BOARD OF DIRECTORS MAY 2017 QUALITY STRATEGY

Transcription

1 BOARD OF DIRECTORS MAY 2017 QUALITY STRATEGY Introduction The Trusts current Quality Strategy was developed as part of the annual planning process for 2014/15 and was aligned with the Trust s Integrated Business Plan and strategic objectives at that time. However, in 2016/17 the Board of Directors approved a new Five Year Strategy, which included refreshed strategic objectives. The Strategy sets out the context within which the Trust operates and emphasises the challenge and tension between delivering quality services within an increasingly contracting financial environment. The Quality Strategy has therefore been reviewed. Development of the Quality Strategy The Quality Strategy has been refreshed for to: Reflect and support delivery of the overall Trust Strategy Reflect changes to the governance structure supporting the Quality Committee Align our approach to quality to the CQC s five domains caring, safe, effective, responsive and well-led Define our overall ambition for quality and for each CQC domain, the aims, measures and priorities for improvement, delivery and monitoring arrangements. How the CQC/ NHS Improvement Well Led Framework is used to underpin the arrangements for quality governance Address how key risks to quality are identified, managed and monitored. Including those identified through services transformation or cost improvement programmes Reflect the ongoing work to develop a Trust wide approach to quality and service improvement. Define how the strategy will be communicated. The Quality Strategy also includes the 2017/18 Quality Priorities which are also defined within the look forward section of the 2016/17 statutory Quality Report. The draft of the revised Quality Strategy was discussed at the March Quality Committee with the final draft being presented in the May. The final version, agreed by the Quality Committee is attached. Recommendation The Board of Directors is asked to approve the Quality Strategy. Dr Julie Attfield Executive Director Nursing May 2017

2 QUALITY STRATEGY Final Draft

3 CONTENTS Section Page 1.Introduction 3 2. Ambition for Quality 3. Purpose of the Quality Strategy Delivering the Quality Strategy 6 Quality Priorities 7 Quality Strategy on a Page 8 Quality Domain Safe 9 Quality Domain Effective 10 Quality Domain Caring 11 Quality Domain Responsive 12 Quality Domain Well-Led (Governing for Quality) Communicating the Quality Strategy 18 Appendix 1 Trust Governance Structure 19 Appendix 2 Division Governance Structure 20 Appendix 3 Quality Priorities in Detail 21 Page 2 of 23

4 The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can for the rest of our lives. It works at the limits of science bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most. The NHS Constitution 1. Introduction Nottinghamshire Healthcare NHS Foundation Trust s Strategy supports and enables the delivery of this Constitution through our own Vision and Values detailed within our Five Year Strategy and Business Plan. Our Quality Strategy ensures that quality is at the heart of everything we do. Vision Our vision describes what we want to achieve. We will do this by ensuring our services are delivered in a way that will enable people to be in a better position to take ownership of their own health and care needs. We want to move away from reactive, hospital based treatment models to a pro-active approach of prevention and early intervention, delivered in community locations where this is appropriate. This is described in the vision statement: Our Values Through partnerships, improve lives and the quality of care The Trust is known and recognised for its POSITIVE value base. Our ongoing commitment is to listen and learn from our patients, service users, carers and staff and ensure that we live by our values in a real and meaningful way. Page 3 of 23

5 Our Strategic Objectives Our objectives are the four key areas that describe how we will achieve our vision. Having set the direction of our Trust for the next five years, our Board of Directors and Council of Governors must ensure that it is delivered. We have established a Strategic Programme Executive chaired by the Chief Executive to take oversight of the delivery of our strategic projects and efficiency and transformation plans. A key consideration throughout the delivery of the Trusts Five Year Strategy will be the necessity to balance quality against the challenging financial environment we operate in. This will continue to remain a key area of focus for the Board of Directors. This Quality Strategy supports the overall delivery of the Five Year Strategy and the strategic projects aligned to the objective provide the best possible care and support Page 4 of 23

