Independent Healthcare Quality of Care Approach. Self-evaluation a practical guide

Transcription

1 Independent Healthcare Quality of Care Approach Self-evaluation a practical guide June 2018

2 Healthcare Improvement Scotland 2018 Published June 2018 This document is licensed under the Creative Commons Attribution- Noncommercial-NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit

3 Contents Contents... 1 About this document... 2 The benefits of self-evaluation... 2 Preparing for self-evaluation... 3 Stage 1: Planning the self-evaluation... 4 Stage 2: Conducting the self-evaluation and interpreting the results... 5 Stage 3: What next?... 7 Appendix 1: What should you include?... 8

4 About this document This document is a practical guide for undertaking self-evaluation against the Quality Framework. It provides advice and suggestions about how to manage the self-evaluation process in your service. It is written primarily for the manager or staff member, with responsibility for coordinating the self-evaluation process. The guide should be read in conjunction with the independent healthcare inspection methodology which gives more detail about how self-evaluation feeds into this process. The benefits of self-evaluation Having quality information about the outcomes and impacts being achieved can help a service to better understand the needs of the people using the service. Self-evaluation contributes to continuous quality improvement by providing a structured opportunity to assess performance, and based on this, identify opportunities for improvement. Regular selfevaluation forms part of good internal governance and is a key driver for improvement work. Quality improvement on the basis of self-evaluation, rather than that improvement mandated by external agencies such as Healthcare Improvement Scotland, can inspire greater ownership of issues and design of more effective solutions. The quality of care approach promotes regular self-evaluation complemented by proportionate independent external validation, challenge and intervention as key drivers for improving healthcare. The Quality Framework has been developed primarily to help services to undertake selfevaluation. It contains a range of indicators and suggested sources of evidence that support a holistic approach, allowing a service to tell its story. Each quality indicator is further broken down into themes and factors to consider to guide and support the process. These are neither exhaustive nor prescriptive. The Framework also allows scope for services to self-evaluate and develop the narrative about the quality of the care that they provide using measures that are meaningful and important to the service. Self-evaluation will identify opportunities for improvement. However, this improvement will only happen if there is a subsequent action plan, the identified actions are implemented, and impact monitored and regularly reviewed. Healthcare Improvement Scotland will periodically ask for a copy of the organisational self-evaluation via our portal to inform and guide regulatory activity within a service. However, this should not be the only reason for undertaking self-evaluation. The outcomes of the activity should also be used on an ongoing basis internally to drive improvement. 2

5 Preparing for self-evaluation It is up to you how self-evaluation is carried out and who should be involved. There is no onesize-fits-all approach to the process; it will depend largely on the size and structure of your organisation and the resources available. The process can be split into three broad stages. 1. Plan the self-evaluation 2. Conduct the self-evaluation and 3. What next? interpret the results The following are suggestions to guide each stage of self-evaluation. These are not prescriptive and you may choose to follow alternative or additional courses of action that are more relevant, especially in smaller services. 3

6 Stage 1: Planning the self-evaluation The self-evaluation process against the Quality Framework has been designed to gauge how well a service thinks it delivers person centred, safe and well led care. It is a process of diagnosis and reflection, leading to action where areas for improvement are identified. You may wish to think about how you can capture the views of any staff you employ or your clients in the self-evaluation. Creating the right conditions for self-evaluation can save time and increase the rewards from the process. The following are suggestions for factors to consider in the planning stage. Understanding the framework and the self-evaluation process It is important to understand the Framework before starting the process of self-evaluation. The framework provides those completing the self-evaluation with information and prompts to stimulate discussion. The Quality Framework should be read alongside the supporting guidance and the self-evaluation tool before starting the self-evaluation. Agreeing an approach that is right for your service It is up to you how the self-evaluation is carried out and who is involved. The most important thing is that information is drawn from a range of sources, perspectives and experiences. The time required to do this will vary between services due to size, structure and service organisation. Deciding on the range and number of people who need to be involved and their needs As well as facts and data that can be extracted from various systems and databases, the participation of a range of people is required if the self-evaluation is to be successful. The range includes users of services, staff providing treatment (if appropriate), and those in administrative roles. The number of people that you may wish to involve will vary depending on the size of the service. It may only be yourself if you are a sole trader. Various approaches can be used to capture the views and experiences of groups of stakeholders including focus groups, questionnaires and interviews. Agreeing a plan for completing the self-evaluation For larger services, a defined plan with key milestones can help to keep the process moving and make best use of the available resources. The self-evaluation will provide useful information to inform planning for your service as well as contributing to processes of external quality assurance as required. 4

