Community Engagement Group Agenda Item No .4 Report No. 1 Purpose For - - PDF document

Community Engagement Group

Agenda Item No.4 Report No. 1 Purpose For discussion Date of Meeting 11 November 2013 From: Barbara McLean, Chief Nursing Officer NHS Quality Agenda 1. Purpose 1.1 Community Engagement Group members are asked to consider and discuss the quality agenda report attached to this cover sheet. Author: Barbara McLean

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NHS QUALITY AGENDA

Community Engagement Group

11 November 2013 @ Haverhill Arts Centre - High Street, Haverhill, Suffolk CB9 8AR

Chief Nursing Officer 11/11/2013

Introduction

The NHS Quality agenda is guided by the NHS National Quality Board (NQB). Since its inception, the NQB has produced guidance for the NHS outlining the following operating principles:

• The patient comes first – not the needs of any organisation
• Quality is everybody’s business – from the ward to the board; from the supervisory bodies to the

regulators, from the commissioners to primary care clinicians and managers

• If we have concerns, we speak out and raise questions without hesitation
• We listen in a systematic way to what our patients and our staff tell us about the quality of care
• If concerns are raised we listen and ‘go and look’
• We share our hard and soft intelligence on quality with others and actively look at the hard and soft

intelligence on quality of others

• If we are not sure what to decide or do, we seek advice from others
• Our behaviours and values will be consistent with the NHS Constitution

The principles have subsequently been reiterated as core to the safe handover of services during the recent reorganisation and essential for the operation of Clinical Commissioning Groups and other Commissioners, as well as providers in the reorganised NHS. The Ipswich & East Suffolk CCG have pursued these principles in all of the organisations work on the monitoring and commissioning of services to meet the health needs of Suffolk residents. The attached structure and catalogue details how this work is carried out.

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CHIEF NURSING OFFICER Barbara McLean

Patient Safety Clinical Quality Patient Experience

Clinical Effectivenss Director Infection Prevention & Control Safeguarding Children & Vulnerable Adults Accountable Officer for Controlled Drugs

Executive Assistants Sandy Last Patricia Groves

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PATIENT SAFETY & CLINICAL QUALITY Systems and Process

Systems and Process

Patient Safety and Clinical Quality Team

• Review and cross-referencing of

Information.

• Analysing for themes with and across
• rganisations - potential early warning

system.

• Link with commissioning, reviewing

contractual information

Regulatory Responsibility:

Monitoring quality standards and Quality Accounts verification Safeguarding Children and Looked After Children Safeguarding Vulnerable Adults and the Deprivation of Liberty Standards Liaison with the Care Quality Commission

Patient Safety:

Patient Safety, serious incident reporting and never events, Infection control Undertaking clinical investigations and overseeing serious case reviews Accountable Officer for Controlled Drugs

Patient experience:

Complaints Advice and Guidance enquiries Provider Patient Experience Development

Supporting the provision of Clinical Quality Standards:

Undertaking Quality Improvement Visits Ensuring providers have appropriate clinical governance arrangements. Development of clinical standards Caldicott Guardian

Reporting:

• Provider contract monthly minutes
• Monthly performance reporting
• Exception reporting on serious concerns
• Updating risk register and assurance framework
• Annual reporting on patient experience etc.

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Head of Patient Safety & Clinical Effectiveness Karen Smith

SIRI lead – monitoring numbers, qualities of investigations and completion of action plans, considering with other data as an early warning system of problems for each provider – following up with a QIV for assurance of implementation of actions Member of the team reviewing tender submissions for new/revised service contracts – ensuring the applicant has good patient safety and clinical quality policies and systems Member of the Prison Health Partnership Board – reporting on / monitoring PS & CQ aspects of health provision Monitor the Integrated Services contract concerning patient safety and clinincal quality Monitoring contract data related to PS & CQ for each provider – alerting on concerns/problems which can be taken forward at the contract monitoring meeting Adult safeguarding lead – ensuring providers adhere to policies and guidance and are

• rganisationally treating

people with respect and dignity, linking with the Adult Safeguarding Board to ensure system-wide improvements

Administrator Sharon Keeble PATIENT SAFETY & CLINICAL EFFECTIVENES SS

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Head of Clinical Quality & Patient Experience Susan Barker

Lead on the development of a Patient Experience Strategy Lead on the development of family information to promote self care for parents with 0-5 year olds in line with admission avoidance strategy

Monitor contract data in relation to Safety Thermometer - Lead on the development of a strategy for Falls and on the Pressure Ulcer Ambition Quality Improvement Visits (QIV) with all providers to monitor quality standards

Joint lead with SCC on age inclusive strategy for autism, including leading the task and finish group for CYP diagnostic and treatment pathways Lead for the development of LD CAMHS service as part

