Quality Assurance Framework Toolkit

Quality Assurance Framework Toolkit Project Lead: CHARLOTTE HIGGINS Sponsored by: RORY FARRELLY Acting Chief Operating Officer/Deputy Chief Executive & Director of Nursing and Patient Experience 1

INDEX Page. Executive Summary 3 Introduction 4 Quality Assurance Process 7 Pre-pilot Work 8 Pilot Phase 9 Ward Selection 11 Announced and Unannounced Visits 11 Pre-ward Intelligence 12 Review Teams 14 Review Team Pre-Meetings 16 Visits 17 Methodology 18 Scoring Matrix 21 Review Team Debrief Post Visit 22 Verbal Feedback to Ward 23 Data Validation 23 Key Findings from Visits 24 Patient Survey 30 Staff Survey 31 Feedback Questionnaires - Review Team & Ward Staff 32 Ward Sister/Charge Nurse - Feedback of Visit 34 Learning Outcomes of Pilot 35 Pros and Cons 36 Recommendations 37 Future Considerations Time/Staff/Cost 39 Ward to Board Reporting 42 2

Executive Summary The Trusted to Care follow up review 2015 recommended that the Ideal Ward Framework be refreshed which led to development of the Quality Assurance Framework. Quality assurance was an important principle for re-development of the toolkit as it focuses on strengths and weaknesses to allow for continuous improvement. It also enables standards to be built around the needs of staff, patients, relatives and carers. In August 2016, an Executive Team development group which included Executives and Non Executives from Abertawe Bro Morgannwg University (ABMU) Health Board visited the University Hospitals of North Midlands NHS Trust. The purpose of the visit was to learn about the quality assurance tools they were using to improve standards of care. Following the visit, a quality assurance team from North Midlands NHS Trust visited ABMU Health Board to hold a presentation seminar and share their journey of development and findings. The overall aim of the Quality Assurance Framework Toolkit is to: Provide assurance with regards to Quality & Safety at ward level. Reduce duplication. Identify areas of good practice, or areas for improvement. Embed Health & Care Standards into every day practice across the Health board. 3

Introduction Development of Quality Assurance Framework the Journey so far Currently there is a raft of audit tools being used across the Health Board both at a local level as well as on an All Wales level. Initially a mapping exercise was carried out to scope all the tools in use and then align them to the following Health and Care Standard Themes NMC Code of Conduct Our Values Older Persons Standards, Older person s Commissioner for Wales key recommendations Health & Care standards care indicators Health & Care Standards Annual Audit Staff Survey IMPT Plan All Wales Quality tool Ideal Ward toolkit Local Quality Assurance toolkits Health Board Strategic Objectives and Quality Priorities All Wales Nurse Staffing level Bill The knowledge learnt from North Midland NHS Trust. The result of this process lead to the development of the new ABMU Health Board Quality Assurance Toolkits which are: Safe care Effective care Dignified care Individual care Workforce Patient survey Staff survey 4

The revised toolkits were designed to measure standards, and provide feedback to healthcare staff with information to allow them to assess and adjust performance. Timely Care and Staying Healthy are incorporated into the toolkits and are not a standalone toolkit. The complete quality assurance framework provides a full comprehensive deep dive audit or can be broken down into single units to provide assurance of improvements where areas of concern are identified, i.e. Safe Care, Dignified Care. The Themes of the toolkits include the standards below: Managing risk Preventing Pressure & Tissue Damage Falls Prevention Infection Prevention & Control & Decontaminatio n Nutrition & Hydration Health and Care Standards Medicines Management Safeguarding Children & Safeguarding Adults at risk Safe & Clinically Effective Care Communication Effectively Planning Care to Promote Independence Health Promotion & Improvement Blood Management Medical Devices, Equipment & Diagnostic Systems Quality Improvement, Research & Innovation Record Keeping Timely Access Peoples Rights Listening & Learning from Feedback Workforce Staying Healthy Safe Care Effective Care Dignified Care Timely Care Individual Care Staff & Resources A review has also recently been undertaken across the Health Board in relation to the Health & Care Standards care indicators. The review identified that there was duplication of capturing information e.g. Datix, ESR and also the majority were process measures. The aim of the review was therefore to rationalise and reduce the existing care indicators. A Further piece of work has also been undertaken where the Health Board developed Twelve Standards for Older Frail Patients. A set of Key indicators have now been developed and can also link with the Quality Assurance Framework. 5

