ENCLOSURE: P

Date of Trust Board:

27 July 2016

Title of Report:

Quality Improvement Strategy 2016 – 18

Purpose of Report

For information and assurance.

Recommendation:

To receive the Quality Improvement Strategy 2016 18.

Presented by:

Anna Morgan, Director of Nursing and Quality.

Relevant Trust Objective or Improving Our Quality Quality Goal: Previous consideration by EDT – May 2016 Committee or Executive: QRAC – June 2016 Appendices:

Appendix 1 – Plan Do Study Act Cycle Appendix 2 – Annual Quality Goals Appendix 3 – Commissioning for Quality and Innovation (CQuIN) Appendix 4 - Quality Initiatives Appendix 5 – Quality Improvement Plan

Implications considered for: Compliance with NHS Constitution, CQC registration, legal issues, equality & diversity, environment, stakeholders, staff, patients & public, risks & benefits, value for money, and governance.

Executive summary The purpose of this Quality Improvement Strategy 2016-18 is to set out the Trust’s vision and approach to quality, over the next two years and to ensure we are providing safe, harm free care to patients. The Quality Improvement Action Plan for 2016 – 18 is provided in the Appendix 5 of the document. This document replaces the previous Quality Improvement Strategy which covered the period 2014-16. This revised Strategy gives an overview of the Quality Goals, CQuINs and other Quality Improvement Initiatives that will help to deliver harm free care and supports Norfolk Community Health & Care NHS Trust (NCH&C) as a provider of high quality healthcare that is safe, effective, caring, responsive, well-led and above all patient focused.

Introduction This document is for our staff so that they can see how we will get from where we are now in relation to patient safety and quality to where we want to be. We want to improve our CQC rating from “Good” to “Outstanding” and increase the percentage of our care that is “harm free” to at least 92% and above.

1

The strategy contains details of our: • • • • • • • •

Quality Goals CQuIN projects Quality Assurance Assessments Non Executive Director and Executive Director Patient Safety Visits Sign Up to Safety Pledges Safety Thermometer (Harm-free care) Freedom to Speak Up Clinical Audit

The Quality Improvement Plan in the appendix provides details of the: • • • • •

Quality Improvement Project Executive Leads Monitoring Groups and frequency Assurance Committees and frequency Completion dates

Conclusion By implementing the Quality Improvement Strategy 2016 – 18 we will ensure that we are providing safe, harm free care to patients. This means delivering on our Quality Goals, CQuINs and other Quality Improvement Initiatives and demonstrating to our stakeholders and external monitoring agencies (including the CQC) that we are providing “Outstanding” care to our patients.

2

Quality Improvement Strategy

2016-18

Looking after you locally

Contents Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Page Introduction 3 How we will get from “Good” to “Outstanding” 3 How do we define quality? 3 What is our vision? 4 How do we approach Quality Improvement? 4 How is the quality of our care measured? 4 How do we measure the quality of our care? 5 How can we demonstrate we are providing safe, quality care to our patients? 6 How do we assess our compliance with CQC Fundamental Standards? 6 How does the Quality Improvement Strategy link with the Health & Care 7 Strategy? How do we share the learning to ensure we provide safe, quality care to our 7 patients? Conclusion- Our strategy in a nutshell 7

Appendices Appendix 1 Plan Do Study Act (PDSA) Cycle

8

Appendix 2 Appendix 3

Annual Quality Goals Commissioning for Quality and Innovation (CQuIN) 2016/17

9 10

Appendix 4

Quality Initiatives 1 Sign Up to Safety Pledges 2 Safety Thermometer (Harm-free care) 3 Freedom to Speak Up 4 Clinical Audit Plan Quality Improvement Plan

11

Appendix 5

13

2 V1

Quality Improvement Strategy 2016/18

1.

Introduction

1.1

The purpose of this Quality Improvement Strategy is to provide an overview of the activities we will undertake this year to ensure we are providing safe, harm free care to our patients. This strategy gives an overview of the Quality Goals, CQuINs and other quality improvement initiatives that will help to deliver harm free care. This document is for our staff so that they can see how we will get from where we are now in relation to patient safety and quality to where we want to be.

1.2

Where are we now? • CQC rated us as a “Good” organisation in 2014 • The safety thermometer tells us we delivered 90.06% of harm free care in the year 2015/16.

