Quality
Framework
2013-2018
DRAFT v1.0
For consultation
[email protected]
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Staffordshire and Stoke on Trent Partnership Trust Quality Framework 2013-2018
DRAFT v1.0 Simon Kent & Robin Sasaru
This is a DRAFT consultation document. Questions and statements in bold
and red text are to be answered throughout the consultation.
Contents
Consultation .......................................................................................................................... 3
Consultation questions ...................................................................................................... 3
Introduction / Background ..................................................................................................... 4
Drivers for quality .................................................................................................................. 5
Definitions: What is quality? .................................................................................................. 9
Our values for quality .......................................................................................................... 11
The aim of the quality framework ........................................................................................ 13
How the framework fits into the Partnership Trust ............................................................... 14
What the framework means for our staff.............................................................................. 16
Safety .............................................................................................................................. 16
Effectiveness ................................................................................................................... 16
Experience ...................................................................................................................... 16
The strategic goals in the quality framework ....................................................................... 17
Empowering frontline quality ............................................................................................ 18
Front Line Continuous Improvement (FLCI) ................................................................. 20
Benchmarking .............................................................................................................. 20
Moving to Effective Outcomes ......................................................................................... 21
Assuring Essential Quality Standards .............................................................................. 22
Moving to Excellence....................................................................................................... 23
Customer Service Excellence ...................................................................................... 24
Integrating Quality as a core part of the Organisation ...................................................... 25
Implementation ................................................................................................................... 26
Monitoring: How we measure progress ............................................................................... 27
Monitoring the implementation of the framework ............................................................. 27
Monitoring the quality of care ........................................................................................... 27
The framework monitoring grid ........................................................................................ 27
Appendix: Developing the framework .................................................................................. 29
Consultation Progress table............................................................................................. 31
Impact and Assessment progress.................................................................................... 32
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Consultation
Please respond to this consultation document! The closing date for comments is 19
October 2012
You can email your comments to [email protected] or call one of our Quality Managers:

Robin Sasaru (mobile: 07718 118178)

Simon Kent (mobile: 07718 118176)
This document is subject to a planned consultation process during September and October
2012. Comments are welcomed on any part of the document. In addition, specific questions
for consultation are noted below:
Consultation questions
A. Are there any other key internal strategies or policies in health or social care that the
quality framework needs to take account of? ........................................................................ 4
B. What other drivers for quality should be referenced in this framework? .......................... 8
C.
What other definitions of quality should this framework take account of?.................. 10
D.
What should our definition of quality that encompasses health and social care be? . 10
E. What other values for quality should we include? ......................................................... 12
F. ‘Service users’, ‘patients’ or ‘customers’? What is the most appropriate term for the
people we care for across health and social care? .............................................................. 15
G.
What other local and national learning around quality should we take account of in
this framework?................................................................................................................... 15
H.
What other strategic goals, if any, should be included in this framework? ................. 17
I. How can we empower front line teams and services to deliver quality and continuously
improve the quality of their services? .................................................................................. 19
J. How can we get all parts of our organisation to continually focus on outcomes? .......... 21
K. How can we strengthen our assurance processes around essential quality standards?
22
L. How can we develop a culture of excellence across the whole organisation? .............. 23
M.
What other key tools / work programmes can help us to “move to excellence”? ....... 24
N.
Which actions can we take to fully integrate quality through the organisation? ......... 25
O.
How can we most successfully bridge the culture gap between health and social care
quality? ............................................................................................................................... 25
P. What indicators (and their target directions) should we include to measure progress
against this framework for the next five years?.................................................................... 27
Q.
What should we measure to tell us whether we are achieving our quality framework
strategic goals? ................................................................................................................... 28
R.
Who else should be consulted? ................................................................................ 31
S. Are there any other impact / assessment processes this quality framework should
undergo before approval and ratification? ........................................................................... 32
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Introduction / Background
Staffordshire and Stoke on Trent Partnership NHS Trust was established on 1 September
2011 from three predecessor PCT provider arms of North Staffordshire, South Staffordshire
and Stoke-on-Trent. The Partnership Trust has worked with Staffordshire County Council to
successfully integrate Adult Social Care Services (older people, physical disabilities and
sensory impairment) with community health services from April 2012.
The Partnership Trust’s primary objective over the next five years is to have fully integrated
its health and social care services to drive up the quality of care and services provided and
to deliver our five strategic goals. The integration of three different NHS provider bodies and
social care provision brings unique challenges in relation to defining, measuring and
improving quality. For this reason an overarching framework for quality is needed to ensure
that quality is integral to the organisation.
Our vision is one where all health and social care provided is:




of the highest quality in terms of safety, effectiveness and experience
personalised, allowing our service users the fullest choice and control
where we can increasingly measure and improve the ultimate outcomes of care
where information on quality is acted upon rapidly and effectively to ensure continual
improvement
In order to achieve organisational quality improvements we recognise the major steps to be:


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

setting specific aims around quality improvement and overseeing their achievement
through a robust governance structure
focus on organisational aims and measures to ensure we get it ‘right by design’ first
time every time
engaging all of the executive team in the agenda as well as front line staff
expanding our patient, service user and carer experience programme
building the improvement capability of the organisation to achieve our vision
This quality framework should be read alongside organisational strategies and policies
related to quality, especially around the following:





