Quality Improvement Strategy

Transcription

1 Quality Improvement Strategy Quality can be measured by what you do when no one is looking Working in partnership with; Quality Improvement Strategy Page: 1 of 18

2 Version Control Recommended by Approved by Quality Committee Board of Directors Approval date 29 July 2015 Version number 4.0 Review date August 2016 Responsible Director(s) Director of Quality Responsible Manager(s) (Sponsor(s) For use by Deputy Director of Quality All Trust employees This Strategy is available in alternative formats on request. Please contact the Corporate Governance Assistant on Quality Improvement Strategy Page: 2 of 18

3 Change Record Version Date of change January - February 2015 March - May 2015 June July 2015 Date of release Changed by Reason for change 02/03/2015 Neil Barnes Draft Document creation 19/06/2015 Neil Barnes Consultation with Quality team 03/07/2015 Neil Barnes 4.0 July /07/2015 Neil Barnes Consultation with Internal Stakeholders Presentation to Quality Committee Presented to Board of Directors for approval Quality Improvement Strategy Page: 3 of 18

4 Quality Improvement Strategy Contents i Version Control 2 Ii Change Record 3 iii Contents 4 1. Introduction 5 2. Strategy Principles 7 3. Strategy Aims 7 Aim 1: Continuously seek out and reduce harm 8 Aim 2: Achieve the highest level of reliability for care 8 Aim 3: To listen and respond to what matters most to patients 9 Aim 4: Deliver Safe Care Closer to Home in partnership with local health and social care 4. Strategy Driver Diagram 11 APPENDICES Defining the Strategy Delivering the Strategy 14 Page 3. Strategy Assurance Quality Improvement Strategy Page: 4 of 18

5 Quality Improvement Strategy 1.0 Introduction Patient care is at the heart of what we do. This Quality Improvement Strategy is an enabling strategy that will support our aim to deliver a high quality service to patients by ensuring we deliver the Right Care at the Right Time and in the Right Place. We believe that this is the best way for the North West Ambulance Service to deliver safe, effective care and a positive patient experience. The strategy of the Trust is to provide long term clinically safe, sustainable services to our patients, whilst meeting the national and local performance targets within a challenging financial environment. We will achieve this by moving from a Good organisation, with good staff and a good reputation to a Great organisation with great staff and a great reputation. Our compliance goals as an Ambulance NHS Trust are; Quality: Meeting or exceeding national and local quality standards Finance: Achievement of financial duties Performance: Achievement of the immediately or potentially life threatening cases national response time targets National Ambulance Response Time Targets This strategy acknowledges that the following three national ambulance response time targets are seen as a measurement of quality for Ambulance Trusts. Red 1: Respond to 75% within 8 minutes with a suitably trained and equipped response. This could be an ambulance, a rapid response vehicle or a community responder. Red 2: Respond to 75% within 8 minutes with a suitably trained and equipped response. This could be an ambulance, a rapid response vehicle or a community responder. A19: Respond to 95% of Red 1 & 2 calls within 19 minutes with a vehicle capable of carrying a patient. The Trust has three overarching strategic goals: Delivering safe care closer to home A great place to work Cause no harm Patient and staff safety must be at the heart of everything we do. The public come to us in need and seek our help and compassion. Thankfully, a patient coming to harm while under the care of NWAS is a very rare occurrence, but it does happen and, like all other NHS trusts, we must seek ways to minimise the risk as much as possible. We aim to become the safest Ambulance Service in the UK. Quality Improvement Strategy Page: 5 of 18

6 NWAS has committed to the national Sign Up to Safety Campaign launched during June The vision is for the whole NHS to become the safest healthcare system in the world, aiming to deliver harm free care for every patient, every time. The campaign sets out expectations for organisations and individuals in achieving the aim of reducing avoidable harm by 50% and saving 6000 lives. Three key words to the Sign up to Safety campaign are Listen, Learn, and Act. This means listening to patients, carers and staff, learning from what they say when things go wrong and taking appropriate action to improve patient safety. We will develop and implement a Safety Improvement Plan to describe how we will reduce harm and save lives by working to reduce the causes of harm and take a preventative approach using the following five headings to develop its core pledges; Put Safety First Continually learn Honesty Collaborate Support Quality is delivered by all of our staff in every work setting. The North West Ambulance Service employs more than 5000 staff, working in multiple, mobile and dynamic environments across five counties, both urban and rural. This strategy will encompass a number of existing and new quality-related activities; ensuring a consistent approach for the Trust. However, the Trust will also have in place a separate Clinical Strategy to ensure the best possible clinical experience and outcomes for our patients. The Trust s values pledge is that the care and safety of patients is our first concern and the strategic direction of quality needs to take account of the current healthcare context, including: NHS Constitution Francis Inquiry Keogh Report Compassion in Practice Savile Report Lampard Lessons Learnt Report Morecambe Bay Investigation (Kirkup Report) The Quality Improvement Strategy reflects our focus on the quality of patient care, set against; Patient (and relative/carer) experiences Changing expectations of healthcare availability and provision An increasingly competitive market place Working within a challenging financial environment Transformational change programmes to deliver new healthcare services Quality Improvement Strategy Page: 6 of 18