6 2. Our Ambition for Quality Our ambition for quality is to deliver sustainable safe care that has improved outcomes, is responsive and centred on the needs of our patients and is delivered by caring, compassionate, highly skilled and valued staff. The Trust has adopted the Care Quality Commissions (CQC) five domains of quality as our definition. This means for services to be considered high quality they must be: Safe Effective Caring Responsive Well led. 3. Purpose of the Quality Strategy A clear strategy will help the Trust achieve our ambition for quality and achievement of our strategic objectives by setting out our direction for the next five years. Therefore the purpose of the Quality Strategy is to: Communicate to patients, carers and staff our expectations for quality, how we will deliver this to help us to continue to improve the quality of our services Ensure the quality of care underpins decisions made by individuals, teams and leaders Ensure quality of care and the best use of resources are considered together by the Trust, our commissioners and partners to demonstrate value for money Ensure we meet national best practice and the requirements of our regulators; CQC and NHS Improvement. By focussing on the delivery of high quality services with the principle of right first time the Trust should: Be compliant with CQC s fundamental standards and achievement of at least good ratings Be in Segment 1 of NHS Improvements assessment of Trusts It will define how we deliver the Strategy, what the supporting frameworks are and how we will monitor and measure success. Evidence of effective delivery of the Quality Strategy will be reported on annually in the statutory Quality Report 1. 1 The Quality Report is produced in accordance with the regulations for NHS Quality Accounts Page 5 of 23

7 4. Delivery of the Quality Strategy Overall the responsibility for delivery and monitoring the effectiveness of the Quality Strategy is the Board of Directors through the Board committee structure, in particular, the Quality Committee. This Committee is supported by a number of subcommittees; the Trust structure is attached as Appendix 1 and division structures as Appendix 2. In addition to the Trusts overall ambition for quality, we have also defined our ambition for each of the five domains. QUALITY DOMAIN QUALITY AMBITION Safe We will seek out and reduce to a minimum any harm caused to the people who use our services and protect them from abuse Effective We will achieve the best possible clinical outcomes and quality of life for our services users and patients Caring We will care for patients as we would our own families, with dignity, respect and compassion; ensure they are involved and have a positive experience of our services Responsive We will deliver services that are responsive to the needs of our patients Well-Led We will have effective leadership, management and governance to ensure the delivery of high quality, person centred care Overall implementation of the Quality Strategy is through existing Trust strategies, policies and strategic work streams, delivered through Trust and Division governance structures, from Board to Ward. This is summarised in the Quality Strategy on a Page below. For each of the five domains the Quality Strategy defines: The specific aims The processes that are in place to achieve the aims How quality and improvement will be measured The identified Quality Priorities for improvement Page 6 of 23

8 Quality Priorities Each year the Trust is required to prepare a Quality Report. This includes reporting on progress towards achieving the quality improvement priorities that were agreed at the beginning of the year. The Trust is required to identify at least three priorities relating to safety, effectiveness and patient experience. Appendix 3 provides the detail for the current quality priorities, including: Definition of the priority Why the priority was selected Our ambition; what we want to achieve How progress towards achieving the priority will be measured Our Quality Priorities are developed in consultation with staff, patients and carers, partners and stakeholders and our Council of Governors. We consider issues identified from incidents, performance monitoring, complaints and all other forms of feedback. The Quality Committee will receive a report on progress towards achieving each quality priority bi-monthly. Page 7 of 23

9 ORGANISATION LEARNING Quality Strategy on a Page Our ambition is to deliver sustainable safe care that has improved outcomes, is responsive and centred on the needs of our patients and is delivered by caring, compassionate, highly skilled and valued staff Safe Sign up to Safety Think Family Safeguarding Strategy Incident and Claims Management Health and Safety Management System Mortality Surveillance CQC Compliance Framework Intelligent Monitoring Framework Effective Clinical Outcomes Framework Research Strategy NICE Guidance Clinical Audit Strategy Medicines Optimisation Physical Healthcare Strategy Clinical Systems People and Culture Strategy Caring Involvement Strategy Carers Strategy Being Open and Duty of Candour Right staff in the right place at the right time Complaints Management and Response to Feedback Recovery Strategy Well-Led (CQC and NHS Improvement Framework) Freedom to Speak Up Quality Improvement Strategy Responsive Timely Access to Services - right care, right place, right time Emergency Preparedness Plan Risk Management Strategy Health Informatics Strategy WARD TO BOARD INFORMATION FLOWS Page 8 of 23

