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     Serious untoward incidents will be     Quarterly
          safety incidents and other reportable be in place. IR1 forms and RIDDOR              coded and communicated to identify
          incidents.                            documentation will be accessible in all        personnel within the hospital.
                                                locations.

     b)   Ensure that patient safety notices,     A process is in place to ensure action       A response to key parties will be      By exception
          alerts and other communications         plans from incidents are processed           formulated by senior managers to       reports
          concerning patient safety, which        quickly and circulated to relevant parties   minimise future incidents within two
          require action, are acted upon within   including commissioners                      working days of a serious untoward
          required timescales.                                                                 incident.

                                                                                               Summary of untoward incidents and      Quarterly
                                                                                               trend analysis presented by provider
                                                                                               units.

C2   Health care organisations protect children Policies and Procedures reflect HSC            Evidence that Policy and Procedure is Annually
     by following national child protection      1999/222.                                     reviewed and up dated as required.
     guidance within their own activities and in                                               E.g. and Annually review schedule
     their dealings with other organisations.                                                  presented to commissioners.


C3   Health care organisations protect patients Policies and Procedures are in place that Induction programmes include MV&A           Annually
     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       Random
                                                                                          undertaken.



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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         Exception reports are raised as per    By exception
        infection to patients is reduced, with reflect infection control guidance.             policy and procedures.                 reports
        particular emphasis on high
        standards of hygiene and cleanliness,
        achieving year-on-year reductions in Medical Alert notification system is in           Exception reports are raised as per    By exception
        MRSA.                                  place.                                          policy and procedures.                 reports

     b)   All risks associated with the
          acquisition and use of medical
          devises are minimised.

     c)   All re-usable medical devices are    Policies and Procedures are in place on         Exception reports are raised as per    By exception
          properly decontaminated prior to use decontamination to reflect guidance.            policy and procedures.                 reports
          and that the risks associated with
          decontamination facilities and
          processes are well managed.

     d)   Medicines are handled safely and       Policies and Procedures are in place.         Exception reports are raised as per   Annually
          securely.                              Regular service wide audit is conducted.      policy and procedures. Audit reports.

     e)   The prevention, segregation,              Policies and Procedures are in place.      Exception reports are raised as per    Annually
          handling, transport and disposal of       Regular service wide audit is conducted.   policy and procedures. Audit reports
          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   Clinical Governance mechanisms will Annually
          NICE technology appraisals, where it be treated within the NICE guidelines.          regularly monitor the implementation of
          is available, take into account                                                      NICE guidance through the Clinical
          nationally agreed guidance when                                                      Audit Programme. Submission of
          planning and delivering treatment and                                                clinical governance report.
          care.

     b)   Clinical care and treatment are          All staff employed within the unit will have Workforce development plan will be up Annually
          carried out under supervision and        access to supervision.                       to date and include Personal
          leadership.                                                                           Development Planning and supervision
                                                                                                of the workforce. Annually report and
                                                                                                data as a percentage of the workforce
                                                                                                submitted.

     c)   Clinicians continuously update skills    Professional staff will adhere to continuing National Healthcare Commission       Annually
          and techniques relevant to their         professional development standards laid Reports.
          clinical work.                           down by their respective professional
                                                   bodies.


     d)   Clinicians participate in regular        Yearly audits will be undertaken taking     Mental Health Act Commissioners       Annually
          clinical audit and reviews of clinical   into account environmental and clinical     reports. Also Annually audit schedule
          services.                                issues.                                     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.   Care Programme Approach reports.   Annually
     each other and social care organisations                                       Annually audits submitted to
     to ensure that patients’ individual needs                                      commissioners.
     are properly managed and met.             Unmet patient needs                  Collation of (anonymous) patient   Quarterly
                                                                                    unmet needs




                                                                                                                                   4
                                                  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               Reports from reviews incorporating:   Quarterly
          and corporate governance.              evidence that these elements are integral
                                                 to all aspects of its work. This will include   a)   Clinical governance minutes;
     b)   Actively support all employees to      policies, standards and a review process.
          promote openness, honest, probity,                                                     b)   Clinical risk minutes;
          accountability, and the economic,
          efficient and effective use of                                                         c)   Activity performance reports.
          resources.

     c)   Undertake systematic risk
          assessment and risk management
          (including compliance with the
          controls assurance standards).

     d)   Ensure financial management
          achieves economy, effectiveness,
          efficiency, probity and accountability
          in the use of resources.

     e)   Challenge discrimination, promote
          equality and respect human rights.




