GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Title Quality Framework Report date June 2012 Please classify the paper as: • For discussion/decisi...
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Quality Framework

Report date

June 2012

Please classify the paper as: • For discussion/decision/information • Performance reporting Executive Summary


Please describe as appropriate the link to: • The Trust Strategic Objectives • The Trust In-Year Objectives • The Trust Mission • The Trust Values Please describe how this affects patients/ staff/carers/etc.

The Quality Framework has been updated to reflect the new national guidance and current practice it describes the arrangements and assurance process for the management of Quality

This report affects all four Trust strategic objectives.

The Trust has a Duty of continuous improvement for the provision of care of patients Please describe what stakeholders think There is an expectation that the Trust has a about this. systematic process for clinical governance Please describe how this affects our: • The monitoring of quality & safety are • performance essential elements of the effective management of the Trust. • quality and safety • cost • activity Is what is described in the paper Yes affordable? Please explain when you will be able to Quality assurance is monitored formally at report progress about this issue. the Quality Committee and discussed at each Board meeting. Please identify the risks associated with Failure to monitor Quality & Safety would put this issue and describe how they will be at risk both CQC and Monitor standards, dealt with. periodic review and continuous improvement of the assurance processes helps mitigate any risks. Please describe the aspects of this paper N/A that might require wider stakeholder engagement or public consultation. Please identify any other significant impact N/A or outcomes (where applicable) in relation to Financial issues, Equality and Diversity, the NHS Constitution, Legal issues or Sustainable Development. Recommendation Author/Presenting Director

Quality Framework Main Board June 2012

The Board is asked to approve the Quality Framework Author Director: Andrew Seaton Director of Safety Page 1 of 1


Gloucestershire Hospitals NHS Foundation Trust employs approximately 8000 staff including bank staff comprising of more than 70 professions, such as medical staff, Nursing staff, therapists/Scientific staff and ancillary, administrative and support staff. Our success depends on the commitment and dedication of our staff.


Over the course of a year the average activity for the Trust is more than: 18,000 Planned Inpatient Admissions 62,000 Emergency Inpatient Admissions 74,000 Day Case Admissions 430,000 Consultant OP attendances 105,000 A & E attendances at Cheltenham General and Gloucestershire Royal Hospitals 6000 Births


The Trust serves a population of more than 500,000 and we work hard to reflect the cultural and ethnic diversity of the communities we serve.


Our organisation is made up of two acute hospitals; Gloucestershire Royal and Cheltenham General.


It recognises governance as the systems and processes by which the Board will lead, direct and control its functions in order to achieve organisational objectives, and relate to and work with its stakeholders which include patients, their carers and the public. In addition, the Board recognises that risks to achievement of objectives exist and need to be identified and managed. There are a number of specific areas of governance including corporate governance, financial governance, clinical governance, research governance and information governance. This framework is designed to meet the requirements of Monitor’s Quality Governance Framework (2012-13).


The quality framework sets down how aspects of clinical governance are to be integrated into the Trust arrangements and how quality will be continuously monitored. Quality incorporates patient experience, safety for patients and staff and clinical effectiveness.

Introduction 4.

The Health and Social Care Act 2012 identifies several quality related duties as follows:


Securing continuous improvement in the quality of services provided

4.1.1 4.1.2 4.1.3 4.1.4

Including the effectiveness of the services and the safety of the services, and the quality of the experience undergone by patients and have regard to the quality standards prepared by NICE under section


The quality activities and supporting structures within the Trust need to be standardised where possible whilst also being able to reflective the individualistic nature of the specific Division.


The Trust has contracts for the provision of services with commissioners such as NHS Gloucestershire. These contracts include conditions in relation to clinical governance arrangements and improving quality that the Trust need to meet.

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All NHS organisations will have to account for the care they provide with the same level of scrutiny as used for financial management by publishing quality accounts. The quality accounts will fall report against the three main areas safety, effectiveness and patient experience.


