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FIRST-DOMAIN---SAFETY

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					KEY PERFORMANCE INDICATORS FOR MEDIUM SECURE SERVICES FIRST DOMAIN - SAFETY Patient safety is enhanced by the use of health care processes, working practices and systemic activities that prevent or reduce the risk of harm to patients. Submission Standard Indicator Response Comments date First Domain – Safety
C1 Health care organisations protect patients through systems that: a) Identify and learn from all patient Systematic recording of all incidents will safety incidents and other reportable be in place. IR1 forms and RIDDOR incidents. documentation will be accessible in all locations. Ensure that patient safety notices, alerts and other communications concerning patient safety, which require action, are acted upon within required timescales. A process is in place to ensure action plans from incidents are processed quickly and circulated to relevant parties including commissioners Serious untoward incidents will be coded and communicated to identify personnel within the hospital. Quarterly

b)

A response to key parties will be formulated by senior managers to minimise future incidents within two working days of a serious untoward incident. Summary of untoward incidents and trend analysis presented by provider units.

By exception reports

Quarterly

C2

Health care organisations protect children Policies and Procedures reflect HSC by following national child protection 1999/222. guidance within their own activities and in their dealings with other organisations.

Evidence that Policy and Procedure is Annually reviewed and up dated as required. E.g. and Annually review schedule presented to commissioners.

C3

Health care organisations protect patients Policies and Procedures are in place that Induction programmes include MV&A by following NICE Interventional reflect National Guidance with regards to training as standard. Trainers are Procedures guidance. Management of Violence and Aggression regularly up dated. Data to be submitted in terms of percentages for compliance to targets. Records are available of all training undertaken.

Annually

Random

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FIRST DOMAIN - SAFETY Patient safety is enhanced by the use of health care processes, working practices and systemic activities that prevent or reduce the risk of harm to patients. Submission Standard Indicator Response Comments date First Domain – Safety
C4 Health care organisations keep patients, staff and visitors safe by having systems to ensure that: a) The risk of health care acquired Policies and Procedures are in place to infection to patients is reduced, with reflect infection control guidance. particular emphasis on high standards of hygiene and cleanliness, achieving year-on-year reductions in Medical Alert notification system is in MRSA. place. b) All risks associated with the acquisition and use of medical devises are minimised. All re-usable medical devices are Policies and Procedures are in place on properly decontaminated prior to use decontamination to reflect guidance. and that the risks associated with decontamination facilities and processes are well managed. Medicines are handled safely and securely. Policies and Procedures are in place. Regular service wide audit is conducted. Exception reports are raised as per policy and procedures. By exception reports Exception reports are raised as per policy and procedures. By exception reports

Exception reports are raised as per policy and procedures.

By exception reports

c)

d)

Exception reports are raised as per Annually policy and procedures. Audit reports. Exception reports are raised as per policy and procedures. Audit reports Annually

e)

The prevention, segregation, Policies and Procedures are in place. handling, transport and disposal of Regular service wide audit is conducted. waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment.

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SECOND DOMAIN – CLINICAL AND COST EFFECTIVENESS Patients achieve health care benefits that meet their individual needs through health care decisions and services based on what assessed research evidence has shown provides effective clinical outcomes. Submission Standard Indicator Response Comments date Second Domain – Clinical and Cost Effectiveness
C5 a) Health care organisations ensure that Patients suffering with mental disorder will NICE technology appraisals, where it be treated within the NICE guidelines. is available, take into account nationally agreed guidance when planning and delivering treatment and care. Clinical care and treatment are carried out under supervision and leadership. Clinical Governance mechanisms will Annually regularly monitor the implementation of NICE guidance through the Clinical Audit Programme. Submission of clinical governance report.

b)

All staff employed within the unit will have Workforce development plan will be up Annually access to supervision. to date and include Personal Development Planning and supervision of the workforce. Annually report and data as a percentage of the workforce submitted. Professional staff will adhere to continuing National Healthcare Commission professional development standards laid Reports. down by their respective professional bodies. Annually

c)

Clinicians continuously update skills and techniques relevant to their clinical work.

d)

Clinicians participate in regular clinical audit and reviews of clinical services.

Yearly audits will be undertaken taking into account environmental and clinical issues.

Mental Health Act Commissioners Annually reports. Also Annually audit schedule to be submitted to commissioners.

