Sandwell and West Birmingham NHS Trust Occupational Health and Wellbeing service Accredited July 1 st 2011

Transcription

1 Sandwell and West Birmingham NHS Trust Occupational Health and Wellbeing service Accredited July 1 st 2011

2 SEQOHS accreditation SEQOHS introduction Brief service overview Reasons for going for accreditation Reservations preparing evidence Domain specific evidence, problems and solutions inspection What we are planning next key learning points / tips

3 Safe Effective Quality Occupational Health Service = SEQOHS Working for a healthier tomorrow ( Black 2008) - clear standards of practice and formal accreditation of all providers who support people of working age. The Government s Improving health and work: changing lives endorsed that recommendation. In response to this a broad stakeholder group developed standards and accreditation for occupational health services. Launched as SEQOHS standards in January 2010 and accreditation was launched in December 2010.

4 SEQOHS Aims to enable services to identify the standards of practice to which they should aspire credit good work being done by high quality occupational health services, raise standards where they need to be raised help purchasers differentiate occupational health services

5 The standards six domains A Business probity (business integrity and financial propriety) B Information governance (adequacy and confidentiality of records C People (competency and supervision of occupational health staff) D Facilities and equipment (safe, accessible and appropriate) E Relationships with purchasers (fair dealing and customer focus) F Relationships with workers (fair treatment, respect and involvement) G NHS Standards

6 Service overview Teaching trust with 7000 WTE staff, 2 acute sites OH&W part of workforce division Main base at one site, clinic rooms at other site 5 days per week Self / management referrals Daily clinics, telephone advice line In house committee, policy and divisional work appointments in last 12 months Acute Trust and 5 main external contracts

7 Service overview - Staffing Consultant led WTE equivalent consultant Hierarchical nursing structure - nurse manager, senior nurse, 4.45 WTE band 6, 2 band 5 General manager Health and Wellbeing facilitator Administrative staff Physiotherapist External counselling service contract with us External alternative therapist

8 Why we went for SEQOHS accreditation - Awareness that good practices not always present, formalised or documented hoped process would spotlight any gaps to improve care increasing need to demonstrate good and evidence based practice Increasing business culture- how can we assure customers and patients about quality and continue income generation Priority in last 12 months of promoting profile within Trust

9 Reservations New process no-one to ask! How good is good enough Extra work / cost Need to ensure that any changes we made were for good of service and patients SEQOHS is not an endpoint in service development

10 Practical Tips preparing evidence Need to start well in advance (12 months for us) with gap analysis and action plan Set up regular Meetings with lead staff Use of an Excel RAG rated Spreadsheet Manual folder with index Retain electronic evidence folder Update SEQOHS database only when internal electronic evidence is complete

11 Other practical tips for preparation Staff involvement Trust involvement identify key people early Internal comms Set aside plenty of time for uploads Set aside time to respond to inspectors comments online and react to them Dialogue with inspectors on the website Dialogue with SEQOHS office

12 Domain A Business probity Commercial Pack Leaflet Your appointment with the Occupational Health Wellbeing Service Pre-Employment Checks Report March Confidentiality agreement Budget Report from Accountants Invoice Template SWBH Audit of Accounts - from Finance Manager.

13 Domain B information governance Audit of notes 2011 IT User Policy Induction checklist Cross site transfer of notes policy Key Form Register

14 Domain C - People Workforce Professional Registration records Clinical Staff expertise document Nurse personal files examples Job descriptions Anonymous PDR Report Insurance Certificate Complaints Policy

15 Domain D Facilities / equipment Mostly assessed by inspection on the day Local EIA (Equality Impact Assessment) Customer Survey specific question on privacy and dignity All departmental risk assessments Calibration records, technical sheets etc Records of fridge checks and training delivered to nurses on cold chain with register of attendance and signatures of understanding Vaccines order trail and delivery notes Anaphylaxis training records, equipment checks Medicines management policy (Trust)

16 Domain E Relationships with purchasers - evidence Survey monkey used to administer questionnaire to customers Trust sickness absence policy External SLAs /contracts (without financial detail) Records of meetings held with clients (when) and minutes/summaries of meetings held with them) Management referral form example

17 Domain F Relationships with workers List of leaflets (revision of all leaflets for patients in the 12 months prior to inspection) Consultant attendance at Union meeting within Trust introduced to get worker feedback, selected minutes from other Trust committees Brief role description added to picture board in reception and uploaded Personal file KSF framework which staff sign at their appraisal and includes equality and diversity as a core skill Consent forms and procedures footer for feedback. Item added to staff meeting agenda to review feedback from this and comment cards and action monthly.

18 Domain G NHS standards Local audits submitted (needlestick management and records keeping standards) and evidence of registration with the updated national back pain survey Health and wellbeing plan for the trust with explanation Health surveillance programme minutes Divisional work summary Physiotherapy report / counselling report Staff Nurse induction slides etc Annual Plan 2011 Workforce Dashboard

19 Practical tips inspection day preparation Final staff briefing reminding where policies, documents etc could be found easily Check as to whether our clinic rooms on the other site would be visited too not clear initially Checked most up to date forms / leaflets on display and manuals etc for equipment to hand Networked laptop and projector set up in quiet room for inspectors use Hard copies of evidence and selected personal files, training records etc laid out Cleaners, catering and parking arranged, directions sent

20 Structure of visit our experience Business as usual in the morning staff doing clinics etc as normal. Management team free Inspectors arrived 9am Management team met inspectors 9.30 Presentation about the service staffing, main activities, contracts, in house work, planned developments Inspectors went through each domain and each standard, commented on the electronic evidence

21 Structure of visit ctd Inspection of hard copy evidence eg someone s training certificate for audio competence, calibration records, Trust policies, web information Questions on future plans to address any gaps Premises toured to demonstrate facilities Inspectors spoke to admin staff and asked how they did selected procedures, eg how would they go about transferring records across site

22 Structure of visit ctd Spoke to available nurses and asked about departmental policies Detailed looked at key register, all equipment, toilets, locks, manuals, calibration records, info on display Lunch with inspectors Inspectors had approx 1.5 hours alone to write report Entire OH team and manager invited by us to attend the verdict Inspectors presented a detailed report commenting on our strengths, weaknesses and areas for improvement

23 Hints for the day Think about rota-ing, who it is most appropriate to have free to talk Involve the whole team make it a special occasion, good for morale within our team Check if Trust have policy on external accreditation visits and follow it Ensure you have read and actioned the comments online from inspectors so there are no surprises don t need complete solutions but do need action plans

24 Action plans - required A1.3: Verification of EAPs qualification & supervision. B1.1: Extend audit of all clinical encounters C1.2: Systematic approach to identifying and tracking specific training C2.4 Written protocols need to be consistent to guarantee quality and reproducibility of test procedures G1.1 Recruitment & Sickness Absence policies require review

25 Additions Future plans ctd o Working with Tempus to improve cohort data collection systems to aid SEQOHS accreditation o Using SEQOHS as a platform to raise profile of service locally and nationally. Interview already given to the Nursing Standard o Monthly review of SEQOHS domains by Senior Management Team to ensure standards are maintained and kept updated o Team congratulated by having a celebratory lunch

26 key learning points / tips 1. The process of accreditation is worthwhile and beneficial, not just the end result it will shed light on every corner of your service and make you see it with new eyes. 2. The gap analysis and action plan is the key step 3. Don t overcomplicate things or re-invent the wheel, share practice 4. Talk to the SEQOHS office, to other services and to the inspectors throughout the process