Quality Assurance Framework

Transcription

1 Quality Assurance Framework NHS Bromley Clinical Commissioning Group Quality Assurance Framework was developed to support the commissioning, contract monitoring and procurement processes. NAME OF ORGANISATION/SERVICE Service Lead name and contact details (if applicable): CCG Lead name and contact details (if applicable): Sign below to confirm that the information given within this framework is accurate and return it to: Provider Lead CCG Quality Lead It is Bromley CCG s expectation that providers/potential providers fully understand the contractual, statutory and best practice guidance in relation to quality. This document references quality requirements that the CCG will expect all providers to meet and strongly advise potential and existing healthcare providers to understand and implement the Framework in full. This will be reviewed within contract monitoring. SAFEGUARDING The CCG has a commitment to Safeguarding Adults, Children and Looked-After Children: this is a priority area for Bromley CCG. In order to give consistency and transparency to safeguarding within its commissioning, contract monitoring and procurement processes BCCG has produced a Safeguarding Procurement Standards document that all providers/potential providers need to review alongside this Quality Assurance Framework. SEE SAFEGUARDING PROCUREMENT STANDARDS DOCUMENT found via the following link: BCCG Quality Assurance Framework v

2 Guidance Notes NHS Bromley Clinical Commissioning Group (BCCG) Quality Assurance Framework NHS Bromley CCG is committed to ensuring the quality and safety of commissioned services through Governance processes; Patient and Public Involvement; compliance with national standards and ensuring that services learn from patients experiences to support continuous improvement of services. The purpose of the Quality Assurance Framework The Quality Assurance Framework sets out the minimum criteria that all locally commissioned services are expected to evidence during the procurement process; subsequent contract monitoring and service review meetings. It is designed to assist potential and actual service providers to demonstrate how the organisation meets and in some cases exceeds the quality criteria. In reviewing your organisation s compliance with the Framework we ask you to consider the following: 1. Each section has a heading to guide you on the type of evidence the CCG would consider in reviewing your quality criteria compliance. 2. Ensure that your evidence meets the minimum criteria. 3. The tick boxes are there to assist you to demonstrate that the core evidence includes the minimum criteria. 4. The supporting evidence column is for you to outline available evidence/enhanced evidence. Service Specific Criteria Section There will be service specific criteria that have not been identified in this generic Quality Assurance Framework. Therefore, the intention is that your organisation, or the CCG, will incorporate additional quality criteria in the Service Specific Criteria blank section at the end of the framework. Example A: Identification of specific criteria related to the service from clinical guidelines. Example B: Monitoring of Out of Hours service to include service specific criteria. In addition to completing the Quality Assurance Framework, you may be required to provide information which illustrates impact on: 1. Equality 2. Quality 3. Privacy BCCG Quality Assurance Framework v

3 Who should review the Quality Assurance Framework? Quality Assurance Framework review should ideally be undertaken as a team task, however, it is recognised that it is often carried out by a general manager or project lead who s responsible for completing the necessary documents which are seen as part of a procurement/contract review. The most important thing is that the individual has an understanding and an insight into quality and safety. The key is to choose the person with the right skills, knowledge and interest in undertaking the task. Support available Support in completing the Quality Assurance Framework is available from the Quality Team at NHS Bromley Clinical Commissioning Group. Submission of Evidence The framework should assist the organisation to demonstrate compliance with the quality & governance requirements of the procurement/service specification/contract; however, the CCG may require the organisation to submit written evidence against the quality criteria. BCCG Quality Assurance Framework v

4 STAFFING The service will have a written Appraisal Procedure for the annual appraisal of all clinical and non-clinical staff to include: annual personal development plans (PDPs) appraisals are recorded and reviewed sickness rates The service will need to provide evidence that any member of the team performing specialist skills has acquired the relevant qualifications and/or training to include: qualifications or training undertaken relevant to the specialist service continuing professional development relevant to the specialist service the process by which the organisation is assured of the capability/competency of all staff on an ongoing basis evidence of its staff training programme and its staff induction programme definition of expected clinical and patient reported outcomes and how these will be measured and evaluated a policy to show the dissemination of National Standards published (including NICE guidelines) appropriate DBS checks CLINICAL PROFESSIONALS Confirmation of GMC/NMC registration Confirmation of Revalidation of nurses, midwives and doctors Where requested by the CCG: identity of the practitioners providing the service on your behalf including professional registration number When providing clinical/nursing services implementation of 6Cs agenda in accordance with NHS Compassion in Practice Our Vision Strategy Evidence of annual clinical audit activity that will be or has been undertaken for this service. This should include action plans for improvement from the audit findings BCCG Quality Assurance Framework v