• f the adult LD

tendering process Lead for Complaints and PALS team, liaising with the contract team via the SLA route Lead for Adult Continuing Healthcare team & Lead for Children’s continuing health care and shared care- including out of county placements

Administrator Beata Francis CLINICAL QUALITY & PATIENT EXPERIENCE

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West Suffolk CCG Chief Nursing Officer Service Delivery Catalogue October 2012 (updated Nov 2013)

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Contents

Introduction ....................................................................................................................................................... 8 SECTION 1: Description of Function ................................................................................................................... 8 SECTION 2: Description of Services provided .................................................................................................. 11 SECTION 3: Structure and personnel ............................................................................................................... 11 SECTION 4: Running costs ................................................................................................................................ 11 SECTION 5: Performance review ...................................................................................................................... 11 Appendix A: Roles, Responsibilities and Key Outputs ..................................................................................... 13 Appendix B: Responsibilities that do not fall within this function ................................................................... 19 Appendix C: Structure ..................................................................................................................................... 20 Appendix D: Running costs .............................................................................................................................. 21

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Introduction

This Service Delivery Catalogue (SDC) describes the relationship between the office of the Chief Nursing Officer (CNO) and the West Suffolk Clinical Commissioning Group (WSCCG). It sets out to define the functions of the Chief Nursing Officer’s team as well as the key outputs, structure and operating costs.

SECTION 1: Description of Function

The CNO function will provide the CCG and GP practices with information to provide assurance regarding the provision of high quality safe services for their population, and to implement all statutory duties in relation to the safeguarding of adults and children. The CNO team will work with providers to ensure that they strive to improve the quality of services they provide, identify risks, and learn from incidents that occur. In addition, the CNO team will manage individual funding requests and NHS continuing healthcare. The Office function is responsible for a number of the statutory functions of the CCGs, this includes; Regulatory Responsibility: a) Monitoring quality standards and Quality Accounts verification b) Safeguarding Children and Looked After Children c) Safeguarding Vulnerable Adults and the Deprivation of Liberty Standards d) Liaison with the Care Quality Commission Patient Safety: a) Patient Safety, serious incident reporting b) Infection control c) Undertaking clinical investigations and overseeing serious case reviews d) Accountable Officer for Controlled Drugs Patient experience: a) Complaints b) Advice and Guidance enquiries c) Provider Patient Experience Development Supporting the provision of Clinical Quality Standards: a) Undertaking Quality Improvement Visits b) Ensuring providers have appropriate clinical governance arrangements. c) Development of clinical standards d) Caldicott Guardian Providing expertise and interpretation of national guidance: a) Managing the provision of Adult NHS Continuing Healthcare b) Managing the provision of Children’s NHS Continuing Healthcare and Shared Care c) Managing individual funding requests d) Primary Care Research Network e) Administration of the End of Life Guidance Emergency Planning and Business Resilience That enables clinical commissioners to:

• Deliver their corporate, statutory and regulatory responsibilities.
• Review the quality and safety of services and health outcomes
• Plan, design, develop and manage local services and pathways.
• Ensure improvement and identify risks of services they provide

To deliver the above, the CNO function will directly manage or manage relationships with:

• Service Providers

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• The Care Quality Commission
• The Suffolk Safeguarding Children’s Board
• Suffolk County Council lead for Vulnerable Adults
• The Suffolk Resilience Forum and Suffolk Local Health Resilience Partnership

The function will also ensure that the clinical commissioner and GP practices have access to good quality patient safety and clinical quality information to provide the guidance they need to support high quality clinical effectiveness and patient experience. The NHS Commissioning Board commissioning intelligence toolkit will be completed as part of the authorisation

• process. This will be used to develop the overall business intelligence function and contribute to forming a

development plan for the function. The intelligence provided will enable clinical commissioners to make operational and strategic decisions around the provision of high quality safe services. Detailed description of function and key outputs Appendix A describes roles & responsibilities of the Chief Nursing Officer team in detail. In addition it specifies key

• utputs with key dates and frequency.

Appendix B describes what is not included within the function.

Expected outcomes

The expected outcomes of the function are as follows:

Domain Outcomes

Domain 1: A strong clinical and multi- professional focus which brings real added value

A great CCG will have a clinical focus perspective threaded through everything it does, resulting in having quality at its heart, and a real focus on outcomes. It will have significant engagement from its constituent practices as well as widespread involvement of all other clinical colleagues, clinicians providing health services locally including secondary care, community and mental health, those providing services to people with learning disabilities, public health experts, as well as social care colleagues. It will communicate a clear vision of the improvements it is seeking to make in the health of the locality, including population health.