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SECOND DOMAIN – CLINICAL AND COST EFFECTIVENESS Patients achieve health care benefits that meet their individual needs through health care decisions and services based on what assessed research evidence has shown provides effective clinical outcomes. Submission Standard Indicator Response Comments date Second Domain – Clinical and Cost Effectiveness
C6 Health care organisations co-operate with CPA Policy and Procedure in place. each other and social care organisations to ensure that patients’ individual needs are properly managed and met. Unmet patient needs Care Programme Approach reports. Annually audits submitted to commissioners. Collation of (anonymous) patient unmet needs Annually

Quarterly

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THIRD DOMAIN – GOVERNANCE Managerial and clinical leadership and accountability, as well as the organisation’s culture, systems and working practices, ensure that probity, quality assurance, quality improvement and patient safety are central components of all the activities of the health care organisation. Submission Standard Indicator Response Comments date Third Domain – Governance
C7 Health organisations: a) Apply the principles of sound clinical The organisation has demonstrable and corporate governance. evidence that these elements are integral to all aspects of its work. This will include Actively support all employees to policies, standards and a review process. promote openness, honest, probity, accountability, and the economic, efficient and effective use of resources. Undertake systematic risk assessment and risk management (including compliance with the controls assurance standards). Ensure financial management achieves economy, effectiveness, efficiency, probity and accountability in the use of resources. Challenge discrimination, promote equality and respect human rights. Reports from reviews incorporating: a) b) c) Clinical governance minutes; Clinical risk minutes; Activity performance reports. Quarterly

b)

c)

d)

e)

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Standard Third Domain – Governance
C8 Health care organisations support their staff through: a)

Indicator

Response

Submission date

Comments

Having access to processes which Policies and procedures are in place to permit them to raise, in confidence realise these aims. and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services. Organisational and personal development programmes, which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups. Each member of staff has a personal development plan, which is reviewed at least Annually.

Audit and report of issues are raised with relevant action plans.

As required

b)

Percentage of total workforce that has Annually a personal development plan that has been reviewed in the last 12 months.

Ethnic mix of the staff workforce.

Percentage of the total workforce by ethnic group.

Annually

C9

Health care organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required.

All aspects of information governance and Audit and report of systems to data protection are effectively commissioners. implemented. Policies and procedures are in place and Information Governance Committee available for inspection. minutes. Policy review schedule. Providers have a Caldicott Guardian. Name of individual.

Annually

Quarterly

Annually

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Standard Third Domain – Governance
C10 Health care organisations: a) Undertake all appropriate employment checks and ensure that al employed or contracted professionally qualified staff are registered with the appropriate bodies. Require that all employed professionals abide by relevant published codes of professional practice.

Indicator

Response

Submission date

Comments

Appropriate policies, procedures and systems are in place to achieve these aims. CRB checks are performed prior to employment. Set standards are adhered to.

Percentage of professionally qualified Annually staff appropriately registered with the relevant professional bodies. Exception report. Quarterly

b)

Exception report.

Annually

C11 Health care organisations ensure that staff concerned with all aspects of the provision of health care: a) Are appropriately recruited, trained and qualified for the work they undertake. The numbers of staff employed is Number of WTEs in post by discipline Quarterly reflective of the funded planned and vacancy factor by discipline. requirements for effective service delivery. Outline recruitment strategy and qualified staff benchmarks required for the service. Evidence of involvement in training Percentage of staff attending Quarterly programmes relevant to individual and the mandatory training programmes by environment in which they work. discipline. Minimum dataset of management of Annually violence and aggression, security and health and safety training.

b)

Participate in mandatory training programmes.

c)

Participate in further professional and See C8b. occupational development commensurate with their work throughout their working lives.

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Standard Third Domain – Governance
C12 Health care organisations, which either lead or participate in research, have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied.

Indicator
Demonstrable evidence of adherence to this aim.

Response

Submission date

Comments

The organisation produces a research Annually development plan.