5 REGULATION Providers that are required to be registered with the Care Quality Commission (CQC) must provide evidence of their registration for the designated service. (See Scope of Registration CQC March 2015) If there are any reports provided to or from the CQC on quality of care or adverse incidents these need to be disclosed to the commissioner. INFECTION PREVENTION AND CONTROL (as appropriate to the service) The Organisation/Service should provide evidence of compliance with the 10 Compliance Criteria; as set out in the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. (The Code) Last updated 24 July ile/449049/code_of_practice_280715_acc.pdf (date accessed 12/08/2016) 1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them. 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. 3 Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. 4 Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion. 5 Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people. BCCG Quality Assurance Framework v

6 6 Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection. 7 Provide or secure adequate isolation facilities. 8 Secure adequate access to laboratory support as appropriate. 9 Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. 10 Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection. To prevent resistance and prevent spread of infection; information from the following document must also be considered: UK Five Year Antimicrobial Resistance Strategy (date accessed 12/08/2016) Responses should also provide any relevant information from the following: Current National Institute of Health and Care Excellence (NICE) Guidelines. (date accessed 12/08/2016) Current Care Quality Commission (CQC) Regulations. o Regulation 12 (date accessed 12/08/2016) o Regulation 15 (date accessed 12/08/2016) Health and Safety Executive; Biosafety and Microbiological Containment including Control of Substances Hazardous to Health (COSHH) and Legionnaires Disease (date accessed 12/08/2016) BCCG Quality Assurance Framework v

7 POLICIES and GUIDELINES: The Organisation should have written policies for prevention and control of infection which reflects current legislation and published guidance. The organisation should take responsibility to ensure their response reflects appropriate and practical working documents which ensure staff are able to adhere to policies and guidelines. These may include: Standard Infection Prevention Precautions Procedure Principles and Practice of good hand hygiene Preventing Urinary Tract Infection (UTI) and catheter associated UTI Prevention community -associated pneumonia Preventing and managing sepsis Procedure for clinical and non-clinical waste segregation Reference to the use of personal protective equipment Procedure for specimen handling Procedure for storage and use of medicines including vaccines Procedure for minor operations including Aseptic Technique A Sharps Injury protocol Body Fluid Spillage Procedure Procedure for decontaminating medical devices which identifies that single use medical device will not be reused. Procedure for managing patients with known C. difficile and/or other infectious diarrhoea, including surveillance protocol Procedure for managing patients with MRSA including surveillance protocol. INFECTION PREVENTION & CONTROL (IPC) TRAINING: for clinical and nonclinical staff. The organisation should ensure all staff are trained in IPC. Organisations may have a process of risk assessment which meets their local requirements for training key staff. The risk assessment process of the IPC Training Programmes should be clear and attendance of IPC training should be audited annually, to include: Clinical Staff: 95% annual training attendance (or specific reasons for non-attendance) BCCG Quality Assurance Framework v

8 98% knowledge score (based on risk). Admin Staff: 60% training attendance every 3 years (or specific reasons for non-attendance) 75% knowledge score. Cleaners/Facilities staff: 75% training attendance every 3 years (or specific reasons for non-attendance) 85% knowledge score. The organisation/service should include in their submission the RCA process used, together with numbers of staff compliant with training. INFECTION PREVENTION & CONTROL AUDITS The organisation should demonstrate a systematic review process and evidence of implementing change. Information should be made available on regular audits taking place and may include: Hand hygiene Knowledge of policies and protocols Antimicrobial prescribing Patient environments; including cleanliness Patient infection surveillance Other IPC audit information where available and improvements made MEDICINES MANAGEMENT Where applicable the Service will provide assurances that medicines are used to standards that deliver cost effective use of resources, reduced risks associated with medicines use, improved patient outcomes and experience with medicines. The Organisation will provide a Medicines Policy The Organisation will provide evidence that: The supply of Prescription Only Medicines (POMs) complies with the UK legal framework e.g. by prescription (doctor/ NMP), PGD, PSD BCCG Quality Assurance Framework v

