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): 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 the MINIMUM quality requirements contained within the NHS Standard Contract. The NHS Standard Contract requires providers to run services in line with recognised good clinical or healthcare practice including national standards on quality of care. Bromley CCG will expect all providers to meet these standards and strongly advise potential and existing healthcare providers to understand and implement the Framework. This will be reviewed within contract monitoring. SAFEGUARDING The CCG has a commitment to Safeguarding Adults, Children and Looked-After Children. 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 Page 18 for further information) http://www.bromleyccg.nhs.uk/bccg%20safeguarding%20commissioning%20framework%20-%20july%202017%20final.pdf BCCG Quality Assurance Framework TDS AQP Version 1 1
Guidance Notes The purpose of the Quality Assurance Framework The NHS Standard Contract outlines the requirement for provision of services in relation to Compliance with the Law and NHS Constitution (SC1); Regulatory Requirements (SC2) and Service Standards (SC3). 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. 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. You are not required to complete the parts which are in grey. 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. Please limit word count to 500 per answer. 4. The supporting evidence column is for you to outline available evidence/enhanced evidence. In addition to completing the Quality Assurance Framework the provider will be required to provide ALL relevant policies and procedures where they have been identified as evidence. In addition the provider may be required to provide information which illustrates the impact on: 1. Equality 2. Quality 3. Privacy Who should review the Quality Assurance Framework? Quality Assurance Framework review should be carried out by a general manager or project lead who has responsibility for the service provision. The most important thing is that the individual has an understanding and an insight into quality and safety. 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. NOTE: NHS Standard Contract references are for guidance only BCCG Quality Assurance Framework TDS AQP Version 1 2
Workforce WORKFORCE: GENERAL (GC5) Providers must apply the Principles of Good Employment Practice (where applicable) and the staff pledges and responsibilities outlined in the NHS Constitution Evidence to include: A matrix of all HR policies with review dates, updates to reflect agreed changes and named groups for review A suite of HR Workforce reports outlining key performance indicators and targets for areas such as staff sickness, turnover, retention, stability index, annual appraisals, staff registration, revalidation renewals, and DBS checks (not an exhaustive list) Evidence of frequency and submission to named groups within the business cycle of the organisation and inclusion in business reporting and action plans A process for managing allegations against staff application on Delta for the CCG s HR and Workforce requirements for the Tailored Dispensing Service. Providers must demonstrate the continual evaluation of individual services by: Monitoring actual numbers of clinical staff on duty against planned numbers Monitoring skill mix of clinical staff against planned skill mix Data to be monitored on a shift-by shift basis and by service Publication of detailed reviews of staffing levels and their impact on care at least every 6 months Providers are required to ensure all staff are covered by the Provider s Indemnity Arrangements. APPRAISALS 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 application on Delta for the CCG s HR and Workforce requirements for the BCCG Quality Assurance Framework TDS AQP Version 1 3
Tailored Dispensing Service. QUALIFICATIONS, EXPERIENCE, COMPETENCIES, SKILLS AND TRAINING The Provider 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 appropriate Pre-employment checks including DBS checks The Provider will need to demonstrate that all staff requiring revalidation have these completed by the appropriate professional regulatory body within specified timeframes application on Delta for the CCG s HR and Workforce requirements for the Tailored Dispensing Service. The Provider will be required to undertake an annual staff survey in line with the requirements of the NHS Staff Survey and demonstrate how any negative feedback has been acted upon. MOBILISATION OF STAFF (Relevant to Procurement Process only) Providers will be required to describe their approach and plan to mobilising staff for the delivery of the services and demonstrate its mobilisation capacity. This should be in line with the CCG s key requirements and should include, but not be limited to, the following: A project plan outline with key milestones, mapping activities and risks to timescales with nominated responsible leads, and identifying any other management resources required to deliver effective and timely mobilisation Explanation of the approach for successfully managing TUPE transfers of staff and application on Delta for the CCG s HR and Workforce requirements for the Tailored Dispensing Service. BCCG Quality Assurance Framework TDS AQP Version 1 4
services Confirmation that TUPE/GADE NHS Pensions requirements will apply An outline of proposed use of any additional internal or external agency/bank staff to meet staffing requirements Clinical Professionals CLINICAL PROFESSIONALS Providers will be required to demonstrate: Confirmation of GMC/NMC registration Confirmation of Revalidation of nurses, midwives and doctors Confirmation of professional leadership appropriate to the service Clinical supervision arrangements 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 application on Delta for the CCG s HR and Workforce requirements for the Tailored Dispensing Service. Regulation 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) http://www.cqc.org.uk/sites/default/files/20151230_100001_scope_of_registration_guida nce_updated_march_2015_01.pdf potential supplier information section of the application on Delta. 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. All applicable requirements or enforcement actions issued and remedial action plans arising must be discussed with the commissioner. BCCG Quality Assurance Framework TDS AQP Version 1 5