The Executive Board requested for the quality Assurance Toolkits to be used electronically. The project leads met with a senior project manager from the Information Technology (IT) department to discuss this option. Initially a share point folder was developed which would give reviewers shared access to the toolkits throughout the pilot. However this method did not give instant data results which was required for providing instant feedback to wards as well as during de-brief discussion. I.T advised that completing the toolkits as an excel document would provide instant data. Following this advice the toolkits were designed and setup as an excel document. Five electronic tablets were loaned from the information team for the purpose of the pilot. The evaluation report outlines the steps taken to pilot the Quality Assurance Framework toolkits and includes the following areas: Process including Ward selection Pre intelligence Review Teams Pre meetings Ward Assurance visit Methodology De-brief including Feedback from reviewers learning from the visit, Verbal feedback to the ward. Proposed changes as part of a PDSA cycle refining the tool and the process Outcomes from the visits Learning from the pilots Recommendations for the future The expectation for the future is that all wards across the Health Board will have at least one comprehensive review undertaken by a Multidisciplinary team each year. The reviews will be built into the Service Delivery Units Quality Assurance Annual Plan. 6

Quality Assurance Process Visit to North Midlands Mapping Exercise to align Health & Care Standards Development of Toolkits Workshop to refine and provide overview of the framework Pilot 1 Pilot 2 Pilot 3 Pre meet Visit Pre meet Visit Debrief Visit Debrief Immediate Ward Feedback Immediate Ward Feedback Summary Report Debrief Immediate Ward Feedback Summary Report Action Plans Summary Report Action Plans Action Plans Key Learning from Pilots Recommendations for the Future 7

Pre- pilot work Project brief A project brief was proposed to provide those involved and stakeholders with an over-view of the Quality Assurance Framework. The project brief was presented and discussed at the following meetings: North Midlands Post Visit Task and Finish Groups Nursing Midwifery Board. Quality Assurance workshop The project leads facilitated a workshop with members of the review team to provide an over-view of the quality assurance framework and to give the opportunity to review the toolkits before the pilot phase. The review team were separated into multi-disciplinary (MDT) groups and assigned toolkits to review. The workshop was beneficial, providing positive discussion and feedback. Some of the feedback received on the toolkits included: The wording of the questions such as their clarity and inappropriate use of abbreviations. Duplications Additional questions which were felt to be important but may be missing from toolkits. All comments were noted and amendments were made to the toolkits to reflect this. The review team felt the workshop was productive and displayed positive engagement on a multi-disciplinary level. 8

Pilot phase The pilot phase was from December 2016 March 2017 in Morriston Hospital. The Senior Management Team agreed to pilot the project as it was in line with the First Friday Quality checks which were already in place in the hospital. Over the duration of the pilot, three assurance visits took place on the first Friday of each month, with the exclusion of February due to winter pressures. The process of the pilot was as follows: - Standard Operating Procedure Service Delivery Unit Notice 2 weeks notice given if announced Pre-meet Review team to discuss Intelligent Bundle Report 1 week in advance MDT Team Peer review Clinical Area using Quality Assurance Toolkits High Level feedback to the Ward Manager / Matron following MDT debrief Draft report to ward within 28 working days and response from ward regarding factual accuracy within 10 days of receipt of report Matron/Ward Sister to present Action Plan at Unit Professional Nursing Forum Findings presented quarterly report to Quality & Safety Forum in relation to key themes and actions arising from Reviews Ward to Board reporting Service Delivery Units to organise follow up visit to review progress with implementation of improvement plan 9