10 SAFE Quality Ambition We will seek out and reduce to a minimum any harm caused to the people who use our services and protect them from abuse Our Aims To have no preventable deaths (QP1, 2 & 3) To reduce avoidable harm (QP1, 2 & 3) To have no Never Events 2 To improve learning from incidents To care for people using the least restrictive practice Measured By Human factors analysis of the outcome of internal and external investigations Outcome of Coroner s inquests and issue of Preventing Future Deaths Reports Proportion of harm caused by incidents NHS Safety Thermometer data Number of never events Reduction in repeated causes of serious incidents Reduction in use of seclusion and restraint Reduction other forms of restrictive practice Led by the Trust CIRCLE Group we will achieve our ambition by: Implementation of the Sign up to Safety Campaign Improvement Plans which have a focus on: Assaults, Medication Errors, Falls, Pressure Ulcers Suicide and Self-Harm Restrictive Practice Implementation of: The Mortality Surveillance Improvement Plan (QP6) Safeguarding strategies and policies A human factors approach to incident investigation and analysis (SP1.2) The Health and Safety Management System 2 Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Page 9 of 23

11 EFFECTIVE Quality Ambition We will achieve the best possible clinical outcomes and quality of life for our services users and patients Our Aims To demonstrate robust use of outcomes across all services to drive improvement (QP5) To deliver evidence based practice and innovation in all our services To improve outcomes for users of Trust services through effective monitoring and learning from deaths (QP6) For patients not to be readmitted to our services due to ineffective care being delivered Measured By Year on year increase in the percentage of service lines with core outcomes identified/ measured/used Year on year improvement in clinical outcomes Evidence of implementation of NICE guidance Outcome of clinical audits and year on year improvement evidence of compliance Evidence CPA applied appropriately and compliance with CPA policy Evidence of implementation of research findings into practice SUCE survey outcomes and Friends and Family Test Year on year improvement in the number of teams monitoring clinical outcomes Outcomes of analysis of mortality dashboard Reduction in readmission rates and analysis of reasons Led by the Clinical Effectiveness Sub-Committee we will achieve our ambition by: Implementation of: The Research Strategy The Clinical Audit Strategy The Physical Healthcare Strategy NICE guidance Medicines Management Optimisation Plan Mortality Surveillance Improvement Plan Development and implementation of a Clinical Outcomes Framework (QP5) Page 10 of 23

12 CARING Quality Ambition We will care for patients as we would our own families, with dignity, respect and compassion and ensure they are involved and have a positive experience of services Our Aims To ensure everybody who uses our services has a positive experience, feel involved in their care and the decisions to support their recovery Feedback will be received from all services using appropriate methods and timeframes Patients and carers will be Involved in service development To be open and honest with patients and families To have the right staff in the right place at the right time To Improve experience through better management of complaints (QP4) Measured By Service User and Carer Experience reports, Service Quality Rating, Friends and Family Test Trust Survey percentage of people reporting that services made a positive difference to their health and wellbeing maintained National Community Mental Health Survey be in the top 20% of providers for question about people feeling overall that they had a good experience of care (and no deterioration from previous year) Evidence that all clinical teams seek feedback Evidence of appropriate use of the Duty of Candour and support for families following bereavement Actual versus agreed safe staffing levels Staffing reports to the Board and Workforce, Equality and Diversity Committee Reduction in the number referred to the Parliamentary Health Service Ombudsman Thematic review of complaints utilising human factors and triangulation with other feedback Led by the Patient Experience and Service Improvement Sub Committee we will achieve our ambition by: Delivering high quality compassionate care, ensuring privacy and dignity and always being open and transparent and promote the use of the Duty of Candour Implementing: The Involvement Strategy The Carer s Strategy The Recovery Strategy The Complaints Management Improvement Plan Page 11 of 23