1.3

Where do we want to be? We want to improve our CQC rating from “Good” to “Outstanding” and increase the percentage of our care that is “harm free” to at least 92% and above, this will enable us to achieve our strategic goal of “improving quality”.

2.

How we will get from “Good” to “Outstanding”

2.1

Since the CQC inspection in September 2014 we have completed the following actions: • • • • •

• 2.2

3 “Must do” actions with regards to: Mental Capacity Act and the consent of service users to care and treatment Safe management of medicines Care planning to meet the service users individual needs and ensure their welfare and safety. 22 out of 25 “Should do” actions identified in the CQC report with three of the cross-agency and service development areas moving to other plans to ensure that they continue to be monitored and implemented. 83 out of 86 “Could do” actions that were identified in the CQC report. The 3 actions that are still in progress will be transferred to the “Good to Outstanding” action plan. We also looked at what CQC said of organisations they rated as “Outstanding” (CQC, Celebrating Good Care, Championing Outstanding Care; March 2015), These characteristics are: • Care is person-centred, designed around the individual and includes their involvement. • The importance of the line-of-sight from senior leadership to the frontline staff and services. • Good care includes the provider checking on how well they are doing. We will work with staff at Trust staff forums to identify how we can ensure these characteristics are embedded within our organisation. We will implement Your Voice, Our Future crowd sourcing methodology which will promote even greater engagement of our staff in the Quality Improvement agenda.

2.3

Our work with staff and the work in progress following the CQC reports will inform our “Good to Outstanding” action plan. This is a high level action plan that coordinates the underpinning action plans to improve patient safety and quality of care.

3 V1

3.

How do we define quality?

3.1

Lord Darzi established a single definition of quality in his 2008 review High Quality Care for All. This definition which is now enshrined in law through the Health and Social Care Act 2012, comprises three dimensions of quality, all of which are required for a high-quality service; • • •

4.

Clinical effectiveness Patient safety Patient experience

What is our vision? The Trust’s vision is to ‘improve the quality of people’s lives, in their homes and community by providing the best in integrated health and social care’. We often sum this up as ‘Looking after you locally’. The starting point for the Trust is the patient: this means that quality is at the heart of everything we do.

5.

How do we approach Continuous Quality Improvement? Each year our staff align their annual objectives with our Annual Plan and this gives opportunities to set the right culture, expectation and motivation for quality improvement at an individual level. In addition, to underpin this approach we want to identify a quality improvement approach that is owned by staff within the organisation and assists them in achieving local quality improvements. At the staff forums and team workshops we asked staff about their preferred approaches to quality improvement and identified that both Lean methodology and the “Plan, Do, Study, Act (PDSA) Cycle” (Appendix 1) is the current favoured methodology. Staff informed us that the PDSA methodology was easy to use. We will test the “Plan, Do, Study, Act (PDSA) Cycle” more widely this year across a number of clinical areas to systematically manage our quality improvement projects using real time initiatives, alongside other quality improvement methods, to identify the best approaches for us to use as part of a never-ending cycle of continual quality improvement.

6.

How is the quality of our care measured?

6.1

Internal Scrutiny The Quality & Risk Assurance Committee meets every month to review all quality and risk activities across the Trust (see below 11.3). The Committee receives a detailed report on quality matters and reviews performance in detail. A quality and risk assurance report is also presented to our Trust Board each month. The Board scrutinises this report and is able to monitor our quality performance throughout the year. This report is published on our website for both our staff and the public.

6.2

Well Led Framework The Care Quality Commission and NHS Improvement (NHSI) have developed the Well-Led Framework (WLF) which focuses primarily at Board and Committee level covering: strategy and planning, capability and culture, process and structures, and measurement. The Board undertakes a self-assessment of our progress against the key questions within the Framework so that we can make decisions on our own improvements and then demonstrate to NHSI where we believe we are in the Well Led ‘Quality’ domain.

6.3

Care Quality Commission The Care Quality Commission ensures health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. They monitor, inspect and regulate our services to make sure they meet fundamental standards of 4

V1

quality and safety and publish their findings, including performance ratings to help people choose care. We carry out a number of self-assessment checks and unannounced visits to services and publish the results in our monthly quality report to the board so that we can monitor our adherence to these standards. 6.4

Clinical Commissioning Groups (CCGs) The CCGs commission our services and we are contracted to provide them with evidence to demonstrate the quality of the services we provide at a monthly Clinical Quality Review Group meetings.

