Report to Trust Board of Directors Date of Meeting: 29 July 2014 Enclosure Number: 7 Title of Report: Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Ward Accreditation Framework Interim Deputy Director of Nursing Gail Naylor- Executive Director of Nursing & Midwifery Gail Naylor- Executive Director of Nursing & Midwifery Safety & Quality Committee This report provides an overview of a proposed approach to a ward accreditation framework. This will include: Ward accreditation framework Preceptorship programme Clinical supervision programme This report focuses upon a ward accreditation framework what it is how it will be implemented and ongoing progression. Board Assurance Framework Reference: Risk Rating (high, medium, low risk) and any recommended changes to risk rating: Compliance, legal and national policy regulatory requirements: Financial Implications: Actions required by the Board: 2.4 High CQC Outcome 13 Keogh Action Plan Not yet known but potential impact on IMT to support data collection. To approve: To note: Discussion and decision Where the Board is made aware of key points but no decision required For information: For reading and consideration and for discussion by exception only The Board is requested to APPROVE the approach to a ward assurance programme Data quality: Source: Ward Indicators, Harm free Care, SI, Complaints, ESR data, and Patient Experience Real time. Validated by: Gail Naylor- Executive Director of Nursing & Midwifery Date: 10/7/2014
TRUST BOARD 29 JULY 2014 WARD ACCREDITATION FRAMEWORK 1. INTRODUCTION The purpose of this report is to discuss and approve the way forward to establish a ward accreditation framework for all wards, units and departments across North Cumbria University Hospitals NHS Trust. 2. BACKGROUND AND CONTEXT Trust and confidence are two of the most important words patients and carers will use about the staff who care for them. They quite rightly expect compassionate care, high standards of clinical expertise, in a clean, safe and caring environment. The quality of care a patient receives whether in a ward; unit or department is of the highest importance whoever the care giver is. Being treated kindly with respect, dignity, and being listened to, are the themes that have fallen short nationally in care environments of late, and have not met expectations of patients and carers. Care delivery is at the frontline, and the vision for frontline nurses, midwives and care staff is clearly set out in the Chief Nursing Officers Vision and strategy Compassion in Practice making the 6 C s part of everything that is done. To this end an approach to ensure all care areas are giving patients and their carers the highest quality of service and to ensure care is delivered consistently across the Trust, a proposed programme to deliver high quality services is to be established. The approach is to establish a programme that will improve quality, patient safety and outcomes for patients and carers. It is designed to support ward, unit and department managers to understand how they deliver care, identify what works well and where further improvements are needed. This programme includes: Ward Accreditation Framework Preceptorship Programme for nurses and midwives Clinical Supervision programme This report focuses upon the ward accreditation framework and includes an implementation plan to support roll out whilst engaging and communicating with staff. Nationally, accreditation is not a new concept but is a daily part of the work of the NHS. Any facility offering care must be registered and meet set criteria and
standards to operate. Some wards, units and teams have been successfully achieving Charter mark, ISO status and TQM for some time However, following the Francis Inquiry plus other reports and publications demonstrating the failures of the health systems in England, ward accreditation is gathering momentum with hospital Trusts wanting to demonstrate to their patients, carers and wider public the care they will receive is of the highest quality. WHAT WILLTHE FRAMEWORK OFFER Currently we collate a variety of information, from a variety of sources and it is considered in a variety of arenas. The development of the ward accreditation framework will enable us to consider identified metrics, aligned to each of the corporate aims, in a triangulated fashion, enabling more proactive identification of risk, good practice and performance management. The framework is designed to incorporate elements from care, experience, effectiveness, environment and leadership, together with workforce metrics and finance metrics, enabling the ward/department to be performance managed in a holistic manner. The standards will include an assessment of: Organisation and management of the clinical area Staffing levels Compliance with appraisal and mandatory training; Safeguarding patients Pain management Patient safety Environmental safety Nutrition and hydration End of life care Medicines management Person centred care Tissue viability Elimination Communication Infection control. Whilst all these areas are fundamental to consistently delivering great care, there is also a profound impact on operational and financial effectiveness and efficiency; reducing harm, facilitating achievement of national access targets and reducing length of stay. The ward accreditation framework is based on and will compliment other internal and external assessments. Following consultation, once the metrics have been agreed, a clear plan for how the framework will be populated will emerge.