13 RESPONSIVE Quality Ambition We will deliver services that are responsive to patient s needs, providing the right care in the right place at the right time Our Aims To provide the right care, in the right time, in the right place - timely access to services which are provided from locations which meet patients clinical needs (QP7) To reduce negative feedback from patient regarding access to services To ensure the Trust complies with the Civil Contingencies Act 2004 and the NHS England Core Standards for Emergency Preparedness, Resilience and Response and the NHS Standard Contract Measured By Monitoring of waiting times to access services and reduction where waits are unacceptably long including referral to assessment and assessment to treatment Access to in-patient beds monitored through; delayed transfers of care, out of area transfers, A&E breaches, crisis team access SUCE survey outcomes Compliance with NHS Improvement indicators Assurance reports to the Health, Safety, Security and Emergency Preparedness Committee Successful testing of Business Continuity Management Plans Led by the Finance and Performance Committee and Health, Safety, Security and Emergency Preparedness Committee we will aim to achieve our ambition by: Implementation of Division improvement plans to address issues relating to access to services identified from performance monitoring and patient feedback Implementing and testing robust and joined up Business Continuity Management Plans in place that enable the continued delivery of essential services even whilst responding to an emergency Page 12 of 23

14 WELL-LED (Governing for Quality) Quality Ambition We will have effective leadership, management and governance to ensure the delivery of high quality, person centred care By well-led, NHS Improvement and CQC mean that the leadership, management and governance of an organisation ensure the delivery of sustainable high quality person centred care, support learning and innovation, and promote an open and fair culture. Their Well Led Framework is structured around eight key lines of enquiry This is the model the Trust has adopted to ensure robust quality governance processes are in place to provide assurance on the quality of care and also identify risks to quality to ensure these are escalated and addressed. Our Aims For all services to be compliant with CQCs standards and ratings to be at least good For CQC inspections of the wellled domain to result in at least a good rating To be assigned to Segment 1 by NHS Improvement as defined within the Single Oversight Framework To achieve and maintain target risk scores defined within the Board Assurance Framework To be in the top 20% of our NHS benchmark group for response rates to the annual staff survey. To implement the people and culture strategy To have developed and implemented strategies for compassionate leadership and talent development in line with Measured By Outcome of CQC inspections Outcome of internal CARe reviews Outcome of internal and independent reviews of the Well Led Framework Segmentation applied by NHS Improvement quarterly Outcome of review of BAF by the Audit Committee and other Board committees Outcome of the NHS Staff survey Analysis of the staff survey feedback and the outcome of the discovery phase of the Developing People and Culture Together programme The progress for each phase of the Developing our People and Culture together programme and agreed workforce metrics Strategies in place and being actioned Improved outcomes in staff survey results All staff to be trained in quality improvement Page 13 of 23

15 the national framework Developing People Improving Care To develop a culture where quality improvement is embedded To have improved the diversity of our workforce methodologies and principles incorporated into policies, procedures and practice Progress against E&D action plans, including our Workforce Race Equality (WRES) action plan Analysis if issues identified through the Freedom to speak up guardian and the Speak in Confidence system To ensure the Trust has a culture that encourages staff to have the freedom to speak up (QP8) Delivery of clinical care is supported by effective health informatics systems Led by the Board of Directors and supported by Board Committees we will achieve our ambition by: Board led self-assessment of Well-Led Framework and implementation of the improvement plan Encouraging the use of the Freedom to Speak Up Guardian and the Speak in Confidence System (QP8) Culture and Leadership review discovery design and deployment all initiated Implementation of: Risk Management Strategy People and Culture Strategy Health Informatics Strategy CQC Compliance Framework Development and implementation of: An Intelligent Monitoring Framework A Systematic approach to service and quality improvement (SP1.1) More information on these strategies and processes which enable the Trust to be a well-led organisation are outlined below Page 14 of 23