7 Stage 2: Conducting the self-evaluation and interpreting the results The self-evaluation should tell a story about where you perceive your service to be overall against each domain in the framework, how you know this, and where there could be improvement. For a smaller service not all domains will be relevant to you and guidance is included in Appendix 1 on which parts you should complete and what you should consider when completing them. The following are suggestions for important factors to consider as you work through stage 2 Communicate the process Effective communication with staff is critical to the success of self-evaluation. How people hear about it will influence how they approach and engage with the process. Where appropriate, those involved need to understand the following: the purpose of the self-evaluation how it will be undertaken how people will be involved the timescales involved the steps and activities, and how the information will be used. Collate relevant data and evidence Examples of evidence that would be appropriate for each domain is listed in Appendix 1. When thinking about the data and information to include in the self-evaluation process it is useful to ask the following questions within each of the framework domains: How are you doing in respect of the domain? How do you know this? Please do not upload any evidence: which is published national guidance which is publicly available you have previously submitted (either at registration or with a previous selfassessment/evaluation), unless you have updated this has patient identifiable information, or we can find in care notes, as we will sample these at inspection. 5

8 The examples of evidence we have listed is not exhaustive. You may have other evidence you wish to provide. Interpreting the data and evidence The aim is, based on the data and evidence, to begin to answer the question: What do you need to do next, better or different? You should focus on the outcomes of activities such as evaluation or audit results, outputs from tests of change or lessons learned. In developing, the narrative against each domain it may be helpful to think about: the outcome, for example what happened as a result of implementing a particular policy, service change or improvement activity what was the impact on those in receipt or care, those delivering care or those supporting care provision what (if any) learning was achieved and how was learning shared with relevant people to support ongoing quality improvement, and what plans are in place to implement further improvement? 6

9 Stage 3: What next? 1. Read the quality framework. 2. Read the self-evaluation tool. 3. Complete self-evaluation on the portal and submit evidence when requested by HIS. 4. Create an action/implementation plan for things you need to do. Self-evaluate Check Action plan Implement 7

10 Appendix 1: What should you include? Generic service information/local context This is your opportunity to tell us about anything that has been happening in your service that you feel we should be aware of when reading your self-evaluation. Domain 1 - Key organisational outcomes This domain is required to be completed by all independent healthcare services. This domain is about how well the organisation performs in continually improving the quality of care that it provides and meeting its statutory responsibilities. 1.1 Improvement in quality, outcomes & impact - How does the service measure its performance in continually improving its quality of care and achieving the best possible outcomes for its service users? - What evidence is there of improved outcomes? - How are the outcomes of quality improvement activity embedded and sustained in the service? - Examples of recent complaints investigations/outcomes - Outcomes of UK benchmarking - Complaints policy 1.2 Fulfilment of statutory duties and adherence to national guidelines - How are the statutory requirements of relevant finance legislation, national standards and guidance taken into account and implemented? - What are the key local strategic financial objectives? - What processes are in place to measure these strategic financial objectives and the outcomes produced? - How is the quality of care measured/monitored in real time, dayto-day? - What lessons have been learned about the quality of care and how is learning responded to? - Evidence that standards and guidance are used to direct care (for example, National Health and Social Care Standards and Codes of Practice (NMC, GDC, GMC)) - Key performance indicators performance 8

11 - How do you anticipate what the quality of care will be like in the future? Domain 2 - Impact on patients, service users, carers and families This domain is required to be completed by all independent healthcare services. This domain is about the quality of the experiences of people who use your service, including how well the organisation involves them to ensure that care and support they receive is individualised to their needs and wishes. It also focuses on how confident people are about the organisation and the people that provide their care and support. 2.1 Patients and server user experience - How are the expectations of service users identified, measured and met? - What measures are in place to ensure that the care provided is respectful and responsive to the individual s need? - How are service users involved to ensure their care and support is individualised? - How confident are service users about the people that provide their care and support? - What health promotion information, education and sign-posting is done to encourage service users towards independence and self-care? - What mechanisms are in place for service users to provide feedback on their experience of care? What is done with the information gathered? How are the outcomes shared and who with? - What is the procedure for making a complaint and is it clear, well publicised and made available to service users/families/carers? - How are complaints dealt with, investigated and responded to? Are procedures in place to inform service users or their families what went wrong and why, and say sorry? - Complaints leaflet/feedback form - Patient info leaflets - Patient info includes treatment options, desired outcomes, risks, side effects, rights, OOH access and discharge planning - Patient info available in different formats - Questionnaires/surveys - Website reviews/testimonials - Evidence of changes as a result of feedback - Evidence of staff training on consent issues - Participation strategy - Complaints policy - Safeguarding policy 9

