QUALITY STRATEGY 2012-2016 SPONSOR: Sue Hardy Director of Nursing Signature: AUTHORS: Sue Hardy Director of Nursing Denise Flowers Associate Director Clinical Effectiveness APPROVED BY: Southend University Hospital NHS Foundation Trust Board Signature of Chair: Date Issue No 1 ISSUE AND REVISION RECORD: Details New Strategy Review date
PAGE : 2 of 11 Contents 1 Strategy Statement..3 2 Definition of Quality..3 3 Clinical Governance Framework 5 4 Implementation...6 5 Delivering high quality care.7 6 Making it happen the enablers 8 7 Monitoring and review..8 8 People and skills...9 9 References...9 10 Appendix 1....10 11 Appendix 2.11 2
PAGE : 3 of 11 1 Strategy Statement Southend University Hospital NHS Foundation Trust s (SUHFT) vision is to deliver excellent care, by excellent people. This quality strategy sets the context, framework and direction for the delivery of clinical services across the Trust and determines the important principles and actions required to deliver high quality services for the future as an integral part of the Trust vision. It also provides detail of the outcomes identified for quality improvement and how these will be monitored. The Trust vision is embodied in core values and beliefs, which are anticipated, will be at the heart of our culture striving for continuous improvement in the quality of care the Trust delivers. Specifically the core values and beliefs underpin this quality strategy by identifying that: Everything matters - Patients and staff have the right to know what quality of care they should expect and the quality of care that the Trust expects staff to provide for our patients. Everybody counts - All Patients and staff should be aware that every contact with every patient and every member of staff counts and that we strive to continuously improve systems and processes that we have in place to promote the patient experience to be the best it can be. Everyone is responsible By each individual acknowledging and believing that all staff are responsible and can make a difference to patient care, which will raise the quality of care to the heart of everything that we do. All that we set out to do in relation to quality should be in partnership with our patients. We recognise that the delivery of high quality services can only be achieved by all our staff, both clinically working directly with patients and those staff who support them, keeping quality as our top priority. It is important that our staff feel supported and empowered in their work which in turn, will support the delivery of quality and safety at a local level, clearly owned by the staff involved. In order to support staff in ensuring continuous quality improvement we need to define clearly what is meant by quality so that we can benchmark ourselves against best practice, where available, and provide clear information for our patients and the public about the quality of services that they can expect to receive. Definition of Quality Southend University Hospital NHS Foundation Trust embraces the three key components of High Quality Care for All (June 2008), where quality was placed as the organising principle in the NHS. Quality was defined in relation to three domains: 3
PAGE : 4 of 11 Patient Safety there will be no avoidable harm to patients from the healthcare they receive, this means ensuring that the environment is clean and safe at all times and that harmful events never happen. Clinical effectiveness the most appropriate treatments, interventions, support and services will be provided at the right time to those patients who will benefit. Patient Experience the patient s experience will be at the centre of the NHS approach to high quality care. High Quality Care for All proposed that all NHS providers should produce a Quality Account: an annual report to the public about the quality of services delivered. The Heath Act 2009 made this a statutory responsibility and Southend University Hospital NHS Foundation Trust published their first Quality Account in July 2010 and annually thereafter. As part of the Quality Account, the Trust, in liaison with its governors, members and partners, identify 9 areas for quality improvement for the each year, linked to the 3 domains above. However, the Trust recognises that to deliver a comprehensive, organisation wide approach to high quality care, requires more ambition and drive than just the areas in the Quality Account allow. This strategy brings together the strategic vision and corporate objectives for the Trust Strategic Theme 1- Patient Focus keep getting better, to provide a 4 year ambition for quality improvement. The ultimate purpose of the Quality Strategy is to set a framework for quality improvement, with local ownership and drive which supports the delivery of safe, clinically effective acute services, consistently focussed on the needs of the patient. SUHFT Trust Board of Directors has identified the organisations top three quality priorities as: Leadership for quality Ultimately this is the foundation of our quality strategy by being clear that quality of care is the focus of the Board of Directors which cascades throughout the organisation. The Trust Board will consistently review the measures it sees to continually update, challenge and seek assurance on the quality of care given to the patient. All board members will be part of the patient safety walkabout sessions which clearly place the directors at the heart of patient care, with our staff seeing that quality of care is important to them and the organisation. However, leadership for quality does not just lay with the Trust board. Work-streams will be led by clinicians and clinical leads, providing further influence and motivation to clinical teams to achieve the goals set out within the Trust s strategic objectives. Accountability for quality of care in front line clinical services will be with the business unit director and their teams, thereby allowing prompt actions to be taken when continuous improvement opportunities are recognised. Leadership lies with every one of us and in line with our core value that everyone is responsible, our aim is to instil the belief and commitment that leadership for patient care is the priority for every member of staff who has any contact with a patient. 4
