Quality Framework 2013-2018 Supplemental
Staffordshire and Stoke on Trent Partnership Trust Quality Framework 2013-2018 Supplemental Robin Sasaru, Quality Team Manager Simon Kent, Quality Team Manager Contents 1. Drivers for quality... 3 2. Defining Quality... 10 3. Using the best approach for quality... 13 Page 2 of 14
1. Drivers for quality While there are many national and regional drivers for quality, this section references the drivers that relate primarily to the overarching Quality Framework. Strategies that sit under this framework will make reference to the drivers for that particular area. Quality is central to the Staffordshire and Stoke on Trent Partnership Trust vision: We deliver personalised care of the highest quality, with the best possible outcomes for users and carers, empowering them to remain independent Our values and goals run through the core of our Quality Framework ensuring that quality care and safety is at the heart of everything we do for our people and their families. We put quality first. The Trust s Strategic Organisational Goals: we will provide high quality and safe services which provide an excellent experience and best possible outcomes we will work with partners, users and carers to deliver integrated services simply and effectively our organisation will develop and deliver sustainable innovative services that support independence our workforce will be empowered and supported to deliver care in a way that is consistent with our values we will make excellent use of our resources and improve levels of efficiency across our services The Trust s Organisational Development Strategy contains three organisational objectives that are aligned to quality: Create a culture where individuals are empowered to fulfil their roles and support the Trust s vision. Develop our leaders to be ambitious, innovative, empowered role models for other staff. Support the continuous improvement of the Partnership Trust so that it is effective, efficient and delivers quality safe care that meets the needs of the population it serves. The Partnership Trust is determined to continue to be a beacon and leader of enlightened Equality, Human Rights and Inclusion policies and practices in Staffordshire. The trust s three equality objectives are closely related to the quality agenda. Page 3 of 14
The shared agendas of the Staffordshire Strategic Partnership outlines a commitment from partner agencies with regard to ensuring that Staffordshire will be a safe, healthy and aspirational place to live. The NHS Next stage review (2009) led by Lord Darzi, published high quality care for all. This document advocated that quality should be the prime focus and driving force for the NHS over the next decade. It also provided a general definition of quality under, Effectiveness and. High quality care for all introduced a Quality Framework as the national strategy for quality improvement. The Partnership Trust has already responded to this Quality Framework in its 2011/12 Quality Account. Figure 3: The Quality Framework and the Partnership Trust response 1 Quality Framework: guidance for community services (2009) is best practice guidance that sets the direction for implementing the national Quality Framework within community services. The guidance describes evidence-based interventions, which will help make every service as good as the best. Whilst they are designed principally for front-line staff and clinical team leaders, commissioners will use them to inform service specifications, and with the indicators in the Quality Framework, 1 Transforming Community Services: Quality Framework: Guidance for Community Services, Department of Health, 24 Jun 2009. Access via http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalas set/dh_101426.pdf Page 4 of 14
track improvement. Through the implementation of the framework the Partnership Trust aims to: improve people s experience of health and social care enables and drives a culture of continuous improvement embed quality as the organising principle driving the Trust agenda promote accountability across all stakeholders Equity and Excellence: Liberating the NHS (2011) and the subsequent Health and Social Care Act 2012 affirmed the desire to ensure that health services in England achieve quality and outcomes which are among the best in the world and identified a number of reforms that relate to the quality agenda, in particular: Putting service users at the centre of care; no decision about me without me Creation of an NHS outcomes framework which will span the three areas of quality ( ) Establishment of Local / National Healthwatch, Health and Wellbeing Boards, Clinical Commissioning Groups and a National Commissioning board Strengthening the roles of the Care Quality Commission, the National Institute for Health and Clinical Excellence, and Monitor. The NHS Outcomes Framework sets out the national outcome goals that the Secretary of State for Health will use to monitor the progress of the NHS Commissioning Board. The NHS Commissioning Board will commission the National Institute for Health and Clinical Excellence (NICE) to develop Quality Standards which will set out the evidence-based characteristics of a high quality service for a particular clinical pathway or condition. These standards will, where appropriate, look across several or all five domains of the NHS Outcomes Framework. The framework recognises the importance of aligning outcomes for health and social care, developing a shared accountability where appropriate. Further alignment of outcomes is stated as desirable in future years, as a means of encouraging collaboration and integration. The Department of Health has also published Transparency in Outcomes: a Framework for Quality in Adult Social Care. This framework is based on being clear about what high quality looks like in adult social care, agreeing a data set which supports councils and communities to understand progress and to hold their organisations to account and making information on the quality of social care and outcomes achieved available for the public, service users, carers, commissioners and managers. There are three key elements in the framework: Page 5 of 14