9 There is a robust policy for the transfer of patient s information detailing medicine use, across healthcare settings That all staff that prescribe, administer, supply and/or handle medicines are competent and supported to do so (e.g. use of PGD, NMP scope of practice) Where Patient Group Directions (PGDs) are used that they comply with both the NICE guidance 2013 and the NICE competency framework 2014 The Organisation will demonstrate That medicines use is evidence based, licensed for this use, safe and reflects local/national guidance/ NICE/ formularies.eg audit Compliance with the South East London (SEL) Red list and the SEL Area Prescribing Committee decisions with local Trusts during their contract. Adherence to the transfer of prescribing responsibilities to GPs in accordance with the SEL interface prescribing policy and shared care agreements during their contract. The use of protocols for the review and monitoring of medicines, including support for medicines adherence Antimicrobial Prescribing: Particularly for organisations with prescribing staff, or those without prescribing staff that issue/administer/manage prescribed antibiotic medicines. The following is required: Antimicrobial stewardship. This is an organisational -wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness as per NICE Guidelines [NG15]. The Antimicrobial prescribing policy must comply with NICE guideline NG15 To participate in any local /national CQUIN in relation to antimicrobials that is requested by the Commissioner. Evidence that the organisation has recourse to, and, uses a specialist advisor for antimicrobials. A commitment to achieving maximum therapeutic effect whilst minimising the risk of contributing an additional burden on antimicrobial resistance and BCCG Quality Assurance Framework v

10 Clostridium difficile infection. Evidence of how the organisation complies with local antimicrobial guidelines and what checks are in place to ensure adherence to this policy. The Organisation will provide: Details of budget allocation for medicines and related equipment/consumables Quality assurance and report accuracy for prescribing to identify opportunities for improvement Assurance that they have process for reviewing and reporting adverse reactions and events to the MHRA and implementing national safety alerts INCIDENT REPORTING The service will have an Incident Reporting Procedure which complies with the Revised NHS England Serious Incident Framework (2015) and the Revised Never Events Policy and Framework (2015). This should include the reporting and investigation of incidents, near misses, and serious incidents which includes: Evidence of Culture of learning/ reporting Definition of Serious Incident/ Never Event (compliant with the above) Evidence Collection/ Reporting Patient Safety data Training for staff and investigators Evidence of embedding actions arising from incidents Confirmation of reporting and auctioning of incidents The service should show how information is analysed, root causes are identified, share lessons learnt and describe changes which have been made and how changes which have been made are reviewed. The procedure should reflect the principals of Being Open Evidence of compliance with the Duty of Candour requirements Compliance with stipulated timeframes of SI Framework BCCG Quality Assurance Framework v

11 BEING OPEN AND DUTY OF CANDOUR The organisation policy or process for Duty of Candour (DoC) in accordance with Regulation 20 of the HSCA 2008 (Regulated Activities) (Amendment) Regulations 2015 will include: Named lead for DoC within organisation Definitions of levels of severe, moderate and prolonged psychological harm Timeframes for notification and response to patients and commissioners Breach implications COMPLAINTS HANDLING The service must have a written complaints policy and procedure which is compliant with the NHS Complaints Regulations (2009) and will include: Definition of a reportable complaint Accountability/ Complaints lead Sign off process Role of Parliamentary & Health Service Ombudsman Time limit for making a complaint Support for complainants Explanation of how the organisation monitors and learns from complaints The methods and timescales for acknowledging, processing and responding to complaints Methods of investigation i.e. conducting interviews, reviewing records etc. How changes are made as a result of complaints Reference to the Parliamentary Health Service Ombudsman (PHSO) Principles of good complaints handling Providers are required to comply with HSCIC reporting requirements BCCG require providers to report quarterly on complaints using the format that will be provided A clear statement about the non-discriminatory approach to complaints Details of staff training in complaints handling the frequency of training BCCG Quality Assurance Framework v

