AGENDA ITEM 3.1 14 June 2013 REVIEW AND UPDATE OF THE COMMITTEE WORK PROGRAMME Executive Lead: Committee Chair Author: Assistant Director of Patient Safety & Quality Contact Details for further information: Robert Williams, 02920 336367 Robert.Williams@wales.nhs.uk SITUATION The UHB has a significant patient Quality, Safety & Experience agenda to progress across the organisation. The Board has delegated the monitoring and scrutiny of these arrangements to the. In order to inform the development of this work across the UHB, the Committee considered and approved an Annual Work Programme in order to structure the work of the Committee over the coming year. As part of its approval, the Committee agreed to review the appropriateness of the Programme in light of the changing quality and safety agenda for NHS Wales. The UHB is developing its arrangements to implement Organising for Excellence (O4E), which outlines key areas of work relating to Patient Quality, Safety & Experience and also aligns to the Annual Quality Framework issued by Welsh Government and replaced in 2012 by the publication of Achieving Excellence - The Quality Delivery Plan for NHS Wales 2012-2014. The requirements of these plans have also been factored into the Committee Work Programme, although elements of these plans will also span other Committees of the Board. BACKGROUND The operational plan outlines the range of national strategies and polices which have guided its development, including: Together for Health the Strategic direction for the NHS in Wales and the evolving South Wales Programme. the NHS Wales Quality Delivery Plan (2012-2014) the Quality Outcomes Framework; Standards for Health Services in Wales; The 2013/14 Operational Plan; Organising for Excellence 2013 2016; and Learning from Francis The UHB response to the publication of the Francis Public Inquiry into care at Mid Staffordshire NHS Trust. Work Programme Page 1 of 10 14 June 2013
ASSESMENT The UHB must have robust arrangements in place to reduce waste, variation and harm which in turn will impact positively on the quality and safety of patient care to enable us to realise our ambition of becoming the flagship Health Board in Wales, with an international reputation for excellence and innovation. It is important that in the context of quality and safety, the Board has made a commitment to focus on improving the patient experience and becoming a patient focused organisation, ensuring we are engaged with patients by asking them how we are doing and using what they tell us to change the way we provide services. Since its inception in 2009, the Board has placed patient safety and quality as its top priority. This commitment has been re-enforced with a variety of quality and safety focused areas of work, some examples of which are; Picture the Future an organisational engagement exercise where staff were asked to outline what they felt the organisation needed to do to improve services to citizens / patients; Organising for Excellence (O4E) the UHB Strategy that came from Picture the Future, outlines a series of work streams to develop services provided by the Health Board that shape how the UHB is Caring for People, Keeping People Well which outlines; o New Values Trust and Respect Kindness and Care Integrity and Personal Responsibility o Which helps to shape new behaviours o Outlines four Focus Areas; Patient/Citizen What needs fixing the most Financial Resources Good to Great o What s in; Authentic Clinical Leadership Greater devolution More cohesion and sense of purpose Leading and managing as one o What s out?; Divide and Rule Fear and top down edicts An exclusive focus on finance Externalising our problems The 3 year Strategy Published in October 2013 will have a Big effort on Patient Safety and Integration ; Active participation in local and National Patient Safety Improvement work e.g. Leading Improvement for Patient Safety (LIPS); 1000 Lives + Programme; Strengthening our Board Safety focused Walkrounds to ensure key themes from Francis and the UHB response are the focus of visits; Standards for Health Services in Wales, ensuring the Standards are being embedded across the UHB; Work Programme Page 2 of 10 14 June 2013
