Operational Delivery s Sample Template Operational Policy October 2014 Document MTN-OP-03-10-14
Classification: General Organisation Document Purpose Title Author Operational Delivery s Guidance Sample Operational Policy Template Document MTN-OP-03-10-14 Sue Shepherd and Chris Jones Date and Version October 2014, Version 1.2 Linkages Circulation Description Peer Review Report and Action Plan Annual Report Objectives Work Programme Directors/Managers (for further dissemination to colleagues) This document outlines a template for Operational Delivery s to assist in the development of an Operational Policy to underpin the National Peer Review Process. Indicative headings are provided with a description of suggested section content. This document is intended as an example. Point of Contact Chris Jones and Sue Shepherd Chris Jones Leeds Centre The Leeds Teaching Hospitals NHS Trust Leeds General Infirmary Great George Street Leeds LS1 3EX chris.jones27@nhs.net Contact Details Sue Shepherd Mid Trent Critical Care and East Midlands East Midlands Ambulance Service NHS Trust Beechdale Road Bilborough Nottingham NG8 3LL sue.shepherd@emas.nhs.uk Sue Shepherd, Chris Jones Page i Version 1.2, October 2014
Document Description This document outlines a template for Operational Delivery s to assist in the development of an Operational Policy to underpin the National Peer Review Process. The authors have developed this template as an example and use the term throughout. However, this template can be utilised by Centres and Units by substituting the word for service, MTC or TU as applicable. Indicative headings are provided with a description of section content and are intended to be constructive. The document is one of 3 templates produced to assist s in the writing of a series of documents to underpin the Peer Review process in an attempt to reduce the administrative burden in terms of document submission and review. Further templates include a sample Annual Report (Document MTN-AR-01-10-14) and Work Programme (Document MTN-WP-02-10-14) and Table 1 provides an outline of the suggested content of each document. A matrix identifying where each of the National Peer Review Measures fit within these 3 documents is also included (Document MTN-PRM- 04-10-14). Measures relevant to this document (i.e. those indicated as Operational Policy in the Matrix document) are included in Appendix 1. Relevant Policies and Procedures can be included as appendices to the Operational Policy. Table 1 Outline of National Peer Review Supporting Document Content Annual Report Work Programme Operational Policy Provides a summary assessment of key achievements and challenges within the agreed time period Provides a summary of implementation of previous year s work-programme (including progress on implementing actions from previous reviews) Demonstrates that the is using available information and relevant data to assess its own service Demonstrates consideration and discussion of performance against relevant clinical indicators Illustrates how the is planning to address weaknesses and further develop the service Outlines the plans for service improvement and development over the coming year Identifies actions resulting from audit and from previous reviews Provides an illustration of the including current configuration and governance processes Describes how the functions and how care is delivered across the patient pathway Outlines policies/processes that govern safe/high quality care Confirms agreement to and demonstration of the clinical guidelines and treatment protocols for the This is a work in progress and the authors will welcome all comments and suggestions. Sue Shepherd Director Mid Trent Critical Care and East Midlands Chris Jones and Service Manager Leeds Centre Authors note: This document provides one example of an Operational Policy for Operational Delivery s as part of the National Peer Review Process. It is recognised that there are other documents already in use in some networks and the intention is to provide an example of a framework in which the will operate across a region where no policy already exists. Sue Shepherd, Chris Jones Page ii Version 1.2, October 2014