12 WHISTLEBLOWING/FREEDOM TO SPEAK UP The service has a written Whistleblowing Procedure referencing NHS Whistleblowing in England and includes: A list of reasons for whistleblowing Details of how staff can raise their concerns, both internally and externally Freedom to speak up guardian in place by 1 st October 2016 (NHS organisation only) BUSINESS CONTINUITY The organisation has attained ISO or is actively committed to aligning their organisational business continuity arrangements and business continuity management process to ISO The organisation has a business continuity policy and a plan which clearly outline: The process of analysis, development and implementation of plans and testing and review of plans The roles of responsibilities of those involved and how the plan(s) will be activated Details of how the service will be maintained during an emergency/ major incident/event which could result in but not limited to loss of staff, IT, facilities Details of how the service will be recovered following an emergency/ major incident/event EQUALITY & DIVERSITY The organisation has implemented the NHS Equality Delivery System (EDS2) BCCG Quality Assurance Framework v

13 and publishes the outcomes annually, or in the case of a non NHS organisation can actively demonstrate a similar approach and willingness to implement EDS2. The organisation makes public it s equality ambitions/objectives and demonstrates how it meets/ intends to meet the public sector equality duties as set out in section 149 of the Equality Act 2010 The organisation can provide evidence of the process used to ensure fair access for people with protected characteristics as defined in the Equality Act 2010 The communication needs of patients/carers/public are catered for in accordance with the NHS Accessible Information Standard The organisation can provide evidence on how it ensures employees from black and minority ethnic (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace using the NHS Workforce Race Equality Standard template INFORMATION GOVERNANCE The organisation must be registered with ICO and have a valid/up to date Data Protection Registration Number The organisation s IG Toolkit submission should be independently audited annually and the audit report shared with the CCG The organisation must have achieved Level 2 compliance in the IG Toolkit The organisation will have an up to date, publicly available Fair Processing Notice covering all the data processing relevant to the service An appropriate data processing contract will be in place between the provider and any of its sub- contractors The organisation will be connected to the NHS N3 Network/ HSCIN BCCG Quality Assurance Framework v

14 The organisation will identify high risks from the organisation s risk register and incident reporting system in the most effective way and to perform a separate analysis on each process whilst the system and then integrate the results The organisation is ensured compliance at all times with obligations for Information Security requirements to identify ricks and incidents they have a responsibility to ensure they are managed The organisation has implemented information sharing policies and procedures to make it easier to share information with other organisations The organisation must demonstrate they co-operate fully and liaise appropriately with third party providers of social care services in relation to, and must itself take all reasonable steps towards, the implantation of the Child Protection Information Sharing The organisation must have Information Governance incident reporting policies and procedures The organisation must have implemented measures to ensure all IG incidents are reported in accordance with the HSCIC s Checklist Guidance for reporting, managing and investigating Information Governance Serious Incidents Requiring Investigations HEALTH & SAFETY All organisations (with over 5 employees) are required to have a health and safety policy that is compliant with statutory legislation, this will include, but will not be limited to, the following; Risk Assessments Manual Handling processes COSHH assessments RIDDOR reporting BCCG Quality Assurance Framework v

15 Fire Safety procedures This list is not exhaustive CONFLICTS OF INTEREST GC27 of the 2016/17 NHS Contract requires providers to maintain and publish a register of gifts, hospitality and conflicts of interest. Providers therefore need to: Evidence that internal processes in these areas are consistent with the principles set out in the Committee on Standards of Public Life Demonstrate an understand the guidance set out within Ethical Standards for Providers of Public Services Be willing to adhere to guidance on Conflicts of Interest due to be published later on 2016/17 Safeguarding SEE SAFEGUARDING PROCUREMENT STANDARDS DOCUMENT found via the following link: BCCG Quality Assurance Framework v