Participation in the Welsh Risk Pool (WRP) annual assessment process to review risk management against specific clinical and the Concerns/Claims standards, and demonstrating improvement in processes and risk reduction to improve the safety of services provided to patients. Doing Well, Doing Better Standards for Health Services in Wales Underpin the vision, values, governance and accountability framework for the NHS in Wales. The Fundamentals of Care indicators and the all-wales audit are key tools in demonstrating compliance against a number of the Standards, such as dignity and respect, nutritional care and oral hygiene. The work of Healthcare Inspectorate Wales (HIW) in inspecting and reviewing services and organisations is underpinned by the Standards. In the coming year the Quality Plan will focus on; Improving the patient and user experience and delivering patient driven care; Improving participation and reporting of outcomes against agreed National Clinical Audit priorities for NHS Wales; Securing and demonstrating sustainable quality and safety improvement through mainly 1000 Lives Plus Programme; Strong quality assurance processes aligned with Standards for Health Services in Wales; Board Assurance Framework and the Organisational Risk Register; Participating in agreed peer review processes; Developing and reporting on a set of key quality metrics. Improving Health and Healthcare Quality The Welsh Assembly Government documents Our Healthy Future, Fairer Outcomes for All and Healthy Sustainable Wales: the NHS Contribution together set out a challenge for the NHS and its partners to improve health across Wales. They ask that: across society, we take care of and responsibility for our own health and well-being and that of others; organisations and individuals work together to improve and protect the health of the people of Wales; the gap between communities with poor health and those with good health be reduced; healthy public policy supports and enables people to lead healthy lives; we ensure a strong, healthy and just society; we use sound science responsibly; we promote good governance and achieve a sustainable economy; and we live within environmental limits. ANNUAL COMMITTEE WORK PROGRAMME Attached as Appendix 1, is the Quality and Safety Committee Annual Work Programme for 2013-4. The Programme captures the core quality and safety related business of the UHB as outlined within the Committee s Terms of Reference. Work Programme Page 3 of 10 14 June 2013
The Committee also agreed that the work programme would be subject to periodical review in order to ensure it remained fit for purpose. In developing its work programme, the Committee has also considered the Board Assurance Framework, Corporate Risk Register and the HIW Work Programme 2011-2014. HIW priority work remains; The Standards for Health Services in Wales (underpinning all work); Regulation and inspection functions under part 2 of the Care Standards Act (2000) for Independent hospitals; Independent clinics; Independent medical agencies and Private Dentists; Mental Health Act (1983) monitoring; Mental Capacity Act (2005) including Deprivation of Liberty Safeguards (DoLS) monitoring; Controlled Drugs (Supervision of Management and Use) (Wales) Regulations (2008); Local Supervising Authority for Midwives; Ionising Radiation (Medical Exposure) Regulations (2000) monitoring. Whilst Healthcare Inspectorate Wales is reviewing its work plans in light of the publication of the Francis Inquiry, focused areas of work for the coming year as previously outlined are; Dignity and essential care programme of unannounced visits and consideration of work in response to the Older People s Commissioner Report Dignified Care. Take account of the work carried out in 2010 by the WAO on Hospital Catering and Patient Nutrition and consider the impact of the introduction of the All Wales Nutrition Care Pathway. Consider the impact of the introduction of the Fundamentals of Care audit tool on dignity and respect. Consider the impact of discharge planning on safety, dignity and respect; Ensuring patients and service users in potentially vulnerable situations are safeguarded; this generally relates to Mental Health Act and Mental Capacity Act monitoring; Driving improvement in the environment of care - Unannounced Cleanliness and Infection Control Spot Checks; Being treated by suitably trained and qualified staff IR(ME)R Regulations; the Controlled Drugs (Supervision of Management and Use) (Wales) Regulations; assess the fitness for purpose of those who are contracted to supply agency nurses, healthcare assistants and operating department practitioners to the NHS in Wales; Local Supervising Authority (LSA) for Statutory Supervision of Midwives in Wales; 2012/13 work area priorities; Maternity Services Review; Speech & Language Therapy Services Review; Community Mental Health Teams and Community Treatment Orders; Children s Palliative Care Services; Cancer Services Referral Pathways; Diagnostic Services; Falls and Fractures; Work Programme Page 4 of 10 14 June 2013