Standard Operating Procedure Corporate No notice given to clinical area Pre-meet Corporate MDT Review team to discuss Intelligent Bundle Report 1 week in advance Corporate MDT Team Peer review Clinical Area using Quality Assurance Toolkits High level feedback to key members of the service delivery Draft Report to Delivery Unit within 14 working days Response from Delivery Unit re factual accuracy within 10 working days of receipt of report Unit Director to present Action Plan at Quality and Safety Forum Follow up visit to review progress with implementation of improvement plan 6 monthly update to Health Board Quality and Safety Committee 10

Ward selection Wards were selected in advance of pre-meetings and visits so adequate time was allocated to gather ward intelligence. The chosen wards were selected by the Unit Nurse Director and chosen to ensure that a variety of different wards were visited. The following ward specialties were visited over the 3 month period: December 2 nd 2016 Trauma and orthopaedic, Vascular surgery, Medicine January 6 th 2017 - Medicine February 3 rd 2017 Surgery and Specialist medicine. Implementation Outcome - Wards can be selected as part of the Service Delivery Unit audit program and Annual Quality Framework. - Acute wards were visited during the pilot phase, but the template is transferable to other health care areas. Announced and Unannounced Visits Announced and unannounced visits were trailed during the pilot phase. Three wards were made aware of the visit in advance, and three were not given any notice. The findings indicated that there was no difference in the outcomes of this as the wards were not knowledgeable of the toolkits so therefore were not able to prepare. Implementation Outcome Unannounced visits could be triggered if there are hotspots or wards of concern. 11

Pre-ward intelligence Ward intelligence was obtained via the informatics department, Datix, finance and the Health and Care Standards Care Indicators prior to the pre-meet. There was an element of difficulty on some occasions gathering all of the required information due to it coming from many different sources. The following information was requested from the sources: 12

Implementation Outcome To eliminate the timely gathering of information from different sources. Key information needs to be viewed on one system e.g. Click View, Dash Board Gathering the pre- intelligence information and preparing it for visits took approximately 3 hours. This included emailing the relevant person requesting the information and re-emailing if necessary, formatting and printing the information for review team, printing relevant reports from Health and Care Standards Care Indicators and highlighting areas of poor compliance and concern. The time taken for the teams to populate the information was also considered. Feedback received indicated that this took up to 1 hour to compile for the project lead. 13

Review teams A multi-disciplinary approach was used throughout the process of the Quality Assurance visits. It is recommended that a minimum of 6 people form a review team to enable toolkits to be completed in the allocated time. The review could include teams of: Unit Nurse Director Heads of Nursing Medical Staff Quality & Safety Lead Finance Lead The Team Corporate Nursing General Managers Senior Matrons/ Matrons Patient Advice Liaison Service (PALS) Pharmacist 14

Each review team included a lead reviewer who was identified at the pre meet. It was agreed that the lead reviewer would provide verbal feedback to ward Sister/person in charge & Matron following the debrief. To ensure that people with the right expertise completed each toolkit, certain professionals were assigned to a particular toolkit during the pre-meet. Those with no clinical background paired up with a clinician or completed a non-clinical toolkit. Below is an example of which group member completed and lead on each toolkit: Toolkit Safe Care Effective Care Individual Care Dignified Care Documentary evidence Pharmacy Workforce Staff survey Patient survey Professional Clinician/ Medic or paired up with other professional Clinician/ Medic or paired up with other professional Clinician/ Medic or paired up with other professional Clinician/ Medic or paired up with other professional Clinician/ Medic or paired up with other professional Pharmacist/ Nurse/ Medic General/ HR/ Finance Manager General/ HR/ Finance Manager PALs/ General/ HR/ Finance Manager Two- Three hours was needed to complete the toolkits with the recommended amount of review team members. 15