<insert name> Operational Policy <insert picture> <insert date> Sue Shepherd, Chris Jones Page 1 Version 1.2, October 2014
Classification: General Organisation Document Purpose Title Author Date and Version Linkages Circulation Description Point of Contact Operational Delivery s Guidance <insert name> Operational Policy <insert name> <insert date and version> Peer Review Report Annual Report Objectives Work Plan Provider/Acute Trusts Commissioner organisations SHA Cluster organisations Senates Operational Delivery s Strategic Clinical s NHS England This Policy outlines <include lead contact> <address> <e-mail> <website address> Contact Details Sue Shepherd, Chris Jones Page 2 Version 1.2, October 2014
Contents Introduction... 4 Purpose of Operational Policy... 4 Purpose of the... 4 Philosophy of Care... 4 Patient Profile... 4 Admission and Operational Policy... 4 Transfer Policy... 5 Discharge/Repatriation Policy... 5 Access to Rehabilitation Services... 5 Audit and Research... 5 Service Evaluation, Feedback... 5 Staff Support, Training and Development... 5 Emergency Planning... 5 Appendix 1 Relevant Measures... 6 Sue Shepherd, Chris Jones Page 3 Version 1.2, October 2014
Introduction In this section include a brief introduction to the and services within the pathway of care describing how the operates within an integrated collaborative system. Provide an illustration of the configuration of the and governance arrangements. Outline the scope of the in terms of this policy and include member/stakeholder organisations of the (i.e. major trauma facilities, rehabilitation providers, transport providers etc.). Purpose of Operational Policy In this section describe how the Policy provides a framework within which the major trauma system in the region operates. Additionally you might want to indicate that this Policy will continue to be reviewed as the evolves and how this will be achieved. Purpose of the In this section briefly describe the aim of the ; to provide a co-ordinated approach to the provision of high quality care for major trauma patients in the region. Include anything you consider relevant in terms of equity of care and access, assessment, referral and discharge including rehabilitation support. You might also want to describe any decision making processes to facilitate the delivery of safe quality care for all patients. Indicate how patients are involved in decision making processes and how they are supported in the system. Philosophy of Care In this section describe the s charter for patients. Patient Profile In this section describe the relevant patient groups for your demographic population. Indicate how this is likely to change in terms of population groups, future service changes, ageing population etc. Admission and Operational Policy In this section describe your agreed Admission and Operational Policy indicating how patients are admitted to services within the and how care is delivered across the patient pathway. Include the referral and assessment process and anything peculiar to your in terms of criteria for acceptance. Include a section on refused admissions as appropriate. Describe the operational processes with reference to relevant guidelines and protocols and link to D15 Service Specification and any relevant policies indicated in Appendix 1. Attach relevant Policies and Procedures as appendices to the Operational Policy. Sue Shepherd, Chris Jones Page 4 Version 1.2, October 2014