Social Care quality framework
Clinical Audit and Effectiveness
Risk Management
Service user Experience
Integrated business plan
A. Are there any other key internal strategies or policies in health or social
care that the quality framework needs to take account of?
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Drivers for quality
While there are many national and regional drivers for quality, this section references the
drivers that relate primarily to the overarching quality framework. Strategies that sit under
this framework will make reference to the drivers for that particular area.
The NHS Next stage review (2009) led by Lord Darzi, published “high quality care for all”.
This document advocated that quality should be the prime focus and driving force for the
NHS over the next decade. It also provided a general definition of quality under Safety,
Effectiveness and Experience. “High quality care for all” introduced a Quality Framework as
the national strategy for quality improvement. The Partnership Trust has already responded
to this Quality Framework in its 2011/12 Quality Account.
Figure 1: The Quality Framework and the Partnership Trust response 1
Quality Framework: guidance for community services (2009) is best practice guidance
that sets the direction for implementing the national Quality Framework within community
services. The guides describe evidence-based interventions, which will help make every
service as good as the best. Whilst they are designed principally for front-line staff and
clinical team leaders, commissioners will use them to inform service specifications, and with
the indicators in the Quality Framework, track improvement. The Community Services
1
Transforming Community Services: Quality Framework: Guidance for Community Services,
Department of Health, 24 Jun 2009. Access via
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1
01426.pdf
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Quality Framework has been embedded to deliver the transformational change throughout
the new organisation. Through the implementation of the framework THE TRUST aims to:




improve people’s experience of health and social care
enables and drives a culture of continuous improvement
embed quality as the organising principle driving the quality agenda
enable accountability across all stakeholders
Equity and Excellence: Liberating the NHS (2011) affirmed the desire to ensure that
health services in England “achieve quality and outcomes which are among the best in the
world” and identified a number of reforms that relate to the quality agenda, in particular:

Putting service users at the centre of care; “no decision about me without me”

Creation of an NHS outcomes framework which will span the three areas of quality
(Safety, Effectiveness, Experience)

Establishment of Local / National Healthwatch, Health and Wellbeing Boards, Clinical
Commissioning Groups and a National Commissioning board

Disestablishment of Primary Care Trusts and Strategic Health Authorities

Strengthening the roles of the Care Quality Commission, the National Institute for
Health and Clinical Excellence, and Monitor.
The NHS Outcomes Framework sets out the national outcome goals that the Secretary of
State for Health will use to monitor the progress of the NHS Commissioning Board. The NHS
Commissioning Board will commission the National Institute for Health and Clinical
Excellence (NICE) to develop Quality Standards which will set out the evidence-based
characteristics of a high quality service for a particular clinical pathway or condition. These
standards will, where appropriate, look across several or all five domains of the NHS
Outcomes Framework.
The framework recognises the importance of aligning outcomes for health and social
care, developing a shared accountability where appropriate. Further alignment of outcomes
is stated as desirable in future years, as a means of encouraging collaboration and
integration.
The Vision for Social care (2010) and Think local act personal (2010) emphasises a
system that helps people to live their lives the way they want to, supported by the staff who
work with them. The approach aims to free the front line from bureaucratic constraints and
support local organisations to focus on the quality of care and the outcomes achieved for
people using services and their carers, without the focus on targets. A particular example of
this is the Making It Real2 (2012) key themes and criteria, based on a public commitment to
improving quality in social care. The key themes are based on “I” statements, which
emphasise quality as dependent on service user requirements.
The National Quality Board (NQB) is a multi-stakeholder board established to champion
quality and ensure alignment in quality throughout the NHS. The Board is a key aspect of the
2
See http://www.thinklocalactpersonal.org.uk/
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
work to deliver high quality care for service users. The NQB 2012 draft paper Maintaining
and improving quality from April 20133 highlights the nature and place for quality in a
changing healthcare system, the different parts of the system together with the
corresponding roles, responsibilities and expected values and behaviors to put service users
and the public first.
The NQB 2010 Review of early warning systems in the NHS presents lessons to be learned
from investigation and review of NHS organisations (notably the Francis Enquiry into MidStaffordshire NHS Foundation Trust) and makes clear that safeguarding patients is the
responsibility of every organisation and every member of staff.
The Care Quality Commission (CQC) is the independent regulator of all health and social
care services in England. Its essential standards of quality and safety outline the basic
essential service quality that our organisation should always achieve.
The Commissioning for Quality and Innovation (CQUIN) scheme is a key driver to
ensure boards maintain a focus on the delivery of a quality service. The scheme allows
commissioners to retain a proportion of a Trust’s income. The Trust is required to meet a
series of pre-agreed quality markers to obtain that portion of the funding, and this allows
both parties to ensure quality is integrated into the development and delivery of care.
The Monitor Quality Governance Framework was introduced into the assessment process
for foundation trusts in 2010. A Quality Governance assessment is now part of the
Foundation Trust application process, and there is a requirement for the Boards of both new
and existing NHS Foundation Trusts to self-certify with regards to quality governance.
Monitor is looking for evidence that:




boards accurately understand the quality of the care their organisation provides
boards are able to assess and mitigate risks to quality
quality is seen as a responsibility of the entire board, not only the medical and
nursing directors
trusts are committed to continuous quality improvement, and have put in place the
tools to address poor performance
Quality is central to the the Trust vision:
“We deliver personalised care of the highest quality, with the best possible outcomes for
users and carers, empowering them to remain independent”
Our values and goals run through the core of our quality framework ensuring that quality
care and safety is at the heart of everything we do for our people and their families. We put
quality first.
The Trust’s Strategic Organisational Goals:

we will work with users and carers to deliver services simply and effectively
3
Quality in the New Health System Maintaining and improving quality from April 2013. A
draft report from the National Quality Board. 16th August 2012. Access via
https://www.wp.dh.gov.uk/publications/files/2012/08/Quality-in-the-new-system-maintainingand-improving-quality-from-April-2013-FINAL-2.pdf
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT



we will provide high quality and safe services which provide an excellent experience
and best possible outcomes
our organisation will develop and deliver sustainable new services that are exciting
and support independence
our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
Figure 2: Other drivers and the strategies / policies that will reference them
Other drivers for quality
National Patient Safety Agency
Safety thermometer
Commissioning for Quality and
Innovation
NHS institute: (including productive
series)
National Institute for Health and
Clinical Excellence
National Advisory Group on Clinical
Audit & Enquiries and the Healthcare
Quality Improvement Partnership
NHS constitution
Safety express
NHS Litigation Authority
Patient Environment Action Teams
Safety Thermometer
Customer Service Excellence
Equality Delivery System
Quality, Innovation, Productivity and
Prevention
Commissioning for Quality and
Innovation Payment Framework
Making it real – Think local act
personal
National Quality Board
Strategies / Policies that will reference
them
Risk Management
Risk Management
Risk Management
Transformation
Effectiveness
Clinical Audit
Safety/Effectiveness/Experience/
Transformation
Safety/Effectiveness/Experience/
Transformation
Safety/Effectiveness/Experience/
Transformation
Safety / Experience
Effectiveness
Experience
Effectiveness / Experience
Effectiveness / Experience / Transformation
Effectiveness / Experience
Effectiveness / Experience
Safety/Effectiveness/Experience
B. What other drivers for quality should be referenced in this framework?
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Definitions: What is quality?
Our definition of quality:
Quality refers to our service user and carer
requirements; expressed in terms of safety,
effectiveness, and experience; and ultimately
focussed on outcomes.
In order to clearly define a framework for quality, a clear and trust wide definition of “quality”
must be agreed that encompasses health and social care. This section aims to pull some of
the key health and social care descriptions of quality into one agreed definition, on which the
framework itself can build on.
Healthcare has long subscribed to the Donabedian456 categorisation of quality into structure
(tools and resources), process (activities that go on between practitioners and service
users), and outcome (change in current and future health status).
More recently, the NHS has worked around an updated shared definition of quality. This was
set out by Lord Darzi in the NHS next stage review 20087 as comprising three elements:
Safety: The first dimension of quality must be that we do no harm. This means ensuring the
environment is safe and clean, reducing avoidable harm such as reducing the number of
preventable pressure ulcers and reduced injury as a result of a fall.
4
Donabedian A. Explorations in Quality Assessment and Monitoring, Volume I. The Definition of
Quality and Approaches to its Assessment. Ann Arbour, MI , Health Administration Press; 1980. pp.
1–164.
5 Donabedian A. The quality of care. How can it be assessed? Jama. 1988;260:1743–1748. doi:
10.1001/jama.260.12.1743.
6 Kunkel S, Rosenqvist U, Westerling R. The structure of quality systems is important to the process
and outcome, an empirical study of 386 hospital departments in Sweden. BMC Health Serv Res.
2007;7:104. doi: 10.1186/1472-6963-7-104.
7 High Quality Care for all: NHS next stage review final report. Department of Health June 2008.
Access via
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0
85825
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Experience: Quality of care includes quality of caring. This means how personal care is –
treating people with compassion, dignity and respect. It can only be improved by analysing
and understanding service user’s satisfaction with their own experiences.
Effectiveness: This means understanding success rates from different treatments for
different conditions. Assessing this will include clinical measures such as mortality or survival
rates, complication rates and measures of clinical improvement. Just as important is the
effectiveness of care from the service user’s own perspective – for instance improvement in
pain-free movement after an operation, or returning to work after treatment. Effectiveness
may also extend to people’s well-being and ability to live independent lives.
All three of these elements must be present at the same time to ensure high quality –
delivering on just one or two is not enough.
The Social Care Institute for Excellence (SCIE) describes excellence in social care:
“Excellence in social care is rooted in a whole-hearted commitment to human rights, and a
continuous practical application of that commitment in the way that people who use services
are supported. People who use services are demonstrably placed at the heart of everything
that an excellent service does.” (A definition of excellence for regulated adult social care
services in England, SCIE 2010)
SCIE identifies four essential elements of excellence in social care:




having choice and control over day-to-day and significant life decisions
maintaining good relationships with family, partners, friends, staff and others
spending time purposefully and enjoyably doing things that bring them pleasure and
meaning.
the organisational and service factors which enable the above three outcome-based
elements to be achieved and sustained.
SCIE differentiates between Essential (ie “good enough”) and Excellent services, and
describes how focussing on outcomes for the individual and attempting to enable individuals
to have the greatest possible control over their own life, means that the service will be doing
an excellent job.
Quality is everyone’s business. It is not the responsibility of any one part of the system, it
is a collective endeavour. Quality requires collaboration at every level of health and social
care.
While there may be different definitions and descriptions of quality, everyone in our trust
should have the same understanding of quality. Our view of quality uses Safety,
Effectiveness and Experience as a common starting point.
Our ultimate aim is to improve outcomes for our service users.
C. What other definitions of quality should this framework take account of?
D. What should our definition of quality that encompasses health and
social care be?
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Our values for quality
We will apply the best approaches in health and social care for quality.
We will use the best practice around safety, effectiveness, and experience when dealing with
quality, eg:

Safety: applying national best practice around investigation and prevention of
incidents.