7 2.0 Strategy Principles This Quality Improvement Strategy is built on the following principles; Safety Culture QUALITY Learning Culture Improvement Culture The Trust s approach to applying these principles is to develop; A culture focused on patients Compliance to quality standards agreed and approved via contractual arrangements A competent and compassionate leadership Accountability at every level Quality governance arrangements that assure the quality of care received by patients. The Trust will also use the following CQC key lines of enquiry to demonstrate quality; Caring Effective Responsive Safe Well-led 3.0 Strategy Aims This Quality Improvement Strategy sets out the following four quality improvement aims that will inform and support achievement of these goals and a quality focussed culture; Aim 1: Continuously seek out and reduce harm Aim 2: Achieve the highest level of reliability for care Aim 3: To listen and respond to what matters most to patients Aim 4: Deliver safe care closer to home in partnership with local health/social care Quality Improvement Strategy Page: 7 of 18

8 Aim 1: Continuously seek out and reduce harm As currently measured by: Reduction in harms by 50% in the following target areas: Manual handling related incidents (staff and patients) Medication errors (avoidable outcomes) Patients left at home and re-contacted within 24 hours (avoidable severe harm and un-expected death outcome) Reduction of repeated cause serious incidents Year on year, reduction of the total number of claims reported to the NHSLA Year on year, reduction of the total value of claims reported to the NHSLA IPC Clinical Safety Indicators: Audit Controls Bare Below Elbow Cleanliness Crew Competence Management of Equipment Management of Sharps Management of Waste and Linen Vehicle Deep Clean Areas for Development Current areas of measurement Appropriate ambulance safety measures Eradicate long waits for red calls Reduce long waits for green calls Aim 2: Achieve the highest level of reliability for care As currently measured by: NWAS Care Bundle Compliance: Asthma Management Cardiac Chest Pain Management Falls Mental Health Self Harm Paediatric Care: Febrile Convulsion Pain Management Patient Pathway PRF Completion Stroke Management Trauma Care: Single Limb fracture Hear & Treat Care Call Handling & Clinical Advice 111 Care Call Handling & Clinical Advice Quality Improvement Strategy Page: 8 of 18

9 Ambulance Clinical Quality Indicators National CPI Programme Safeguarding Care Bundles Medicine Management Quality Indicators Adherence to NICE Guidance SIREN Report Red long waits Green long waits Rapid Response Vehicle without ambulance response Community First Responder without ambulance response Paramedic availability Areas for Development Current areas of measurement Women s Health Care Bundle Referral rates for fallers Clinician-level Quality Reporting CQC Compliance and Self-assessment Adherence to agreed care planning Community Care Plans End of life care DNACPR Aim 3: To listen and respond to what matters most to patients As currently measured by: Friends and Family Test Satisfaction Rates Patient Surveys You Said, We Did outcomes Investigations and user feedback Duty of Candour Complaints External incidents Compliments Claims Inquests Incident reporting Areas for Development Current areas of measurement Reduce long waits for green calls PTS performance metrics Listening to patients with Mental health needs Always Events Quality Improvement Strategy Page: 9 of 18

10 Aim 4: Deliver Safe Care Closer to Home in partnership with local health and social care As currently measured by: 24 hour re-contact audit Ambulance System Quality Indicators Hear and treat See and treat Re-contact Electronic Referral and Information Sharing System Acute Visiting Scheme referral and GP deflection rates Areas for Development See & Treat Friends and Family Test Clinical review and improvement process for identified 24 hour re-contact patients Evaluation framework for Community Specialist Paramedics Frequent Caller report Quality Improvement Aim Reporting The Trust s integrated performance reporting processes will be used to ensure that the organisation is suitably informed from Board to Station/Emergency Operational Control of how we are doing. Wherever possible, we will compare our performance to others and set ourselves the challenge of improving to become one of the best ambulance services in the country. Quality Improvement Strategy Page: 10 of 18