                                                                                                                                                   5
                                                                                                                                     Submission
                  Standard                                         Indicator                              Response                                 Comments
                                                                                                                                        date
Third Domain – Governance
C8   Health care organisations support their
     staff through:

     a)   Having access to processes which        Policies and procedures are in place to    Audit and report of issues are raised   As required
          permit them to raise, in confidence     realise these aims.                        with relevant action plans.
          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.

     b)   Organisational and personal              Each member of staff has a personal       Percentage of total workforce that has Annually
          development programmes, which            development plan, which is reviewed at    a personal development plan that has
          recognise the contribution and value     least Annually.                           been reviewed in the last 12 months.
          of staff, and address, where
          appropriate, under-representation of
          minority groups.                         Ethnic mix of the staff workforce.        Percentage of the total workforce by    Annually
                                                                                             ethnic group.

C9   Health care organisations have a              All aspects of information governance and Audit and report of systems to          Annually
     systematic and planned approach to the        data protection are effectively           commissioners.
     management of records to ensure that,         implemented.
     from the moment a record is created until
     its ultimate disposal, the organisation       Policies and procedures are in place and Information Governance Committee         Quarterly
     maintains information so that it serves the   available for inspection.                minutes. Policy review schedule.
     purpose it was collected for and disposes
     of the information appropriately when no      Providers have a Caldicott Guardian.      Name of individual.                     Annually
     longer required.




                                                                                                                                                          6
                                                                                                                                      Submission
                  Standard                                       Indicator                                 Response                                Comments
                                                                                                                                         date
Third Domain – Governance
C10 Health care organisations:

     a)   Undertake all appropriate               Appropriate policies, procedures and       Percentage of professionally qualified Annually
          employment checks and ensure that       systems are in place to achieve these      staff appropriately registered with the
          al employed or contracted               aims.                                      relevant professional bodies.
          professionally qualified staff are
          registered with the appropriate         CRB checks are performed prior to          Exception report.                        Quarterly
          bodies.                                 employment.

     b)   Require that all employed               Set standards are adhered to.              Exception report.                        Annually
          professionals abide by relevant
          published codes of professional
          practice.


C11 Health care organisations ensure that staff
    concerned with all aspects of the provision
    of health care:

     a)   Are appropriately recruited, trained    The numbers of staff employed is             Number of WTEs in post by discipline Quarterly
          and qualified for the work they         reflective of the funded planned             and vacancy factor by discipline.
          undertake.                              requirements for effective service delivery. Outline recruitment strategy and
                                                                                               qualified staff benchmarks required for
                                                                                               the service.
     b)   Participate in mandatory training       Evidence of involvement in training          Percentage of staff attending           Quarterly
          programmes.                             programmes relevant to individual and the mandatory training programmes by
                                                  environment in which they work.              discipline.

     c)   Participate in further professional and See C8b.                                   Minimum dataset of management of      Annually
          occupational development                                                           violence and aggression, security and
          commensurate with their work                                                       health and safety training.
          throughout their working lives.




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                                                                                                                          Submission
                 Standard                                   Indicator                             Response                             Comments
                                                                                                                             date
Third Domain – Governance
C12 Health care organisations, which either   Demonstrable evidence of adherence to   The organisation produces a research Annually
    lead or participate in research, have     this aim.                               development plan.
    systems in place to ensure that the
    principles and requirements of the
    research governance framework are
    consistently applied.