Effectiveness: focussing on outcomes, personalisation and choice in social care, as
well as the clinical effectiveness of treatments and interventions

Experience: use of latest validated tools for measuring experience, such as the net
promoter score
Using the underlying simple principles8 from a variety of methodologies, our vision for Quality
includes a focus on:





understanding the problem with a particular emphasis on what the data says
understanding the processes and systems within the organisation – particularly the
service user pathway and whether these can be simplified
analysing the demand, capacity and flows of the service
choosing the tools to bring about change, including leadership and clinical
engagement, plus staff and service user participation
evaluating and measuring the impact of a change
While there are many approaches to quality improvement, across healthcare, social care,
and industry, they are often based on similar principles and a common body of tools for
improvement. Drawing on work by the NHS Institute for Innovation and Improvement9, our
common values for quality improvement are:







define quality first
identify the process
beware of the exclusive promotion of one approach to quality improvement
think about who the “customer” is
understand the people – the individuals working in the system and their behaviours
get data about quality before you start
recognise the importance of whole system leadership
8
Quality Improvement Made Simple: Identify, Innovate, Demonstrate, Encourage. The
Health Foundation - Inspiring Improvement. 6th September 2010. Access via
http://www.health.org.uk/public/cms/75/76/313/594/Quality_improvement_made_simple.pdf?
realName=uDCzzh.pdf
9
Quality Improvement: Theory and practice in healthcare. NHS institute for innovation and
improvement. Access via
http://www.institute.nhs.uk/index.php?option=com_joomcart&main_page=document_product_info&pr
oducts_id=403&cPath=67
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
There are clear synergies between the approaches outlined above and the current social
care quality framework:
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

Only the customer can define quality; learn what’s important to customers
Define and refine standards
Measure how well we are meeting these standards
Take action to address unmet standards
Monitor customer satisfaction
Continuous quality improvement is a philosophy that intends that most things can be
improved and is the scientific method of improvement in everyday work. Plan-do-study-act
cycles and quality circles are examples of techniques that embrace this philosophy of quality
as a journey not a destination.
E. What other values for quality should we include?
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
The aim of the quality framework
The quality framework aim is that service users receive the highest quality of care, by
ensuring that front line teams are empowered by the organisation to provide this.
This Framework aims to provide an overarching direction and coordination on quality for the
organisation to enable delivery of the highest quality health and social care. It will make use
of best practice around proactive and responsive quality assurance and improvement.
To set the direction for quality the following strategic goals will be pursued over the next five
years:

Empowering frontline quality

Moving to Effective Outcomes

Assuring Essential Quality Standards

Moving to Excellence

Integrating Quality as a core part of the Organisation
Three strategies will directly support the quality framework:



Safety: Risk management strategy
Effectiveness: Effectiveness strategy
Experience: Service user and carer experience strategy
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
How the framework fits into the Partnership
Trust
Our conceptual model of the organisation is depicted through the interaction of layers
against a backdrop of the quality framework. The dynamic matrix interaction of these layers
with the framework ultimately influences the care that front line teams provide. This model
develops James Reason’s adapted model10, recognising the necessity of a whole-systems
approach to quality.
Service
Users
and carers
Front Line Teams
Service
Users
and carers
Front Line Teams
Teams supporting quality
Front Line Teams
Each layer supports
high quality for
the customer
Front Line Teams
Teams supporting quality
Strategies, policies, systems and processes
"Customer
requirements"
define Quality
Organisational leadership, vision and values
The Quality Framework
influences all layers to
improve quality
Our service users ultimately define what quality is. They are at the heart of what we do, and
we recognise that front line staff and teams deliver the care and services they require.
Front Line Teams and services are the next most important element – both clinical and
managerial staff, who directly deal with service users and carers and are responsible for
their competencies, conduct and for the quality of care they provide for service users.
There are many organisational teams that support quality. The Trust benefits from these
teams, which support Front Line Teams to deliver highest quality care and continuously
10
Reasons Adapted model: A Protocol for the investigation and analysis of clinical incidents,
Association of Litigation and Risk Managers , September 1999. Accessed via
http://www.patientsafety.ucl.ac.uk/CRU-ALARMprotocol.pdf
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
improve quality, while simultaneously capturing and analysing information about service user
requirements to improve support mechanisms.
Support mechanisms for front line staff and teams comprise of strategies, policies,
systems and processes. These provide consistency of direction, allowing the front line to
provide quality care.
The Quality Framework ties the organisational objectives, strategies and processes
together and provides a platform to facilitate and ensure an effective contribution to care and
safety. It will catalyse the development of high quality support mechanisms, while enabling
the organisational leadership to respond to service user quality requirements.
Our evolving model for quality will learn from a local and national knowledge base, taking
into account any conclusions, recommendations and findings from reports such as the Mid
Staffordshire NHS Foundation Trust Public Inquiry, which is due to be published in 2013,
and the Care Quality Commission Winterbourne View report (July 2011).
F. ‘Service users’, ‘patients’ or ‘customers’? What is the most appropriate
term for the people we care for across health and social care?
G. What other local and national learning around quality should we take
account of in this framework?
[email protected]
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
What the framework means for our staff
We recognise the connection between having an open culture for the organisation, quality
priorities of our service users and the values, aspirations and skills of our staff.
Organisations whose staff are engaged and have job satisfaction deliver better care. There
is compelling evidence that staff well-being and staff experience correlate with service user
experience and outcome.
Supporting and developing our staff to feel engaged, valued and empowered in delivering
quality improvements is essential for our ambition for better quality. Engaging and listening
to staff is a key part of our values for empowering staff to deliver care in a way that is
consistent with our values.
Safety




Staff are aware of their individual professional responsibility and corporate
accountability to raise concerns and provide high quality, safe care
Staff are supported and empowered to make decisions about care and safety and
they are prepared when system failures occur. When things have not gone well, staff
focus on learning lessons and improving quality
Leaders avoid over simplified explanations of system failures and the need to work
together in order to understand the true reasons for risk
Staff are open to raise concerns and are listened and responded to
Effectiveness