6.5

Healthwatch Norfolk Healthwatch Norfolk represent the patients’ views and experiences to help inform and improve the services that are commissioned and provided in Norfolk. They are an independent organisation but have statutory powers. We work closely with Healthwatch to ensure that we work together to embed quality.

6.6

Quality Surveillance Groups (Local and Regional) A network of NHS England Quality Surveillance Groups meets locally and regionally to provide leadership for quality improvement. They provide an opportunity for the exchange of information that may indicate an early warning of a problem and assurance that appropriate actions are being taken when problems arise. We receive feedback on our performance through discussions with NHSI.

6.7

Aspirant Community Foundation Trust benchmarking The Trust is part of a group of 13 community trusts on a journey to achieve foundation trust status in the future. These community trusts have agreed to share a range of data in order to benchmark performance against one another to stimulate debate and identify opportunities for sharing best practice. This data is reported on a monthly basis to the Board and includes a section on patient safety and quality.

6.8

Annual Quality Account Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The Quality Accounts are approved at the public Trust Board meeting and uploaded onto both the NHS Choices website and NCH&C’s website in June each year.

6.9

Annual Clinical Audit Plan The Trust operates a Board approved clinical audit plan. This includes national and local clinical audits that are designed to assess, improve or provide assurance on the quality of care provided by Trust services. Clinical audits review care against evidence based standards such as NICE guidance or best practice from Royal Colleges. Information on these clinical audits and improvement actions are reported to Board quarterly.

7.

How do we monitor the quality of our care?

7.1

Every year we develop our Annual Plan which identifies our Annual Priorities and Quality Goals (appendix 2); these flow from our three identified strategic priorities:


Improving Quality: To ensure patients are at the heart of all our services and reshaping how we provide care to help us move from ‘Good’ to ‘Outstanding’.




Enabling our people: Working together to make NCH&C a great place to work. 5

V1




Securing our Future: Play a leading role in partnership to ensure both we and the health and care systems in which we operate improve, stay sustainable and represent value for money.

7.2

The Annual Plan, Quality Goals, CQuIN projects (appendix 3) and other Quality Initiatives (appendix 4) are developed using an engagement strategy, which includes the delivery of staff workshops, completion of a staff, public, patient and stakeholder questionnaire and meetings with our Governors.

7.3

The Quality Goals, CQuIN projects and other Quality Initiatives are owned by both executive sponsors and clinical leads who develop SMART action plans to ensure they are delivered effectively. The quality projects are reviewed at a quarterly Quality Leads meeting chaired by the Director of Nursing and Quality who ensures that any issues affecting delivery are identified and mitigated.

7.4

The Board uses a number of methodologies to both set the tone and triangulate data and information to provide assurance in relation to quality and safety. This includes: • • • • • •

Reports to Board Spotlight Sessions Patient Story at Board Scrutiny and challenge in committee Patient experience and Friends and Family test Patient Safety Walkabouts/visits

The visits by Non Executive Directors (NEDs) and Executive Directors are highly valued by staff and provide a key opportunity for the Board to engage with patients and staff. 8.

How can we demonstrate we are providing safe, quality care to our patients?

8.1

We demonstrate the quality and safety of our care through a number of measures including: • • • • • • • • • • • • • • •

Incident reporting Safety Thermometer Early Warning Trigger tool Key Performance Indicators Recording on SystmOne Patient Feedback Complaints/Claims/Compliments Clinical Audit Research Implementation of NICE guidance Implementing learning Safe staffing Continuous professional development and revalidation Appraisals and clinical supervision. Assessing compliance with CQC fundamental standards.

8.2

It is essential that the data we input is robust to enable us to make accurate effective decisions with patients about their care and treatment.

8.3

We must interrogate the information we produce on the quality of our care regularly to ensure that we are providing safe and effective care to our patients. The analysis of quality data at team and locality meetings which will generate rich discussions about how we are doing so that we can understand the changes we need to make to improve outcomes for patients.

6 V1

9.

How do we assess our compliance with CQC Fundamental Standards?

9.1

To ensure we are compliant with CQC Fundamental Standards we have developed a quality assurance assessment process which consists of three elements: 1) 2) 3)

10.