1. The National Data Set for Adult Social Care a single, agreed set of data requirements which encompasses all routine social care information derived from council sources. In the first year this will be made up of the existing Referrals, Assessments and Packages of Care (RAP) data, Adult Social Care Combined Activity Return (ASC-CAR) data, Abuse of Vulnerable Adults (AVA) data and other data returns; 2. A set of outcome-focused measures of performance that will allow councils and citizens to interpret the raw data and paint a picture of what social care is achieving locally; and 3. A Local Account a self-assessed account of the quality and outcome priorities which the council has chosen, in consultation with its partners, and the progress it has made in achieving them during the past year. The Vision for Social care (2010) and Think local act personal (2010) emphasises a system that helps people to live their lives the way they want to, supported by the staff who work with them. The approach aims to free the front line from bureaucratic constraints and support local organisations to focus on the quality of care and the outcomes achieved for people using services and their carers, without the focus on targets. A particular example of this is the Making It Real 2 (2012) key themes and criteria, based on a public commitment to improving quality in social care. The key themes are based on I statements, which emphasise quality as dependent on service user requirements. The National Quality Board (NQB) is a multi-stakeholder board established to champion quality and ensure alignment in quality throughout the NHS. The Board is a key aspect of the work to deliver high quality care for service users. The NQB 2012 draft paper Maintaining and improving quality from April 2013 3 highlights the nature and place for quality in a changing healthcare system, the different parts of the system together with the corresponding roles, responsibilities and expected values and behaviors to put service users and the public first. The NQB 2010 Review of early warning systems in the NHS presents lessons to be learned from investigation and review of NHS organisations (notably the Francis Enquiry into Mid-Staffordshire NHS Foundation Trust) and makes clear that safeguarding patients is the responsibility of every organisation and every member of staff. In addition, a further report from a Public Inquiry is anticipated in early 2013 4 2 See http://www.thinklocalactpersonal.org.uk/ 3 Quality in the New Health System Maintaining and improving quality from April 2013. A draft report from the National Quality Board. 16 th August 2012. Access via https://www.wp.dh.gov.uk/publications/files/2012/08/quality-in-the-new-system-maintainingand-improving-quality-from-april-2013-final-2.pdf 4 www.midstaffspublicinquiry.com Page 6 of 14
The Care Quality Commission (CQC) is the independent regulator of all health and social care services in England. Its essential standards of quality and safety outline the basic essential service quality that our organisation should always achieve. There are numerous reports on the CQC website related to quality; high profile cases such as the investigation into services at Cornwall Partnership NHS Trust, and the closing of a care home in Haringey following inspection, present significant learning opportunities for all care providers. The Commissioning for Quality and Innovation (CQUIN) scheme is a key driver to ensure Boards maintain a focus on the delivery of a quality service. The scheme allows commissioners to retain a proportion of a Trust s income. The Trust is required to meet a series of pre-agreed quality markers to obtain that portion of the funding, and this allows both parties to ensure quality is integrated into the development and delivery of care. The CQUIN system incentivises quality improvement and innovation over and above that required within the commissioned service. At its best, the CQUIN scheme should be much more than payment linked to meeting quality markers, it is intended to be one of the ways to have shift in focus to a continuous improvement culture amongst commissioners and providers and commissioning for quality. CQUIN schemes represent an investment by commissioners in quality improvement and innovation. The National Patient Agency (functions now transferred to the NHS commissioning board) was set up in response to a recognition that the same things go wrong again and again 5. The agency set up a National Reporting and Learning System, the world s most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause. The Monitor Quality Governance Framework was introduced into the assessment process for Foundation Trusts in 2010. A Quality Governance assessment is now part of the Foundation Trust application process, and there is a requirement for the Boards of both new and existing NHS Foundation Trusts to self-certify with regards to quality governance. Monitor is looking for evidence that: boards accurately understand the quality of the care their organisation provides boards are able to assess and mitigate risks to quality quality is seen as a responsibility of the entire board, not only the medical and nursing directors trusts are committed to continuous quality improvement, and have put in place the tools to address poor performance 5 Organisation with a memory. Department of Health 2000 Page 7 of 14
