QUALITY ASSURANCE UNPACKING AND UNDERSTANDING NATIONAL CORE STANDARDS 24 MAY 2018
WHAT HAS TO BE REGULATED? WHAT & HOW DO WE MEASURE? Sub- Risk Domains Extreme Domains Categories Vital Essential 2. Safety, Clinical Risk Developmenta l Standards 1. Patient Rights 3. Clinical Support Assessment Services • DOC Methods C • OBS 4. Public Health Criteria • PI O • PRA 5. Leadership and Corporate Gov. M • SI Check Lists • STATS P 6. Operational Management Supporting L Evidence 7. Facilities and Infrastructure I HOW ARE MEASUREABLES A Priority GROUPED/ORDERED? N Areas THEY ARE CONCEPTUALLY DEVELOPED C E 1. Values and attitudes Functional Area 2. Waiting Times • M- Magement 3. Cleanliness • P- Patient care Dependant on 4. Patient Safety • C- Clinical support Type of Facility • S - General support services 5. Infection Prevention and Control Questionnaire 6. Availability of medicines and supplies
NCS & SUBDOMAINS National Core Standards Six Priorities 2. Safety, clinical Patient Safety, 1. Patient Patient Rights: Risk (6 subdomains) Clinical rights (8 Subdomains) Governance & 3. Clinical support 1. Values and Care: Services (7 subdomains) attitudes 4. Patient safety 5. Infection 2. Waiting times 4. Public health (4 subdomains) prevention and 3. Cleanliness control 5. Leadership & corporate Governance (6 subdomains) Clinical Support Facilities & Services: 6. Operational management infrastructure: 6. Availability of (7 subdomains) medicines and 3. Cleanliness supplies 7. Facilities & infrastructure (7 subdomains) 6
DOMAINS AND SUB-DOMAINS Domain 1. Patient Rights: Domain 4. Public Health: 1.1 Respect and dignity 4.1 Population based service planning and delivery 1.2 Information to patients 4.2 Health promotion and disease prevention 1.3 Physical access 4.3 Disaster preparedness 1.4 Continuity of care 4.4 Environmental control 1.5 Reducing delays in care Domain 5. Leadership & Corporate Governance 1.6 Emergency care 5.1 Oversight and accountability 1.7 Access to package of services 5.2 Strategic management 1.8 Complaints management 5.3 Risk management 5.4 Quality improvement Domain 2. Patient Safety - Clinical governance & Clinical Care 5.5 Effective leadership 2.1 Patient care 5.6 Communications and public relations 2.2 Clinical management for improved health outcomes Domain 6. Operational Management: 2.3 Clinical leadership 6.1 Human resource management & development 2.4 Clinical risk 6.2 Employee wellness 2.5 Adverse events 6.3 Financial resource management 2.6 Infection prevention and control 6.4 Supply chain management 6.5 Transport and fleet management Domain 3. Clinical Support Services: 6.6 Information management 3.1 Pharmaceutical services 6.7 Medical records 3.2 Diagnostic services Domain 7. Facilities & Infrastructure 3.3 Therapeutic and support services 7.1 Buildings and grounds 3.4 Health technology services 7.2 Machinery and utilities 3.5 Sterilisation services 7.3 Safety and security 3.6 Mortuary services 7.4 Hygiene and cleanliness 3.7 Efficiency management 7.5 Waste management 7.6 Linen and laundry 7.7 Food services
Functional Areas (cont.) MANAGEMENT (11) PATIENT CARE (13) GENERAL SUPPORT (13) P 01 - A+E S 01 - CSSD M 01 - CEO / Hospital P 02 - Outpatients S 02 - Cleaning services manager P 03 - Maternity S 03 - Food services M 03 - Communications P 04 - Medical ward S 04 - Laundry services M 04 - Facility P 05 - Surgical ward S 05 - Maintenance services infrastructure P 06 - Paediatric ward incl. garden services M 05 - Financial P 07 - Generic wards S 06 - Record archive P 08 - Physio S 07 - Waste management management P 09 - ICU / HCU / Burns / S 08 - Transport services M 06 - HR management speciality ward S 09 - Security services M 07 - Infection control P 10 - Operating theatre S 10 - Entrance reception M 08 - Management of incl. cath labs and help desk information P 11 - Psychiatric ward S 11 - Patient administration M 10 - Procurement P 12 - Occupational therapy S 12 - Mortuary services M12 - Occupational P 13 - Speech therapy Health and Safety CLINICAL SUPPORT (5) M 14 - Clinical C 01 - Blood services management group C 02 - Lab services M 16 - Case C 03 - Health technology Management services C 04 - Pharmacy 5 C 05 - Radiology
UNDERSTANDING THE SEQUENCE 1. DOMAIN 1.1. SUBDOMAIN 1.1.1. STANDARD 1.1.1.1. CRITERIA 1.1.1.1.1. MEASURE / CHECKLIST
Department or functional area Criteria Domain Measure
Assessment type – method used to assess compliance: e.g. observation, document analysis Denotes risk level X - EXTREME V = vital E= essential D= developmental Score – the compliant (1) or non compliant (0) score for that question. If it is checklist then fraction of 1 is the Notes section for score i.e. 0.75 comments or observations
RISK RATING MEASURES • Extreme Measures (non-negotiable and the compliance is 100%) are those measures that ensure safety of patients and staff is safe guarded from harm or endanger patient life or might cause death. • Vital Standards (90% compliance is required) are risk measures to ensure safety of patients and employees. • Essential Standards (80% compliance) are risk measures that are considered fundamental to the provision of safe, decent quality care. • Developmental Standards (60% compliance) are elements of quality of care to which health management should aspire to in order to achieve optimal care.