Transfer Policy In this section describe your agreed Transfer Policy indicating any specific transfer requirements for primary and secondary transfers. Include details of any transfer audit and make links to other Operational Delivery specialties i.e. bordering s, Critical Care s etc. Discharge/Repatriation Policy In this section describe your agreed Discharge/Repatriation Policy indicating how patients are discharged/repatriated from the major trauma ward area either to home or to other services or facilities within the. Include links with rehabilitation services and follow-up arrangements. Access to Rehabilitation Services In this section give a brief description of the rehabilitation services in your region. Include referral guidelines and any service analysis, future developments or changes in service provision. Make reference to the rehabilitation prescription and any issues this has highlighted. Audit and Research In this section explain any current audit and research programmes within the and how these link to service improvement and development. Service Evaluation, Feedback In this section describe how the captures and acts on feedback from patients and carers and from other healthcare users. Identify any innovative areas of practice. Staff Support, Training and Development In this section provide a brief summary of relevant training and development programmes. Describe any links to Trust programmes and to the Education and Training Strategy identifying any gaps in current training programmes. Emergency Planning In this section indicate how the will operate in an emergency situation, i.e. major incident. Demonstrate that regional plans are in place and are agreed with partner/stakeholder organisations. Sue Shepherd, Chris Jones Page 5 Version 1.2, October 2014
Appendix 1 Relevant Measures National Peer Review Programme: Regional Measures (revised 2014) PLEASE NOTE: Previous measures were numbered T13-xx-xxx (2013). The revised measures included herewith are numbered T14-xx-xxx (2014). Where the number for the measure for T13 and T14 remains the same no indication of change is given and the only change is that T14 replaces T13. However, where any measure now numbered T14 was previously included under a different number as T13 this is indicated for ease of reference to assist with the identification of previous evidence supplied against the previous T13 measure number. Governance Measures Adults MTC Children's Units Measure MTN MTC T14-1C-101 Configuration T14-1C-102 Governance Structure T14-1C-104 T14-1C-105 Individual Pre-Hospital Provider Feedback Transfer Protocol from Units to MTC Unit Pre- Hospital T14-1C-106 1C-105) Transfusion Protocols for Units T14-1C-107 2B-110) T14-1C-108 T14-1C-109 T14-1C-111 T14-1C-112 (included in Reception and Resuscitation Measures T14-2B- 307) Teleradiology Facilities (included in Reception and Resuscitation Measures T14-2B- 306) CT Protocol for Adults Imaging Protocol for Children Management Guidelines Management of Severe Head Injury T14-1C-113 Management of Spinal Injuries T14-1C-114 1C-108) Emergency planning T14-1C-115 [also Rehab Measure T14-2D-101] 2D-101) T14-2D-201 The Director of Rehabilitation T14-1C-116 2D-110) T14-2D-210 Directory of Rehabilitation Services T14-1C-117 [also Rehab Measure T14-2D-109 2D-111) T14-2D-211 Referral Guidelines to Rehabilitation Services T14-1C-118 [also Rehab Measure T14-2D-110 2D-112) T14-2D-212 Patient Transfer T14-1C-119 [also Rehab Measure T14-2D- 111] Patient Repatriation Policy Sue Shepherd, Chris Jones Page 6 Version 1.2, October 2014
Pre-Hospital Care Measures Adults MTC T14-2A-101 T14-2A-102 T14-2A-103 T14-2A-104 Children's Units Measure Pre Hospital Care Clinical Governance Triage Tool and Immediate Transfer Policy 24/7 Consultant Medical Advice for the Ambulance Control Room 24/7 Paramedic Advice in the Control Room Centre Unit Pre- Hospital T14-2A-105 2A-106) Enhanced Care Teams available 24/7 T14-2A-106 2A-107) T14-2A-107 T14-2A-108 Pain Management Protocol for Adults Pain Management Protocol for Children Pre-Hospital Administration of Tranexamic Acid for Adults T14-2A-109 Application of Pelvic Binders T14-2A-110 Hospital pre-alert and handover Sue Shepherd, Chris Jones Page 7 Version 1.2, October 2014