Our Commissioners (Primarily the Clinical Commissioning Groups and the NHS Commissioning board) each have priorities for quality improvement, which will influence this framework s supporting strategies and workstreams. Perhaps most importantly, our service users are a key driver for quality: it is predicted that there will be an increase in population age and health need support for carers will become increasingly important Involvement of service users and carers is essential for quality Our evolving model for quality will learn from a local and national knowledge base, taking into account any conclusions, recommendations and findings from reports such as the Mid Staffordshire NHS Foundation Trust Public Inquiry, which is due to be published in 2013, and the Care Quality Commission Winterbourne View report (July 2011). Figure 4: Other drivers and the strategies / policies that will reference them Other drivers for quality Patient Function of the NHS Commissioning Board (formerly National Patient Agency) Commissioning for Quality and Innovation NHS institute: (including productive series) National Institute for Health and Clinical Excellence National Advisory Group on Clinical Audit & Enquiries and the Healthcare Quality Improvement Partnership NHS constitution express NHS Litigation Authority Patient Environment Action Teams Thermometer Customer Service Excellence Equality Delivery System Quality, Innovation, Productivity and Prevention (QIPP) Commissioning for Quality and Innovation Payment Framework Strategies / Policies that will reference them Risk Management Risk Management Transformation, Effectiveness Effectiveness Clinical Audit, Transformation, Transformation, Transformation,, Effectiveness Effectiveness, Effectiveness,, Transformation Effectiveness, Page 8 of 14
Other drivers for quality Making it real Think local act personal National Quality Board (e.g. Review of early warning systems in the NHS ) Staffordshire & Stoke on Trent Adult Safeguarding Interagency Adult Protection Procedures OFSTED and Joint Children and Young Peoples Services inspections e.g. looked after children and children with disabilities inspections. Independent Safeguarding Authority Leading Improvement in Patient (LIPS) Starting Out: Common Induction standards www.skillsforcare.org.uk Professional body standards (e.g. Nursing and Midwifery Council code of conduct) National Institute for Health Research NHS Operating Framework The CARE campaign www.thecarecampaign.co.uk Being open: communicating patient safety incidents with patients, their families and carers Health and Wellbeing Boards and commissioners (CCGs) Department of health Guidance for NHS trusts on the NHS friends and family test The Shipman Inquiry The Bristol Inquiry The Victoria Climbié inquiry The safe and secure handling of medicines: a team approach (Royal Pharmaceutical society of Great Britain) Patient and Public Involvement in Health: The evidence for policy implementation (Department of Health) Patient Involvement and Public Accountability: A report from the NHS future forum Whistle blowing policy Strategies / Policies that will reference them Effectiveness, Effectiveness, Effectiveness Effectiveness, Effectiveness, Quality Assurance Programme Page 9 of 14
2. Defining Quality In order to clearly define a framework for quality, a clear and trust wide definition of quality must be agreed that encompasses health and social care. This section aims to pull some of the key health and social care descriptions of quality into one agreed definition, on which the framework itself can build on. The NHS has worked around a shared definition of quality set out by Lord Darzi 6 with three elements: : The first dimension of quality must be that we do no harm. This means ensuring the environment is safe and clean, reducing avoidable harm such as reducing the number of preventable pressure ulcers and reduced injury as a result of a fall. It also means safeguarding vulnerable people from harm. : Quality of care includes quality of caring. This means providing personalised care, treating people with compassion, dignity and respect. It can only be improved by analysing and understanding service user s satisfaction with their own experiences. Effectiveness: This means understanding success rates from different treatments for different conditions. Assessing this will include clinical measures such as mortality or survival rates, complication rates and measures of clinical improvement. Just as important is the effectiveness of care from the service user s own perspective for instance improvement in pain-free movement after an operation, or returning to work after treatment. Effectiveness extends to people s well-being and ability to live independent lives, receiving personalised care through assessment and support planning processes. All three of these elements must be present at the same time to ensure high quality delivering on just one or two is not enough. The Social Care Institute for Excellence (SCIE) describes excellence in social care: Excellence in social care is rooted in a whole-hearted commitment to human rights, and a continuous practical application of that commitment in the way that people who use services are supported. People who use services are demonstrably placed at the heart of everything that an excellent service does. (A definition of excellence for regulated adult social care services in England, SCIE 2010) 6 High Quality Care for all: NHS next stage review final report. Department of Health June 2008. Access via http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_0 85825 Page 10 of 14
SCIE identifies four essential elements of excellence in social care: having choice and control over day-to-day and significant life decisions maintaining good relationships with family, partners, friends, staff and others spending time purposefully and enjoyably doing things that bring them pleasure and meaning. the organisational and service factors which enable the above three outcomebased elements to be achieved and sustained. SCIE differentiates between Essential (i.e. good enough ) and Excellent services, and describes how focussing on outcomes for the individual and attempting to enable individuals to have the greatest possible control over their own life, means that the service will be doing an excellent job. Standardisation is a recognised way to quality in many industries. It is important that the need for standardised processes and consistency of approach based on evidence and best practice in care is not omitted in order to emphasise the need for flexible