Quality Assurance Framework. Powys thb provided and commissioned services Quality and Safety Committee November 2013

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1 Quality Assurance Framework Powys thb provided and commissioned services Quality and Safety Committee November

2 Background Together for Health vision for NHS Wales 6 domains of quality Effectiveness Safety Patient/ user centeredness Patient/ User Efficiency Timeliness Equity 2

3 Powys thb context Powys thb requires assurance regarding the quality of services secured and provided for Powys residents and English residents with Powys GPs. PtHB provides community services in 9 hospitals and a range of community settings PtHB commissions services from Welsh and English organisations, mainly from 5 HBs and Trusts. 3

4 Commissioned services Delivered in Powys- e.g. Primary Care, Out of Hours Care, Nursing Home Care, MH community, audiology, lymphodoema, day surgery and outpatient services, such as ENT. Delivered outside of Powys acute care in DGH, MH acute, hospice, residential care, specialised services (through WHSSC) By 5 main providers (13 secondary care contracts): Shrewsbury and Telford Trust; Wye Valley Trust (Hereford); Aneurin Bevan University Health Board (Abergavenny); Abertawe Bro Morganydd University Health Board (Swansea); Hywel Dda Health Board (Aberystwyth) All Wales services, e.g. Velindre (cancer), Welsh Ambulance 4

5 Context Reports: Francis WAO/HIW BCUHB report Duerden (Healthcare Acquired Infections in BCUHB) Internal Audit reports Inspectorate Bodies in Wales: Health Inspectorate Wales, Community Health Councils, Welsh Risk Pool, Wales Audit Office 5

6 Framework Together for Health Delivering Safe Care, Compassionate Care Quality Delivery Framework (Wales) English Assurance system (Kings Fund) 6

7 NHS Wales - quality measures WG is currently taking forward a public engagement programme to identify and agree a set of priority targets and outcome measures that the public should expect to enable them to assess the quality of services provided in NHS Wales. In the interim, organisations report on their performance to WG against a range of Tier 1 plus other targets, which include, for example, waiting times for treatment and reduction in level of healthcare acquired infections Powys thb reports against these targets in its provider role, while other organisations report on quality outcomes for Powys residents within their own data 7

8 English and Welsh providers In England all organisations providing services report to their commissioners on a range of quality and performance measures, relating to that commissioned population, which may or may not equate to those measures used in Wales For example, different waiting times targets; NICE quality and service standards used routinely as the basis for commissioning in England There will be increasing alignment between quality reports in England and Wales as Wales adopts NICE and RCP standards, e.g. stroke now collecting same SSNAP data. Recently revised SLA with NICE opens up opportunities for increased adoption of NICE guidelines and quality standards in Wales 8

9 Specialised services- Quality dashboard project Whilst data collection has commenced in NHS England for a number of quality dashboards, it is important to recognise that this project is a pilot to assess the effectiveness of the tools and process. As such throughout the year there has been further development and refinement of some of the quality dashboards, which has delayed their implementation and subsequent data submission. However, there is an intention to develop a further 20 quality dashboards. At present NHS Wales does not have any arrangements in place with NHS England to submit data into the quality dashboard, or to access the quality dashboards. Furthermore, following discussion with a number of the providers within NHS Wales, it is clear that further work is required on the existing quality dashboards before they can be adopted as a tool to 9 measure the quality of Welsh services.

10 Bringing together information for effective monitoring of quality As a provider of services in Wales and a commissioner of services from Welsh and English organisations around its borders, Powys has a range of systems within which to operate and secure services for its residents, in line with its annual and 3 year plans. The variety of inspection, reporting and governance arrangements within which the various providers operate need to be harnessed into a comprehensive set of information for the Powys population. It needs to be both timely and accurate and be drawn together to provide both the Board and the public with assurance that the thb understands how well services are being delivered for patients and can effectively monitor them for quality, ensuring appropriate mechanisms are in place to take forward improvements where these are required. 10

11 Assurance mechanisms in Powys Principles: that universal and national (England and Wales) and locally determined indicators are established to take into account the principles of equitable access to services together with appropriate variation to meet the unique requirements of local communities. In addition to an agreed and established set of quality metrics and outcome measures, which may be population user based, rather than Powys based, Powys thb needs to receive detailed information, by provider, regarding the following 3 areas: Access, incidents, complaints/concerns 11

