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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
Standar
NHSLA Standards
d 1 2 3 4 5
Criterio
Competent & Safe Clinical Learning from
n Governance
Capable Workforce Environment Care Experience
1 Risk management Corporate induction Secure environment Patient identification Incident reporting
strategy
2 Policy on procedural Local induction of Child protection Patient information Raising concerns
documents permanent staff
3 Risk management Local induction of Vulnerable adults Consent Complaints
committee(s) temporary staff
4 Risk awareness training Supervision of medical Moving & handling Clinical record-keeping Claims
for senior management staff in training standards
5 Risk management Risk management Slips, trips & falls Transfer of patients Investigations
process training
6 Risk register Training needs analysis Inoculation incidents Medicines management Analysis
7 Responding to external Medical devices training Maintenance of medical Blood transfusion Improvement
recommendations specific devices & equipment
to the organisation
8 Clinical records Hand hygiene training Harassment & bullying Resuscitation Best practice - NICE,
management NCEs & national
guidance
9 Professional clinical Moving & handling Violence & aggression Infection control Best practice - NSFs &
registration training high level enquiries
10 Employment checks Supporting staff involved Stress Discharge of patients Being open
in an incident, complaint
or claim
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 19 February 2007
DOMAIN Safety
CORE / DEVELOPMENTAL STANDARD NO. DETAIL
C4d 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 Martin Hodgson
LEAD MANAGER Richard Hey & Alastair Gibson
CURRENT POSITION Element 1: Compliant
Element 2:Planned compliance by 31st March 2007
FORCAST POSITION Compliant
ASSURANCE REPORT
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 LOCATION
• See attached index of evidence. Director of Pharmacy Office – MRI / BH
• AUDIT DETAIL See attached index of evidence
• SIGNED
• LEAD EXEC DIRECTOR LEAD MANAGER PEER REVIEWER
• Martin Hodgson Richard Hey & Alastair Gibson Richard Hey &
Alastair Gibson
Description of Evidence In portfolio Ref #
Assurance Report - Standard C4d 01
Healthcare Commission – Inspection guide C4d 02
Index of Evidence cont:
Background to Pharmacy Services
Director of Pharmacy Job Description 03
Central & Children’s Pharmacy Organisation Charts 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 05
Trust wide Medicines policy (index only included) 05
Unlicensed Medicines policy and procedures 06
Application for new medicines policies and procedures 07
Medicines Management Committee – Terms of Reference, membership and recent Agenda and 08
minutes.
Medicines Clinical Guidelines web page 09
Clinical Trials Pharmacist & Senior Technician Job Descriptions 10
Evidence Documents
Pharmacy staff induction programme
Pharmacy staff training programmes (various examples e.g. Aseptics, Ward Based Techs)
11
12
Pharmacy SOP’s 13
Chemotherapy policy (adults & children’s) (Front page & index) 14
Intrathecal Chemotherapy Policy, registers and training records (held in aseptic services office) 15
Duplication / Direct Overlaps
Incident reporting
SfBH NHSLA
C1a – Health care 1.5.1 The organisation has
organisations protect approved documentation
patients through systems which describes the
that identify and learn from process for managing the
all patient safety incidents risks associated with the
and other reportable reporting of all internally
incidents, and make and externally reportable
improvements in practice incidents.
based on local and national 1.5.6 Analysis
experience and information 1.5.7 Improvement
derived from the analysis of
incidents.
Child Protection
SfBH NHSLA
C2 Health care 1.3.2The organisation
organisations protect has approved
children by following documentation which
national child describes the process
protection guidance for managing the risks
within their own associated with child
activities and in their protection
dealings with other
organisations.
Best Practice
SfBH NHSLA
C3 Health care organisations 1.5.8 The organisation has
protect patients by following approved documentation
NICE Interventional which describes the process
Procedures guidance. for ensuring that agreed best
C5a Health care practice as defined in NICE
organisations ensure that they clinical guidelines, national
conform to NICE technology confidential enquiries and
appraisals and, where it is other nationally agreed
available, take into account guidance is taken into account
nationally agreed guidance in the context of the clinical
when planning and delivering services provided by the
treatment and care; organisation.
Infection Control
SfBH NHSLA
C4a Health care organisations 1.2.8 The organisation has
keep patients, staff and approved documentation
visitors safe by having which describes the process
systems to ensure that the risk for ensuring the delivery of
of health care acquired effective hand hygiene training
infection to patients is for all relevant permanent staff
reduced, with particular groups.
emphasis on high standards of 1.4.8 The organisation has
hygiene and cleanliness, approved documentation
achieving year-on-year which describes the process
reductions in MRSA; for managing the risks
associated with infection
prevention and control.
28 Further overlaps
C4b Medical Devices 1.2.7/1.3.7 Medical
Devices
C4d Medicines 1.4.6 Medicines
Management Management
D1 Patient Safety and 1.4.5 Transfer, Standard
Transfer 5 1-10 Patient Safety
C5b Supervision and 1.2.4 Supervision of
Leadership Medical staff in training
28 Further overlaps
C5c Update of skills Standard 2 1-10,
Competent and
Capable Workforce
C5d Clinical Audit All NHSLA Standards
at Level 2
1.4.5 Transfer of
C6 Co-operation with patients, 1.4.10
partner organisations Discharge of patients
28 Further overlaps
D2a NICE / NSF 1.5.8 NICE, NCEs
planned care, D2d and National
Evidence based Guidance, 1.5.9 NSFs
practice and high level
enquiries
C7a Sound Clinical Standard 1, 1-10,
and Corporate Governance
Governance
28 Further overlaps
C7c Risk 1.1.1 Risk
Management Management Strategy
1.1.3 Risk
Committees
1.1.5 Risk Process
1.1.6 Risk Register
28 Further overlaps
C7e Equality and 1.3.8 Harassment and
human rights Bullying
C8a Raising 1.5.2 Raising
Concerns Concerns
C9 Management of 1.1.8 Clinical records
Records Management, 1.4.4
Clinical Record
keeping Standards
28 Further overlaps
C10a Employment 1.1.10 Employment
Checks Checks
C11a Staff Recruited, 1.1.9 Professional
Trained and Qualified Registration, 1.1.10
Employment Checks
C11c Further 1.2.6 Training Needs
Professional Analysis
development
28 Further overlaps
C11b Mandatory Training 1.2.1 Corporate Induction
Program 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 1.4.3 Consent
C14a Complaints 1.5.3 Complaints
C14b Discrimination
Following Complaints
C14c Acting on Concerns 1.5.7 Improvement
C16 Information
1.4.2 Patient Information
C20a Safe and Secure 1.3.1 Secure
Environment 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?