Review team pre-meetings Pre-meetings were planned the week before each audit and would be approximately one hour in duration. The purpose of the pre-meeting was to discuss and plan for the following week. The wards to be visited must be chosen prior to the pre-meet and review teams identified. Ward intelligence was gathered from a number of sources as discussed above. This information was discussed with the group and gave review team members intelligence information of the wards to be visited. The pre-meeting also gave group members the opportunity to familiarise themselves with Quality Assurance Framework toolkits and electronic devises, discuss previous visits and action plans devised. Key issues Identified in Pre-Meetings: Due to hospital pressures and clinical commitments, attendance to the premeetings were limited. This meant that review teams were not confirmed in advance due to uncertainty about who would be attending on the day. Due to the hospital pressures, one pre-meeting was cancelled. The implications of this were: - Pre-intelligence information was not looked over or discussed prior to day of visits. - No pre-information on who would be attending on the day. The teams could therefore not be agreed until the morning of audit. - No discussion about the findings and actions of the wards visited on previous Quality Assurance audits. The volume and presentation of pre-ward information was difficult to analyse and discuss fully within the time frame. It was requested that less, but more focused information would be useful in the future. It was suggested that a dashboard featuring key themes would be clearer in identifying areas of concern straight away. Review pre-meetings were scheduled for 1.5 hours. This was sufficient time to discuss pre- intelligence information and plan for the visit. 16

Visits Each pilot visit took place on a Friday and during the morning. 07:00 Senior Nurses attended the agreed wards to be present at handover and also worked with the teams. This was part of Morristons First Friday ward visits and not a compulsory part of the Qualit Assurance Visits. 09:30-09:45 09:45-12.15 All review team members met to confirm roles and expectations of the day. The teams consisting of 5-6 members of multi-disciplinary staff attended the wards. A PALS representative and Pharmacist attended all three wards to undertake the patient and medication elements. The teams had 2.5 hours on the wards to complete the toolkits 12:30-13:00 13:30-14:00 Review teams re- grouped for approximately 1 hour for analysis of findings and debrief Lead reviewer revisited ward for approximately 30 minutes to provide ward Sister/Charge Nurse and Matron with summarised report of key findings, areas of concern and immediate recommendations The compulsory stages of the Quality Assurance visit took 4.5 hours. Implementation outcome The pilot phase was conducted during working hours of the working week. The process could also be followed during different times of the day such as during the night or weekend. 17

Methodology Recording findings and data collection Data was collected by a number of methods, which included: Observing the ward and care areas - The reviewers were instructed to score what they could see. This section created a sub-total which would contribute towards the toolkit overall total. Reviewing documentation - Reviewers were asked questions which involved checking to see if the documentation was present or filled in correctly in Nursing records, medical records and bedside charts. The documentary sub-total score was added with the observational sub-total to provide a total percentage score for the toolkit. 18

Critical questions, highlighted in yellow, were included throughout the toolkits in both observational and documentary evidence. Critical questions represented never events and safety. If full compliance was not achieved for these questions, a flag was initiated and immediate action taken by the reviewer to discuss with ward Sister/ Charge Nurse and Matron. Feedback from staff One reviewer was allocated to speak to 3 members of staff from the ward multi-disciplinary team. Quantitative and qualitative data was collected. Feedback from patients The PALS team were allocated to speak and listen to 3 patients on the ward. Quantitative and qualitative data was collected. 19

The Ward observations and documentation were scored by the reviewer. A peer review was applied to ensure validity and credibility of the data collection. A peer review is a process where the reviewer does not directly manage the area and is therefore independent. The excel Toolkits were created as a shortcut on the desktop of the electronic devices before data was inputted. This also included inputting pre-information into the workforce toolkit. This pre-work took approximately 1 hour. 20