“Walk Round” tool - completed monthly by the Modern Matrons who will complete the three sections of the tool (Safe, Caring and Responsive to people’s needs) over a 3 month period. CQC compliance self-assessment tool – The electronic tool is completed quarterly by the ward managers covering all five CQC key lines of enquiry. This will be rolled out across all NCH&C services in the next two years. Targeted visits – to services that are identified as requiring investigation conducted by an internal assessment team comprising members of the Quality and Risk team, subject matter experts, senior clinicians and Healthwatch.

How does the Quality Improvement Strategy link with the Health & Care Strategy?

10.1 Our Health & Care Strategy describes how we are going to deliver our services and follows on from our three year Clinical Strategy (2012). It incorporates national and local challenges, and the views of staff and stakeholders on how care should be delivered over the next five years to achieve our vision of “looking after you locally”. The Health & Care strategy adopts the ‘Levels of Care’ model which provides a consistent approach in the delivery of care and underpins how services will be developed and managed by the Trust. 11.

How do we share the learning to ensure we provide safe, quality care to our patients?

11.1 Organisational Learning – The Trust is committed to learn from incidents and complaints in a culture that is open and transparent, and share this learning across the organisation. This is achieved in a number of ways; Learning is shared through Weekly Messages and the Monthly Exchange bulletins for staff Safety and Quality Newsletter Engagement events for staff to consider the implications and learning from external reviews (e.g. Francis, Winterbourne and Keogh reports) Learning events aimed at all clinical staff, these have included learning from Serious Incidents, Pressure Ulcers, INR testing and Management of Insulin, Record Keeping, DNA CPR and Social Media The Management Forum is used to share new initiatives, disseminate good practice and learning Staff responses on the Patient Opinion website to public and patient stories

• • • •

• • 11.2

Locality/Business Unit Governance Meetings – These meetings have a standardised clinical governance agenda to ensure that all relevant topics are covered appropriately. The safety and quality data reviewed at the clinical governance meetings directly link to the monthly Locality /Business Unit Performance meetings which are attended by the Operational ADs and scrutinised by the Executive Directors.

11.3

Quality and Risk Assurance Committee – The Quality and Risk Assurance Committee (QRAC) is a standing committee of the Trust Board. The role of QRAC is to enable the Board to obtain assurance that high standards of care are provided by the Trust and, in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the Trust to: • • • •

promote safety and excellence in patient care; identify, prioritise and manage risk arising from clinical care; ensure the effective and efficient use of resources through evidence-based clinical practice; and protect the health and safety of Trust employees. 7

V1

12

Conclusion – Our strategy in a nutshell By implementing the Quality Improvement Strategy 2016-18 we will ensure that we are providing safe, harm free care to our patients. This means delivering on our Quality Goals, CQuINs and other Quality Improvement Initiatives and demonstrating to our stakeholders and external monitoring agencies (including the CQC) that we are aspiring to provide “Outstanding” care to our patients.

8 V1

Appendix 1 Plan Do Study Act (PDSA) Cycle

9 V1

Appendix 2 – Annual Quality Goals Quality Goals 2016/17 1

2

Patient Safety: a

We will increase the percentage of patients receiving harm Anna Morgan free care and reduce the number of catheter acquired infections, avoidable pressure ulcers, falls resulting in injury, venous thrombo-embolisms and medication incidents.

b

We will continue to implement our medicines’ optimisation Penny strategy to ensure the safe and effective use of medicines Newman including antibiotic stewardship and prescribing review.

c

To implement a consistent process of case review to improve Penny the quality of care and learning from avoidable patient death Newman and harm.

Patient Experience: a We will ensuring a systematic approach to capturing Anna Morgan feedback - empowering staff with knowledge of how to capture patient experience feedback and the tools and techniques with which to do it and ensuring this informs a trust-wide plan. b

3

Exec Lead

We will build meaningful and systematic engagement and Anna Morgan involvement by spreading and building on where good engagement and involvement of our patients, carers and Members exists and supporting development across the Trust.

Clinical Effectiveness: a We will improve the effectiveness of our care in our services Anna Morgan by implementing the following NICE guidance: • Acute Kidney Injury: Prevention, Detection and Management [CG169]. • The recognition, diagnosis and management of severe sepsis [due 7/16] • Transition from children’s to adults’ services for young people using health or social care services [NG43].