There are several key principles that have to be established for a successful and sustainable framework:


The Director or Chief of Service is accountable for quality, and will need to demonstrate how they discharge this responsibility through scrutiny of their services and reporting to the Quality Committee.


The importance of embedding safety, effectiveness and good patient experience into everyday practice.


The need to be transparent with quality information in line with publishing quality accounts and accountability.


This framework has been established to provide evidence to support compliance with CQC regulation and outcomes and connects to the other governance arrangements to include


The legal and governance arrangements in place for the conduct of research on NHS patients, staff and in NHS premises


The Risk Management Framework and associated Divisional risk management arrangements including the Maternity Units


Information Governance arrangements.


Cancer Services standards and reviews.

The Framework 10. 11.


The main purpose of the framework is to describe how the Trust monitors the quality of care provided in the Trust. Monitoring of the Trust performance will identify areas of good practice and areas of improvement. The areas of improvement will be identified and taken forward as part of the planning process. The definition of quality is framed by the three domains for the Quality accounts, they are as follows:

12.1 Safety 12.2 Effectiveness 12.3 Patient Experience 13.

Safety will provide a focus on preventing harm and improving reliability of care, a main aspect of this will be infection control. The framework will expect systematic learning from mistakes through openness and clinical enquiry which leads to the development and embedding of safety systems for patients and staff: Understanding mortality and external benchmarks within the hospital, in the context of avoiding harm and improving quality, will enable improvement in a wide range of systems, (for example – rescue of patients) and should play a major part in Divisional systems.


Effective and reliable care is a major element of safer care, by standardising systems & eliminating variation and reducing waste, patients will have clinically effective

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treatments leading to shorter hospital stays and save clinical time which can be reinvested back to direct patient care: 14.1 Evidence based care within the context of effective care has been shown to reduce mortality, length of stay and readmissions. For example in sepsis when giving antibiotics at the optimum time is essential, outcomes can be improved for patients. This is equally important for staff when evidence based guidance is not in place for work related illnesses such as stress and back care, good systems reduce absence from work. 15.

Understanding patients’ experience of their care and listening carefully and responding to their comments and ideas will provide a different insight on areas that need to be improved. This will change the way we provide care so that we meet the patients needs more effectively and improve the quality of care.


Innovation and doing things differently is central to the objective of continuously improving the quality of care and may occur in any of the three domains.

16.1 Innovation may be associated with service improvement – changing ways of working, pathways or procedures - or with the identification and development of innovative healthcare technologies, devices and products. This may involve research and development programmes and collaboration with academic, commercial or other partners to identify, test and diffuse the innovation across the wider NHS”. Organisation 17.

Wards and departments should have regular team meetings and as a minimum discuss, improve and monitor any specified performance indicators including Nursing metrics, patient survey, complaints, compliments and concerns, investigate and feedback learning from incidents, maintain the H&S manual and discuss any H&S concerns and share any new policies.


Specialties will monitor quality performance by establishing a representative multidisciplinary committee using the terms of reference for specialities (Appendix 1). The specialty quality lead will receive exception based reports from the relevant wards and departments as indicated above (22) at the meeting.


Divisions will review formally the quality arrangements performance of each specialty at least once a year. They will produce a quality report each quarter bringing together the three aspects of quality, relevant Trust objectives including good practice which will be ratified by the Chief of Service through a formal route. These reports will be scrutinised periodically by the Quality Committee and Trust Management Team (at least twice a year).


The Quality Committee will receive a quarterly Directors statement from the clinical directors and a Quality report providing assurance against the three areas of quality objectives, core CQC outcomes on a rolling programme and elements of the Quality Account. The committee will individually scrutinise Divisional performance through a series of detailed presentations and as necessary further explore areas of concern or good practice.

Education and training 21.

The Human Resource/Learning and Development building blocks that contribute to patient /service quality and Clinical Governance systems are:• • • •

Human resource management and workforce planning. Risk Management & H&S training Professional Self Regulation and Continuing Professional Development. Leadership and Team Building.