16 Compliance with Care Quality Commission Standards All Trust services that are registered with the Care Quality Commission are required to be compliant with CQC s fundamental standards. By focussing on delivering high quality care and by implementing this Quality Strategy, Trust services should be compliant with the standards. To support staff and services to understand these standards and what compliance looks like the Trust has a CQC Compliance Framework, led and monitored by the Audit and Clinical Compliance Committee. This Framework includes a selfassessment tool for clinical teams and managers and internal CARe reviews of services. These reviews are supportive visits to services by trained CARe reviewers to assess compliance against the standards and provide advice and support to achieve compliance. Where non-compliance is identified, required improvements are monitored. Service and Quality Improvement The Trust has formally adopted a Quality Improvement Strategy which articulates the approaches through which service improvement will be delivered. A Trust Wide Service Improvement and Involvement Group has been established to support the development and implementation of the Quality Improvement Strategy. This group will support the development of standardised approaches to the delivery of service improvement and link specific individual improvement projects into a coherent overarching service improvement plan. It will also support the development and implementation of relevant service improvement methodologies such as Human Factors, Foundation in Improvement Science for Healthcare, Theory of Constraints and Lean Six Sigma. The Group will report to the Patient Experience and Service Improvement Sub-Committee. This work form is a project as part of Workstream 1: Provide Best Possible Care and Support, led by the Trusts Strategic Programme Executive. Measuring Quality and Identifying Risks to Quality To identify whether we are improving and moving towards achieving our quality ambitions; accurate and timely information is necessary. We need: The right information, in the right place, at the right time The information must be meaningful, where possible identify trends that are statistically significant, be easily understood by staff and patients and be available at clinical team level. This will also help us to benchmark internally and externally so we Page 15 of 23

17 can compare ourselves against the best. The information should be truly Board to ward. The Trust is reviewing the metrics used, to ensure they measure what we need to know as well as monitoring compliance against national requirements as set out in NHS Improvements Single Oversight Framework. The sections above which define our ambitions for quality and how we are going to achieve these define some of the measures the Trust uses to measure quality. When risks to quality are identified, these are captured on the Trusts Risk Register. The Trust has a systematic approach defined within the Risk Management Strategy. This ensures there is appropriate management, monitoring and escalation of risk. In addition, if there is a risk to the achievement of the Trusts strategic objectives, these would also be captured on the Board Assurance Framework (BAF). Oversight of the BAF and implementation of the Risk Management Strategy sits with the Audit Committee; however each Board Committee reviews risks relevant to their terms of reference. Risks to quality may also be identified through the development of cost improvement programmes (CIPs). The Trust has a robust approach to assessing and monitoring the quality impact of CIPs and all schemes with a Quality Impact Score of 8 or above have to be approved by the Executive Director of Nursing and Executive Medical Director. People and Culture Strategy People are central to everything we do and our workforce, including our wider workforce of volunteers, people on work experience and students are our greatest asset. Ensuring that we create the right culture for our people to perform to their best will be a key focus within the Trust. We recognise the importance of ensuring a workforce culture, which reinforces our Positive values, is based on an ethos of partnership, learning and continuous improvement. Our workplace culture will be inclusive and one where people feel able to be themselves. As such we will have a zero tolerance approach towards all forms of inequality, including harassment, discrimination and bullying. The delivery of our People and Culture strategy will be enabled by an overarching programme of work Developing our People and Culture Together, this programme will fundamentally support the development of a sustained desired workplace culture, and compassionate inclusive leadership for staff at every level. Page 16 of 23

