ward accreditation for quality - hc-uk
TRANSCRIPT
the very best care for every patient, every day
Ward
Accreditation for
Quality
David Thorpe MSc. BSc. RN
Deputy Chief Nurse
the very best care for every patient, every day
Objectives
• Devising and delivering a quality assurance accreditation
scheme
Benefits
Key Enablers
Shared learning
• Provide assurance of compliance against NHSI Guidance in
developing and implementing ward/unit accreditation
programmes
https://improvement.nhs.uk/documents/4951/NHSI_Ward_accreditation_guidance_F
INAL.pdf
• What does success look like
the very best care for every patient, every day
The difference between Reassure and Assurance
• Reassurance – we say it’s in practice.
• Assurance – positive evidence that shows that we are doing it in practice, we understand, and if we have a gap we know what are we doing about the gap.
• The current systems in the Trust supports us to do this for our clinical areas
the very best care for every patient, every day
National Overview
• Influence Change
• Highest standards being met
• Commitment to Long Term Plan
• Quality Improvement
• Shared Governance – decision
making at ward level
• Different Accreditation models
the very best care for every patient, every day
The HOW - Practical Guide – your checklist
• Alignment of the accreditation framework to external assurances.
– Care Quality Commission’s fundamental standards
– NHS Improvement’s Single Oversight Framework.
• Select a project lead - oversee the development of the trust’s accreditation programme.
• Base your quality standards on evidence of best practice and use a range of existing metrics
– National indicators of quality
– Performance
– Workforce
– Locally agreed indicators.
the very best care for every patient, every day
Practical Guide cont.
• Encompass all aspects of quality with
measures for patient experience, patient
safety and clinical effectiveness.
• Develop a programme of assessment
days and who will make up the
assessment team.
– Assessment length can vary depending on
the style (visits or panel)
• Decide what constitutes achievement of
accreditation
– Bronze, Silver, Gold
– Ward Matron
the very best care for every patient, every day
Benefits
• Reduces unwarranted variation -providing an evidence-based, standardised approach to supporting the delivery of care and improving quality.
• Increases staff engagement, encourages team working and improves staff morale, leading to reduced turnover, sickness and reliance on temporary staff
• Helps nurses, midwives and care staff understand what the expected standards are at ward and unit level by providing a clear set of standards and a measure of how well a ward or unit is delivering quality care.
• Provides ward-to-board assurance on the quality of care and demonstrates compliance with fundamental standards which enables preparedness for external inspections.
the very best care for every patient, every day
Benefits cont.• Creates a platform for continuous
improvement in patient safety and patient experience, and encourages staff engagement in local quality improvement projects.
• Improves accountability and encourages shared governance by enabling a focus on the key risks associated with the delivery of care as well as by identifying excellent practice.
• Provides a platform for shared learning so that wards and units can learn from each other and disseminate excellent practice.
• Creates a culture of pride and accomplishment
the very best care for every patient, every day
Factors for Continuous Improvement
• Culture
– Positive
– Open
– Supportive
• Good leadership
• Staff engagement
– Empowering – Shared
Governance
the very best care for every patient, every day
The Framework consists of nine care
headings:-Person Centred Care
Patient needs and preferences
Pain Management
End of Life
Bladder & Bowel
Dignity & Respect
Consent
Leadership & Professionalism
Ward management and Environment
People Management
Mentorship
Safecare and Treatment
Falls
Risk Assessment & Care Planning
Blood Transfusion
Acute illness management
Tissue Viability
Medicine Management - Storage
Administration of Medication
Patient Identification
Medication Documentation
Safe Discharge Planning
Medical Staff
Diabetes
Safeguarding from Abuse
Safeguarding Adults and Children
Nutrition and Hydration
Infection Control, Cleanliness and Safety & Equipment.
Infection prevention and Control
Hand Hygiene
Cleanlines of the Ward
Patient shared equipment
Safety
Clinical Governance
Complaints
Incident & Investigations
Learning from experience
Audits & Risk
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What does success look likePerson Centred Care
– Staff are aware of facilities available for family/carers in End of Life Care situations e.g. access to car parking, washing / toilet / sleeping facilities, restaurant facilities
– Patient’s pain score is addressed appropriately
Dignity and respect
– Staff introduce themselves to patients and their relatives using Hello my name is...
– Patients have been asked / encouraged to get dressed in own clothes today
– Patients are called by their preferred name and this is documented on the Patient Bed Board
Consent
– Staff are able to explain the conditions and arrangements under which consent can be delegated.
– Staff understand the process for assessing a patient's capacity to consent to examination and treatment, and the procedure to be followed where it is determined that the patient lacks capacity to consent to a specific procedure.
the very best care for every patient, every day
What does success look like cont.