WEIGHTING VALUES Weighting Values (%) X V E D 40 % 30 % 20 % 10 %
PERFORMANCE COLOUR CODES DOING WELL / INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC
Overall Performance (Weighted) Outcome 72% Non-Compliance Cut-Off Levels Results Outcome Extreme Measure (X): Overall score < 100% “Non - Compliance” Vital Measures (V) Overall score <90% “Non - Compliance” Overall score < 80% “Non - Compliance” Essential Measures (E) Developmental Measures (D) Overall score < 60% “Non - Compliance”
Areas with risk rating (X, V, E, D) • Domains • Six Key Priorities • Standard • Assessment Method – Documentation (Doc) – Observation (OBS) – Patient Interview (PI) – Patient Record Assessment (PRA) – Staff Interview (SI)
Risk by domain Actual Domain by Risk Score X V E D 1 Patients Rights 164 4 20 115 25 2 Patient Safety / Clinical Governance / Clinical Care 168 48 37 75 8 3 Clinical Support Services 168 2 31 123 12 4 Public Health 37 0 0 24 13 5 Leadership and Corporate Governance 62 0 7 49 6 6 Operational Management 96 2 14 77 3 7 Facilities and Infrastructure 166 32 35 82 17
PRIORITY BY RISK Actual Priority Area by Risk Score X V E D Availability of medicines and supplies 57 7 8 41 1 Cleanliness 53 0 25 21 7 Improve patient safety and security 262 71 64 117 10 Infection prevention and control 98 8 20 68 2 Positive and caring attitudes 55 1 4 47 3 Waiting times 36 0 2 31 3
WEIGHTING VALUES (cont) No of Standards by Score Range No of Count of Standards Breakdown Standards 80-100 50-79 <50 1 Patients’ Rights 12 4 3 5 2 Patient Safety / Clinical Governance / Clinical Care 9 8 0 1 3 Clinical Support Services 11 7 3 1 4 Public Health 4 2 1 1 5 Leadership and Corporate Governance 4 1 0 3 6 Operational Management 8 3 1 4 7 Facilities and Infrastructure 13 7 3 3 Total 60
STANDARDS BY RISK Actual Weighted Standards by Risk Score X V E D 1.1.1 Patient are treated in a caring and respectful manner by staff with the appropriate 76.17% 0 1 25 0 values and attitudes 1.1.2 Patient opinions inform quality improvements in the health establishment 28.57% 0 0 3 1 1.1.3 Health establishment meets the patients’ expectations of cleanliness / hygiene / 40.07% 0 4 9 0 accommodation 1.2.1 Patients are provided with information to enable them to make informed decisions 84.43% 97 0 12 4 regarding their care 1.2.2 Patients have access to information on the services provided by the health 98.46% 0 0 1 11 establishment 1.3.1 All patients in the designated catchment area are able to access the facility and its 72.73% 0 2 6 4 services 1.4.1 Management of referrals preserves the quality of patient care 20.7% 0 1 16 2 1.5.1 Waiting times in busy areas are managed to improve patient satisfaction and care 51.06% 0 3 18 2 1.5.2 Waiting times for patients to access elective care are managed to improve efficiency 100% 0 0 11 0 in the delivery of healthcare 1.6.1 The management of emergency patients arriving at or referred from the health 38.57% 0 4 1 0 establishment preserves the quality of patient care 1.7.1 The package of services offered at the health establishment are in accordance with 100% 0 0 1 0 national guidelines or licensing specifications 1.8.1 Patients complaints are managed systematically and to patients satisfaction 12.5% 0 0 8 0
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