Reception and Resuscitation Measures Adults MTC T14-2B-101 T14-2B-103 Children's T14-2B-201 T14-2B-203 Units T14-2B-301 T14-2B-302 T14-2B-303 Measure Centre Unit Team Leader Team Activation Protocol Agreement to Transfer Protocol from TUs to MTCs Pre- Hospital T14-2B-104 T14-2B-204 24/7 Surgical and Resuscitative Thoracotomy Capability T14-2B-105 T14-2B-205 T14-2B-304 24/7 CT Scanner Facilities and onsite Radiographer T14-2B-106 T14-2B-206 T14-2B-305 CT Reporting (included in Measures T14-1C-108) (included in Measures T14-1C- 107) T14-2B-107 T14-2B-108 T14-2B-109 T14-2B-110 2B-111) T14-2B-111 2B-112) (included in Measures T14-1C- 109) T14-2B-207 T14-2B-208 T14-2B-209 T14-2B-210 T14-2B-211 T14-2B-306 T14-2B-307 CT Protocols Teleradiology Facilities 24/7 MRI Scanning Facilities 24/7 Interventional Radiology Interventional Radiology Facilities 24/7 Access to Emergency Theatre and Surgery Damage Control Training for Emergency Consultant Surgeons T14-2B-112 2B-113) 24/7 Access to On-site Surgical Staff T14-2B-308 24/7 Access to Surgical Staff T14-2B-114 2B-115) T14-2B-309 Dedicated Orthopaedic Operating Theatre T14-2B-115 2B-116) T14-2B-213 Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries T14-2B-116 2B-117) T14-2B-117 (previously T14-2B-118) T14-2B-214 T14-2B-215 T14-2B-310 Management Guidelines as specified in T14-1C-111 MTC and TU should include relevant local details On-site Intensive Care Unit T14-2B-119 (previously T14-2B-120) T14-2B-217 24/7 Specialist Acute Pain Service T14-2B-120 (previously T14-2B-121) T14-2B-218 T14-2B-311 Transfusion Lead Clinician T14-2B-121 (previously T14-2B-122) T14-2B-219 T14-2B-312 24/7 Specialist Transfusion Advice T14-2B-122 2B-123) T14-2B-220 Massive Transfusion Protocol for the Centre T14-2B-313 Transfusion Protocol T14-2B-123 2B-124) T14-2B-221 T14-2B-314 Administration of Tranexamic Acid Sue Shepherd, Chris Jones Page 8 Version 1.2, October 2014
Definitive Care Measures Adults MTC T14-2C-101 T14-2C-102 T14-2C-103 T14-2C-104 T14-2C-105 T14-2C-106 T14-2C-107 T14-2C-108 T14-2C-109 T14-2C-110 T14-2C-111 T14-2C-112 T14-2C-113 T14-2C-114 T14-2C-115 2C-114) Children's T14-2C-201 T14-2C-202 T14-2C-203 T14-2C-204 T14-2C-205 T14-2C-206 T14-2C-207 T14-2C-208 T14-2C-209 T14-2C-210 T14-2C-211 T14-2C-212 T14-2C-213 T14-2C-214 Units T14-2C-301 T14-2C-302 T14-2C-303 T14-2C-304 T14-2C-305 T14-2C-306 T14-2C-307 Measure Centre Lead Clinician Lead Clinician Designated Specialty Service Coordinator Service Co-ordinator Service MDT Meeting MDT Conference Facilities Dedicated Ward or Clinical Area Protocol for Formal Tertiary Survey Management of Neurosurgical Management of Craniofacial Centre Unit Management of Spinal Injuries Management of Multiple Rib Fractures Management of Musculoskeletal Facilities for Fixation of Fractures Management of Hand Management of Complex Peripheral Nerve Injuries Management of Maxillofacial Vascular and Endovascular Surgery Pre- Hospital T14-2C-116 2C-115) T14-2C-215 T14-2C-308 Designated Specialist Burns Care T14-2C-117 2C-116) T14-2C-216 Nutritional Management Policy T14-2C-118 2C-117) T14-2C-217 T14-2C-309 Discharge Summary Sue Shepherd, Chris Jones Page 9 Version 1.2, October 2014
Rehabilitation Measures Adults MTC Children's Units Measure Centre Unit Pre- Hospital T14-2D-101 [also Measure T14-1C-115] 2D-101) The Director of Rehabilitation T14-2D-201 Clinical Lead for Acute Rehabilitation Services T14-2D-102 2D-103) T14-2D-202 T14-2D-301 Rehabilitation Coordinator Post T14-2D-103 T14-2D-203 Specialist Rehabilitation Service T14-2D-104 2D-105) T14-2D-204 Key worker T14-2D-105 2D-106) T14-2D-205 T14-2D-305 Rehabilitation Prescriptions T14-2D-106 2D-107) T14-2D-206 Rehabilitation for tic Amputation T14-2D-107 2D-108) T14-2D-207 Facilities for Family/Carers T14-2D-108 2D-109) T14-2D-208 Patient Information T14-2C-109 [also Measure T14-1C-117 2D-111) T14-2D-209 Referral Guidelines to Rehabilitation Services T14-2D-110 [also Measure T14-1C-118 2D-112) T14-2D-210 Patient Transfer T14-2D-111 [also Measure T14-1C- 119] T14-2D-211 Patient Repatriation Policy T14-2D-302 Unit Agreement to the Repatriation Policy T14-2D-112 2D-113) T14-2D-212 Clinical Psychologist for Rehabilitation T14-2D-113 2D-114) T14-2D-213 24/7 Access to Psychiatric Advice T14-2D-303 T14-2D-304 Physiotherapy Services Access to Rehabilitation Specialists Sue Shepherd, Chris Jones Page 10 Version 1.2, October 2014