The Burden of Bureaucracy Standards for Better Health and the NHSLA Risk management Standards for Acute Trusts – a duplicated process? NHSLA Risk Management Standards for Acute Trusts (previously CNST and RPST) A „three tier‟ assessment process to assure Trusts and external stakeholders that clinical and a proportion* of non clinical risk is being managed appropriately by the organisation. Safety and Financial benefits to achievement. Achievement dependant on external assessment Assessment schedule dependant on level of achievement * Finance and performance covered by other assessments. Standards for Better Health Component part of the Annual Health Check, examines in detail the management of aspects of clinical and non clinical risk. Annual process based on self assessment and „spot check‟ review „Ratings‟ benefits to Trusts More public process Overlap NHSLA Standards part of cross checking process for Healthcare Commission Duplicate submission still required NHSLA Standards 1 2 Criterio n 1 2 3 4 5 6 7 Standar d 3 4 5 Governance Risk management strategy Policy on procedural documents Risk management committee(s) Risk awareness training for senior management Risk management process Risk register Responding to external recommendations specific to the organisation Clinical records management Professional clinical registration Employment checks Competent & Capable Workforce Safe Environment Clinical Care Patient identification Patient information Consent Clinical record-keeping standards Transfer of patients Medicines management Blood transfusion Learning from Experience Incident reporting Raising concerns Complaints Claims Investigations Analysis Improvement Corporate induction Local induction of permanent staff Local induction of temporary staff Supervision of medical staff in training Risk management training Training needs analysis Medical devices training Secure environment Child protection Vulnerable adults Moving & handling Slips, trips & falls Inoculation incidents Maintenance of medical devices & equipment Harassment & bullying 8 Hand hygiene training Resuscitation Best practice - NICE, NCEs & national guidance Best practice - NSFs & high level enquiries Being open 9 10 Moving & handling training Supporting staff involved in an incident, complaint or claim Violence & aggression Stress Infection control Discharge of patients TOTAL 50 STANDARDS Standards for Better Health Domain 1 – Safety (9 Core + 1 Dev.) Domain 2 – Clinical Cost Effectiveness (5 Core + 1Dev.) Domain 3 – Governance (14 Core + 5 Dev.) Domain 4 – Patient Focus (9 Core + 3 Dev.) Standards cont. Domain 5 – Accessible and Responsive Care (3 Core + 1 Dev.) Domain 6 – Environment and Amenities (3 Core 1 Dev.) Domain 7 – Public Health (4 Core + 1 Dev.) TOTAL 60 STANDARDS Standards for Better Health - assurance DATE DOMAIN CORE / DEVELOPMENTAL STANDARD 19 February 2007 Safety NO. C4d DETAIL Element 1: The Healthcare organisation has systems in place to ensure that medicines are handled safely and securely, taking into account Building a safer NHS: improving medication safety [Department of Health, 2004], and in accordance with the statutory requirements of the Medicines Act 1968. Element 2: The healthcare organisation has systems in place to ensure that controlled drugs are managed in accordance with the Misuse of Drugs Act 1971, the Misuse of Drugs Act 1971 (Modification) Order 2001 and Safer Management of Controlled Drugs: Guidance on strengthened governance arrangements [Department of Health, 2006] LEAD EXECUTIVE DIRECTOR LEAD MANAGER CURRENT POSITION Martin Hodgson Richard Hey & Alastair Gibson Element 1: Compliant Element 2:Planned compliance by 31st March 2007 FORCAST POSITION ASSURANCE REPORT Compliant This Standard has been modified for 2006/7. Element 1 remains unchanged and the Trust remains compliant. Element 2 introduces additional governance requirements around the safer management of controlled drugs following the recommendations of the Shipman inquiry. Final DoH guidance was published in January 2007 and the Trust is undertaking a self-audit against the guidance to assure compliance. Once complete it is expected the Trust will be able to indicate compliance in readiness for the Healthcare Commission commencing full assessment of Trusts from 1st April 2007. Continued • • • • • • • • EVIDENCE See attached index of evidence, which is under review following modification of this standard. DETAIL See attached index of evidence. LOCATION Director of Pharmacy Office – MRI / BH AUDIT DETAIL SIGNED See attached index of evidence LEAD EXEC DIRECTOR Martin Hodgson LEAD MANAGER Richard Hey & Alastair Gibson PEER REVIEWER Richard Hey & Alastair Gibson Description of Evidence Assurance Report - Standard C4d In portfolio Ref # 01 Healthcare Commission – Inspection guide C4d Index of Evidence cont: 02 Background to Pharmacy Services Director of Pharmacy Job Description Central & Children’s Pharmacy Organisation Charts 03 04 “The healthcare organisation should have clearly defined processes for obtaining medication, and should ensure staff, including prescribers, are confident and competent in their handling of medicines” Clinical Mandatory Training – Medicines Management session Trust wide Medicines policy (index only included) Unlicensed Medicines policy and procedures Application for new medicines policies and procedures Medicines Management Committee – Terms of Reference, membership and recent Agenda and minutes. Medicines Clinical Guidelines web page Clinical Trials Pharmacist & Senior Technician Job Descriptions Pharmacy staff induction programme 05 05 06 07 08 09 10 11 12 13 14 15 Pharmacy staff training programmes (various examples e.g. Aseptics, Ward Based Techs) Pharmacy SOP’s Chemotherapy policy (adults & children’s) (Front page & index) Evidence Documents Intrathecal Chemotherapy Policy, registers and training records (held in aseptic services office) Duplication / Direct Overlaps Incident reporting SfBH NHSLA C1a – Health care organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents. 1.5.1 The organisation has approved documentation which describes the process for managing the risks associated with the reporting of all internally and externally reportable incidents. 