11 4.0 Strategy Driver Diagram Aims Primary Drivers (High-level factors you need to influence, to achieve your aims) Secondary Drivers (Specific projects or activities that act upon the high-level factors) Reduce Harm Leadership & Culture Trust Vision and Values Francis Report Our Pledge Workforce Strategy Communication & Engagement Strategy Leadership Development Sign up to Safety Freedom to Speak Up Improve Reliability of Care Listen & Respond to Patients & Staff Patient & Community Focus Improvement Capability & Capacity Learning Systems Communication & Engagement Strategy Point Taken 2 Patient Feedback Social Media Projects (#999/GoPTS) Healthwatch/HSC Complementary Resources Shadow Council of Governors Partnership working with other providers and emergency services Community Specialist Paramedic Project Workforce Strategy QI development programme for individuals and teams Links with Academic Institutions and Networks Measuring and Monitoring Patient Safety Integrated Performance Reporting Real time quality and safety reporting Clinician-level Quality Dashboard Demand & Capacity Measures Learning Forum and Incident Learning Policy HR Processes SIs & Risk Management Patient Experience Internal and External Assurance Clinical Audit Staff forum, Survey and Suggestion Scheme Induction & Mandatory Training/CPD Safe Care Closer to Home Portfolio of Projects Safe Care Closer to Home Safety Improvement Plan Electronic Patient Record & Interoperability NHS Number New EOC for Cheshire & Mersey Medicine Supply Chain Review CQUIN schemes Self Service (Business Intelligence) Quality Improvement Strategy Page: 11 of 18

12 APPENDICES Quality Improvement Strategy Page: 12 of 18

13 Appendix 1 - Defining the Strategy Trust Vision Good to Great Strategic Aim Right Care, Right Time, Right Place Strategic Goals Finance, Quality, Performance Delivering Safe Care Closer to Home, A Great Place to Work, Cause No Harm Business Objectives Integrated Business Plan Primary Drivers Leadership & Culture Patient & Community Improvement Capability & Capacity Learning Systems Portfolio of Projects Quality Governance Clinical Quality QUALITY DIRECTORATE Clinical Safety Risk, Safety & Patient Experience QUALITY VISION Performance & Informatics Legal Services Be the safest Ambulance Service in the UK Everyone engaged with quality and have a role in its improvement QUALITY AIMS Continuously seek out and reduce harm Achieve the highest level of reliability for care Listen and respond to what matters most to patients Deliver safe care closer to home in partnership with local health and social care QUALITY GOALS Safety, Learning and Improvement Cultures QUALITY OBJECTIVES Reduce patient harms by 50% in our identified target areas Reduce staff harms by 50% in our identified target areas Year on year, reduce the number of claims reported to the NHSLA Year on year, reduce the value of claims reported to the NHSLA Define and understand Quality Performance Define and understand Quality Improvement Define and understand learning from patient/staff harm incidents Quality Improvement Strategy Page: 13 of 18

14 Appendix 2 - Delivering the Strategy 5 year Goals Be the safest Ambulance Service in the UK Define and understand patient and staff safety measures Measure and monitor defined patient and staff safety measures Reduce harms to patients and staff Ensure the organisation and staff learn from safety incidents For everyone to be engaged with quality and have a role in its improvement Undertake a period of consolidation, baseline and diagnostic work Develop a Quality Improvement Framework Develop improvement capacity and capability across the workforce Define what high quality looks like Identify how we will know when a change is an improvement 3 Year Objectives Develop improvement capacity and capability across the workforce Reduce patient harms by 50% in our identified target areas Reduce harm by improved staff communication and information Reduce harm from manual handling related incidents Reduce harm to patients with mental health needs Reduce harm from medication errors Reduce harm from patients left at home and re-contacted within 24 hours Reduce staff harms by 50% in our identified target areas Reduce harm by improved staff communication and information Reduce harm from manual handling related incidents Year on year, reduction of the total number of claims reported to the NHSLA Year on year, reduction of the total value of claims reported to the NHSLA Define and understand Quality Improvement Define and understand Quality Performance Define and understand learning from patient and staff harm incidents Quality Improvement Strategy Page: 14 of 18

15 2 Year Objectives In conjunction with the Health Foundation and AQuA, over an 18 month period, develop a suite of agreed patient harm measures for use within an Ambulance Service setting Implement a suite of agreed patient harm measures for use within an Ambulance Service setting Develop and implement an improved Quality Improvement Framework Develop and implement an improved Quality performance Framework Develop and implement an improved incident learning and improvement Framework 1 Year Objectives Achieve the year 1 milestones identified to reduce harm to patients with mental health needs by March 2016 Achieve the year 1 milestones identified to reduce harm to patients from medication errors by March 2016 Achieve the year 1 milestones identified to reduce harm to patients re-contacted within 24 hours by March 2016 Achieve the year one milestones to reduce harm to staff from manual handling by March 2016 By March 2016, reduce the total number of claims reported to the NHSLA By March 2016, reduce the total value of claims reported to the NHSLA Implementation The Strategy Driver Diagram, at Section 4 of this document will be developed into an implementation plan to further describe the activities that will take place during year one of the Trust s quality improvement journey. Quality Improvement Strategy Page: 15 of 18