There is an investment in clinical leaders and staff in ensuring they are developed
and trained to focus on the effectiveness and outcomes their teams and services
Staff are recognised for their contribution to improving quality outcomes, in those that
are ‘measured’ and where staff go the extra mile in delivering excellence
Staff appraisal and development harnessing their potential for front line continuous
quality improvement
Experience


Being aware, willing to change, supported to adjust and respond to the external and
internal environment where appropriate
When things go well opportunities to hear about and spread improvements and
information across the organisation so others can learn and to improve equity,
equality and diversity.
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
The strategic goals in the quality framework
The five strategic goals in this framework provide the vision and direction for all strategy
and processes in relation to quality. Each objective works in harmony with the others to
enable the organisation to deliver the highest quality service.
Quality Framework Theme Areas
Empowering FrontLine
Quality
Effective outcomes
Integrating quality as a core
part of the organisation
Assuring Essential Standards
Moving to Excellence
The strategic goals were chosen in response to national and local priorities:





Empowering Front Line Quality is a prerequisite requirement for a quality service
Moving to effective outcomes follows the national drive to measuring quality by
means of outcomes in preference to process targets. This move reflects a wholesystems approach to health and social care, placing the service user (rather than the
service) at centre stage.
Assuring Essential Quality Standards responds to the organisational requirement for
an essential standard of quality that is placed upon us by ourselves as well as
multiple external agencies. The Trust must be able to provide a robust answer to the
question of quality to service users, commissioners, and regulators as well as itself.
Moving to Excellence recognises the need to continually strive for the highest quality
possible, in line with our own vision “to deliver personalised care of the highest
quality, with the best possible outcomes for users and carers, empowering them to
remain independent”
Integrating quality as a core part of the organisation recognises the unique challenge
facing the organisation as a partnership covering health and social care across a
large geography.
H. What other strategic goals, if any, should be included in this framework?
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Empowering frontline quality
Quality is everyone’s business, and the front line is the biggest influence on the level
of quality we deliver. Quality needs to be at the core of all teams – not an add-on.
Leadership is a key factor in developing quality teams that lead by example.
Where we are now: We have made significant progress in bringing together teams and
services from different organisations, but recognise the challenge that integration will bring to
front line teams over the coming years. We also recognise that teams need to build
confidence in the quality of their services by benchmarking and learning from experience.

The Trust’s transformation agenda aims to bring previously separate health and
social care teams together under a new arrangement of integration.

The development of a children’s directorate will also result in new arrangements of
teams. These new teams will need to have quality factored in at the outset, and have
full ownership and support for improving the quality of care that they provide.

The ongoing requirement to demonstrate value for money, improving efficiency while
maintaining quality in the context of a reducing financial envelope, will require every
team to own the quality agenda.