and patient centred services. These are two sides of the same coin. Quality is everyone s business. It is not the responsibility of any one part of the system, it is a collective endeavour. Quality requires collaboration at every level of health and social care. It includes working together for a common purpose, appreciating each others contribution. Our ultimate aim is to improve outcomes for our service users. Even in health and social care, services that are evidence-informed, highly skilled and sometimes technically complex, an underlying principle that only the customer can define quality drives many definitions of this term. Service users expect high quality service in line with best practice, and monitoring this requires objective and measurable standards. There are many phrases that people think of when considering the definition of quality : Right people at the right time Getting it right first time With realistic expectations Getting the right services for them based on sound clinical evidence Goal based, personalised and planned with the consent and involvement of service user Delivered consistently by experienced skilled competent caring and motivated staff Sufficiently flexible to responding to changing need. Page 11 of 14
Care delivered in the best place (e.g. at home or as close to home as possible whilst ensuring safety and effectiveness) Using the most appropriate medication and equipment Cost effective Leading to the best possible outcomes With minimum risk of adverse outcomes Problems, issues, incidents and concerns are recognised and addressed as they arise, lessons are learned and changes made to improve services and reduce risk of recurrences Safe discharge from services Effective and appropriate ongoing or long term support services where needed Minimising for as long as possible the need for more intensive services Maximising ability to care for oneself and enjoy activities of daily living for as long as possible Minimising the risk of future unplanned or emergency services care that people approaching the end of life receive is aligned to their needs and preferences While there may be different definitions and descriptions of quality, everyone in our trust should have the same understanding of quality. Our view of quality uses, Effectiveness and as a common starting point. We recognise that minimum levels of quality in these areas require a swift response, and that a culture of continuous improvement means that our minimum levels of quality will constantly increase. In summary, quality refers to our service user and carer requirements; expressed in terms of safety, effectiveness, and experience; and ultimately focussed on outcomes. We therefore subscribe to the definition put forth by Darzi as follows: High quality care is where; service users are in control, have effective access to treatment or care, are safe, and where illnesses are not just treated, but prevented. Page 12 of 14
3. Using the best approach for quality Using the underlying simple principles 7 from a variety of methodologies, our approach to Quality includes a focus on: understanding the problem with a particular emphasis on what the data says understanding the processes and systems within the organisation particularly the service user pathway and whether these can be simplified analysing the demand, capacity and flows of the service choosing the tools to bring about change, including leadership and clinical engagement, plus staff and service user participation evaluating and measuring the impact of a change While there are many approaches to quality improvement, across healthcare, social care, and industry, they are often based on similar principles and a common body of tools for improvement. Drawing on work by the NHS Institute for Innovation and Improvement 8, our common approach to quality improvement is: define quality first identify the process beware of the exclusive promotion of one approach to quality improvement think about who the customer is understand the people the individuals working in the system and their behaviours get data about quality before you start recognise the importance of whole system leadership Our approach to quality includes individual behaviours as well as improvement of systems and processes. We also recognise the need to involve service users in quality assurance and quality improvement. 7 Quality Improvement Made Simple: Identify, Innovate, Demonstrate, Encourage. The Health Foundation - Inspiring Improvement. 6 th September 2010. Access via http://www.health.org.uk/public/cms/75/76/313/594/quality_improvement_made_sim ple.pdf?realname=udczzh.pdf 8 Quality Improvement: Theory and practice in healthcare. NHS institute for innovation and improvement. Access via http://www.institute.nhs.uk/index.php?option=com_joomcart&main_page=document_product_info&pr oducts_id=403&cpath=67 Page 13 of 14
There are clear synergies between the approaches outlined above and the organisation s social care Quality Framework: Figure 5: social care Quality Framework diagram Only the customer can define quality; learn what is important to customers Define and refine standards Measure how well we are meeting these standards Take action to address unmet standards Monitor customer satisfaction Continuous quality improvement is a philosophy that intends that most things can be improved and is the scientific method of improvement in everyday work. Plan-dostudy-act cycles and quality circles are examples of techniques that embrace this philosophy of quality as a journey not a destination. In line with the overall direction of the framework, it is important to support, develop and share local team based improvement initiatives. This highlights the importance of developing a culture supporting the testing of quality improvement initiatives at a local level. Staff and service users are the best source of information about quality of services. This means that the organisation must always acknowledge of the role of staff and service users, and respond to concerns and suggestions. Page 14 of 14