                                                                                                                                              8
                                               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   Complaints report, including:      Quarterly
          carers with dignity and respect.          Advocacy Service.                       •  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

     b)   Appropriate consent is obtained when Consent to Treatment                         MHAC Reports                       By occurrence
          required, as per the Data Protection Policies and Procedures                      Clinical Audit                     Annually
          Act, for all contacts with patients and Caldicott Guardian.
          for the use of any patient confidential Policy and Procedure on Confidentiality   Serious Untoward Incidents         By occurrence
          information.                            MHAC Visits

     c)   Staff treat patient information        Complaints                                 MHAC Reports                       By occurrence
          confidentially except where                                                       Advocacy Reports                   Quarterly
          authorised by legislation to the                                                  Complaints Report                  Quarterly
          contrary.                              Survey of Staff                            Surveys                            Annually
                                                 Survey of Patients




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                                                                                                                                 Submission
                  Standard                                         Indicator                          Response                                     Comments
                                                                                                                                    date
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             Patient / Carer Information Booklet   Complaints Report                      Quarterly
          information about, and clear access      Complaints Policy and Procedure       Surveys                                Annually
          to, procedures to register formal        Patient Surveys
          complaints and feedback on the
          quality of services.

     b)   Are not discriminated against when       Complaints                            Complaints Report                      Quarterly
          complaints are made.                     Patient Surveys                       Surveys                                Annually
                                                                                         Systems Audit / Review                 Annually

     c)   Are assured that organisations act Complaints                                  Complaints Report                      Quarterly
          appropriately on any concerns and, Audit                                       Clinical Audit                         Annually
          where appropriate, make changes to Policy / Systems Review                     Systems Audit                          As required – as
          ensure improvements in service                                                                                        changes
          delivery.                                                                                                             implemented

C15 Where food is provided, health care
    organisations have systems in place to
    ensure that:

     a)   Patients are provided with a choice      Menu Revision                         Catering Reports                       Quarterly
          and that it is prepared safely and       Complaints                            Complaints Report                      Quarterly
          provides a balanced diet.                                                      Environmental Health Officer Reports   As required –
                                                                                                                                following
                                                                                                                                inspections

     b)   Patients individual nutritional,         MDT Notes / CPA Documentation         Clinical Records Audit                 Annually
          personal cultural and clinical dietary   Clinical Records                      Complaints Reports                     Quarterly
          requirements are met, including any      Complaints                            Catering Reports                       Quarterly
          necessary help with feeding and          Catering Provision
          access to food 24 hours a day.




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                                                                                                                       Submission
                 Standard                                   Indicator                              Response                         Comments
                                                                                                                          date
Fourth Domain – Patient Focus
C16 Health care organisations make             Patient / Carer Information Booklet     Patient Surveys                 Annually
    information available to patients and the MHAC Leaflets on rights, treatment etc   Systems Audit                   Annually
    public on their services, provide patients Freedom of Information Act Compliance   Clinical Audit                  Annually
    with suitable and accessible information                                           Freedom of Information Report
    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   Yearly –
    others are sought and taken into account public is evidenced.                       and Action Plan.                        Satisfaction
    in designing, planning, delivering and                                                                                      Survey
    improving health care services.          Patients and carers involved in treatment CPA Procedures.                          CPA Annually
                                             planning.                                                                          Report
                                                                                                                                Quarterly –
                                                                                                                                Action Plan
                                                                                                                                update




                                              A fair and efficient complaint process will Number of complaints not completed    Quarterly
                                              be in place.                                within 20 days.

                                                                                        Number of complaints referred for       Quarterly
                                                                                        Independent Review.

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




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                                                                                                                                    Submission
                 Standard                                       Indicator                                 Response                               Comments
                                                                                                                                       date
Fifth Domain – ACCESSIBLE & RESPONSIVE CARE
C18 C18 Health care organisations enable all C18 (i) All Patients referred for                C18 (i) Number of patients waiting    Quarterly
&   members of the population to access      assessment should be seen within 3               more than 3 months for assessment
C19 services equally and offer choice in     months of receipt of the referral.               from date of referral by Providers.
    access to services and treatment
    equitably

     C19 Health care organisations ensure that C19 (i) Patients identified as urgently        C19 (i) Number of urgent referrals     Quarterly
     patients with emergency health needs are requiring assessment should be seen             requiring assessment not seen within 1
     able to access care promptly and within     within 1 month of receipt of the referral.   month of referral receipt
     nationally agreed timescales, and all
     patients are able to access services within C19 (ii) Patients identified, as emergency   C19 (ii) Number of emergency referrals Quarterly
     National Expectations on access to          referrals should be assessed within two      not assessed within two working days
     services.                                   working days of receipt of the referral.     of referral receipt

                                                C19 (iii) Patients agreed for admission   C19 (iii) Number of Patients waiting      Quarterly
                                                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.