The Provider must meet its obligations under Law in relation to the production and publication of annual Quality Accounts Infection Prevention and Control INFECTION PREVENTION AND CONTROL APPROACH AND COMPLIANCE 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 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4490 49/Code_of_practice_280715_acc.pdf (date accessed 12/08/2016) application on Delta for the CCG s Infection Prevention and Control requirements for the Tailored Dispensing Service. 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. 6 Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the BCCG Quality Assurance Framework TDS AQP Version 1 6
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 2013-2018 https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistancestrategy-2013-to-2018 (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. https://www.nice.org.uk/guidance/health-protection (date accessed 12/08/2016) Current Care Quality Commission (CQC) Regulations. o Regulation 12 http://www.cqc.org.uk/content/regulation-12-safe-care-and-treatment (date accessed 12/08/2016) o Regulation 15 http://www.cqc.org.uk/content/regulation-15-premises-and-equipment (date accessed 12/08/2016) Health and Safety Executive; Biosafety and Microbiological Containment including Control of Substances Hazardous to Health (COSHH) and Legionnaires Disease http://www.hse.gov.uk/biosafety/index.htm (date accessed 12/08/2016) BCCG Quality Assurance Framework TDS AQP Version 1 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. application on Delta for the CCG s Infection Prevention and Control requirements for the Tailored Dispensing Service. 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) application on Delta for the CCG s Infection Prevention and Control requirements for the Tailored Dispensing Service. BCCG Quality Assurance Framework TDS AQP Version 1 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 application on Delta for the CCG s Infection Prevention and Control requirements for the Tailored Dispensing Service. Medicines Management 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. MEDICINES POLICY You are not required to complete this part application on Delta. The Organisation will provide a Medicines Policy BCCG Quality Assurance Framework TDS AQP Version 1 9
PRESCRIBING, SUPPLY, ADMINISTRATION 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 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 You are not required to complete this part within this document. Please see the application on Delta. EVIDENCE AND GUIDELINE ADHERENCE 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 [See link for local guidelines and policies: South East London Area Prescribing Committee] You are not required to complete this part application on Delta. BCCG Quality Assurance Framework TDS AQP Version 1 10
ANTIMICROBIAL PRESCRIBING Minimum criteria Met Supporting Evidence (Service to complete) 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 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. You are not required to complete this part application on Delta. FINANCIAL AND QUALITY ASSURANCE Medicines Management 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 You are not required to complete this part application on Delta. Incident Reporting INCIDENT REPORTING (SC3.4 SC33) The service will have an Incident Reporting Procedure which complies with the Revised BCCG Quality Assurance Framework TDS AQP Version 1 11
NHS England Serious Incident Framework (2015) https://improvement.nhs.uk/uploads/documents/serious-incidnt-framwrk.pdf AND The Revised Never Events Policy and Framework (2015) https://improvement.nhs.uk/uploads/documents/never-evnts-pol-framwrk.pdf The provider must report any Serious Incident via the Strategic Executive Information System (STEIS) in line with the timeframes set out in the NHS SI framework and ensure that such incidents are also reported to the National Reporting and Learning System (NRLS) and the commissioners.(where the provider is unable to access STEIS reporting is to commissioners and NRLS.) The Provider will be required to show how information is analysed, how root causes are identified, lessons learnt are shared and describe changes which have been made. Providers will need to evidence: Policy and Procedure for Serious Incident and Never Event Management to include a definition of SI/NE that is compliant with the NHS SI Framework A culture of reporting and learning from incidents Collection and reporting Patient Safety data Training for all staff in incident reporting RCA training for all incident investigators Culture of learning from incidents including embedding actions arising from incidents Evidence that changes arising from incidents have been reviewed and are sustainable. Evidence of compliance with the Duty of Candour requirements (see below) BEING OPEN AND DUTY OF CANDOUR (SC35) Being Open and Duty of Candour The provider must demonstrate how it acts in accordance with Regulation 20 of the HSCA 2008 (Regulated Activities) (Amendment) Regulations 2015. The organisational policy/procedure to 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 BCCG Quality Assurance Framework TDS AQP Version 1 12