18 Risk Management Strategy Risk management is recognised by the Trust as an integral part of good management practice. Risk management involves understanding, analysing and addressing risk to make sure organisations achieve their objectives. The strategy: Sets out the Trust s objectives for the management of risk at a strategic and operational level; Describes the risk management framework that is in place by defining a systematic approach to how risk will be managed across the Trust; and Ensures that associated thinking and practice is embedded in everyday processes, policies and activity. Effective risk management will assist the Trust in achieving its vision, strategic objectives and divisional objectives, optimising the quality and efficiency of our service delivery, and upholding and enhancing the Trust s reputation. The Trust s significant strategic risks are recorded and managed via the Trust s Board Assurance Framework (BAF). Health Informatics Strategy The Trust is developing a new Health Informatics strategy which will describe how data, information, knowledge and Information and Communications technologies (ICT) will be harnessed and deployed over the next few years to improve care, effectiveness and safety and to help the Trust fulfil its business strategy, and in particular to help the Trust respond to the following key information drivers : a) The need for clinicians to be using electronic patient records in all situations in which they see, diagnose, review, treat and communicate with or about patients by 2020, which is a requirement of 5 Year Forward view and its related document Personalised Health and Care 2020 : 3 b) The need to work with other local health and social care partner organisations in delivering local and national informatics policy, in particular, to break down the systems, governance and cultural barriers that prevent the Trust sharing more patient information electronically with partners, and in turn prevents them from sharing patient data with us, so as to minimise gaps in the provision of care c) To communicate with our patients, service users, carers and their families in digital ways, where this is regarded as an improvement to the overall patient experience 3 Personalised Health and Care 2020 : Page 17 of 23

19 d) To capture patient reported experience and outcome measures in an identifiable manner so that the linkage of such data with their core trust records can help us to understand more readily which treatment interventions are the most beneficial from an outcome, cost, quality, experience or efficiency perspective, and to re-use this with others in research, clinical audit and care pathway evaluations. 5. Communicating the Quality Strategy Our Quality Strategy will be communicated and promoted internally and externally. Communication Method Quality area on website Quality area on Connect (intranet) with links to improvement information and data Poster Displays setting out our overall ambition for quality and ambition for each domain Progress reporting through the Quality Report Part of core induction for staff Use of Trust and Division newsletters Formally issued with copies Quality as an element of staff appraisals For Patients and the Public For Staff For Stakeholders Page 18 of 23

20 TRUST GOVERNANCE STRUCTURE Page 19 of 23

21 Page 20 of 23 Appendix 2

22 Appendix 3 QUALITY PRIORITIES 2017/18 The table below sets out our priorities, why we have chosen them and how, in addition to monitoring progress at the Quality Committee, they will be monitored and measured. Specific ambitions and trajectories for improvement, particularly relating to safety will be developed where appropriate and included in the Trust s Quality Strategy and Sign Up to Safety Campaign. SAFE 2016/17 Priorities Our Ambition How we will Measure the Priority 1. Reduce avoidable harm, with clear focus on: 1.1. Physical assaults 1.2. Pressure ulcers 1.3. Medication errors 1.4. Patient falls 2. Suicide prevention and reducing self-harm Priorities 1 and 2 were chosen as monitoring of quality and safety has identified these as incidents that occur more frequently and potentially could cause significant harm. The Trust is also committed to reducing suicides 3. Reduce restrictive practice to ensure the least restrictive principle is applied for all patients This priority was chosen as we recognise that using restrictive interventions can delay recovery, and cause both physical and psychological trauma to both people who use services and staff These are also the Trusts Sign up to Safety priorities Our ambition is to have no incidents causing severe harm or death and to reduce avoidable harm by 50%. Increase the reporting of these incidents Effective delivery of Safety Improvement Plans for each work stream, including one key action to deliver maximum impact To assess the impact of implementation of the Safety Improvement Plans some key metrics will be monitored: % incidents causing moderate harm or above (assaults, medication errors, falls, self-harm) % incidents high volume/low number of patients (assaults, falls, self-harm) Number of suicides potentially preventable Restrictive Practice metrics such as restraint including - prone, medication and mechanical and seclusion and longterm segregation Number of Stages 3 & 4 pressure ulcers Number of repeated issues identified following investigations Improvements in clinical risk assessment and management Run charts with key actions mapped and use of Statistical Process Control Metric to monitor accuracy of recording degree of harm to be developed Board Lessons Learned Report 3 monthly Monitored by Trust CIRCLE Page 21 of 23

