use of positive equalities framework, including action planning from team meetings Evidence of equality monitoring within the organisational structure Evidence of on-going training and development at all levels Evidence of governing body review of equality monitoring Evidence understanding and considering the use of the NHS Equality and Diversity System 2 (EDS2) model Evidence specific training and development for the governing body and management team Evidence of review of positive equality frameworks Evidence of governing body reviewing and action planning from equality monitoring Evidence of implementation of EDS2 7 P a g e

8 Evidence of support and supervision for those responsible for recruitment for team members Quality Area 6 Leadership and Management The key to delivering a high quality service is to ensure that the leadership and management of the organisation are of excellent quality. This Quality Area requires your organisation to demonstrate a clear commitment to quality in areas such as recruitment, internal communications, compliance with your policies and procedures and a commitment to open sharing of the organisations plans. The principles must be underpinned by an open model of leadership based on reflection supported through effective supervision. Demonstrate that recruitment is focused on the competencies required for roles Demonstrate appropriate and robust supervision and support systems Commitment to positive communication channels across the whole organisation Commitment to adherence to policies and codes across the whole organisation Evidence of an open and transparent leadership model based on reflection and supported by effective supervision and appraisal Commitment to sharing and developing a common understanding of organisational plans Copies of recruitment policies and job/role descriptions Copies of induction documentation Evidence of and supporting documentation for an active supervision process Copies of codes of conduct Copies of organisational plans with supporting evidence of how these are openly discussed as part of implementation Copies of training records Evidence of skills audits Evidence of succession planning Evidence of governing body review of recruitment processes and succession planning Evidence of supervision for members of the governing body Evidence of processes to deal with breaches of codes of conduct (at all levels) Evidence of team input to service delivery planning 8 P a g e

9 Evidence of review and action planning arising from skills audits Evidence of review of all codes of conduct Evidence of review of organisational plans by the governing body and management team Evidence of appropriate training for management and governing body Quality Area 7 Governance The Key to good leadership is good governance. This Quality Area requires your organisation to reflect on its governance and demonstrate that it supports the delivery of a quality health service. This reflection will ensure that your organisation links its governance to the needs of its service users and not just the organisation. Compliance with the objects of the governing documents Compliance with appropriate legal and regulatory frameworks Evidence of all appropriate insurances Evidence of the governing understanding and delivering on all collective and individual responsibilities Evidence of the governing body setting and reviewing organisational policies and procedures Evidence of the governing body setting and reviewing the strategic direction of the organisation Evidence of the governing body providing strong financial management and delegating powers as appropriate Commitment, lead by the governing body, to quality and continuous improvement Evidence of clear, easily understood and accessible governing documents Evidence of compliance with governing documents Evidence of regulatory documents Evidence of appropriate insurance and indemnity cover Copy of governing body induction pack including role descriptions Evidence of governing body review of organisational polices Evidence of governing body compliance with code of conduct 9 P a g e

10 Evidence of governing review of codes of conduct Copies of organisational plans, linking to Key Performance Indicator s Evidence of awareness, at all levels within the organisation, of its organisational plans Copy of audited accounts/annual report Evidence of appropriate income generation activity Evidence of review of governing documents and linkage to regulatory requirements Evidence of review of governing body role descriptions Evidence of compliance with internal risk register requirements Evidence of governing body review of organisational plans Copy of financial strategy and financial management policies, including regular review Evidence of HRMC registration Quality Area 8 Outcomes and Impact This Quality Area requires your organisation to consider how it plans and delivers a truly outcome-focused service to its users and aims to deliver long term impact to both users and the wider community it serves. This will require reflection on outcome setting, how it manages to deliver parity of esteem to its users, support users to increase their own self care, and how outcomes, both planned and delivered, are linked to local strategic priorities. Delivery of flexible, outcome focused services, tailored to individual need Service delivery plans are formulated with individual users and linked to local strategic priorities Clear understanding of and contribution to local strategic priorities Outcome frameworks take into account parity of esteem Service users are supported to self manage and take part in the measurement of their own health outcomes Robust measurement, recording and evaluation of health outcomes in order to demonstrate the difference made to service users 10 P a g e

11 Evidence of services user involvement in determining the outcomes that are important to them Evidence of agreeing service delivery with users, including parity of esteem Evidence of appropriate adaption of service delivery plans Evidence of improved-self care Evidence of support to measure health outcomes Evidence of flexibility in service delivery to meets needs Evidence of appropriate levels of understanding of local strategic priorities Evidence of adapting outcomes to meet changing needs Evidence that outcomes delivered are linked to local priorities and needs of service users Evidence clear and diligent planning to meet needs of parity of esteem Copies of tools used to measure outcomes Evidence of adapting tools and education for service users in order for them to measure their own outcomes Evidence that outcomes measurement impacts on future individual service delivery planning Evidence that outcomes measurement impacts on future organisational planning Evidence of interaction with strategic partners in order to influence local priorities Quality Area 9 Connectivity The final section of the system explores how your organisation connects with other healthcare providers in the local community. Organisations will need to demonstrate how they embrace the principles of connectivity, including recognising its importance in delivering real benefits to users, the building of relationships, sharing of information and cross-referrals to meet unmet needs. Recognise the importance of both formal and informal partnership working Building of relationships with other health providers and managing referrals Sharing of information with other providers and commissioners Demonstrating the benefits of engagement and partnership working to both the organisation and to service users Linking to external communication streams Active role in local networks 11 P a g e

12 Evidenced of working with other providers Evidence that joint working brings about improved outcomes for service users Evidence of safe management of referrals from other providers Information published about the services and support offered Sharing of published information and communications with providers and commissioners Evidence benefits gained from joint working Evidence of organisational commitment to partnership working Evidence of benefits, to the organisation and service users, gained from partnership working Evidence of actively seeking referrals Evidence of an active role in networks and partnerships Evidence of a reviewed communication action plan that seeks to influence local strategic planning Evidence of involvement in joint funding/contract delivery Evidence of connectivity within the organisational planning Copy of the communication strategy Evidence of target setting for gathering referral from other providers /commissioners 12 P a g e

13 13 P a g e