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• • •

• •

Performance Management. Appraisal and Development Review - linked to competency frameworks and Trust Objectives. Education, Learning and Development - to achieve job competency, national targets and standards as well as trust objectives and personal development plans. Knowledge Management and evidence based practice. Education governance – quality assurance and contract management.


These elements will be monitored and assured through the Employment Committee and form part of the overall performance management framework.


Information from these areas will be provided to the Divisions in support of their monitoring and continuous improvement.

Leadership and accountability 24.

The Chief Executive is the Accounting Officer for the Gloucestershire Hospitals. He is accountable for ensuring that the Trust can discharge its legal duty for all aspects of governance and quality each year, and for the health & safety of staff, visitors and contractors in the Trust.


The Director of Safety is the lead for quality improvement, patient safety and the delegated lead for health & safety. This includes coordination of the Risk Management system and Trust risk register and the Board Assurance Framework.


The Director of Safety, in partnership with the Executive Directors will ensure organisational arrangements are in place which satisfy the legal requirements of the Trust for quality, patient safety, Health & Safety and continuing improvements for patients and staff.


The Head of Patient Experience will lead the work of improving patient experience, by ensuring the Trust uses every opportunity to inform practice through service user involvement and feedback, and by ensuring the Trust meets related legal and national standards.


Executive Directors and Chief of Services are accountable for the quality, safety and patient experience in their areas of responsibility; their organisational structure must be able to discharge the requirements of the Strategic Objectives, The Care Quality Commission Regulations, National Health Service Litigation Authority standards, legislative requirements and other specific NHS standards.


The Director of Clinical Strategy is responsible for Research & Development in the Trust and for coordination of the Quality Account.


The Director of Safety is responsible for ensuring that exception reports on SUIs are included in reports to both the Trust Management Team meeting and the Quality Committee and for maintenance of the Trust Risk Register.


Managers are responsible for the safety of patients and\or staff and\or hospital buildings. They have a duty to implement systems that monitor safety and take reasonable action to maintain and improve safety.


All staff are responsible for their own and others’ health and safety within their immediate environment and for participating in wider governance, quality & risk management issues within their department. This includes ensuring that they: -

have access to, understand and follow all Trust policies and procedures;

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work in a safe manner at all times having due regard to any person who might be affected by their actions;


in addition, all staff should have clear objectives set and documented as part of their annual performance reviews.


The Trust Board has specific duties placed on it in relation to all aspects of governance including financial, information, research, clinical and corporate governance. In addition, it needs to integrate these aspects so that it can be assured across all of these areas. A number of Trust Board Committees with Non-executive Director chairs and members have been established to make sure that the necessary assurances can be provided to the full Board in support of its responsibilities to assure that robust systems are in place to manage governance, quality and Safety.


The Board will take an active leadership role on quality encouraging proactive approaches to improving quality (e.g. it actively seeks to apply lessons learnt in other trusts and external organisations) whilst ensuring appropriate resources (time and money) to deliver quality initiatives. The Board will also be actively engaged in the delivery of quality improvement initiatives (e.g. some initiatives led personally by board members).


A key role for the Non-executive Director (NEDs) is to seek assurances and provide a challenge to the Executive team, therefore the NEDs need to have a level of understanding of basic processes and information presented to them in the key committees.


These committees are: The Audit Committee The Quality Committee The Governance & Nominations Committee


Assurance of quality systems is provided by the Expert Advisory Groups (H&S, Transfusion, Infection Control and Radiation etc). These groups will be responsible for monitoring standards and systems, developing policy, training and alerting the Trust to any concerns:

37.1 These groups should report or highlight specific issues to the Trust management team at any time. 37.2 They will provide advice and assist in problem solving with the Divisions. 38.

Assurance of quality activity will be provided by the Divisions on a quarterly basis and will be established through their governance, quality and safety arrangements. This means that the key role for managers at this level is not only to direct governance activity and manage risk, but also to set up monitoring systems that assures them that this activity is being carried out within their area of responsibility.