12 1.Timely access to services, planned and unscheduled Timeliness Equity Due to the geographical variation across Powys and between Wales and England, Powys residents may receive a different level of service from other patients. For example, SaTH reports a thrombolysis rate of 10% (requiring stroke patients to access acute services within 4 hours from onset of symptoms). However this reduces to 4 % when data includes Powys patients alone. It is only possible currently to access this Powys specific data from our English providers; the same issues are potentially the case for acute services provided in Wales. Waiting times targets for planned services are currently different between England and Wales and therefore are also reported and monitored separately. 12

13 2. Incidents affecting Powys residents Effectiveness Healthcare Acquired Infections (HCAI) and pressure sores, for example, that originate in DGHs or the community prior to admission to a Powys hospital need to be reported separately to understand where the quality of care has failed Falls occurring outside of Powys by Powys patients may impact on prognosis and LOS in Powys hospitals for rehabilitation Other adverse incidents need to be reported by patient, not population, for full investigation Safety 13

14 3. Complaints and Concerns raised by patients, carers, staff Concerns about care for patients receiving service secured by Powys thb need to have specific intelligence about what issues, themes are being raised, even if investigated by external provider. Themes may relate to unique issues relating to distance travelled, differences in waiting times, prescribing, etc. Patient/ user centeredness Frequent themes: transport, transfer, discharge planning, equity of treatment with English patients, e.g.cancer delays Patient/ User Efficiency 14

15 Informal feedback/engagement mechanisms Patient experience framework needs to be applied to take into account different providers of care for patient in one episode Intelligence from range of sources Interface between PtHB and providers at different levels to ensure framework operating well, e.g. exec to exec, Locality and CCGs 15

16 PtHB Patient Feedback Framework Real Time Undertaken whilst patients are in our care. Fundamentals of Care -real time patient satisfaction survey Patient diary stroke service Walkrounds observations from perspective of patient and carer experience MDT meetings with patient present Face to face communication between patient and health care professional Proactive On a permanent basis to allow patients, carers and families to express views at any time not yet available but aim to provide on line access to thb website On a commissioned basis to seek views from the wider community on specific issues e.g. Carers information needs, experience of out of county services Retrospective Follow up phone call after discharge from hospital, day surgery, maternity services, reablement Postcards: What did you like/what did you not like? - Therapy services Questionnaires following education sessions -Xpert patient, Diabetes, stroke Patient feedback book - maternity services Community Health Council (CHC) Hospital Patient Environment Assessment Reports Balancing Patient stories used to gain in depth narrative feedback on services, including external providers Patient Forum and support groups/individuals used to gain feedback on all services Surveys and other feedback from Community Health Council Third sector Other organisations 16

17 Francis: Commissioning for quality All new arrangements and contract reviews need to be set up using service specifications with clearly defined outcome measures. (Note Powys Care Homes Governance Internal Audit (August 2013) recommendations re commissioning procedures and contract management) For example: Francis Recommendation 205: Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to nurse staffing arrangements or provision facilities, and to record whether they accepted or rejected the advice, in the latter case recording its reasons for doing so. 17

18 Internal Audit - Clinical Quality & Safety Audit: In respect of healthcare that is commissioned, the Quality and Safety Committee should ensure that NICE guidelines have been implemented by the provider and that in other ways the provider is fulfilling its contractual obligation that treatments should be in keeping with national guidelines This should be done by receiving and reviewing clinical governance information (to include clinical audit, and NICE implementation reports) which the providers already produce for internal purposes 18

19 Reporting and accountability Contract review arrangements between Locality Management and contracted service, inc Primary care Need to develop further across all localities and directorates to ensure these are robust and comprehensive and are informed by a consistent and appropriate range of quality metrics against which to assess performance and standard of care Focus on exception with escalation system in place if consistent failure and/or serious incident May be based on whole population served by that provider but on Powys patients specifically in relation to 3 specific areas: access, incidents, complaints (concerns) by theme, e.g. Discharge Role of Quality and Safety Unit in providing Powys intelligence function in supporting commissioners management of quality reports in contract review Quality Assurance Framework to be established as part of overarching PtHB organisational performance framework Supported by Powys thb commissioning review underway 19

20 Learning from Francis: New areas identified from self assessment culture that puts patients first organisational values reporting of concerns/incidents professional representation at Board full investigation of all patient feedback publication of complaints commissioning for quality policy review nursing recruitment, appraisal and leadership training key worker role interactions with patients/relatives electronic patient information systems Areas already underway in Powys compliance with fundamental and professional standards openness in complaints and incidents time for nursing team working discharge basic care ward prescribing and observations publication of quality accounts data patient information and feedback systems death certification risk assessment of service change. 20

21 Making it easy to do the right thing at all levels Listening to Patients/Public Listening to Staff Listening to the system Measuring /monitoring the right things Understand what its telling us Triangulate it Act on it LEARN 21

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