Safety Triangulation Accreditation Review Christine Morris - PowerPoint PPT Presentation

Safety Triangulation Accreditation Review Christine Morris Associate Director of Governance October 2018

Sept 2016

What Did Staff Say? • Patients are at the centre of it all of it - we should be assuring them • We spend a huge amount of time collecting data - is it used ? • We don't need more resources - just need to work smarter • Not always convinced the data is accurate • There is lots of duplication • Lots of audits, not always with a clear pathway • Doesn't feel like everything is gathered in a single place • Various instances where things are being done but not fed upward • Individual systems exist, but without an overarching strategy • Lack of visibility and shared learning (both positive and negative) • Assurance needs to tie into accountability • Are the right people doing the right bits? • Only helps ward managers a small amount in terms of doing the day job • Estates is sometimes on periphery and should be integrated • Some audits are "done at" departments rather than with them • There’s a disconnect - things that would help elsewhere but not being used • RAG rating and dashboards often provide more reassurance than assurance • No standardised template for action plans, but there is probably a "popular one"! • Can end up with a complex set of actions/plans, a bit like a "house of cards" • Not always clear how the lessons learned process works • Examples of good action plans but process means they aren't always owned at ward level

Our Vision Our Framework for Excellence will provide assurance on the standards of care across Lancashire Teaching Hospitals. The system will empower staff by providing a framework and clear standards. These standards will be used to work in partnership with peers to provide evidence that is credible, reliable, open and honest, allowing areas to benchmark and eliminate variation and provide a platform for continuous improvement.

Key Principles Our framework will be:  Consistent with achieving an outstanding rating in line with the CQC standards  Align with LTH core ambitions and values  Patient and family focussed  Credible, measureable and relevant to all staff and the work they do  Flexible to allow for local variation  Responsive, dynamic, action focused

Roles and Responsibilities Ward / Department Divisional Matron / Professional Manager Nurse/Midwifery/AHP Leads Director Ensure the outcomes • Undertake STAR of the review are • Ensure improvement monthly review actioned actions for areas / • Monthly reporting repeated shortfalls Place the results of the to Divisional Nurse are addressed review on the ward / Midwifery / AHP appropriately governance meeting Director agenda • Quarterly reporting to Divisional Agree actions and Governance Boards collectively resolve areas requiring • Reporting to Safety improvement and Quality Committee Quality Assurance Matron Quality Assurance Team Quarterly Report to the Support Quality Deliver Group

Triangulation

STAR Monthly Reviews • Undertaken by the Matron or Professional Lead • Completed by 26 th of each month • Recorded on the Audit Management and Tracking (AMaT) system • Focus on fundamental standards that underpin a safe and effective environment for patients and staff

STAR Monthly Reviews 14 questions - one from each of the 4 categories following domains :  Well Led  Quality Improvement • Documentation  Staff Health and Well Being  Infection Prevention and Control  Safeguarding Vulnerable adults  Medicine Management • Environment  Performance Data  Environment  Documentation • Staff Feedback  Listening to Patients  Harm Free Care  End of Life  Acutely Unwell • Patient Feedback  Discharge

Clinical areas - Wards - Inpatients - Outpatients - Therapies - Clinics - Satellite units

STAR Monthly Review Scoring

STAR Reviews Monthly Reporting

STAR Monthly Review Trust Wide

STAR Visit Process • Undertaken at least every 6 months by: • Quality Assurance Matron / member of Quality Assurance Team (to ensure consistency of standards) • Ward / Departmental Manager • Matron • Layperson or peer assessor from a different clinical area • Recorded on the Audit Management and Tracking (AMaT) system • Focus on fundamental standards that underpin a safe and effective environment for patients and staff • Opportunity to benchmark against others providing a similar service • Will include the same questions asked in the STAR Monthly Review

STAR Visit Process • 15 step challenge (on the way to the area) • Checking • training records • risk assessments • departmental minutes • audits • Discussion with patients, carers and staff • Observation of environment and care given • Review of documentation

STAR Accreditation Visit Scoring and Revisits

Feedback - High level and any patient safety / immediate issues addressed before leaving the ward - Quality Assurance Matron - written feedback within 48 hours 4 Categories • Documentation • Environment • Staff Feedback • Patient Feedback

Where are we now ?

Additional Support Will include but not limited to:

MIAA – Baseline Review

Our story of Red To Green Outpatients Team Sharon Brown Judy Pendlebury