1.5.6 Analysis 1.5.7 Improvement Child Protection SfBH C2 NHSLA 1.3.2 Health care organisations protect children by following national child protection guidance within their own activities and in their dealings with other organisations. The organisation has approved documentation which describes the process for managing the risks associated with child protection Best Practice SfBH NHSLA C3 Health care organisations protect patients by following NICE Interventional Procedures guidance. C5a Health care organisations ensure that they conform to NICE technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care; 1.5.8 The organisation has approved documentation which describes the process for ensuring that agreed best practice as defined in NICE clinical guidelines, national confidential enquiries and other nationally agreed guidance is taken into account in the context of the clinical services provided by the organisation. Infection Control SfBH NHSLA C4a Health care organisations keep patients, staff and visitors safe by having systems to ensure that the risk of health care acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year-on-year reductions in MRSA; 1.2.8 The organisation has approved documentation which describes the process for ensuring the delivery of effective hand hygiene training for all relevant permanent staff groups. 1.4.8 The organisation has approved documentation which describes the process for managing the risks associated with infection prevention and control. 28 Further overlaps C4b Medical Devices C4d Medicines Management D1 Patient Safety and Transfer C5b Supervision and Leadership 1.2.7/1.3.7 Medical Devices 1.4.6 Medicines Management 1.4.5 Transfer, Standard 5 1-10 Patient Safety 1.2.4 Supervision of Medical staff in training 28 Further overlaps C5c Update of skills C5d Clinical Audit C6 Co-operation with partner organisations Standard 2 1-10, Competent and Capable Workforce All NHSLA Standards at Level 2 1.4.5 Transfer of patients, 1.4.10 Discharge of patients 28 Further overlaps D2a NICE / NSF planned care, D2d Evidence based practice C7a Sound Clinical and Corporate Governance 1.5.8 NICE, NCEs and National Guidance, 1.5.9 NSFs and high level enquiries Standard 1, 1-10, Governance 28 Further overlaps C7c Risk Management 1.1.1 Risk Management Strategy 1.1.3 Risk Committees 1.1.5 Risk Process 1.1.6 Risk Register 28 Further overlaps C7e Equality and human rights C8a Raising Concerns C9 Management of Records 1.3.8 Harassment and Bullying 1.5.2 Raising Concerns 1.1.8 Clinical records Management, 1.4.4 Clinical Record keeping Standards 28 Further overlaps C10a Employment Checks C11a Staff Recruited, Trained and Qualified C11c Further Professional development 1.1.10 Employment Checks 1.1.9 Professional Registration, 1.1.10 Employment Checks 1.2.6 Training Needs Analysis 28 Further overlaps C11b Mandatory Training Program 1.2.1 Corporate Induction 1.2.3 Local Induction 1.2.6 Training Needs Analysis 1.2.8 Hand Hygiene Training 1.2.9 Moving and Handling training 28 Further overlaps C13b Consent C14a Complaints C14b Discrimination Following Complaints C14c Acting on Concerns C16 Information C20a Safe and Secure Environment 1.4.3 Consent 1.5.3 Complaints 1.5.7 Improvement 1.4.2 Patient Information 1.3.1 Secure Environment Aims of the NHSLA Standards The standards and assessment process are designed to: provide a structured framework within which to focus effective risk management activities in order to deliver quality improvements in organisational governance, patient care and the safety of patients, staff, contractors, volunteers and visitors increase awareness and encourage implementation of the national agenda for the NHS encourage and support organisations in taking a proactive approach to improvement reflect risk exposure and empower organisations to determine how to manage their own risks contribute to embedding risk management into the organisation's culture reduce the level of claims by reducing the number of incidents and the likelihood of recurrence assist in the management of adverse incidents and claims provide assurance to the organisation, other inspecting bodies and stakeholders, including patients. Aim of the Annual Health Check The aim of the annual health check is to promote improvements in healthcare for patients and the public. It replaces the old system of 'star ratings' and looks at a much broader range of issues than ever before. Solution Agree areas for regulation Agree evidence formats Assess each area once Share information Evaluate within realistic timescales What do we want? Maintain system of regulation / accreditation – but streamline it. Allow Trusts the time to complete the developmental work required to demonstrate progression by reducing the administrative burden of regulation. Questions?