Leads Annette Paul Libby Gray and Rachel Dennis Louise McGreevey Chris Street Chris Street

Chris Street

Christine Little Lucy Love

Christine Little Lucy Love Lorrayne Barrett

Debbie Beresford John Mallet Amie Daynes

b

We will improve the quality of patient care by auditing goal Penny achievement, outcome measures and discharge destination Newman after specialist rehabilitation, and considering how these measures can be applied to other in patient units.

Grace Underwood Venu Harilal Christine Harvey Deborah Wooller

c

We will improve the effectiveness of our services by ensuring Penny patients are admitted into and transferred out of our services Newman appropriately, focusing particularly on those patients who are returned rapidly to the Acute Trust following discharge to our inpatient care.

Chris Street

10 V1

Appendix 3

Commissioning for Quality and Innovation (CQuIN) 2016/17

1 Commissioning for Quality and Innovation (CQuIN) 2016/17 CQuIN indicators are contractual commitments, some are nationally mandated and some are developed in partnership with our various commissioners. They are intended to improve quality and encourage innovation within key areas of local services. If these indicators are achieved, they attract additional funding that can be used to make further improvements. The CQuIN indicators for 2016/17 that have been negotiated and agreed with our commissioners are as follows: 1.1 NHS Staff health and wellbeing (National Indicator) – Estimates from Public Health England put the cost to the NHS of staff absence due to poor health at £2.4bn a year – around £1 in every £40 of the total budget. This figure excludes the cost of agency staff to fill in gaps, as well as the cost of treatment. As well as the economic benefits that could be achieved, evidence from the staff survey and elsewhere shows that improving staff health and wellbeing will lead to higher staff engagement, better staff retention and better clinical outcomes for patients. 1.2. Community Frailty Pathway Individualised Care and Support Plan – (Central Norfolk CQUIN) This CQUIN scheme will ensure patients receive a holistic assessment by way of a Frailty Care Bundle which will enable Individual Care and Support Plans to be developed which are extremely important to help avoid crises; to help maintain the best possible quality of life when living with sometimes complex needs; and to inform decision-making with regard to future treatments. 1.3. Positive Behaviour Support Programme (Central Norfolk CQUIN) – The Positive Behaviour Support Programme is a pre-diagnoses course consisting of three 2-hour workshops for parents whose children are “waiting” for an Autistic Spectrum Disorder assessment. 1.4 Short Breaks Transition Planning (Great Yarmouth & Waveney CCG) – Young people attending Little Acorns for residential short breaks will have a personalised short breaks transition plan produced in partnership with families and the young person. Little Acorns will have a clearly identified transition strategy in line with NCH&C quality goals and NICE guidance for transition. The strategy will be written in conjunction with key stakeholders. 1.5 Reducing the Incidence of Unplanned and Avoidable Re-Admissions (NHS England). A CQuIN intended to reduce the incidence of unplanned and avoidable re-admissions into the acute trust by first gaining a robust understanding of the reasons for re-admissions, and then proactively considering how re-admissions can be better anticipated and prevented with the introduction of appropriate strategies. 1.6 Child Health Information Systems (CHiS); Digitalising Patient Records – This CHiS service to continue with a project piloted in 15/16 aimed at to digitalising Trust held paper records by scanning on to their SystmOne electronic record. 1.7 Suffolk Early Supported Discharge (Ipswich and East Suffolk CCG) – Service improvement aimed at easing the transition for patients following their six weeks of intensive support from the Early Supportive Discharge Service in Suffolk 1.8

Improving the Clinical Outcomes for Frail Patients through the Implementation of Care Bundles (West Norfolk CCG) – CQUIN designed to improve clinical outcomes for frail patients identified through the use of the Edmonton frailty screening tool who access services. The aim is to optimise patient clinical management through the development and implementation of care bundles developed in collaboration with all providers involved with the management of patients who present with frailty syndromes along the frailty pathway. This will include in-patient services, community teams, mental health services, partner agencies and key stakeholders. A care bundle is a structured way of improving the processes of care and patient outcomes utilising clinically evidenced approaches. The CQUIN will also ensure that clear pathways are developed and/or are in place to support those patients, and their families/carers who access clinical services and that clear pathways are developed with partner organisations that link to care bundles.