23 CARING 4. Improve experience through better management, understanding and response to issues raised through complaints This priority was chosen because efficient and effective handling of complaints ensures that NHS organisations continuously review and improve the quality and safety of care they deliver. The focus of the priority going forward will be on what complaints are telling us and how this triangulates with other feedback EFFECTIVE Our ambition is to have a complaints process that meets national best practice: Complainant at the centre Easily understood and accessible for all, including seldom heard groups Addresses concerns raised Responsive Focused on improvement Integral part of feedback Review of effectiveness Complaints Management Improvement Plan Analysis of complaints information by service area, in particular: Reasons for complaint Complainant satisfaction with process Response times % Upheld or upheld in part Number referred to the Parliamentary Health Service Ombudsman Triangulation of issues with other forms of feedback Thematic review utilising human factors and triangulation with other forms of feedback (including compliments) Monitored by the Patient Experience and Service Improvement Sub-Committee 5. Improve the health and quality of life of our patients and service users through implementation of a Clinical Outcomes Framework This priority was chosen because we use a variety of clinical outcome measures across our services and we want to continue to ensure there is a consistent approach 6. Improve outcomes for users of Trust services through effective monitoring and learning from deaths of patients who die whilst in receipt of services, or within six months of discharge. This priority was chosen because the Trust, whilst having robust systems in place for reporting and investigating serious incidents, a wider piece of work is required to understand mortality rates and causes of death and avoidability. To have a Trust clinical outcomes framework which demonstrates clinically effective care and treatment is being delivered resulting in positive outcomes for patients. To reduce deaths that are considered to be preventable through implementation of best practice, clinically effective care. Progress with implementation of the Clinical Outcomes Framework Year on year increase in the percentage of service lines with core outcomes identified/ measured/used Specific outcome measures to be monitored at Trust level in 2017/18 to be agreed. Monitored by the Clinical Effectiveness Sub-Committee Review of effectiveness of actions completed in the Mortality Reporting Quality Improvement Plan Development and monitoring of Mortality Dashboards (metrics to be agreed) Thematic review utilising human factors and triangulation with other sources of information Compliance with the National Quality Board s National Guidance on Learning from Deaths Participation and acting upon outcomes of the LeDeR programme for review of deaths of people with a learning disability Board Lessons Learned Report 3 monthly Monitored by Trust CIRCLE Page 22 of 23

24 RESPONSIVE 7. Deliver services that are responsive to patient s needs, provided consistently across the Trust; providing the right care in the right place at the right time This priority was chosen as feedback from service users and carers, as well as monitoring of waiting times and other access metrics, points to this being an area requiring quality improvement. WELL-LED Our ambition is to ensure all waiting time targets are met and negative feedback reduces. Patients are cared for in the most appropriate service to meet their clinical need. Responsive Metrics for 2017/18: Monitor access targets IAPT & First Episode Psychosis Delayed Transfers of Care 28 day re-admission Length of stay Occupancy rate Out of area placements A&E breaches Waiting times referral to assessment and assessment to treatment Impact of Out of Area Transfers on quality of care Analysing relevant feedback complaints & patient surveys Monitored by the Finance and Performance Committee 8. Ensure the Trust has a culture that encourages staff to have the freedom to speak up This priority was chosen as we want our staff to speak up about any concerns they have, feel they are listened to and their concerns acted upon For all concerns to be raised to help us to keep improving our services for all patients and the working environment for our staff. We want to investigate what staff say and provide access to the support they need. Specific measures are being developed Top 20% Trusts with relevant national staff survey questions. Monitored by Trust CIRCLE and the Workforce, Equality and Diversity Committee Page 23 of 23