IMPLEMENTATION The assessment process will be a peer process led by a Matron. The team will include a ward/ unit manager from another area. Mindful of the recruitment challenges we are facing, the assessments will be planned in advance and the work the Executive Director of Nursing and Midwifery and the Chief Operating Officer are facilitating with the Business Units will aim to realign the role of the Matrons and Ward Managers to focus on quality to ensure the ward accreditation framework is one of their core responsibilities. Wherever possible, other staff, especially student nurses/midwives and medical students will be involved. It is envisaged that as the programme evolves and embeds into the organisation non-executive directors, member governors, senior managers and patients may want to be a participant in the assessment. All assessments will be unannounced (except to the assessment team) and will cover observation of care given, and discussion with patients, carers and staff members. There will be a review of ward performance prior to the visit led by the team lead and include current performance against key performance indicators for safety including incidents, HCAIs, pressure ulcers and falls, experience including complaints and PALs, staffing, finance and CQUINS. The frequency of assessments is yet to be determined. Each area assessed will have an assessment completed and will be accredited with a status that demonstrates the area meets: Meets all the standards and is deemed excellent Meets all the standards expected for that area will be accredited Failure to meet the expected standards of that area Wards that consistently demonstrate excellence will be deemed as an exemplar within the organisation, and be a site for best practice and learning. Recognition of exemplar status will need to be confirmed but can range from wall plaques, certificates, celebration of achievement at Trust award ceremonies. The actions following an assessment will be determined from the results of the assessment. All improvement plans will be developed by the ward/ unit manager along with the multi-professional team to establish ownership and accountability. All improvement action plans will be clear in purpose with timescales that are achievable but not lengthy and will be monitored through existing quality fora. Monthly updates will be received to ensure progress is made and highlight any particular areas of difficulty. Progress reports will be produced for Trust Board via existing quality reports. The opportunity to share learning from the assessment process will be undertaken via the existing communication channels and clinical business unit systems. The ward/department manager will be clearly accountable for achieving the standards; however, it is critical she/he is supported by the wider multi-disciplinary team, especially the medical leads for the area. To support the ward/department
managers, we are working to consider how we can accommodate enhanced supervisory status for the ward/department managers to facilitate them having time to lead as recommended in the CNO strategy and the National Quality Board paper on safe staffing. The implementation plan for the ward accreditation framework can be found in Appendix 1. 3. SUMMARY AND CONCLUSION A ward accreditation framework once established will provide assurances to the Trust Board that care delivered at the frontline is of the highest quality, where improvements are needed these will be identified and rectified. There are challenging timescales for the implementation of the ward accreditation framework however the task in hand is achievable. All four elements of the programme will work in synergy to ensure all aspect of care delivery meet the recognised standards and delivered by competent staff. The strengthening of leadership at all levels of the frontline team and accountability of ward and unit managers will be realised. The Board of Directors is requested to NOTE the proposed approach and support the vision and direction. G Naylor Executive Director of Nursing & Midwifery of Nursing Interim Deputy Director
APPENDIX 1 WARD ACCREDITATION FRAMEWORK IMPLEMENTATION PROGRAMME JULY 2014 The programme of implementing the ward accreditation framework will be approached systematically and continually monitored to ensure achievement of key milestones and actions to deliver the outcomes of the programme. This is a working document and 'live'. Therefore open to change (actions and responsibilities) due to the dynamic nature of the ambitious programme ACTIONS Proposal Information collection & research DATE TO BE COMPLETED 9/7/14 RESPONSIBLE OFFICER(S) PROGRESS (RAG) COMMENTS Meeting with key managers (STM) -Director of Nursing -Senior Nurses 10/7/14 Finalise proposal for ward accreditation framework (WAF) paper including implementation plan with DoN. 10/7/14 Present proposal for ward accreditation framework to EMT. 1:1 meetings with key managers and identification of key people to comment on draft WAF 16/7/14 16/7/14 Gail Naylor / Debbie Edwards Meetings booked in diary Further work to draft following 1:1 meetings Identify assessors - leads and members Circulate draft ward accreditation framework to relevant staff for comment 17/7/14 6
APPENDIX 1 Comments to be received by close of play Finalise ward accreditation framework Identify and agree trust lead Develop train the trainers programme and have agreed Agree roll out of the accreditation assessment - 10 wards/ units -First tranche - end Sept 2014 -Second tranche - end of Nov 2014 -Third tranche - Jan 2015 28/7/14 Gillian Heathcote/ Victoria Angel Staff identified to comment Gail Naylor Gail Naylor & Snr Nurse team Implementation of train the trainers programme Timetable of assessments to be shared Assessments commence 11/7/14 w/b 18/78/14 Trust lead & Debbie Edwards Assessment teams Communications Discuss communication process with communications team Development of communications Communications programme commenced utilising existing communication fora utilising -Presentations and discussion -Team meetings -Briefings - newsletters 16/7/14 16/7/14 17/7/14 ongoing TBA / Comms team Gail Naylor 7
APPENDIX 1 Updates to board & senior management team Agree sharing assessment outcomes and communicating learning and good practice Celebration of achievements / award ceremony TBA TBA Gail Naylor/ Snr Nurses Trust lead Comms team 8