Medication alignment with older persons National Service Framework and WAO work in this area; 2013/14 work area priorities; Young People moving from Child to Adult Healthcare; Disabled children: Are disabled children and young people and their carers and families provided with the necessary support to enable them to live an independent and fulfilled life? ; Provision of Care and Services to people with Autism; Food, Fluid and Nutritional Care: Are the food, fluid, nutritional and dietary needs of patients being met?; Blood Transfusion; Putting things Right ; Palliative Care: Are palliative/end of life care services supporting terminally ill people to die with dignity, in comfort and without unnecessary pain? ; The University Health Board has a significant agenda for improving quality and strengthening patient safety, with the overall aim of Caring for People, Keeping People Well. It is important therefore that a structured Committee Work Programme is in place that monitors and informs the development of this agenda. The attached Work Programme has been developed, taking into account UHB priorities, aligned to the priorities of NHS Wales, the Board Assurance Framework underpinned by the Standards for Health Services in Wales and the HIW Work Programme 2011 2014 and Organisational Risk Register. It will be important also that this Committee Work Programme is used to inform and develop related work at Division / Clinical Board/ Directorate / Locality levels. RECOMMENDATION The is asked to; Approve the Committee Work Programme for this coming year and support its review and amendment in light of any related matters that inform the work of this Committee. Work Programme Page 5 of 10 14 June 2013
Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and diversity There is no financial impact of this report The Work Programme is a key document aligned with the UHB Board Assurance Framework that helps align the work of the Committee, with key areas. Standard 1 Governance & Accountability guides the process for ensuring robust arrangements are in place to inform the governance & accountability framework of the UHB. A robust but flexible work programme helps inform the governance arrangements and guide the work of the Committee. The Work Programme is aligned with the organisational Risk Register and Board Assurance Framework. Whilst there are no Equality and Diversity implications of this report, the Programme ensure all strands of the quality, safety & experience Committee work is covered. Work Programme Page 6 of 10 14 June 2013
Appendix 1 FORWARD COMMITTEE WORK PROGRAMME 2013 2014 Meeting Date / June September October December February April Agenda Item 2013 2014 Presentation of a Patient/Service User Story Standard 9 BAF Objective 4 Meeting Action Log Quality and Safety Performance Report Standards 6 and 7 BAF Objective 2 Presentation of Divisional / Clinical Board Reports Standards 1 and 7 BAF Objectives 2, 3 & 4 Patient Experience Report on Progress, to include CHC Feedback; Carers and Volunteering as appropriate Standards 5 & 9 BAF Objective 2, 3, 4 & 5 Public Health Standard 3 BAF Objective 1 Committee Terms of Reference Standard 1 BAF Objective 5 Children and Women Mental Health Medicine Clinical Diagnostics & Therapeutics Primary Community & Intermediate Care Surgery Themes: Currently a standing item on Board Agenda - No need for duplication at QSE Committee, but provides avenue for any related matters to feature at this Committee. Immunisation /vaccination Work Programme Page 7 of 10 14 June 2013
Appendix 1 Meeting Date / Agenda Item Committee Work Programme Standard 1 BAF Objective 5 Quarterly update on Concerns and progress with implementation of the new Regulations. Standard 23 BAF Objective 2 Corrective Action Plan monitoring (this includes Ombudsman Section 16; HIW etc) Standard 23 BAF Objective 2 1000 Lives + Programme Standard 6 BAF Objective 2 & 7 Progress with NPSA Alert Implementation BAF Objective 4 & 5 Patient Safety Friday Walkrounds BAF Objective 2 & 4 HIW Workplan and UHB Progress Standard 1 BAF Objective 5 & 12 June 2013 September October December February 2014 Review Quarter 1 & Annual Report Quarter 2 Quarter 3 April Work Programme Page 8 of 10 14 June 2013
Appendix 1 Meeting Date / Agenda Item Standards for Health Services in Wales Standard 1 BAF Objective 5 & 12 Welsh Risk Pool Annual Assessment BAF Objective 2, 5 & 12 Clinical Audit BAF Objective 2 Annual Quality Statement BAF Objective 2 & 5 Annual Report of Committee BAF Objective 2 & 5 Annual Meeting with Internal Audit Standard 1 BAF Objective 5 Progress reports on Safeguarding Standard 11 BAF Objectives 1, 9 &10 Infection Prevention & Control update Standard 13 BAF Objectives 1 & 2 Corporate Risk Register June 2013 Internal Audit related report Progress against Plan (Approval) September October December February 2014 Review and approve WRP Action Plans (Approval) Including staffing situation 2013 / 14 process 2013 / 14 Assessment process Progress against Plan April Progress Work Programme Page 9 of 10 14 June 2013
Appendix 1 Meeting Date / Agenda Item Progress reports on Nutrition Standard 14 BAF Objectives 1 & 4 Progress report on Medicines Management Standard 15 BAF Objectives 1 & 6 Progress report on Medical Devices and Diagnostic Systems Standard 16 BAF Objective 9 Outpatient Schedule & Booking Standard 23 BAF Objective 2 June September October December February 2013 2014 Risk Medication Issues (Matter referred by Audit Committee) April Work Programme Page 10 of 10 14 June 2013