PAGE : 5 of 11 Improving the patient experience A patient judges their experience on a number of fronts, but the national surveys of patient s experiences has clearly shown that our patients expect and deserve to be treated with care and compassion by our staff. If the patient experience is poor, it not only harms the reputation of the Trust, but also diminishes our staffs satisfaction in the work they do. This quality strategy therefore identifies specific work-streams to move this vital area of work forward. Work identified will be escalated and monitored through the Quality Assurance, a sub-committee of the Trust board, thereby allowing review and challenge to continuously improve the patient experience. We will actively seek to inspire our patients with confidence that their comfort and wellbeing is our goal. Continuous review of the friends and family net promoter score, as well as other methodologies accessing feedback on the patient experience, will help us attain the high standards of patient experience we wish to achieve. Improving clinical outcomes and avoiding harm Our patients expect and deserve to have a positive outcome from the care they have received, with no actions or omissions in their care which may inadvertently cause them harm. As a hospital which aspires to excellence, we are clear in our goal to eliminate any avoidable harm for patients in our care. We actively seek to learn from any mistakes we make, with a fair and just culture which supports the continuous learning cycle. Our patients deserve to leave our care in the knowledge that we have improved their outcome in the clinical choices they have made. We believe in the standard of no decision without me and will continually focus on this as a means to involve patients in the decisions supporting their care. 2 Clinical Governance Framework Clinical Governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish (Scally & Donaldson, 1998). Leadership for quality has been strengthened over the last year with the development of the Clinical Assurance, which holds the Business Units to account for the quality of care being delivered within the organisation. SUHFT is committed to demonstrating excellent clinical governance, which underpins the concept of Ward to Board and Board to Ward, with quality information moving fluidly through the organisation. SUHFT has a range of systems and processes that support the delivery of good clinical governance, specifically: The Trust will track on-going performance and drive improvement relative to quality priorities at Business Unit (BU) level through the review of integrated balanced scorecards and reporting to the executive directors in a confirm and challenge performance management process. Quality information is also expected to be reviewed and debated through the BU clinical governance meetings which ultimately report to the organisation s Clinical Assurance (CAC). 5
PAGE : 6 of 11 BU s will provide quarterly reports to the CAC through the completion of compliance bundles identified through the development of the Care Quality Commissions (CQC) Provider Compliance Statements, which ultimately provide evidence of compliance with CQC standards and high quality of care. Corporate and trust-wide clinical activities for example safeguarding, blood transfusion, medicines management (Appendix 1) will all provide quarterly reports to the CAC. A Clinical Assurance Progress Report will be received by the Quality Assurance on a quarterly basis, which will give a comprehensive overview of clinical outcome measures; trust wide quality measures; patient safety indicators; national standards; and Directorate Quarterly Reports. The Quality Assurance (QAC) is a sub-committee of the Board and will be responsible for scrutinising the report in detail. The clinical governance and quality structure which supports this framework can be found at Appendix 1. 4 Implementation The quality strategy applies to all employees of; or individuals contracted to work on behalf of SUHFT, since everyone is responsible for the provision of high quality care. Our vision for quality is that SUHFT and its partner organisations have clear sight that everything matters to our staff which will allow them to focus on high quality care; specifically: The Trust will have a culture of continuous improvement through clinical leadership and devolved responsibility to Business units. Quality will be at the heart of planning and performance management, with quality related objectives in every cost and service improvement plan. The Quality Strategy will support and drive the organisation s strategic objectives. The Trust s quality priorities will be linked specifically to the strategic objectives and will be chosen to improve safety, clinical effectiveness and patient experience. The Trust will work in partnership with Commissioners and other key stakeholders including the public to deliver high quality care. The Trust will build on its culture of learning lessons when things go wrong to improve quality. To achieve this vision: Patients will: Be treated as individuals and have their individual needs taken into account. 6
