Developing a new Quality Improvement Framework

Transcription

1 Report to: Public Board of Directors Date of Meeting: 29 th May 2014 Report Title: Developing a new Quality Improvement Framework Status: Mark relevant box with X Prepared by: Executive Sponsor (presenting): Appendices (list if applicable): For Discussion Assurance Approval Regulatory information requirement X X X X Dr Harold Hosker Dr Harold Hosker, Interim Medical Director Developing a new Quality Improvement Framework document Purpose of the Report Following the recent CQC inspection, our previous medical director started to develop a new quality assurance framework which gained the outline approval of the Trust Board. The aim was to create a clear and effective structure to deliver safe and effective health care. The original principles and processes envisaged by the quality improvement framework were felt to be consistent with these comments, so further work has taken place to develop the model to provide safe, effective patient care. The attached document, Developing a new Quality Improvement Framework, provides a clear outline of the proposed structure and processes. Vision In 3 years time, the Trust will be producing live, accurate and comprehensive quality dashboards covering all aspects of its activities, visible to all and showing trends. Information will be collated centrally in a data hub. Intelligent analysis of information will be provided to inform changes in service and alert clinicians and executives immediately when adverse events or trends develop. All reports will be automatically populated with accurate data electronically for internal and external reports. Recommendation The Trust Board of Directors are asked to receive and comment on the new Quality Framework Improvement document

2 Airedale NHS Foundation Trust Developing a new Quality Improvement Framework Introduction Following the recent CQC inspection, our previous medical director started to develop a new quality assurance framework which gained the outline approval of the Trust Board. The aim was to create a clear and effective structure to deliver safe and effective health care (see below). During this process, at a time when arrangements were in transition, a review of the Trust s governance and quality strategy was conducted by the Foresight partnership. The review made the following observations: In the view of the review team, there is however scope for some fine tuning to further strengthen the current quality governance arrangements. Specifically, the feedback identified the need for the Trust s clear commitment to quality to be further strengthened by: The development of a longer term overarching quality strategy that clearly sets out the quality dimensions of the overall Trust strategy. This would need to give balanced attention to all three aspects of quality experience, safety and outcomes. It was noted that this was work in progress at the time of the review. The setting out of a clearer quality governance architecture that is well understood and widely owned by the staff who operate within it and where roles and accountabilities are also crystal clear. The review team was not given a clear, comprehensive and consistent account of the approach to quality governance by all those charged with operating within it. It was noted that at the time of the review the board was in the process of refreshing the role, process and terms of reference of the quality focused committee. Ensuring that quality intelligence is provided to the board at a sufficient level of granularity to allow it robustly to test and triangulate the quality risk judgements that are, appropriately, being made at levels below the board. The original principles and processes envisaged by the quality improvement framework were felt to be consistent with these comments, so further work has taken place to develop the model to provide safe, effective patient care. Vision In 3 years time, the Trust will be producing live, accurate and comprehensive quality dashboards covering all aspects of its activities, visible to all and showing trends and intelligent analysis. These will inform changes in service and alert clinicians and executives immediately when adverse events or trends develop. All reports will be automatically populated with accurate data electronically for internal and external reports. Principles behind our quality improvement framework Our quality improvement strategy will be underpinned by three supporting domains:-

3 Patient safety - Will I feel safe? - Will I be protected from avoidable harm and death? Patient experience - Will I feel cared for? - Will I be treated with compassion, dignity and respect in a clean, safe and well led environment? Patient outcomes and effective care - How will my clinical procedure be carried out? - What will its results be? - Is it best practice? - What about my quality of life after treatment? The overriding principles of the QI framework include: Clarity of structure, reporting arrangements, ToR Clarity of responsibility (no gaps, no duplication) Principle of ward to Board Intelligent analysis of data and trends by experts in the team The Quality account is at the centre of QI but needs review and expanding to include all core parts of the Organisation Trust Board involvement and assurance The framework needs to deliver a comprehensive, Trust-wide overview of all metrics available to the organisation the horizontal view. In addition, the principle of Ward to Board communication of quality Improvement is necessary, and CSAC is being developed to provide this vertical alignment. Any agreed QI structure needs to deliver both horizontal and vertical elements of the process. Information sources and how they are handled There are a variety of information sources reflecting quality of care within the Trust. The following gives an idea of the variety of information available; it is not an exhaustive list: External CQC intelligent report CHKS, Dr Foster (HSMR, SHMI) H&SCIC East Midlands dashboard (mortality, readmissions etc) Deanery reports

4 CQC concerns NICE, NPSA, CAS alerts, PROMs Published outcomes for surgery etc Coroners GMC and Ombudsman National audit participation NICE compliance Staff surveys FFT and other patient surveys Monitor rating NHSLA Research participation Internal Trust dashboard Maternity dashboard Dr Foster individual appraisal data Ward / dept governance meetings Complaints, PALs SIRIs, RCAs, never events Litigation Appraisal / revalidation ratings Individual MSF and patient surveys Telemedicine Reviews into depts AEFs Formal complaints from staff Informal concerns Dept performance eg ED DMG log Falls, ulcers, infections, nutrition, medication, DNAR CQUINs Local audits Safeguarding reports Healthwatch, patient experience, patient story Compliments