12 2.2 Success in involving carers and families - How are the needs of carers and families taken into consideration in the care planning process? - How is the quality of carers and families experience measured? - How is feedback used to improve the quality of care, appropriate to the care setting? - Carers/family questionnaires/surveys/testimonials - Support mechanisms for carers/ families - Examples of where improvement made as a result of family/carer involvement. - Information leaflets for carers and families - Website reviews/testimonials - Evidence of changes made as a result of feedback - Participation policy Domain 3 - Impact on staff This domain should only be completed if the service employs staff. This domain is about professional involvement and commitment of staff and how you encourage and support staff to feel motivated, empowered and enabled to contribute to quality improvement. 3.1 The involvement of staff in the work of the organisation - How do you involve staff in the planning of the service s visions, values and aims? - How do you enable staff to feel motivated, empowered and supported to contribute to quality improvement and development of the service? - How are staff views about feeling valued and supported to do their job well monitored and measured? - Staff appraisals/pdp - Staff survey and any results and action plans - Staff engaged/consulted in decision making and any changes made as a result - Staff supervision/appraisal records - Staff meeting minutes - Development programme for staff 10

13 Domain 4 - Impact on the community Independent clinics are not required to complete this domain if not relevant. All other independent healthcare services should complete this domain. This domain is about the impact the organisation has on the wider community (including the wider health community) and confident the public is in the services it provides. 4.1 The organisation s success in working with and engaging the local community - What methods are used to engage with local communities about the care delivered? - What monitoring is carried out to check whether local communities feel sufficiently engaged? - How are outcomes of this monitoring and good practice with local communities used? - Integration and involvement with community (for example, local groups, community resources), stakeholders including the Integrated Health and Social Care Partnership and Education Authority - Public consultations about what the community wants from the service. - Communications strategy - Participation strategy Domain 5 - Safe, effective and person-centred care delivery This domain is required to be completed by all independent healthcare services This domain is about the implementation of appropriate systems and policies to ensure a safe environment that meets people s needs and supports them to feel safe. This includes a proactive approach to the improvement of safety, reducing harm and improving reliability of care through a culture of openness, transparency and continuous learning. 5.1 Safe delivery of care - What quality assurance system is in place to ensure that the care environment and equipment are safe? - How do you ensure services users are safe and feel safe whilst in the service? - How is a transparent, open and effective safety culture implemented and managed? - Quality assurance governance structure - Terms of reference, minutes of governance groups - Results of relevant audits - Relevant policies, procedures and documentation to demonstrate safe delivery of care. 11

14 5.2 Patient or service user assessment and management - What assessments are carried out to assess service users needs appropriately? - How are service users empowered to manage their own care? - What measures are in place to ensure clear and accurate documentation and handovers? Documentation to demonstrate: - Patient assessments - Patient reviews - Care Planning/patient involvement - Management of medicines - Complication management - Aftercare and follow-up - Advanced statements/directives - GIRFEC SHANARRI - Best practice models 5.3 Continuity of care - How are service users supported to move between care settings and providers? - What processes are in place to ensure effective working relationships with partner agencies? - Mutlidisciplinary team/multi-agency team working arrangements - Discharge/transfer arrangements and ongoing care 5.4 Clinical excellence - How are recognised standards and agreed best practice taken into account and implemented in respect of care delivery, and outcomes measured? - Clinical audit undertaken - External reviews undertaken 5.5 Data for improvement and evidence-based learning - What improvement data is collected, how is it recorded and how is it analysed? - How are lessons learned from improvement data analysis and who are they shared with? - Action following debriefs, adverse events, safety walkrounds, inspections, audits, complaints or performance data. 12

15 5.6 Quality Improvement processes, systems and programmes - What process do you have in place to drive improvement in your service? - Involvement in national improvement programmes - Examples and evaluation of improvement activities - Quality assurance systems Domain 6 - Policies, planning and governance This domain is required to be completed by all independent healthcare services. This domain is about how the effectiveness of policies, planning and governance in the service. 6.1 Policies and procedures - What policies and procedures are in place to support staff to deliver consistently safe, effective and personcentred care? - What support infrastructure is in place to ensure staff have appropriate knowledge relating to these procedures? - How is the suitability and effectiveness of these policies and procedures assessed, measured and reviewed? - Review process and schedule for policies and procedures - Caldicott Guardian (inpatient services only) - Training/induction for staff 6.2 Risk management and audit - How are general and specific risks to service users, carers and their families identified, assessed, recorded and reviewed? - What controls are in place to reduce harm from these identified risks? - What auditing processes are in place to ensure risks are being appropriately managed? - Risk register - Risk assessments - Outcomes from audit activity - Accident / incident reports - Examples of investigations/outcomes - RIDDOR reports - Health and Safety/Risk management committee terms of reference and minutes 13

