CLINICAL GOVERNANCE
Presentation for Assembly of
Governors
Thursday 15 December 2011
CLINICAL GOVERNANCE REVIEW
• Review produced in November 2010 set out to:
– Reduce the number of corporate committees
– Improve accountability of the committee and sub
committees
– Strengthen overall governance arrangements
CLINICAL GOVERNANCE REVIEW
• As a result:
– Number of corporate committees reduced – with a
stronger focus on corporate areas supporting/ going out to
operational divisions
– Revised terms of reference / work plans
– Clinical Governance dashboard- reflecting ‘Ward to Board’
indicators
– Increase ‘synthesis’ of data across quality themes.
– Strengthened of membership of committee
KEY PRIORITIES
(ANNUAL PLAN 2011)
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Management and prevention of violence training
Reducing the severity of assaults
Implement new electronic risk management system
Strengthen safeguarding arrangements
Developing the use of outcome measures
Implementation of RIO – patient information system
Real time feedback systems
Improve physical health care support
CQC
(Care Quality Commission)
• Reviews
– ‘Responsive’ review: January 2011
– Themed review: July 2011
– MHA reviews:
• On going process (reflecting previous role of MHA
Commission)
• On going compliance issues:
– Prison Healthcare (internal monitoring)
RESPONSIVE REVIEW
• 3 sites, inpatient and community teams
– Solihull Wards & Lyndon Clinic
– Zinnia: Lavender ward and CMHT
– Reservoir Court and Older People CMHT
• Four standards (outcomes) reviewed
– Major concern: Safeguarding process
– Moderate concerns for other standards
RESPONSIVE REVIEW
• Key Issues identified:
– Excellent staff – Overall felt they saw very good
examples of team working and professional staff.
– Mixture of positives and negatives.
– Concerns raised over Physical Health care –
particularly in relation to the consistency of
approaches
– Solihull A&E – concerns were raised over
arrangements at Solihull Hospital for patients in need
of emergency care
– Safeguarding procedures – concerns that thresholds
for escalating safeguarding concerns were not clear /
clearly understood
RESPONSIVE REVIEW
• Key Issues identified continued:
– DOLS training – concern of a lack of awareness of
DOLS process
– Specific Concerns in relation to Lavender ward relating
to:
• Staffing levels – staff did not feel that they were safe
• Clinical Supervision
– Concerns over notifications (to CQC) and how these
are classified.
THEMED REVIEW
• All 3 PICU units: July 2011
– 1 unit – Fully compliant
– 1 unit – moderate and minor concern
– 1 unit – 2 moderate and 2 minor concerns
ISSUES ARISING FROM CQC VISITS
• CQC approach is to reflect what is seen (and
said on the day). There is little triangulation
• Issues have arisen which could have been
predicted reflecting:
– The effectiveness of the team
– ‘Transparency of purpose’ (i.e. are all staff focused on
priorities, ensuring risks are escalated)
– On going issues / concerns which are not addressed
These have informed the Quality strategy…
MHA VISITS
• Function of CQC which was formally separate as
part of Mental Health Act commission
• Role is to review compliance with requirements
of the MHA;
BUT,
• CQC is demonstrating much closer working and
correlation between MHA and regulation
requirements
QUALITY STRATEGY
• Setting a common framework for quality
improvement across the organisation. Which is
clearly understood at all levels of the
organisation
• Reflecting the Monitor Quality Governance
framework
• ‘Ward to Board’ monitoring
QUALITY STRATEGY
• Incorporated projects:
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Nursing Strategy
Nursing metrics (monthly quality monitoring)
Quality support team / visits
Integrated dashboard reporting
Essence of care
Quality Support Teams – Scheduled Visits
Annual schedule of visits to all clinical teams – inpatient and community.
Teams of 3 – senior professional or manager (8b); a peer reviewer (Band 7) and a service user/carer representative
Core Aspects of Service reviewed: Welcome; Respect and involvement of people who use our services; Consent to care and
treatment; Suitability of staffing; Safeguarding and safety; Quality and management
Visit lead notifies Team/Ward
Manager, SDM, Lead Nurse and
Clinical Director immediately
and escalates to Executive
Officer, then….
Yes
Serious
concern(s)?
No
Visiting team complete report
and forward to Head of
Compliance and/or Corporate
Lead Nurse
Decision on
outcome
UNACCEPTABLE
CONCERNING
POSITIVE
EXCELLENT
Local management notified,
urgent remedy and
assurance required. Further
visit planned
Zone management team
notified. Required to
remedy, further visit
planned
Zone management team
notified. Notification may
be displayed in service
area
Zone management
notified. Governance
team roll out learning
to other areas
Quarterly summary report of all visits prepared by Governance team for Quality and Safety Committee
Quality Support Teams – Ad Hoc Visits
Head of Compliance monitors Ward and Team performance and liaises continuously with corporate departments – i.e. HR,
complaints, risk management
Information emerges which indicates there may be concerns(s) about a particular area of service
Ad hoc visit arranged to service area. 8b (or above) plus another professional. Visit not announced and focuses on identified
area of concern. Generally short of no more than one hour duration.
Visit lead notifies Team/Ward
Manager, SDM, Lead Nurse and
Clinical Director immediately
and escalates to Executive
Officer, then….
Yes
Serious
concern(s)?
No
Visiting team complete report
and forward to Head of
Compliance and/or Corporate
Lead Nurse
Report relates solely to areas of concern identified pre-visit and documents findings (unless
others become evident during the course of the ad hoc visit.) If findings indicate serious
concerns then zone management team are required to remedy situation and provide
assurance. Follow up unannounced visits may be arranged depending on whether the
identified concerns were found to be valid.
Quarterly summary report of all visits prepared by Governance team for Quality and Safety Committee
COMPLIANCE FUNCTION
• New function within the Governance umbrella
(recently appointed)
• Compliance team will:
– Provide support to teams to maintain compliance
– Improve overall intelligence, liaison and correlate
information and issues being raised by the CQC
– Develop arrangements for monitoring non compliance
and reviewing teams
LOOKING FORWARD
Internal (continuing issues):
– Prison Governance arrangements
– Compliance with CPA (Care Programme Approach)
– Safeguarding
LOOKING FORWARD
• National:
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NICE quality standards
National outcomes framework
Quality Accounts – increased profile of quality
Mid Staffs review