The trust recognises the challenge of moving to FT status will create additional
criteria for maintaining quality and safety.
The trust has multiple teams that support various elements of quality. Many of these teams
are working in a unified way across the trust, with a notable example around the integration
of the safeguarding team. We recognise teams that support quality will always benefit from
further development and integration to become world-class in the quality support they
provide to the organisation. In addition, we have a valuable set of staff knowledge, skills and
experience around quality, which needs to be harnessed, maintained and improved.
Where we want to be: Our front line teams and services have a culture of quality and own
their quality improvement agenda. They value the support they receive from the organisation
– teams that support quality are internally and externally recognised as experts in improving
quality and safety of health and social care. Teams are recognised regionally and nationally
for quality, and set the direction for effective team working in the organisation. We
consistently adopt best practice quality assessment and improvement methodologies, using
a range of trusted tools and techniques. We have built a track record for developing teams
and services to provide quality care and support quality improvement.
How we will get there: We will provide induction training and development so that new
integrated teams know how to put quality first. We will use best-practice team working and
staff development techniques to empower teams to achieve their potential, acknowledging
the link between effective teams and quality. We will actively support teams to ensure that
quality is not significantly impacted by reconfiguration and transformation.
[email protected]
Page 18 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
We will systematically learn from and develop the best of both health and social care quality
tools and techniques. We will align health and social care quality methodologies (e.g. quality
circles and clinical audit) to support Front Line Improvement.
We will make effective use of team meetings, away days, and other techniques to improve
the quality of teams and services. We will develop measures that demonstrate the
contribution that our teams make to the financial health of the organisation when they
improve quality.
We will develop teams that support quality to have the appropriate knowledge, skills and
experience to be classed as experts in their respective roles. We will also provide
opportunities for our staff to develop skills across the quality disciplines, to increase
resilience and promote a holistic approach to quality. We will ensure that teams supporting
quality are visible to the front line, and that they develop productive working relationships
across the organisation.
We will aim to publish papers in peer-reviewed journals on aspects of quality. We will
support regional and national networks for health and social care. We will present at local,
regional and national conferences, showcasing our work and quality improvement. We will
contribute to national registers and databases related to quality, thereby benchmarking our
services.
I. How can we empower front line teams and services to deliver quality
and continuously improve the quality of their services?
[email protected]
Page 19 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Front Line Continuous Improvement (FLCI)
As pictured in framework conceptual model, front line professionals and teams most directly
affect quality of care. Improvements in quality are delivered first and foremost by teams11.
Front line staff and teams most often know why quality and excellence are not achieved.
Efforts should centre on helping front line teams to improve quality, giving them the tools to
understand and improve the quality of their service, drawing from the widest possible theory
and experience base. FLCI is an essential component of this quality framework.
Through group working techniques and application of quality improvement theory at the front
line, quality support teams will facilitate front line teams to suggest and make intentional and
demonstrable changes that directly improve care and safety. Successful facilitation will
require use of models such as the Johari Window and Betari Box to successfully influence
service teams to become self-learning change teams, learning from experience to initiate
their own quality improvements.
Benchmarking
At team level, the main purpose of indicators and benchmarks is to support improvement.
High performing teams proactively benchmark themselves against other teams.
Indicators already exist, including the clinical audit programme, which enable this to happen.
We need to ensure that existing indicators are used appropriately to facilitate comparisons
and minimise duplication.
Adaptation of techniques such as “Essence of Care” can help teams to look for ideas for
excellence outside of their own practices and experiences.
High Quality Care for all – measuring for quality improvement: the approach. Department of Health.
Access via
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_09044
4
11
[email protected]
Page 20 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Moving to Effective Outcomes
Our organisation aims to have a mindset of continually focussing on the outcome “the end result” - of any structures and processes. To improve quality front line teams
we must focus on outcomes rather than outputs.
Where we are now: Some parts of our organisation are fully focussed on service user
outcome measurement and improvement. Also we routinely measure outcomes by means of
CQUINS and other initiatives in some areas. We want this good practice to be enhanced and
extended to encompass the whole organisation.
Where we want to be: Quality improvement activities result in demonstrable, measurable
improvement in outcomes. Dashboards, indicators, and other routine measurement systems
feature important outcome-based measures and staff regularly monitor and act on these
measures. Best-practice methods are used to measure and understand outcomes,
improving confidence in their use. Change activities are routinely assessed before
implementation for their impact on outcomes in terms of safety, experience, and
effectiveness. Front line teams develop, test, and use outcome measures as part of their
day-job, striving for continually improving their outcomes. Key outcome measures, such as
“making it real” statements in Think local act personal, are routinely used by integrated
teams to monitor and improve health and social care.
How we will get there: We will support front line teams to measure what they do, using
good and timely information as a basis both to improve the care they provide and to
compare themselves with other teams. We will advocate best practice techniques to develop
and understand outcome measures across health and social care. We will ensure that
outcome measures for safety are routinely used in all areas.
We will, with the help of national information, service user experience and a high quality
evidence-base, help teams to define and measure outcomes.
Through demonstrable evidence on service improvements and lessons learned on a local
and national scale, we will ensure that improvements and good practice innovations are
routinely shared across all teams and services. Once proven, we intend to share our
improvements and experiences with the rest of the NHS family.
J. How can we get all parts of our organisation to continually focus on
outcomes?
[email protected]
Page 21 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Assuring Essential Quality Standards
We aim to be able to assure ourselves and others that the care we provide always
meets essential quality standards of safety, effectiveness, and experience. We aim to
be able to act swiftly to prevent anything from threatening our essential quality
standards of care.
Where we are now: We currently have governance structures for health and social care,
regular reporting on all quality issues, a quality visit programme (including responsive
reviews) that provides the Partnership Trust with assurance of quality. Our social care
services have a range of quality standards which are monitored on a quarterly basis with
subsequent service improvement plans developed at a locality level. Social care quality
improvement interviews are regularly conducted based on service user feedback. We are
currently harmonising our policies and guidance documents. Our HealthAssure database is
available and is in the process of being populated with evidence of compliance with essential
standards for healthcare. We have started performing thematic reviews around specific
quality areas. Some of these processes are still bedding-in, and other processes are in
development, such as unified dashboards and our Quality Early Warning Intelligence
System.
Where we want to be: Our Quality Early Warning Intelligence System provides regular
consistent intelligence on quality for every team in the Trust, helping to spot trends before
they significantly impact on quality. Our databases for evidence of assurance are regularly
updated by staff in health and social care, and routinely used for reporting on assurance.