PAGE : 7 of 11 Be treated with compassion, respect and dignity. Be involved in their own care. Be kept fully informed and share in decision making about their care. Have any concerns addressed as early as possible. Be clearly communicated with. Be cared for in a clean and safe environment. Receive appropriate right treatment at the right time in line with national guidelines. Achieve the best possible clinical outcomes. Have a positive experience. Staff will: Be proud of the care we give and have quality at the heart of everything that we do. Treat patients with dignity and respect and be consistently person-centred. Will identify at least one quality objective to be included in their personal objectives each year. Will promote safety within their work environment and actively participate and promote a culture of continuous learning and incident reporting. Will be supported with appropriate education and training to provide high quality care for our patients. Will focus on learning lessons and improving quality when mistakes are made. Will share the learning when things go well. 4 Delivering high quality care SUHFT has defined its strategic objectives and classified them into six themes: Patient Focus keep getting better Sustainability - keep the core strong Sustainability - grow selectively Research Education & Innovation- investing in the future Staff feel proud to work here & keep making a difference Partnership - our hospital, our community Outcome measures have been determined within the Trust s strategic objectives, which now shape the quality strategy for the next four years. The outcome measures are not intended to be exclusive as innovation from staff will continue to flourish and influence the direction of travel for providing high quality care. The outcome measures for quality of care are: To be in the top 20% of Trusts in the national patients experience survey. Clinical outcomes will be in the top quartile of Trusts in England, as measured against the national outcomes framework. The standardised hospital mortality index (SHMI) will be in the top quartile of Trusts. We will see a year on year 10% reduction in complaints. 7
PAGE : 8 of 11 We will see an increase in proactive incident reporting and aim for no recurrent serious incidents. Provide evidence of a clinical audit programme which identifies adherence with best practice. That we reduce variation in mortality and morbidity by providing a 7 day consultant led service. Work-streams will be identified on an annual basis, supported by the service improvement team, thereby providing a project structure approach in supporting the achievement of the above outcomes (Appendix 2). A wide range of activities will support the work-steams and underpin the delivery of the outcome measures. 5 Making it happen the enablers There are key policies and procedures in place which support the delivery of the quality strategy. There is recognition of the need to adhere to best practice wherever defined and follow local policies where not. Key knowledge components are essential to achieving this and include, but are not limited to the following: NICE Guidance Implementation. NSF Standards Adherence. National Policy development. National and local review recommendations. National and Local Clinical Audit findings. Local and national research and innovation developments. Local and national incident trend analysis. Infection control benchmarking analysis. Complaints and compliments. Serious incident lessons learned evaluations. Locally developed patient safety and care quality toolkits. Provision of support by the clinical directorate and clinical networks. Effective clinical engagement and leadership. Development of knowledge management procedures. Provision of assurance through the use of outcome measures and benefits realisation. Quality Impact Assessment policy 6 Monitoring and review The quality strategy will be reviewed annually in line with best practice. Ultimately the QAC will be responsible for reviewing the quality strategy and monitoring its effectiveness. This will be delivered through: Quality reports provided from the CAC Review of the Clinical Assurance Progress Report Reporting against the Trust Quality Account priorities through a Quarterly Quality Account update. 8
PAGE : 9 of 11 Trust Board of Directors monitoring of the Trust strategic objectives Provision of a bi-annual report from the strategic Theme 1 Steering Group responsible for monitoring the work of the work-streams delivering Patient Focus - keep getting better. 7 People and skills Measures are in place to safeguard that staff have the relevant knowledge, competencies and capacity to support the delivery of the quality strategy. The measures include the specific and relevant training and guidance that staff will require. The Trust undertakes to ensure all staff, regardless of level, providing patient contact and care fully understands the importance of this strategy and providing high quality care for patients, services, business units, the Trust as a whole and our external partners. 8 References High Quality Care for All: NHS Next Stage Review, Darzi, Department of Health (2008) Clinical Governance and the drive for quality improvement in the new NHS in England, Scally & Donaldson; (1998). 9
Appendix 1 Quality and Governance Strategy/Structure Trust Board Quality Assurance Clinical Assurance Assurance Reporting Management s Dr Foster Reports and Action Plans National Audit Overviews and Action Plans Safeguarding Adults and Children Training and Action Plans Complaints and PALS Trend Analysis and Action Plans Governance and Audit committee Resuscitation Safe Guarding Hospital Transfusion Clinical Effectiveness Reports and Action plans Litigation Reports and Action Plans Health and Safety Patient and Carers Experience Forum QRP Compliance Central Alert Status and Action Plans Medicines Management Research and Development Incidents Trends Analysis and Action Plans PROMS Quarterly Compliance and Action Plans Serious Incident Reports and Action Plan Implementation NICE Quarterly Compliance and Action Plans Infection Prevention and Control CQC Compliance and Action Plans New High and medium Risk Assessments (Clinical) Facilities compliance reports and action plans Governance Business Unit Compliance Bundles
Appendix 2 GOVERNANCE STRUCTURE QUALITY STRATEGY STEERING GROUP