Leadership and Professionalism
– Ward is visibly clean and clutter free
– Staff can articulate the purpose of safety thermometer and are aware of what is monitored
– Three copies of previous ward minutes available that show evidence of learning and sharing from incidents and complaints
– There is evidence of staff having a personal development plan linked to corporate and service priorities and individual needs
Safe Care and Treatment
– A falls risk assessment is completed within 6 hours of arrival and interventions are in place
– Health records are stored in a secure facilities
– On admission and/or transfer, pressure ulcer risk assessment is undertaken within 6 hours and reassessed as a minimum weekly
– Staff are able to articulate the management of hypoglycaemia as per Trust guidelines
– All patients have a VTE assessment completed within 24 hours of admission
the very best care for every patient, every day
What does success look like cont.
Safeguarding from Abuse
– Staff are up to date with the level of Safeguarding Adults and Children Mandatory training as relevant to their role.
– Staff are aware of how and from where to seek advice within the Trust about Safeguarding matters and have access to, current procedures and guidance for raising and responding to concerns of abuse.
– All vulnerable patients are identified on the safety huddle which includes safeguarding, heightened observation, pressure ulcers , falls and DNA CPR.
Nutrition and Hydration
– The patients MUST is completed with 24 hour on admission or transfer
– Protected mealtimes is adhered to
– Water is within easy reach of all patients
– Hydration risk assessment is completed daily
– Patients feel they get enough help from staff to eat their meals
the very best care for every patient, every day
What does success look like cont.
Clinical Governance
– Staff are able to describe how they would deal with a situation in which a patient or relative
reported informal concerns.
– There is evidence that themes from complaints are discussed at ward meetings and appropriate
actions have been identified and shared with staff
– Patients feel comfortable raising concerns with their care
– Staff can describe the process for reporting incidents, and give 3 examples of the types of
incidents that have or they might report
– There is evidence that incidents/complaints and outcomes from investigations are fed back at
ward meetings
the very best care for every patient, every day
Ward Accreditation, how are we doing?
Ward Accreditation level Ward Accreditation level
LANGLEY- pilot ward
change in ward
manager therefore not
to be awarded CCUPG3 Gold
STROKE UNIT Gold CROXLEY
change in ward manager
therefore not to be
awarded
ALDENHAM Gold WINYARD Silver
AAU B / Isolation/ yellow
3 Silver AAU YELLOW LEVEL 1 Silver
Tudor Bronze AAU PURPLE LEVEL 1 Silver
CASSIO Silver RIDGE Silver
OXHEY Gold AAU Green LEVEL 1 Silver
BLUEBELL Silver Letchmore Silver
the very best care for every patient, every day
What have we learnt‘I think the ward accreditation process enhanced us to see our ward safety and
governance more closely. As a band 7, I have chosen this as my reflective account for
revalidation, a brilliant piece of work to reflect on. Preparing for the presentation was a
team effort. I have included my newly qualified nurse and health care assistant to present
in front of the panel. We as a team felt valued and really over the moon when we have
achieved “ Gold Award” from our Chief Nurse and Quality Lead!’
‘This award had boosted our energy to do more at the safety aspects because we believe
every patient enter into our Trust should feel confident that they are entering.’
‘Although preparing and delivering a presentation has it stressful moments, it was highly
satisfying to have the opportunity to talk about my passion and specialist subject – my
ward & team’
‘Key point: involve the team and let them understand how important is this award for the
ward, arrange ward meeting and keep them informed about what is ACE programme.’
‘Reflect back on which are the areas that needs some improvement and challenge
yourself (as manager) in making effort to improve in those areas at the following review.’
‘I think that involving your ward to be part of this Quality Improvement journey is certainly
a good moment to create a stronger team working concept within the unit and as ward
manager to reflect about your strengths and weakness.’
the very best care for every patient, every day
How do we support wards that require further
development? • Data gathered from ward accreditation and
ward scorecards are analysed monthly at our Quality Improvement Forum where wards are identified if they need support and focus –proactive approach
• Senior Team discussions include Chief Nurse, Deputy Chief Nurse, Heads of Nursing, Quality Lead Nurse and Specialist Nurses
• The clinical area with their senior team decide which are the areas of focus and decide their KPI’s. A senior team are then parachuted in to undertake a programme of intense support over a set timeframe.
• Currently 2 clinical areas being supported –aim is to keep revisiting, monitoring and supporting.
the very best care for every patient, every day
Summary
• Consultation groups
• Checklist for success
• Base your quality standards on evidence of best practice that you will already
have
• Develop your programme of assessment days.
– Assessment length and can vary depending on the style (visits or panel)
– How are you going to recognise achievement
– How are you going to support improvement
• Governance
• Leadership
the very best care for every patient, every day
Ultimately …….
Supporting the Trust Vision:
‘the very best care for every patient every day’The Trust values:
‘Commitment, Care & Quality’
Aligning to the Nursing ,Midwifery and Allied healthcare professional strategy
Exemplifying inspirational leadership
Stewardship of the budget
Exemplifying professional practice
Ensuring a positive patient experience through the patient pathway.
the very best care for every patient, every day
Thank you