Scoring Matrix Total Percentage scores for each assessment tool were converted into red, amber, green (RAG) scores. This method of scoring was agreed with the Nursing Midwifery Board as it was aligned with internal, All Wales audit reporting and Health and Care Standards Annual Audit. The RAG scores were then converted into numerical scores. Standard of compliance RAG score Numerical score 0-50% 1 51-84% 2 85-100% 3 Numerical scores for Safe Care, Dignified Care, Individual Care, Effective Care, Workforce and Pharmacy toolkits were added together for a total RAG score of the assessed ward. Patient and staff feedback was not included in the over-all RAG score. Instead they were referred to as additional intelligence information. See example below of scoring matrix, each theme with corresponding score and total score providing overall result i.e. score of 11 (Amber). 21

Review Team Debrief Post Visit Review teams re-grouped following each ward visit for a debrief.the meetings were approximately 1 hour in duration. The debrief allowed review teams to reflect on the experience, discuss good practice and areas for improvement on the wards visited. The sessions also gave the opportunity for team members to provide feedback to the project leads throughout the pilot phase. The feedback was valuable to the development of the project. Members of the review team confirmed that completed toolkits gave a true representation of the ward. The following amendments were made on review team recommendations: Toolkits - Questions which were identified as duplications were removed which contributed to some toolkits becoming shorter to complete. - Questions were amended and abbreviations removed for clarity. Staff survey - The review team felt that the staff survey was too long and that it would keep staff away from their clinical work for too long. This led to the development of a brief staff survey toolkit which was in line with the All Wales Staff Survey. It was agreed that the long version would still be available if a more in-depth approach was needed. Medicines management The Medicines Management questions were removed from Safe Care and developed into separate toolkit. The Pharmacist and reviewer suggested that the questions should become a separate booklet for ease of use and prevent confusion. The feedback following this change was positive. Patient survey The PALS team raised that some of the questions in the toolkits were not appropriate or needed amending. Following this feedback the project lead met with the PALS and discussed amendments. The review team debrief lasted approximately 1 hour. This was sufficient to discuss key findings and reflect on the process. 22

Verbal Feedback to Ward Following the review team debrief, the lead reviewer re-visited the ward to give feedback to the ward Manager and Matron. The feedback was a summary of key findings, areas for concern and immediate recommendations. The ward feedback lasted approximately 30 minutes. This was sufficient to discuss key findings and recommendations. Data Validation As only 5 electronic devices were available during the visits, some toolkits had to be completed in paper form. The project lead had to input this data into the excel documents after the visits in order to obtain a total score and to complete the summarised reports. The project lead also checked each toolkit to ensure that there were no gaps in the data which could affect the outcome. Converting the written data into electronic took up to 3 hours. Checking the data was inputted correctly took approximately 1 hour. Implementation outcome Inputting data recorded by someone else, by hand, created more work for the project lead. At times it was also hard to understand the reviewer s handwriting which could have affected the validity of the data. 23

Key findings From Visits A summarised report was completed within 1 week containing individual scores for each theme, on a RAG rating basis. The report identified areas of positive observational and documentary evidence, as well as areas which require improvement. Patient feedback was also identified and included under each theme. The following provide an example of the summarised report containing key findings within the Quality Assurance visits. Safe Care Key findings Examples of good Practice Managing risks Falls, pressure area care and manual handling risk assessments not completed Infection control Nursing staff complying with bare below the elbow policy. Medical staff observed wearing longer sleeves. Wards cluttered with equipment due to lack of storage Falls Opportunities missed checking patient s shoes and feet. Poor condition of flooring Nutrition and Hydration Patients were observed to have jugs of water and cups within easy reach. Staff observed encouraging patients to drink and assisting. This good practise was also feedback through the patient survey, as every patient who was asked reported that staff had encouraged them to drink and regularly filled their jugs with water. Recommendations Infection control Remind all staff of bare below elbow policy when in the Clinical Area. 24