5 These metrics can be divided and colour coded into the 3 domains of patient safety, patient experience; and patient outcomes within the groups. All information sources need to be received, collated, disseminated and triangulated effectively within the organisation, and an analysis provided for relevant groups. This horizontal receipt and dissemination of information could be improved by a central hub for receipt of all information, intelligent analysis, triangulation and distribution, receiving requests for information / dashboard and delivering timely, and high quality outputs including analysis of trends and risks. The hub would provide data to support all reports (both internal and external). This fulfils the principles right person right time and will avoid duplication of effort. At present a wide variety of committees are involved in this process, with the potential for duplication and for gaps in responsibility. Areas where quality improvement and outcomes metrics are lacking include: telemedicine metrics (is it safe, effective, patient feedback); appraisal and revalidation metrics (FQA report ratings etc); and Deanery reports and ratings. In addition, clinical audit needs to be aligned with both Trust priorities (national requirements) and individual appraisal (revalidation) needs. Further recommendations for improving delivery of the QI strategy include: Review current structure Organisational chart, roles, reporting, responsibilities Simple explanatory booklet for staff Review Quality account Metrics, context, analysis, narrative for EAG and Trust Board Strengthen audit department Allocate audits for revalidation according to Trust s corporate requirements Quality improvement data hub At the centre of the framework is the concept of a central hub for data collection and analysis, (QI data Hub). The Hub will be a physical unit, with monthly meetings of its membership. It would report to a high level, strategic scrutiny group. The role of the Hub would be to receive, analyse and triangulate all metrics relevant to QI, and provide real time information to all other groups both within (including DAGs and CSAC) and external to the Trust, along with a definitive analysis. The Hub would comprise an information analyst, informatics, EMD and DN, Assistant director of Q&S, Deputy DN, quality analyst, HR and ops representatives, CDs, clinical audit, and the IT lead. Informatics support to the Hub will be crucial. The Delivery Assurance groups (DAGs) will work closely with the hub and provide a nominated member to join the hub, providing a clear link and a hub and spoke model. In this way timely information will be provided into the dashboards, and the timelines, templates and for DAG dashboards can be standardised. The DAG members of the hub will provide expertise and resource into the hub. The Hub will develop a timeline of all metrics received into the Trust, and collate these promptly into the relevant dashboards. The Hub will need resources and administrative support, and succession planning for the information analysis role is crucial. Terms of reference for the data hub AF and CB to draft

6 The QI scrutiny Group There is a need for an overview committee to receive, review, distribute and filter the outputs from the data hub. The QI scrutiny (or surveillance) group would replace QSOG, report to EAG, and meet monthly. It would receive reports from other sources including the DAGs and woud be responsible for the QA risk register. The group would report to EAG and provide EAG with timely, appropriate and mandated information and reports. Any learning would be disseminated to appropriate groups including the DAGs. Membership would include EMD, DN, DDN, AMD Q&S, Information analyst, Cath Gregson, GMs, Director of Ops and CD for education and training. In addition, a senior CD would be a core member. The group would be chaired by the Medical and/or Nursing directors. Terms of reference for the QI scrutiny Group AF and CB to draft CSAC The structure and functions of CSAC has recently been revised, and no changes to these are envisaged. DAGs (Delivery Assurance groups) The structure and terms of reference for the DAGs will remain unchanged. One member of each DAG(either a senior matron or a GM) will join the QI scrutiny group, providing resource to the scrutiny group and ensure close cooperation between the 2 groups. It is proposed that each DAG will take specific responsibility for one or more Trust-wide issues (eg resuscitation for the medical DAG). It is likely that the DAGs will receive the minutes from more meetings and will be responsible for taking appropriate action. Minutes received by this (and other groups) will routinely include an agenda item called items for reporting to to streamline information flows. Specialty Governance meetings The structure and terms of reference for the specialty governance meetings will remain unchanged. SMLT and NMLG Both the Senior Medical leadership team (SMLT) and Nursing, Midwifery Leadership group (NMLG) meetings provide useful learning opportunities which could be disseminated more widely. A joint meeting (quarterly) of both groups with a focus on patient safety would provide an opportunity for more sharing of ideas and knowledge. This could be called the Senior Clinical Leadership Group (SCLG). Minutes and reports would go to the QI scrutiny group. Terms of reference for the joint SMLT / NMLG CDs, Debra Fairley, Cath Gregson and Linda Beckett to draft

7 A proposed organisational structure is shown below.

8 The key goals for improving safer care remain unchanged: Reduce avoidable mortality Reduce harm Reliable care Conclusions and next steps. Subject to the approval of EAG and the Trust Board, the medical Director s Unit will: Agree overall principles of a new QI strategy and framework Set up the QI scrutiny group Agree structure beneath the steering group Develop data hub and review the quality account Implement the agreed CSAC arrangements Ensure safe transition HH/21/5/14 v4