The Divisional arrangements will be an integral element of the Trust’s framework and form a major part of the initial performance management focus.


Using standard terms of reference and a set agenda\checklist in Divisional meetings will also provide structure to allow appropriate monitoring of activity.


Governance (including information and research), quality & risk staff will support the Divisions and Directorates in achieving their responsibilities by developing systems, education programmes and providing expert advice and support for managers and staff and a range of Boards and committees.

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Committee Structure 42.

To enable the Trust Board to discharge its legal duty of quality, health & safety and other legislative requirements, it must establish effective communication and monitoring processes:

42.1 The day-to-day management of quality, safety and patient experience is the duty of the Trust Management team with support from the corporate clinical governance, research, information and safety team. 42.2 The assurance of these processes and activity has been delegated to the Quality Committee, supported by information from the Directors and Divisions and a network of specialty and expert committees (see above). 43.

In addition and crucially, the Trust Board will then assure itself through its regular review of reports received from these arrangements, for example, the Trust Risk Register, Board Assurance Framework, Infection Control Report and Directors Quality Statement.


The Trust Management Team is responsible for validation and managing significant risks to the operation of the Trust, and the governance and quality issues arising from the management of the Trust’s activities. It will do this through the regular review of the Trust risk register. The Trust risk register will be made up of the most significant risks from the Divisions and specific risks identified by the Executive team and other Directors.


The Quality Committee will monitor quality systems. This process will provide assurance to the Trust Board that it is discharging its legislative requirements across all these areas. It will discharge its duty by ensuring that there is an appropriate committee structure monitoring standards and reporting progress and concerns, and by receiving reports from Directors and Division on quality, safety activity and patient experience. In particular, the Committee will monitor and assure themselves that the Divisions: -

have appropriate structures in place to discharge their responsibilities; that they are consistently discharging their responsibility by monitoring and reporting their quality and safety activity; are reporting their concerns formally and transparently; that they are continuously improving.


The Quality Committee will receive minutes from the Patient Safety Forum, The Health & Safety Committee and the Patient experience (Inpatient & outpatient) committees.


The Quality Standards Review Group will systematically review the evidence template for each core CQC outcome and provide assurance to the Quality Committee that there are no breaches of compliance or that relevant action plans are in place. This group will also continually review the Quality Risk Profile produced by the CQC and annually review Monitors Quality Governance Framework.


The Safety & Experience Group will monitor, Serious Untoward Incidents (SUIs), Claims, Inquest and serious complaints ensuring prompt investigation, closure of actions plans, communication with families following the Being Open principles and identification of any trends. This information will be reported in the Trust Quality report. Significant SUIs, complaints, incidents or inquests will be reported to Trust Board each month.

Divisional Structure 49.

The Divisional accountability and meeting structure will be presented each year to the Quality Committee to ensure that it meets the requirements of the Quality Framework:

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49.1 The Chief of Service will be the lead for Quality and may delegate responsibility to another competent senior manager. 49.2 Lead nurses and identified Lead clinicians play a key role in all Divisions and will continue to provide leadership in, and coordination of, quality, safety and patient experience at a local level. Where an area does not have a lead nurse they should identify a suitable post holder to take on this responsibility. The role must include: 50.

reducing infection; the investigation of orange incidents; identifying trends of incidents, complaints and patient feedback and surveys; monitoring of local standards through audit; implementing and embedding lessons learnt; facilitating local quality improvement. meeting relevant Trust objectives

The Divisions will set up and maintain systems to enable the following activity to occur:

50.1 To performance manage quality activity in the Division over the three domains through an annual individual specialty review and collation of the Divisional Quality Report. 50.2 Maintain compliance with the Care Quality Commission Regulation and report any concerns with compliance 50.3 To report exceptions and concerns to the Trust Management Team. 50.4 To manage and review the Divisional Risk register by following the Gloucestershire risk management and assessment procedure. To validate the Departmental\Specialist Risk Register and receive quarterly update reports. To report any significant risks to the Trust Management Team. 50.5 To provide assurance via a formal and standardised quarterly reports to the Quality Committee across the three domains. 50.6 To monitor red and orange incidents, significant complaints, patient feedback, claims and inquests, trends and their action plans. To monitor response times to complaints and to ensure that actions on issues raised are taken. 50.7 To monitor essential audit activity and plans. To co-ordinate responses for national reports relevant to the clinical area, and to monitor and report progress on NSFs, NICE and other guidance. 50.8 Demonstrate public and patient involvement and ensure actions are taken as necessary in response to patient feedback mechanisms. 50.9 To monitor quality indicators and outcomes across all activities and take appropriate actions. 50.10 To monitor appraisal, training and development activities. External Assurance 51.

External assurance from visits, inspections and accreditations are an essential part of quality assurance and management, recommendations need to be implemented where possible.


This report will have identified any recommendations made by the external organisation at the visit and each recommendation will have an action point, which includes responsibility for completing the actions and timescales.

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The Senior Manager responsible for the visit will assess if this is a specialty, divisional or corporate issue: • Specialty meetings will monitor progress of the action plan • Where Divisional Issue-outcomes reported through the Divisional Quality Report. • Where Corporate issue-outcomes reported through Directors statement as part of the Quality Report.

Review 54.

The Framework will be reviewed every two year and continually improved.

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APPENDIX 1 AREA Governance Arrangements

STANDARD Specialty meetings are held at least quarterly • Yes • Sometimes • Never • Divisional & Specialty Meetings record key findings and actions taken • There is clear evidence of improvement and learning from quality data

Effectiveness M&M Meetings

Understandin g Mortality

Clinical Audit Framework

NICE Quality Standards

Learning from M&M meetings is discussed at Specialty level meetings • Yes, at least quarterly • Sometimes • Never Mortality rates are monitored by relevant Specialty Meetings • All • Some • None Division submits an annual audit plan each April that includes required national, regional and local audits • Yes (plan Apr, follows prioritisation template) • Yes (plan submitted after Apr) • No plan Specialty meetings monitor compliance with NICE Quality Standards • Yes • Sometimes • Never Non-compliance added to risk register • Yes • Some • None

Patient Experience Real time survey


Confidential Enquiries


The Divisional Board\ Quality meeting will receive a report on all red rated survey questions in the Division Lead Nurses will report red rated\deteriorating scores and their action plans to specialty quality meetings Response rate to complaints is at 95% for the Division • 95% response rate met • Not met Learning from complaints is discussed at Speciality level • Discussed at each meeting • Sometimes • Never Response made to C.E. reports which include gap analysis & action plan where appropriate • Yes (response, gaps, action p) • Combination • None of the above Each Division has nominated research lead The Research lead represents the division on the Trust’s Research Leaders’ Forum The Division regularly reviews the number of open portfolio studies and the number of patient accruals to these studies

Safety Infection Control

Discussed at specialty level meetings (in accordance with ward to Board process) • Discussed at each meeting

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Risk Management

• Sometimes • Never Specialty has a risk register • Yes • No Risk register is regularly reviewed and up to date with all sections complete • Yes, at least quarterly • Other • Not reviewed All risks on the risk register are formally assessed • All • Some • None Action plans for orange incidents are received and monitored by specialty level meetings at least quarterly • Action plans in place and reviewed quarterly • Orange incidents reviewed, action plans present but not monitored • No review and no action plan Learning from red and orange graded incidents in discussed at specialty level meeting • Yes • No Health & Safety Management is listed on each specialty agenda. • Yes • No Health & Safety incidents and risk assessments are discussed at specialty level. A Divisional Health & Safety representative or their deputy attends every Trust H&S Committee Feedback from the Trust H&S committee is provided to the Divisional committee responsible for Quality. Safety Alerts are discussed at closed as per national targets

External Visits

Relevant External visits and assessments are discussed at Specialty level and actions agreed Progress against action plans are reported to the Divisional Quality Board Risks of non-compliance are assessed and added to the Specialty\Divisional Risk Register (as per policy)

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