Breach implications Minimum criteria Met Supporting Evidence (Service to complete) Complaints Handling COMPLAINTS HANDLING (SC16) The Provider must publish, maintain and operate a written complaints policy and procedure which is compliant with the NHS Complaints Regulations (2009) http://www.legislation.gov.uk/uksi/2009/309/pdfs/uksi_20090309_en.pdf and will include: Definition of a reportable complaint Accountability/ Complaints lead Sign off process Role of Parliamentary & Health Service Ombudsman including reference to Principles of Good Complaints Handling (PHSO) Compliance with timeframes for acknowledging, processing and responding to complaints Support for complainants Explanation of how the organisation monitors and learns from complaints Methods of investigation i.e. conducting interviews, reviewing records etc. Providers are required to comply with NHS Digital 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 COMMUNICATING WITH/INVOLVING SERVICE USERS, PUBLIC AND STAFF (SC12) The Provider will be required to evidence: partnership working across professional and service boundaries to ensure patients experience co-ordinated, high quality care. compliance with the Accessible Information Standard active engagement with service users, carers and families, staff and stakeholders in an open and clear manner seeking feedback as appropriate Providers will be required to submit evidence of: BCCG Quality Assurance Framework TDS AQP Version 1 13
Minimum criteria Met Supporting Evidence (Service to complete) carrying out FFT Surveys in accordance with guidance carrying out annual staff surveys (including NHS Staff Survey) Acting on surveys WHISTLEBLOWING/FREEDOM TO SPEAK UP (GC5) 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 The provider has a named Freedom to Speak Up Guardian in place (in line with the NHS Standard Contract) Business Continuity & Emergency Planning EMERGENCY PLANNING (SC30) The provider is able to evidence progress on its EPRR workplan The Provider has a major incident response plan to include: Trigger Levels Response Management Roles and Responsibilities Command and Control arrangements BUSINESS CONTINUITY The organisation has aligned their organisational business continuity arrangements and business continuity management process to ISO 22301. The organisation has a business continuity policy and a business continuity plan which clearly outlines: The process of analysis, development and implementation of plans and testing and review of plans BCCG Quality Assurance Framework TDS AQP Version 1 14
Minimum criteria Met Supporting Evidence (Service to complete) The roles of responsibilities of those involved and plan activation 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 and Diversity EQUALITY & DIVERSITY (SC13) The provider must demonstrate the following: The organisation has implemented the NHS Equality Delivery System (EDS2) 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 recorded and 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 The organisation can provide evidence on how it ensures employees with a disability have equal access to career opportunities and receive fair treatment in the workplace using the NHS Workforce Disability Equality Standard (WDES) template. BCCG Quality Assurance Framework TDS AQP Version 1 15
Pastoral, Spiritual and Cultural Care (SC14) Minimum criteria Met Supporting Evidence (Service to complete) Provider must take account of the spiritual, religious, pastoral and cultural needs of service users Information Governance INFORMATION GOVERNANCE (SC28) (GC 20/21) 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 application on Delta the CCG s Information Governance requirements for the Tailored Dispensing Service. 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 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 and then integrate the results The organisation is ensured compliance at all times with obligations for Information Security requirements to identify risks and incidents they have a responsibility to manage. 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 BCCG Quality Assurance Framework TDS AQP Version 1 16
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 The organisation must have in place an implementation plan to be compliant with General Data Protection Regulation by 25 May 2018. Health & Safety HEALTH & SAFETY (SC1) 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; ONLY COMPLETE IF APPORPRIATE TO YOUR ORGANISATION/BUSINESS Risk Assessments Manual Handling processes COSHH assessments RIDDOR reporting Fire Safety procedures This list is not exhaustive Conflicts of Interest CONFLICTS OF INTEREST (SC24) 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 (Nolan grounds for discretionary exclusion section of the application on Delta. BCCG Quality Assurance Framework TDS AQP Version 1 17
Principles) Minimum criteria Met Supporting Evidence (Service to complete) Evidence adherence to NHS England guidance on Conflicts of Interest published in February 2017. https://www.england.nhs.uk/wpcontent/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf Safeguarding SAFEGUARDING (SC32) Bromley CCG Safeguarding Procurement Standards form part of the overall Safeguarding Commissioning Framework. It forms part of the overall published procurement documentation. The Safeguarding Procurement Standards are in two categories: Essential and Additional Quality Standards. The Essential standards will be used for the Standard Selection Question phase of procurement (self-assessment by prospective bidders). Subsequently, the Additional Quality Standards will be used for the Invitation to Tender phase. Both categories of standards will be used to evaluate subsequent bidder submissions. application on Delta. The following hyperlink will take you to the Safeguarding Procurement Standards document: http://www.bromleyccg.nhs.uk/safeguarding%20procurement%20standards%20d ocument%20-%20%20june%202017.docx BCCG Quality Assurance Framework TDS AQP Version 1 18