Effective Care Examples of good Key findings Recommendations Practice Signage Up to date posters and signage appropriate for area, such as dementia friendly symbols for toilets and bathrooms. Patient property Improvements are needed when storing patient s property. On a number of occasions signatures and dates were missing from PP5 documentation. Documentation NEWS documentation completed and correctly actioned. Improvements needed with integrated nursing assessment e.g. missing information or not filled in correctly. Communication Staff communicating with patients well, responding to their needs and call bells in a timely manner. This was reiterated by the patients who reported that staff were quick to respond to their needs. Communication It was noted that some wards did not have a day room for patients to go and spend time in away from the ward environment. Wards were observed to have little reminders of home life for patients. One ward did have games available for patients, but due to clinical duties staff did not have time to play these with patients. This was discussed during a debrief and the PALS team suggested the use of volunteers to help with these activities. 25

Dignified Care Key findings Examples of good Practice Recommendations Pain Staff observed assessing and reassessing patients for pain and analgesia. Compliance with pain assessment documentation. Privacy Patients privacy catered for on most wards with single sex bays and toilets Improvement needed where some toilets are not allocated male or female. Foot and nail care No on-going evaluation of patient s foot and nail care. Opportunity missed to assist diabetic patient with foot and nail care. Continence Each ward was observed to care for patients continence needs appropriately and in a timely manner. Patients were observed to be assisted to their preferred toileting method and wards had good stocks of continence products. Good compliance with continence documentation was also present as each set of notes looked at had evidence that a continence needs assessment had been completed on admission. Patients also reported that their continence needs were addressed by staff appropriately Dignified care Ward information booklets not available to patients/ relatives. This was discussed with the PALs in the debrief who said they would work with identified wards to produce them. This could also be a consideration for the health board. Foot and nail care Increase awareness of disposable nails sets on the wards. Increase foot and nail care training for staff. 26

Individual Care Examples of good Key findings Recommendations Practice Communication Staff listening to patients and supporting them to make choices and decisions. Accessible information regarding how patients or relatives can raise a formal complaint was also visible on most wards. Improvements needed regarding safety crosses as most wards did not have them displayed or up to date. Patient experience Improvements required when displaying patient experience information including you said, we did, SNAP 11 and All Wales Patient Experience questionnaires. MDT working There was good evidence of multi-disciplinary working, with the presence of medical teams, therapists and domestic staff End of life care On one ward a patient was receiving end of life care. Good communication was observed with the patient and family. The patient was being transferred to Ty Olwen as this was their preferred place for care. Full compliance with end of life care documentation. Discharge Poor compliance around discharge documentation. Information was missing including evidence that discharge planning had begun and estimated date of discharge. However, patients reported that EDD and plans had been discussed with them. This suggests that discharge planning had begun and discussed with patients, but staff are not documenting this information appropriately. 27

Pharmacy Examples of Key findings Recommendations good Practice Storage Controlled drugs found to be stored correctly in packaging and all in date. Signage for CDs Signatures missing for administration for controlled drugs. On one occasion when signature was missing from documentation, two nurses were observed to be present during the administration process. Administration Good administration of medicines was observed on all wards. Medicines management During a debrief the size of the medication room on one ward was discussed. It was highlighted that its large size and volume of medications has associated risks. The advantages of an Omnicell system on this ward was discussed. 28

Workforce Key findings Examples of Recommendations good Practice Training Poor compliance with staff training. During the staff survey it was mentioned that staff do not have time to complete E-learning Governance Staff were observed to comply with All Wales Dress code Governance Name badges sometimes not visible Discussions commenced in de-briefs around staff names being embroidered onto uniforms. Four hours was needed to create a summarised report for each ward. 29