16 6.3 Assurance framework and governance committee - What governance structures are in place to provide assurance of the safe, effective person-centred care delivery? - Terms of reference and recent minutes of clinical governance committee and Board - Evidence of service user involvement at board/senior level 6.4 Planning - How do you co-ordinate effective delivery of services? - How do you ensure processes are designed, implemented and reviewed to ensure the efficient delivery of safe, effective and person-centred care? - What key challenges have been identified in improving planning and governance arrangements and how are you overcoming these? - Business planning arrangements - Anticipatory care planning systems Domain 7 - Workforce management and support This domain should only be completed if the service employs or contracts staff. This domain is about how well the service recruits and manages staff. 7.1 Staff recruitment, training and development - What processes are in place to ensure the safe and effective recruitment, induction, training and development of all staff and volunteers? - How are roles and responsibilities made clear and accountability demonstrated? - Induction programme and evidence of induction - staff files - Mentor/buddy system - PVGs recording system - Professional register checking system - Revalidation checking process - Process for granting practicing privileges - Staff development strategy/annual training plan - Training records - Appraisals (for practicing privileges staff) - Examples of job descriptions - Recruitment policy 14

17 - Job/post descriptions 7.2 Workforce planning, monitoring and deployment - How effective is workforce planning? How well does it demonstrate a flexible and responsive approach where: o Appropriate staffing levels are considered, o Skills mix match the services requirements, o Resourcing and capacity constraints are considered, and o Safe, effective and personcentred care is at the core - What key challenges have been identified in terms of workforce planning and how are these being overcome? - Staffing arrangements including rotas - Workforce planning data - Performance management process - Exit interviews 7.3 Communication and team working - How effective is communication between staff at all levels of the service? - How do staff work together to solve problems and make improvements? - How is team working demonstrated? - Staff meeting minutes - Records of communication with staff Domain 8 - Partnerships and resources Independent clinics are not required to complete this domain if not relevant. All other independent healthcare services should complete this domain. This domain is about how well the service works with others and makes best of resources available. 15

18 8.1 Collaborating and influencing - What key partnerships have been identified for the service? How have the expectations of these partnerships been identified and met? - What challenges to collaborative leadership have been identified and how are these being overcome? - Has collaboration with stakeholders lead to improvement? What processes are in place to encourage collaboration with staff and stakeholders and demonstrate effective outcomes from this collaboration? - Examples of partnership working - Improvements made to the service as a result of partnership working. 8.2 Cost effectiveness and efficiency - What systems are in place to review cost effectiveness and efficiency? - What challenges to cost effectiveness and efficiency have been identified and are these being overcome? - Budget planning - Finance strategy 8.3 Sharing intelligence - What mechanisms are in place to ensure that learning is spread throughout the service and intelligence shared with relevant external stakeholders and partner organisations in the interests of safety? - Learning following adverse events and/or complaints - Membership of national professional bodies - Membership of local/national networks - Duty of candour policy/framework 16

19 Domain 9 - Quality improvement-focused leadership This domain is required to be completed by all independent healthcare services. This domain is about how leadership encourages an improvement culture and supports staff, where appropriate, to innovate and improve services locally. If you do not employ staff in your service, this is about how you maintain a quality improvement focussed service. 9.1 Vision and strategic direction - What is the strategy and vision of the service? Does it have a clear purpose, values and aims which are understood by staff and stakeholders? - How are the expectations of your service users, carers and families identified and met? - What arrangements are in place to demonstrate assurance that the service is well led? - What key challenges have been identified for the service as a whole and how are these being addressed? - Strategic/corporate plan - Organisational aims and objectives - Annual report - Corporate newsletter - Board/senior meetings minutes 9.2 Motivating and inspiring leadership - How does the leadership of the service empower and motivate its staff and how is this demonstrated? - Leaders deal effectively with bullying and harassment. - Corporate plan - Annual report - Statement of aims and objectives - Staff surveys - Whistleblowing policy - Bullying and harassment policy 17

20 9.3 Developing people - How are staff given opportunities to develop and increase their ability to contribute to the strategic aims of the service? - How are staff developed in terms of autonomy and accountability? - What processes are in place for staff development and learning and improving? - How do staff learn from adverse events and complaints and receive feedback on them? - Supervision and appraisals - Career progression opportunities - Training opportunities - Training records - Learning from adverse events 9.4 Leadership of improvement and change - How is an improvement culture encouraged within the service? - What processes are in place to innovate and improve the service? - How does the service seek out good practice and learning to improve the service? - What processes are in place to support staff to innovate and improve? - How are staff kept informed of strategic changes to the service? Are they involved in decision making? How are successes and achievements celebrated in the workplace? - How are service user outcomes are considered are in developing innovative improvement ideas? - Membership of professional bodies - Examples of effective service leadership - Opportunities for staff development - Staff recognition programmes Summary Please tell us about your three main priorities for your service for the next 12 months. 18

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22 Published June 2018 You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Advisor on or Healthcare Improvement Scotland Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP