Meeting: Date: Title: REPORT SUMMARY SHEET Trust Board 11th June 2015 Executive Director of Nursing s presentation on the Nursing Quality Indicator (NQI) Framework Providing assurance on the quality of nursing care Lead Director: Francis Rice, Director Mental Health & Disability / Executive Director of Nursing/AHPs Corporate Objective: Providing safe high quality care Making best use of resources Support people and communities to live healthy lives and improve their health and wellbeing Purpose: Approval High level context: Summary of Key Issues for Trust Board Proposed Nursing Quality Indicator (NQI) Framework Providing assurance on the quality of nursing care. The application of a NQI framework will be central to providing evidence on the impact of nursing care on patient experience and outcomes. Amis are to - Increase public confidence through provision of safe person-centred care, responsive to individual need. Providing clear mechanism for patients to report on their experiences of care and improving engagement and involvement with patients and families in service improvements. Increase organizational confidence through provision of more comprehensive, validated and reliable independent audit information on which to gauge assurance on the quality of nursing / midwifery care. Specifically includes patient experience and Personal Public Involvement (PPI). Links to other work / assurances strands i.e., Quality Improvement Framework and focused service improvement Increase professional confidence through clearer, predictable programme of monitoring, freeing up staff time to care. Opportunity for development of auditing skills with support from experts and engagement with patients on their experiences of care. Greater understanding of and involvement in PPI initiatives.
Key issues/risks for discussion: - Background to the Nursing Quality Indicator initiative Nursing Quality Indicators (NQIs), also known as nursing metrics, are used worldwide to monitor compliance with nursing care processes, impact on patient safety and the quality of nursing care. They provide quality improvement tools that enabled comparisons on care quality across organisations and nations. UK drivers include Darzi s focus on safety, effectiveness and compassion in nursing care and the Francis Report which called for comparable data on nursing outcomes. Phase 1 - In 2011 Trust senior nurses developed a range of Nursing Quality Indicators (NQI) aimed at measuring compliance with nursing care processes. Each directorate developed their own indicators and the EDN has bi-annually reported to Trust Board on the level of compliance. As different directorate care priorities emerged so did the number of audits undertaken and despite the support of an IT database, monthly auditing of NQIs has become an increasingly onerous and time consuming task for ward/team managers and staff. Further, it was recognised that the NQIs could not capture the patient experience and there was no clear Personal and Public Involvement (PPI) link to subsequent service improvements initiatives. - Summary of research findings Phase 2 - In 2014 the EDN commissioned research which aimed to identify those elements which should be included in measuring the quality of nursing care. The research recommended analysis on the person s care journey approach rather than individual element reviews. The research findings proposed a framework which included measuring the quality of a patient s journey across four domains, i.e., Nursing Care Processes, Nursing Care Outcomes, Patient Experiences and Nurses Knowledge of Care Needed. The research also recommended - A limit on the number of NQIs to be included in the quality analysis A review of the associated audit tools A limit on number of auditors undertaking the audits thus ensuring more reliable and validated outcomes data and that all auditors should be trained Clear engagement of PPI Leads in any subsequent service improvements initiatives. - Proposals for implementing the NQI Framework Phase 3 - Trust senior nurses agreed with the research findings that applying the NQI Framework whereby the outcomes from the 4 domains were considered collectively did provide a more comprehensive and balanced picture of the quality of nursing care, as
opposed to when elements were considered singly. A NQI Framework Steering Group, chaired by EDN with senior nurse members, has been set up to explore how the framework could be implemented across the Trust and Have identified 12 core NQIs which the Trust is required to report on regionally. Are reviewing the NQI audit tools to ensure that they reflect the 4 domains. Have scoped the organisational arrangements which need to be in place in order to report on the quality of nursing care both locally and regionally. Propose that, given the substantial nature of the audit tools, 3 monthly audits, rather than monthly, will be completed on all wards / facilities. However, Ward Srs/CNs/Team Leaders will continue to undertake monthly audits on their own wards / facilities where directed e.g., where outcomes from independent audits indicate this action is required to improve quality. The NQI Framework Steering Group will review the suite of indicators periodically or as required. - Wider application of the NQI Framework There are clear opportunities to merge Patient/Client Experience Standards and 10,000 Voices initiative activities into the Framework and the principles behind the NQI Framework could be applied within other professional groups (e.g., AHP / SW). The Framework could be expanded to reflect the Trust s Quality Improvement Framework or to support the Trust s regional reporting arrangements e.g., for Quality 2020, QIPs etc. thus reducing duplication. Trust Board is asked to consider the proposals for the implementation of the new NQI Framework. Summary of SMT challenge/discussion: Welcomed a more robust audit approach to streamlining the nursing indicators to ensure focus is on the quality of patient care, patient experience, learning and service improvements including PPI, rather than process measures. Clarified understanding of how this proposed approach links with other work underway including the Acute directorate s work on NEAT and the Trust s overall Quality Improvement Framework. Internal/External engagement: Trust ward managers and nurses participated in the research and a NQI Framework Steering Group, chaired by EDN, has led discussion on the implementation of the framework within the Trust s care directorates. Ongoing engagement of Personal and Public Involvement (PPI) Leads on involving patients in service improvement initiatives.
Research was approved by the Ethical Research Committee (NI) and funded by ST Research Governance Committee. Research and nursing leads have also engaged with the PHA leads of the Patient / Client Experience Standards and 10,000 Voices initiative to ensure cross-agency information sharing and learning. Human Rights/Equality: There are no perceived specific HR or equality issues within the context of the framework approach proposed. The focus of nursing quality indicators is to provide assurances on high quality compassionate care that supports Trust delivery of Human Rights and equality requirements.
Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: Trust Board Meeting 11 June 2015 Briefing on Allied Health Professional Internal Review Francis Rice, Executive Director of Nursing & Allied Health Professionals Provide safe high quality care Maximise independence and choice for our patient and clients Support people and communities to live healthy lives and to improve their health and wellbeing. Make best use of resources. For Information Summary of Key Issues for Trust Board High level context: This report provides an updated review of key areas of improvement resulting from the internal review of AHP services and also considers key associated challenges. Key issues/risks for discussion: Key review actions Visibility and action planning to address improvement in performance against target and best practice standards. Opportunity taken by Trust to influence HSCB methodologies to address capacity planning assumptions SHSCT Brief on Internal AHP Review June 2015 1
Professional Best Practice and corporate approaches to workforce planning to maximise resources for success. Ongoing workforce planning with AHP professions and staff side engagement to progress band/skill mix exercise. Draft centralisation model for AHP clinics to achieve maximum workforce efficiency and skill mix deployment for clinic based AHP services will require SMT to agree an effective engagement model with GPs to support this reform. Implementation of phased outcomes with immediacy from the Regional AHP- profession specific care pathway action plans that support demand reduction and improve capacity. Exploiting evidence based smart ways of working (eg., virtual approaches, self-help resources/websites, signposting to reduce demand using public health solutions) and potential bids against Regional ICT Innovation Fund. Challenges remain including: A continued lack of agreement on capacity gaps related to absence of established Service & Budget Agreement baseline volumes. Performance challenging in number of areas with escalating risk in the clinical pathway as areas of review beyond the clinically indicated timescale continue to become more visible and indicate significant delays in some areas. Challenge in relation to a sustained workforce, in terms of being able to recruit to short term absences for either non-recurring positions or part time maternity leaves. Significant reduction in capacity for some services due to Maternity leave and funding available for only fifty percent cover. Implementation of revised band/skill mix profiles will be medium to long term in nature. Summary of SMT challenge/discussion: Review of the reduced performance position at the end of 2014/15 and challenge to redress the trend in 2015/16 in the absence of agreed capacity gaps or additional commissioned activity; Agreement to give priority to addressing patients waiting beyond their clinically indicated review SHSCT Brief on Internal AHP Review June 2015 2
timeline and acceptance that this may impact further on access for new patients but this risk to be balanced profession by profession;. Assurance sought on adherence to the IEAP in particular strict chronological management and DNA/CNA practices; Assurance sought on ongoing validation of waiting lists by service leads; Agreement to continue targeting of senior capacity to support improvement; Escalation of delay in completion of regional demand/capacity modelling and onging absence of agreed SBA and capacity gaps Internal/External engagement: HSCB, PHA, DHSSPS, Trust Staff and Staff Side Human Rights/Equality: There are no humans rights/equality issues for case weighting planning assumptions/ evidenced based approaches to smart working/ band/skill mix rebalance plan and the Implementation of the Corporate Workforce Plans and Centralisation Models will enhance equality issues for the local population. SHSCT Brief on Internal AHP Review June 2015 3
1.0 Areas of Improvement in Performance arising from the AHP Internal Review 1.1 Visibility and momentum has been captured and reported in the identification of issues affecting performance against access targets and best practice standards including reviews/treatments beyond their clinically indicated timescales, and waiting times for urgent/complex patients; Monthly performance meetings with Service leads/directorate AHP representatives established with a focus on performance improvement; Additional capacity was provided in 2014/15 and into April to address in the main review/treatments waiting beyond their clinically indicated timescales. This lead to improvements in longest waits and volumes in a range of areas. This funding has now ceased and temporary staff retained into April 2015 has now been stood down. Improvements to date have seen Reduction in waits for clinically indicated reviews in paediatric dietetics, paediatric speech & language therapy and podiatry. Plans are also in place in paediatric occupational therapy to do the same over the next few months. Whilst there are ongoing issues related to demand and capacity where the commissioned level of capacity is insufficient to meet the demand, which will see a continued increase in access times for new assessments, some improvements have been made where this is within the Trust control. Improvements to date have seen Reduction in access time for paediatric dietetics with appointment of additional senior paediatric allegory dietician to meet the specific demands in this area. Further reductions in access time have been achieved in adult dietetics and learning disability occupational therapy and plans are in place to achieve same in physical disability occupational therapy services. A plan of local and regional actions to seek further improvement has been collated and this is reviewed at the AHP AD Steering Group fortnightly and actions taken forward within the operational Directorates; In the context of potential available non-recurrent funding in year the areas highlighted will provide a focus for additional capacity should additional funding become available via June monitoring round. 1.1 A range of service improvements are being progressed regionally with professional colleagues to improve the patient pathway on track for close down regional consensus by 30 th June 2015. Actions include: SHSCT Brief on Internal AHP Review June 2015 4
Standardization of criteria for categorisation of urgent and routine patients, treatment review intervals and pathways; Standardization of referral pathways/access criteria to services; Development of standardised timescales for reviews/treatments beyond their clinically indicated timescales; Increased thresholds for service access with proposed areas of work to be channelled through public health pathways. 1.2 The Trust has made a determination on approach to be taken to un-commissioned AHP work and written to commissioner seeking engagement. LCG have agreed to a meeting when PHA/HSCB share demand capacity assumptions. Commissioner has advised engagement will be after the regional demand and capacity work has been completed 1.3 Ongoing fortnightly meetings with professional leads in place to address professional practice issues to afford effective governance and workforce development within all aspects of the internal review including a robust application of IEAP protocols and the following:-. Effective engagement with staff side professional, operational, and HR leads, producing work plans for the band/skill mix rebalance exercise which is being considered by the AD Steering Group. This includes:- A draft centralised clinic model for AHP services that will require support form Estates plan but will impact positively on a more efficient band/skill mix, improved throughput and reduced travel costs for clinical based AHP services. However it should be noted that in some professional areas, eg OT, a significant percentage of the workforce is delivered in the domiciliary environment; Strict implementation of the agreed processes to scrutinise all replacement/new posts to support the Skill/Band Mix Rebalance work plan as agreed with staff and staff side representatives; Continuous capturing, cleansing and targeted reporting across all specialities of the new data definitions for AHP services; Active validation of waits appropriately removing patient/clients from SLT and Dietetics waiting lists; The band mix skill mix internal exercise will position the Trust favourably for the planned DHSSPSNI regional workforce review. SHSCT Brief on Internal AHP Review June 2015 5
1.4 Meetings with operational and professional leads and staff side to operationalise a corporate approach to the AHP rotational posts and a revised more responsive on-call physiotherapy rota are taking place. 1.5 Implementation of evidence based smart ways of working to reduce demand and improve capacity is ongoing. 2.0 Remaining Challenges 2.1 Performance challenges continue to present both for access times for first assessment and in managing clinical risk associated with review/treatment which are waiting beyond their clinically indicated timescales associated with capacity issues, related to both lack of commissioned capacity and reduction workforce capacity in some areas associated with high levels of maternity leave/unplanned absence 2.2 Regional IEAP Guidance and revised Data Definitions paper following workshop on 16 th Jan 2015 is not yet issued to Trusts to support new data definitions. The Trust have produced internal guidance to support this and have alerted the HSCB/PHA to this gap and shared interim internal guidance with regional colleagues. This guidance is necessary to achieve agreement on a range of specific concerns to support clarity and regional consistency in reporting. 2.3 The interim solutions work plan to comply with regional revised AHP data definitions is almost completed with 15% of remaining activity to be closed down by 31 st May 2015 to ensure all activity is easily sourced. 2.4 It is also of note that revised Data Definitions in some cases rephrase demand, by change the recording of activities previously included as a new referral to a review referral. This will impact on caseload and must be considered going forward with a robust agreed case weighing approach. 2.5 Outcome of regional PHA/HSCB review which will determine approach to establish capacity, in form of an agreed Service & Budget Agreement volume, and take a view on current demand is still awaited. SHSCT has shared its view on planning assumptions which could be used to form and develop a model to establish capacity and has met with PHA and HSCB to share thoughts on model. 2.6 Ongoing workforce issues associated with high level of maternity leave which impact more significantly on small specialist teams and ongoing challenge of recruiting to less attractive short term and part time vacancies and the impact of 50% backfill for maternity leaves, reference SLT. 2.7 Timeframes to achieve the relevant band/skill mix required within the current workforce profiles. SHSCT Brief on Internal AHP Review June 2015 6