Patient Survey Two or three patients per ward were asked about their stay in hospital. Specific comments relating to each theme have been included in themed results. In general all patients who took part had positive things to say about the staff and care they had received on the wards: I can call staff to use the toilet at anytime On admission I became anxious. Staff reassured me Staff made sure support was available to prevent me falling Feedback where improvements are required: I have not been kept informed of treatment delays I have not had a leaflet with ward information I don t know what the small white tablets or yellow capsules are for My call buzzer does not work The PALS team were asked how patients felt about taking part in the survey and if they had made any comments during the process. The following feedback was received. I told the patient that we were PALS representative and the Health Board was formulating a new patient questionnaire. I find patients are usually interested in giving their opinion, good or bad, especially if they have a captive audience. But generally I think that the comments were favourable. 30

Staff Survey Two or three staff per ward were asked about their experience of working in their area. It was suggested that a range of different roles were asked to get a broad range of feedback. In general staff were very positive about their work place: It s interesting, I m using lots of skills Part of a good team What would you do to improve patient experience? A day room would make such a difference Nothing to occupy patients with little family visits More time spent with patients What would you do to improve staff experience? Time to do E- Learning More staff Encouraged to develop, but would like more opportunities 31

Feedback Questionnaires On the last Quality Assurance visit of the pilot phase, feedback questionnaires were completed by the review teams and ward staff. Review team feedback Positive experience: The process - Useful and enjoyable experience The process - Multi-disciplinary approach that demonstrated good team work The process - Open and honest discussions The visit - Completed with minimal disruption to the ward Areas for improvement The process - Too many questions to complete within timeframe The visit - Some occasions not enough review staff to complete toolkits Recommendations: The process - Pre-population and links to other data The visit - Timing Need to be there for meds rounds/ mealtimes 32

Ward Staff feedback Positive experience: The process - I think the Quality Assurance Visits are of benefit to staff, enabling them to raise any concerns, also updating nurses on what we can improve The visit - Yes it was completed in a professional manner The visit - As far as possible it was completed with minimal disruption to the ward Areas for improvement: The visit - The staff involved with the visits are being taken away from patients for 3 hours this morning The visit - There were 3 people (auditors), I felt this was too many Recommendations: The visit - Maybe less people completing the Quality Assurance Visits. Also it is a busy time with ward rounds, washing, and medication rounds 33

Ward Sister/Charge Nurse Feedback of Visit Feedback was gathered from the Ward Sister/Charge Nurse who was present during the visit. They were asked how they found the visit and what actions have been taken as a result of it. How did you find the visit? I was not aware of the visit before everyone arrived on the ward. It was daunting having the Unit Nurse Director present but once it was explained I felt comfortable. I was apprehensive. The previous visit had been cancelled so I know it would happen at some point. I felt Ok because I was expecting it. The reviewers were polite and let my staff prioritise patient care. Did you find the verbal feedback helpful? Yes, I was given verbal feedback throughout the process Yes the feedback was helpful. I have also received a report and we are working through areas in need of improvement Actions taken since: We have moved things around to create a new store room and decluttered the treatment room We have made improvements on our risk assessments by ensuring all patients are risk assessed. For example, with falls assessments we have improved on assessing patients who have walking aids. 34

Learning Outcomes of Pilot Expectation of Program Clarity of roles and responsibilities to ensure reviewers are knowledgeable of toolkits MDT approach; different views and skills add to the richness of the visits. Strong leadership and management needed throughout the process. Organisation and Management of Process Gathering the right data Feedback suggested that the pre-intelligence information was too extensive Difficulty with gathering pre-information from a range of different sources. Importance of review team pre-meeting Adequate amount of electronic devices Dedicated time for staff to take part i.e. No Medics present on visits Making a difference Using findings through right governance Good communication with wards visited throughout process. Triangulating different sources of information Avoiding duplication of other audits 35

Pros and Cons When weighing up the pros and cons of the Quality Assurance audits, the pros outweighed the cons. Pros Opportunity to streamline existing systems including back to floor audits MDT ownership Supports external assurance visit structure Time constraints Cons Lack of investment Informatics, electronic devices Data sources from different places Brings findings all together including staff, patient and clinical outcomes Transferability to other areas care homes etc. Opportunity to support and independently validate Health & Care standards Tailor Quality Assurance visits to clinical area such as areas of concern 36