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FOURTH DOMAIN – PATIENT FOCUS Health care is provided in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well being. Submission Standard Indicator Response Comments date Fourth Domain – Patient Focus
C13 Health care organisations have systems in place to ensure that: a) Staff treat patients, their relatives and Feedback from patients, relatives and carers with dignity and respect. Advocacy Service. Complaints report, including: Quarterly • Trend Analysis • Number • Category • Department • Designation • Outcome • Seriousness  Number of complaints not completed in 20 days  Number referred for Independent Review Report from Advocacy. Quarterly MHAC Reports Clinical Audit Serious Untoward Incidents By occurrence Annually By occurrence

b)

Appropriate consent is obtained when Consent to Treatment required, as per the Data Protection Policies and Procedures Act, for all contacts with patients and Caldicott Guardian. for the use of any patient confidential Policy and Procedure on Confidentiality information. MHAC Visits Staff treat patient information confidentially except where authorised by legislation to the contrary. Complaints

c)

Survey of Staff Survey of Patients

MHAC Reports Advocacy Reports Complaints Report Surveys

By occurrence Quarterly Quarterly Annually

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Standard Fourth Domain – Patient Focus
C14 Health care organisations have systems in place to ensure that patients, their relatives and carers: a) Have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services. Are not discriminated against when complaints are made.

Indicator

Response

Submission date

Comments

Patient / Carer Information Booklet Complaints Policy and Procedure Patient Surveys

Complaints Report Surveys

Quarterly Annually

b)

Complaints Patient Surveys

Complaints Report Surveys Systems Audit / Review Complaints Report Clinical Audit Systems Audit

Quarterly Annually Annually Quarterly Annually As required – as changes implemented

c)

Are assured that organisations act Complaints appropriately on any concerns and, Audit where appropriate, make changes to Policy / Systems Review ensure improvements in service delivery.

C15 Where food is provided, health care organisations have systems in place to ensure that: a) Patients are provided with a choice and that it is prepared safely and provides a balanced diet. Menu Revision Complaints Catering Reports Complaints Report Environmental Health Officer Reports Quarterly Quarterly As required – following inspections Annually Quarterly Quarterly

b)

Patients individual nutritional, personal cultural and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day.

MDT Notes / CPA Documentation Clinical Records Complaints Catering Provision

Clinical Records Audit Complaints Reports Catering Reports

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Standard Fourth Domain – Patient Focus

Indicator

Response
Patient Surveys Systems Audit Clinical Audit Freedom of Information Report

Submission date
Annually Annually Annually

Comments

C16 Health care organisations make Patient / Carer Information Booklet information available to patients and the MHAC Leaflets on rights, treatment etc public on their services, provide patients Freedom of Information Act Compliance with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after-care.

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FIFTH DOMAIN – ACCESSIBLE AND RESPONSIVE CARE Patients receive services as promptly as possible, have choice in access to services and treatments, and do not experience unnecessary delay at any stage of service delivery or of the care pathway. Submission Standard Indicator Response Comments date Fifth Domain – ACCESSIBLE & RESPONSIVE CARE
C17 The views of Patients, their carers and Accountability to patients, carers and the Report on Patient Satisfaction Survey others are sought and taken into account public is evidenced. and Action Plan. in designing, planning, delivering and improving health care services. Patients and carers involved in treatment CPA Procedures. planning. Yearly – Satisfaction Survey CPA Annually Report Quarterly – Action Plan update

A fair and efficient complaint process will Number of complaints not completed be in place. within 20 days. Number of complaints referred for Independent Review.

Quarterly

Quarterly

Patient Public Involvement Forums (PPIF) Report of PPIF involvement in service Annually have access to services. planning and delivery forums.

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Standard

Indicator

Response
C18 (i) Number of patients waiting more than 3 months for assessment from date of referral by Providers.

Submission date
Quarterly

Comments

Fifth Domain – ACCESSIBLE & RESPONSIVE CARE
C18 C18 Health care organisations enable all C18 (i) All Patients referred for & members of the population to access assessment should be seen within 3 C19 services equally and offer choice in months of receipt of the referral. access to services and treatment equitably C19 Health care organisations ensure that C19 (i) Patients identified as urgently patients with emergency health needs are requiring assessment should be seen able to access care promptly and within within 1 month of receipt of the referral. nationally agreed timescales, and all patients are able to access services within C19 (ii) Patients identified, as emergency National Expectations on access to referrals should be assessed within two services. working days of receipt of the referral.

C19 (i) Number of urgent referrals Quarterly requiring assessment not seen within 1 month of referral receipt C19 (ii) Number of emergency referrals Quarterly not assessed within two working days of referral receipt Quarterly

C19 (iii) Patients agreed for admission C19 (iii) Number of Patients waiting should be admitted within three months of over three months from decision to the decision to admit. admit by service.