11 V1

Appendix 4 Quality Initiatives 1

Sign Up to Safety Pledges:

Pledge 1: Putting safety first: We will continue to reduce the number of patients who are harmed in our care by reducing the main cause of harm to patients in NCH&C 1a) We will reduce the harm caused by Grade 3 and 4 Pressure Ulcers by: • Reviewing the effectiveness of Waterlow or alternative tool • Reviewing staff responsibilities for assessing pressure area care and timing of interventions • Reviewing the training package to ensure consistent assessment and treatment of pressure ulcers. Revising the Pressure Ulcer Management policy • 1b) We will reduce the harm caused by injurious falls by: • Developing the falls reporting and validation process to provide benchmarking figures for year 2 (2016/17). • Reviewing the falls RCAs and Datix questions to be able to decide if the falls were avoidable or unavoidable. • Reviewing the Falls management procedures and policy. Pledge 2: Continually learning: We will actively learn from our complaints and incidents by: • Ensuring we have a robust process in place to learn from our complaints and incidents to improve the quality of care. Pledge 3: Being Honest We will support our staff to implement the Duty of Candour by: • Ensuring that patients (carers/relatives) are aware when things have gone wrong in relation to their care and treatment and provide an explanation and an apology. Pledge 4: Collaborating We will involve patients and service users in service re-design by: • Leading, delivering and formally reviewing specific involvement projects in line with requirements for NCH&C transformation and wider service change, ensuring Complaints and Service re-design are used to identify priority areas. • Developing a patient experience and involvement toolkit for services to use at a local level • Maintaining, reviewing and sharing a patient involvement in service re-design database ensuring good practice models are replicated Pledge 5: Being Supportive We will develop a bespoke care leadership programme to support our ward managers and service leads by: • Following a study with trusts the TDA identified key areas of development for our ward managers and key service leads. • Developing a bespoke training and support package for our staff with a view to developing leadership by 2016. 2

Harm Free Care (NHS safety thermometer) The NHS Safety Thermometer is an improvement tool for measuring, monitoring and analysing a point prevalence of patient harms and harm free care. It measures the number of patients that are ‘harm free’ at the point of care. The organisation’s harm free care results are published in the Quality and Risk Assurance Committee report every month. 12

V1

3

Freedom to Speak Up Sir Robert Francis QC chaired a public inquiry into Mid Staffordshire NHS Foundation Trust, which exposed a culture that deterred staff from raising concerns Freedom to Speak Up. His report was published in 2015 to provide independent advice and recommendations to organisations on creating a more open and honest reporting culture in the NHS. Norfolk Community Health and Care NHS Trust has committed to implement the high standards set out by the Francis inquiry and the Freedom to Speak Up review.

4

Clinical Audit Plan Clinical audit is a quality improvement process that assesses patient care against evidence-based objective standards. The Trust develops an annual clinical audit plan that brings together national and local audits. These are developed by clinicians based on assessment of risks, previous incidents or complaints, or the need to implement change, such as new national guidance. Possible improvements in care are identified and action plans developed to address these. Projects on the Trust annual plan are monitored regularly and support given to clinicians to ensure they are completed according to best practice guidance for clinical audits.

13 V1

Appendix 5 Quality Improvement Plan Quality Project Quality goals

Improvement Executive Lead

Monitoring Group and frequency Director of Nursing and Quarterly Quality Leads Quality Meeting Director of Integrated Care CQuIN projects Director of Nursing and Quarterly Quality Leads Quality Meeting Director of Integrated Care Director of Finance & Performance Quality Assurance Director of Nursing and Monthly Quality Surveillance Assessments Quality Group Director of Integrated Care NED and Executive Director Board Monthly Quality Surveillance Patient Safety Visits Group Sign Up to Safety Pledges Director of Nursing and Quarterly Quality Leads Quality Meeting Director of Integrated Care Safety Thermometer (Harm- Director of Nursing and Monthly Quality Surveillance free care) Quality Group Director of Integrated Care Freedom to Speak Up Director of Nursing and Monthly Quality Surveillance Quality Group

Assurance Committee and Completion date frequency QRAC Quarterly and annual 31/3/17 report

Clinical Audit Plan

QRAC Quarterly and annual 31/3/17 report

Medical Director

Clinical Effectiveness Group

QRAC Quarterly and annual report

31/3/17

QRAC Quarterly and annual 31/3/17 report QRAC Quarterly and annual report QRAC Quarterly and annual report

31/3/17 31/3/17

Monthly Quality Assurance 31/3/17 and Risk report Monthly Quality Assurance 31/3/17 and Risk report

14 V1