Recommendations Pre-information Key indicators A few key indicators which could form the dashboard or ward click view. Areas to focus on could include pressure areas, falls, medication errors, infection control, patient safety incidents, and patient and staff experience. Process Agree number of MDT members in teams as minimum and maximum number to perform review. Review teams must be agreed in advance so each reviewer is familiar with toolkit before visit. Pre- meeting must go ahead to discuss pre-information and plan expectations of the day. Lead reviewer agreed Toolkits Full set of tools to be used at least annually and built into to Governance plans. The toolkit can be used as follow up for red areas or tailored audits for areas of concern. Findings Gap analysis linking findings and further information together to formulate action plan. I.e. ward intelligence, Health Care Standards and National Standards. Action plans Action plans to be discussed via Service Delivery Unit governance process e.g. Quality and Safety Committees, findings to be used as part of Health 37

& Care Standards assessments. High level feedback corporately. Support IT support and costings for electronic devices. Pre- intelligence information from different resources. Dashboard at ward level or click view would provide clearer information. Support to produce findings noting that North Midlands had a resource of a team in place. Continuation of 15 step challenge to determine progress from visits. Leadership, Management and Governance Service Delivery Units to take ownership of quality assurance framework Service Delivery Units to develop role out plan within annual audit plan For example: o A 20 ward hospital could potentially complete two visits per month with two teams of reviewers. Further Recommendations and Developments Standard operating procedures for pre visits, debrief sessions and visits Link with Specialist areas to refine their own tools Time built into Medics job plan to take part in visits Discontinue The Quality Assurance Framework would lead towards the discontinuation of other actions, this would include: Back to floor Fridays Individual audits, such as patient property Duplication of results if Click view is developed Development of different audit tools as the framework would be a standardised toolkit. 38

Future considerations Time A time analysis was performed to demonstrate the total time of the Quality Assurance process. Stage of process Action Time taken in hours Total time in hours Pre-visit Compiling and 4 6.5 organisation of pre-information Preparation for 1 pre-meetings and visit Review team premeeting 1.5 Visit Review team previsit 0.5 4.5 meet Ward visit 2.5 Review team 1 debrief Ward feedback 0.5 Post- visit Data validation 4 7 Summarised report 3 18 39

Staff An analysis of which staff member/ group took part in each stage of the process was produced. Stage of process Action Staff Pre-visit Compiling intelligence information Project lead, informatics department, DATIX, finance Organising intelligence Project lead information Preparation for premeetings Project lead and visit Review team premeeting Project lead, MDT Visit Review team pre-visit Project lead, MDT meet Ward visit Project lead, MDT Review team debrief Project lead, MDT Ward feedback Senior reviewer, ward Sister, Matron Post- visit Data validation Project lead Summarised report Project lead 40

Sustainability A cost analysis was performed to demonstrate the approximate cost of time dedicated by staff to support the Quality Assurance toolkit. The total cost is based on midpoint of their pay scale and the total amount of hours that member of staff contributed to one visit. Staff Contributed hours Total cost. Graduate management Trainee 8b Senior Matron/ Corporate Nursing 18 180 6 206.04 Unit Nurse Director 5.5 257.91 8c Heads of Nursing/ Management/ Governance leads 5.5 223.90 Band 8b Pharmacist 5.5 189 8a Matron/ General Manager 5.5 157.90 Band 5 PALs 5.5 88 Medical Consultant 1.5 82.15 1,384.90 41

The Quality Assurance Toolkit visits provide Ward to Board Reporting Board External Audits Quality & Safety Forum Health Board Corporate Quality & Safety Service Delivery Unit Management Team QUALITY Ward ASSURANCE FRAMEWORK 42