C19 (iv) Responsible Commissioners C19 (iv) Number of Patients waiting for Quarterly should ensure that Patients should wait no a transfer/discharge bed over three longer than three months for a discharge months by service. placement once this has been agreed between the Commissioner and the Service Providers.

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SIXTH DOMAIN – CARE ENVIRONMENT AND AMENITIES Care is provided in environments that promote patient and staff well-being and respect for patients’ needs and preferences in that they are designed for the effective and safe delivery of treatment, care or a specific function, provide as much privacy as possible, are well maintained and are cleaned to optimise health outcomes for patients. Submission Standard Indicator Response Comments date Sixth Domain – Care Environment and Amenities
C20 Health care services are provided in environments which promote effective care and optimise health outcomes by being: a) A safe and secure environment, The number of reported incidents by which protects patients, staff, visitors group to identify trends. and their property, and the physical assets of the organisation. Identified risks and untoward incidents are action planned. Number of reported incidents by Quarterly Patients Staff Visitors Minutes from Clinical Risk Group with Quarterly accompanying Action Plans. Report on Patient Satisfaction Survey Annually and Action Plan. Untoward Incident Reports. Ad-Hoc

b)

Supportive of patient privacy and confidentiality.

Patient privacy and confidentiality is evaluated. Policy and Procedures in place. Caldicott Guardian in place.

C21 Health care services are provided in Standards of cleanliness meet national environments which promote effective standards. Evidence of action plans care and optimise health outcomes by following recommendations. being well designed and well maintained with cleanliness levels in clinical and nonclinical areas that meet the national specification for clean NHS premises

Report and action plans from Patient Environmental Action Team (PEAT)/ environmental inspections.

Annually following PEAT / Environmental Inspection Report

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Information Schedule for KPIs
Domain Code(s) C1, C4, C13, C20 Information Required o Incident data categorised by type of incident and trend analysis, differentiated by patients, staff and visitors o Reporting of all serious untoward incidents (SUI) and outcomes. o Exception reports to include incidences of hospital acquired infections, medicine errors, issues with CRB clearance, and breaches of professional standards. o List of all Policies and Procedures and review schedules. o Components of the Induction Programme o Number of staff trained as a percentage of the total workforce and by discipline across mandatory training such as MVA, Security, Fire & Safety, etc o Percentage of professionally qualified staff appropriately registered with the relevant professional bodies by discipline o Number of WTEs in post by discipline and vacancy factor by discipline. o Collation of (anonymous) patient unmet needs o Clinical governance report o Workforce development plan o Number of staff with an up to date personal development plan as a percentage of the total workforce. o Number of staff receiving clinical supervision as a percentage of the total workforce. o Healthcare Commission report o Mental Health Act Commission report o Audit schedule o CPA Audit report o Clinical and information governance meeting minutes o Risk management (including clinical) meeting minutes o Percentage of the total workforce by ethnic group o Name of Caldicott Guardian o Research development plan o Activity performance reports to include:  Number of patients waiting more than 3 months for assessment from date of referral by Providers.  Number of urgent referrals requiring assessment not seen within 1 month of referral receipt  Number of emergency referrals not assessed within two working days of referral receipt  Number of Patients waiting over three months from decision to Frequency Quarterly By occurrence and at quarterly meetings By occurrence Annually Annually Annually

C2, C4, C6, C8, C9, C10, C11, C12

Annually Quarterly Quarterly Annually Annually Annually Annually Annually By occurrence Annually Annually Quarterly Quarterly Annually Annually Annually Quarterly

C5, C6, C7, C8, C9, C12, C13, C14, C15, C16, C18, C19, C20

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C13, C14, C15, C16, C17, C20, C21

o o o o o o o

All Domains

admit by service. Number of Patients waiting for a transfer/discharge bed over three months by service.  Number of referrals including acceptances, rejections, opinion only and HO Direction  Number of patients admitted, discharge, awaiting admission or on trial leave.  Number of occupied bed days, bed numbers, activity (planned and actual) and variation. Complaints report (see C13 a for detail) Advocacy reports Staff and patient surveys Environmental Health officer reports Freedom of Information reports Report of Patient Public Involvement Forums in service planning and delivery forums. Infrequent audits by commissioners of the service or elements provided by it. 

Quarterly Quarterly Annually Following inspections Annually Annually Random

East of England SCG – July 2007

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