Our governance processes are unified across health and social care, providing a clear line of
accountability for quality from the Board to front line teams. We are compliant with all
relevant health and social care external assessments, and confident of excellence in relation
to future assessments. Our responsive quality visit system provides a focussed fast
improvement response to any quality concerns, and is not routinely required due to high
quality services and robust governance arrangements.
How will we get there: We will develop clear, consistent and concise reporting to enable
committees and groups in the governance structure to see clearly any issues relating to
quality. We will strengthen current processes around complaints, PALS, service user
experience, incident reporting and clinical audit, learning from best practice, social care
quality standards and quality improvement interviews so that they consistently provide robust
intelligence on potential system failures. We will improve the existing committee structure to
ensure clear migration of information ward to board and vice versa. We will work to attain
and maintain NHSLA risk management standards. Our intelligence systems will be designed
to cross-reference intelligence to provide information for multiple external assessments, as
well as internal quality intelligence. We will use an internal responsive quality visit process to
provide an additional layer of quality assessment and improvement to supplement our
existing systems for quality, particularly around patient safety. We will develop a
standardised quality and safety dashboard for front line teams.
K. How can we strengthen our assurance processes around essential
quality standards?
[email protected]
Page 22 of 32
Figure 1
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Moving to Excellence
Excellence surpasses the ordinary, providing a level of quality that is unusually high.
Excellence is essential; it raises staff morale, fosters goodwill with commissioners
and delights service users. Today’s excellence is tomorrow’s standard12; we cannot
afford to stand still.
Where we are now: Processes are in place to provide assurance around patient safety,
respond to service user feedback, and identify areas for quality improvement. Standardised
working practices are not yet fully achieved and some processes and programmes require
further development and embedding. ‘Pockets of service excellence’ exist throughout the
organisation including achievements such as a National Nurse of the Year for 2012/13.
Where do we want to be: Striving for excellence is embedded into the culture of the
organisation, as front line teams have a clear understanding of their essential standards, and
their team-defined goals for pursuing excellence in their services. The organisation routinely
finds and celebrates the successes and innovations of individuals and teams. Quality
support staff are visible in across the front line of the partnership trust, fostering a culture of
safety and innovation, spreading ideas for excellence. Quality visits are used to discover
and promote excellence, and are positively received by front line staff as an improvement
enabler; supporting not scrutinising. Continuous quality improvement philosophies such as
Lean and six-sigma are adapted and routinely used by front line teams to achieve
excellence. The organisation wins national recognition in areas related to quality and
excellence. The organisation has a reputation for everyday excellence as a first class
foundation health and social care community provider. Services make regular use of internal
and external benchmarking to help adopt innovations. The level of research and
development undertaken by or supported by the Trust will increase each year. The
organisation can demonstrate excellence in relation to key patient safety indicators such as
avoidable pressure ulcers, harm from falls, and hospital acquired infections.
How we will get there: Teams will be supported to move from essential standards toward
excellence. Trust-wide initiatives and work programmes, such as the “Customer Service
Excellence” standard, aim to achieve excellence in themed areas. The quality team will
develop the use of in-house programmes for excellence, such as Front Line Continuous
Improvement. The Quality Early Warning Intelligence System will be developed to contain
measures for excellence in addition to essential standards. We will use clinical audit to
measure and improve, ultimately demonstrating excellence in relation to national standards.
We will promote research and development within the organisation as a way to advance best
practice. We will to redefine the requirements for excellence on a regular basis, raising the
bar for the quality of our services.
L. How can we develop a culture of excellence across the whole
organisation?
12
1: Mehl B. Defining excellence. Am J Hosp Pharm. 1993 May;50(5):921-8. PubMed
[email protected]
Page 23 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Customer Service Excellence
(see http://www.customerserviceexcellence.uk.com)
Customer Service Excellence is a Government standard, developed to offer services a
practical tool for driving customer-focused change within their organisation.
The Customer Service Excellence standard tests in great depth those areas that research
has indicated are a priority for customers, with particular focus on delivery, timeliness,
information, professionalism and staff attitude. There is also emphasis placed on developing
customer insight, understanding the user’s experience and robust measurement of service
satisfaction.
Our customer service standards build on the national standards:
1: People are at the centre of everything we do
2: We take pride in delivering a high standard of health and social care
3: We enable people to make choices about their care by providing understandable high
quality information
4: We treat each other and people who receive our services with dignity and respect
5: We all act with responsibility for what we do
M. What other key tools / work programmes can help us to “move to
excellence”?
[email protected]
Page 24 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Integrating Quality as a core part of the Organisation
Quality must be the golden thread that stitches the organisation together. We strive,
not to be seamless, but to be integrated.
Where we are now: Progress has been made in integration in many areas of the Trust, but
some differences in ways of working still exist. The service user experience team using a
single consistent method for gathering the “net promoter score” and other service user
experience information across the Trust. Multiple work streams exist for improving quality,
but these are not yet orchestrated centrally. Legacy IT systems currently hamper integration
efforts. Some areas of the organisation have good levels of incident reporting and clinical
audit activity, but there is progress to be made in achieving a good safety culture
consistently across all areas in the Trust. The MASH (Multi-Agency Safeguarding Hub) is a
notable example of integration which brings staff from external partner organisations
together to share intelligence and work in harmony. Harmonisation of policies, procedures
and ways of working is required across the whole Trust. Separate frameworks and
committee structures exist for health and social care quality, along with significant cultural
differences.
Where we want to be:, Quality is systemic, and acknowledged as the collective effort and
shared responsibility of all individuals. Front line teams have a single approach to quality
measurement and improvement, supported by an integrated Quality Governance structure.
Unified IT systems support quality measurement and improvement, including dashboards
and benchmarking.
Single line management structures ensure managers look at quality for the whole
organisation. The organisation has developed a new language of quality that combines the
best of health and social care approaches. The organisation has a best-in-class safety
culture that works across all areas of health and social care.
How we will get there: We will identify and share best practice on quality, especially around
safety culture across the organisation. We will make use of networking opportunities to know
each other’s roles, benchmark and learn from each other. We will run a series of health and
social care quality summits to develop and implement a unified quality assessment and
improvement methodology. We will continually use the principles of Seven Steps to Patient
Safety, Patient Safety First, Safety Express and other recognised tools for safety across the
whole organisation.
We will develop a clear language for quality and quality improvement that reduces reliance
on health or social care jargon. We will harmonise processes for social care quality such as
the current social care quality framework along with other systems and processes for health
N. Which actions can we take to fully integrate quality through the
organisation?
O. How can we most successfully bridge the culture gap between health
and social care quality?
[email protected]
Page 25 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Implementation
The Nursing and Quality Directorate has a work plan with key priority areas for 2012/13. The
implementation of this framework will:

build on the current 2012/13 work plan, providing overall direction for this years work

use a phased approach for subsequent years, ensuring progress against each of the
theme areas while maintaining in-year flexibility for responding to quality issues
Each December the annual Implementation plan for the next financial year will be produced
and the framework theme areas will be reviewed.
The implementation plan will be developed so that each action on the plan is Specific,
Measurable, Attainable, Relevant, and Time-bound.
Using the Framework Conceptual Model, implementation will take place according to three
broad overlapping phases, drawing on Monitor’s Quality Governance Framework13:
1. Structure: Align strategies, policies and the capabilities and culture of support teams
to fulfil framework strategic goals
2. Process: Ensure clear roles and accountabilities in relation to quality governance are
in place, with clear processes for escalating and resolving issues
3. Outcome: Embed routine measurement of outcomes, with appropriate quality
information being analysed and challenged
13
See “Applying for NHS foundation Trust Status – guide for applicants” Monitor 2010
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Page 26 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Monitoring: How we measure progress
There are two key elements of monitoring that are attached to this framework, which will be
combined into a single framework monitoring grid.
Monitoring the implementation of the framework
Each quarter a progress report against the quality framework annual implementation plan
will be submitted to the Safety and Effectiveness Sub Committee. The progress report will
note the proportion of completed actions, and provide brief exception reports for actions that
are not progressing to schedule.
Monitoring the quality of care
Monitoring of the quality of care will take place primarily using the Quality Early Warning
Intelligence System, at a team level. This system will be developed to provide regular
tracking of performance relative to the strategic goals in this framework.
Each year the Trust will produce a quality account, in parallel with the annual report and
financial accounts. Quarterly progress reports will provide a valuable information stream for
the annual quality account. In addition, a quality framework annual report will summarise the
progress that has been made in implementing the framework.
The framework monitoring grid
P. What indicators (and their target directions) should we include to
measure progress against this framework for the next five years?
Key indicators will track the achievement of the framework aims over the next five years.
Many of the indicators are routinely collected for other strategies or purposes, Their inclusion
in a dataset for the quality framework is not intended to duplicate reporting but to maintain an
overview of organisational quality and achievement of the framework.
A key part of this consultation will be to define appropriate measures for the quality
framework, along with their measurement methods and target / directions.
[email protected]
Page 27 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Table: Some example indicators that could measure progress against the quality
framework:
Strategic goal
Indicator
How
measured
Target / direction
Assuring Essential
Quality Standards
Number of quality visits
Assuring Essential
Quality Standards
Number of different data elements
used in the Quality Early Warning
Intelligence System
Empowering
frontline quality
Number of Front Line
Improvements logged
Assuring Essential
Quality Standards
Number of incidents reported
Year-on-year
increase in incident
reporting.
Assuring Essential
Quality Standards
Ratio of serious / non-serious
incidents reported
Year-on-year
decrease in the
ratio
Moving to
Excellence
Audits – proportion of audits with
completed action plans
Moving to
Excellence
Service user experience – net
promoter score
Assuring Essential
Quality Standards
NICE / national guidance
implementation
Assuring Essential
Quality Standards
Research projects undertaken
Moving to
excellence
Papers published in peer-reviewed
journals
Moving to Effective
Outcomes
Service users who agree with key
statements in “Making it Real” (e.g.
“I have the information and support
I need in order to remain as
independent as possible”)
Integrating Quality
as a core part of
the Organisation
Number of teams working under
Single line management structures
Decrease in
number of
responsive visits
Q. What should we measure to tell us whether we are achieving our quality
framework strategic goals?
[email protected]
Page 28 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Appendix: Developing the framework
A small group set a series of dates for planning the development of the framework. The first
meeting took place on 25 July 2012. Initial development of the framework made use of a
“blank page” template with key prompts around potential strategy goals. The first iteration
involved 1:1 conversations with senior quality directorate staff, using the template to bring a
focus to the requirements of the quality framework and ensure high-level alignment with
organisational direction. This approach was designed to enable flow of ideas in an iterative
manner, while allowing for full development of the framework by subsequent consultation
and engagement with all staff.
Developing a high profile,
nationally acclaimed quality team
Strong Intelligence for Quality Assurance
Where we are now
"How we will get
to where we want
to be"
Moving towards Effective Outcomes
Where we want to be
Quality
Framework
Organisational Objective: Deliver tangible improvements
to the effectiveness, safety, and customer experience of
our services.
Integrating Quality as a core part of the organisation
[email protected]
Moving to Excellence
How we will do it
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Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
The timetable for development below is being followed, as reported to Quality Governance in
July:
Outcome
Progress
Steering group for Quality Framework
established mid July 2012
Initial planning meetings scheduled for
25 July, 1 August, 8 August
Draft Quality Framework – presented to Quality
Governance Committee on 5 September 2012
Development of draft has involved
1:1s with members of the quality
directorate and key staff within social
care quality.
Consultation on the draft framework document,
September & October 2012
Attendance at AGM September 17
Intentions by Quality team to consult
groups and individuals according to
the “consultation progress” table.
Consultation with internal and external
stakeholders, including development of Equality
analysis – September & October 2012
Consultation end date 19 October 2012
Final Quality Framework presented to at Quality
Governance Committee on 7 November 2012
Development of 2013/14 implementation plan:
December – March 2013
[email protected]
Page 30 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Consultation Progress table
Name:
Date:
Outcome:
Patient and service user
groups
Senior Management Teams
Social care
Safety and Effectiveness
Groups
September 2012
Presented for discussion, feedback
and follow up discussions required
Locality Service Meetings
Annual General Meeting
attendees
HR
Finance
Transformation
Medical staff
General communication to all
staff
Website
Membership database
Matrons meetings
Offender health
Executive Directors
Non-executive directors
Commissioners
Local HealthWatch
R. Who else should be consulted?
[email protected]
Page 31 of 32
Staffordshire and Stoke on Trent Partnership NHS Trust: Quality Framework v1.0 DRAFT
Impact and Assessment progress
Date of Assessment:
Outcome of Assessment:
Equality Impact
Assessment
Financial
Implications
Assessed
Staffing
Implications,
Including Training
Needs
Compliance with
Regulation
Impact on Existing
Strategy
S. Are there any other impact / assessment processes this quality
framework should undergo before approval and ratification?
[email protected]
Page 32 of 32