                                                                                                                                                       13
                                      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           Number of reported incidents by       Quarterly
          which protects patients, staff, visitors group to identify trends.                     Patients
          and their property, and the physical                                                   Staff
          assets of the organisation.              Identified risks and untoward incidents are   Visitors
                                                   action planned.                               Minutes from Clinical Risk Group with Quarterly
                                                                                                 accompanying Action Plans.

     b)   Supportive of patient privacy and       Patient privacy and confidentiality is         Report on Patient Satisfaction Survey Annually
          confidentiality.                        evaluated.                                     and Action Plan.

                                                  Policy and Procedures in place.                Untoward Incident Reports.             Ad-Hoc

                                                  Caldicott Guardian in place.

C21 Health care services are provided in         Standards of cleanliness meet national          Report and action plans from Patient   Annually
    environments which promote effective         standards. Evidence of action plans             Environmental Action Team (PEAT)/      following PEAT
    care and optimise health outcomes by         following recommendations.                      environmental inspections.             /
    being well designed and well maintained                                                                                             Environmental
    with cleanliness levels in clinical and non-                                                                                        Inspection
    clinical areas that meet the national                                                                                               Report
    specification for clean NHS premises




                                                                                                                                                         14
Information Schedule for KPIs

Domain Code(s)             Information Required                                                           Frequency
C1, C4, C13, C20           o Incident data categorised by type of incident and trend analysis,            Quarterly
                               differentiated by patients, staff and visitors
                           o Reporting of all serious untoward incidents (SUI) and outcomes.              By occurrence and at quarterly meetings
                           o Exception reports to include incidences of hospital acquired infections,
                               medicine errors, issues with CRB clearance, and breaches of                By occurrence
                               professional standards.
C2, C4, C6, C8, C9, C10,   o List of all Policies and Procedures and review schedules.                    Annually
C11, C12                   o Components of the Induction Programme                                        Annually
                           o Number of staff trained as a percentage of the total workforce and by        Annually
                               discipline across mandatory training such as MVA, Security, Fire &
                               Safety, etc
                           o Percentage of professionally qualified staff appropriately registered with   Annually
                               the relevant professional bodies by discipline
                           o Number of WTEs in post by discipline and vacancy factor by discipline.       Quarterly
                           o Collation of (anonymous) patient unmet needs                                 Quarterly
C5, C6, C7, C8, C9, C12,   o Clinical governance report                                                   Annually
C13, C14, C15, C16, C18,   o Workforce development plan                                                   Annually
C19, C20                   o Number of staff with an up to date personal development plan as a            Annually
                               percentage of the total workforce.
                           o Number of staff receiving clinical supervision as a percentage of the        Annually
                               total workforce.
                           o Healthcare Commission report                                                 Annually
                           o Mental Health Act Commission report                                          By occurrence
                           o Audit schedule                                                               Annually
                           o CPA Audit report                                                             Annually
                           o Clinical and information governance meeting minutes                          Quarterly
                           o Risk management (including clinical) meeting minutes                         Quarterly
                           o Percentage of the total workforce by ethnic group                            Annually
                           o Name of Caldicott Guardian                                                   Annually
                           o Research development plan                                                    Annually
                           o Activity performance reports to include:                                     Quarterly
                                     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


                                                                                                                                                    15
                                        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.
C13, C14, C15, C16, C17,   o   Complaints report (see C13 a for detail)                                 Quarterly
C20, C21                   o   Advocacy reports                                                         Quarterly
                           o   Staff and patient surveys                                                Annually
                           o   Environmental Health officer reports                                     Following inspections
                           o   Freedom of Information reports                                           Annually
                           o   Report of Patient Public Involvement Forums in service planning and      Annually
                               delivery forums.
All Domains                o   Infrequent audits by commissioners of the service or elements provided   Random
                               by it.



East of England SCG – July 2007




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