16 Appendix 3 - Strategy Assurance Internal Assurances Corporate Governance Arrangements NWAS has in place the following Corporate Governance arrangements for the provision of quality assurances; Board of Directors Charitable Funds Committee Nominations Committee Remuneration Committee Audit Committee Quality Committee Finance, Investment & Planning Committee Workforce & Communities Committee Risk Moderation Group Clinical Governance Group Information Governance Group Incident Learning Forum Health & Safety Group The Quality Committee, a non-executive committee of the Board of Directors, will seek assurances on behalf of the Board, from its membership, members of the Trust and its designated sub-groups on the management and effectiveness of service quality. The Quality Committee will use the following CQC key lines of enquiry to provide quality improvement assurances to the organisation; Caring Effective Responsive Safe Well-led Annual Governance Statement We will produce an Annual Governance Statement in accordance with the mandatory guidance defined within chapter 1 of the NHS manual for accounts and to provide assurances about the stewardship of the organisation. Quality Account We will produce an Annual Quality Account, in accordance with our statutory duties and to describe how we have delivered and improved quality during a current year, and set out our quality improvement priorities for the following year. Quality Improvement Strategy Page: 16 of 18

17 Monitor Quality Governance (self-assessment) Framework We will continue to use the Monitor Quality Governance Framework to self-assess its level of quality within the organisation. NWAS will continue to aim to ensure that its organisational self-assessment score remains below 4.0. Risk Management NWAS recognises that effective risk management is an integral part of providing a quality service. The Trust s Risk Management process provides the framework by which the Trust ensures that risks are identified and mitigated appropriately. The Board of Directors accept that due to the nature of our core business there will be risks present. Through effective risk assessment we will determine acceptable risk levels and ensure that measures are implemented to reduce and mitigate these risks as far as possible. The Board of Directors recognise that the implementation of an effective Risk Management process is a key element of continuous improvement. Staff are encouraged to report adverse events or near misses and there is a process to encourage learning at both individual and organisational levels. The Director of Quality is the designated executive lead for the management of risk, health, safety and security within the Trust. External Assurances Department of Health (DoH) We will continue to contribute to the National Ambulance System and Quality published monthly by the Department of Health. Outcome Indicators, National Health Service Trust Development Authority (NHS TDA)/Monitor We will continue to adhere to the requirements of the NHS TDA and/or Monitor, as appropriate. Care Quality Commission (CQC) NWAS is registered, without condition by the CQC and will continue to abide by the requirements of that Registration. Commissioning for Quality We will agree an annual programme of quality improvement programmes with our lead Commissioners, building on our track record of success in delivery of Commissioning for Quality and Innovation (CQUIN) programmes. We will report on quality to our commissioners across the North West via the Quality Commissioning Group. We will agree local quality standards for our services as part of our annual contract negotiations. We will agree on a quality dashboard to inform emerging commissioners and their communities. Quality Improvement Strategy Page: 17 of 18

18 National Health Service Litigation Authority (NHS LA) We will continue to be a member of the NHS LA and will continue to abide with the requirements of that membership. Internal and External Auditors We will continue to invest in annual audit quality assurance programmes. Responsibilities For this Strategy to be effective it must be owned by individuals within the organisation, as well as the organisation as a whole. The Board of Directors are required, as the most senior leaders and managers within the organisation, to demonstrate excellence in quality leadership and management practice. Making our quality strategy come to life requires dedicated resources, supported by both our Commissioners and the Board. The Director of Quality is accountable to the Board of Directors for the development and delivery of the Quality Strategy. At a corporate level, the Quality, Operations and Organisational Development Directorates provide leadership, expertise and guidance on quality. Directors and senior managers are required to demonstrate effective leadership and management of quality through appropriate Trust processes and are also required to ensure that managers and leaders within their teams are competent at promoting quality in the desired manner. At a local level, we will provide clinical supervision and leadership for every ambulance station and contact centre. These clinical leaders will be the key to realising the potential for delivery of an excellent ambulance service, one of the best in the country. Consultation This Strategy will be developed and prepared with key stakeholders and then shared widely across the organisation and with relevant external stakeholders. Consideration will be given to the production of a easy to read, user friendly version of this Quality Improvement Strategy for distribution to relevant stakeholders. Quality Improvement Strategy Page: 18 of 18