Domain 2: Meaningful engagement with patients, carers and their communities

CCGs need to be able to show they will ensure inclusion of patients, carers, public, communities of interest and geography, health and wellbeing boards and local authorities. They should include mechanisms for gaining a broad range of views then analysing and acting on these. It should be evident how the views of individual patients are translated into commissioning decisions and how the voice of each practice population will be sought and acted upon. CCGs need to promote shared decision-making with patients about their care.

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Domain Outcomes

Domain 3: Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within the financial resources, in line with national requirements (including excellent

• utcomes), and local joint health and

wellbeing strategies.

CCGs should have a credible plan for how they will continue to deliver the local QIPP challenge for their health system, and meet the NHS Constitution requirements. These plans will set

• ut how the CCG will take responsibility for service

transformation that will improve outcomes, quality and productivity, whilst reducing unwarranted variation and tackling inequalities, within their financial allocation. They need a track record of delivery and progress against these plans, within whole system working, and contracts in place to ensure future delivery. CCGs will need to demonstrate how they will exercise important functions, such as the need to promote research.

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SECTION 2: Description of Services provided

How the service will be provided to the CCG

• The CCG team may take responsibility for scoping the areas of work that are best organised across the CCG

however the CNO team will be responsible for delivery of the work. This could include:

• Quality Improvement visits
• Clinical Investigations and reviews
• Serious case reviews
• Liaison with the Care Quality Commission
• Liaison with the Suffolk Safeguarding Children’s Board
• The Head of Patient Safety & Clinical Effectiveness and the Head of Clinical Quality and Patient Experience will

work across the CCG ensuring that the teams work is co-ordinated as appropriate and resourcing is managed fairly and appropriately.

• The Chief Nursing Officer will lead on safeguarding children and vulnerable adults.
• The Chief Nursing Officer will lead on the development of quality monitoring standards for the CCG.
• The Chief Nursing Officer will provide executive level representation on the Local Health Resilience Partnership

to asses risks and determine emergency preparedness strategy for the Health economy of Suffolk.

SECTION 3: Structure and personnel

The structure of the function is set out in Appendix C. Staff will be line managed through regular one-to-one meetings and appraisals and will be expected to keep up-to-date personal development plans.

• The strategy of the CNOs teams will be steered by the CCG clinical leads. The Chief Nursing Officer will liaise with

and co-ordinate work plans across the teams to ensure that there is no duplication of resources committed to the same tasks.

• Line management will be provided as per structure chart in appendix C.
• Professional clinical leadership across the CCG will be delivered by the Chief Nursing Officer.

The function will provide interim services to local systems to provide a minimum level of service in cases of annual leave, sickness, long-term sickness or maternity leave. The function will be embedded in the CCG. It is therefore intended that these team members will be available to work from these localities i.e. Bury St Edmunds and Bramford. Team members will be required to travel between sites as appropriate.

SECTION 4: Running costs

The cost of the function is set out in Appendix D

SECTION 5: Performance review

12 On a quarterly basis the Chief Nursing Officer will seek feedback from the CCGs’ management. Feedback will be sought on:

• Reporting content and format
• Reporting explanation and analysis
• Timeliness of reporting
• Availability of team members
• Attitude of team members (approachability, helpfulness etc)

Escalation of issues

Any issues with the function within the CCG:

• Should be escalated to the Chief Nursing Officer.
• Escalated issues should be discussed and resolved with the CNO and the Chief Operating Officer within the CCG.
• Through the annual review of the Chief Nursing Officer’s function service arrangement

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Appendix A: Roles, Responsibilities and Key Outputs

Deliverable Key Process Key Outputs/ Dates/ Frequency Corporate, Statutory & Regulatory Responsibilities - reporting to the CCG's key decision makers and externally to the DH and the NHSCB

Quality Accounts verification

• Review quality accounts of provider organisations and verification of statement

Annual Safeguarding Children and Looked After Children Designated Nurse: Safeguarding expert

• Production of an annual report on Looked After Children and Safeguarding.
• Representation at the Suffolk Safeguarding Children’s Board and the sub-groups –

Training, Policies and Procedures, Quality standards and audit, Missing Children and Sexual exploitation panel.

• Support providers in the investigation of Safeguarding serious incidents
• Over-view reports for Serious Case Reviews
• Support providers in the completion of Section 11 Audits (further guidance

expected).

• To provide multi-agency training on effective supervision. Support to practice nurses

through the Practice Nurse Forum. Designated Doctor: Safeguarding expert

• To work with practices on the action plans identified from serious case reviews.
• Support to Hospital and Community Paediatricians.
• Attendance at the Child Death Overview Panel, a source of expertise on trends in

Suffolk.

• To work with named GPs for Safeguarding to review the training requirements for

GPs and practice staff.

• A high risk area to support the CCG with media involvement in high profile cases.

Annual As required As required As required On-going As required On-going On-going On-going As required Vulnerable Adults and the Deprivation of Liberty (DOLs)

• To liaise with Suffolk County Council as the statutory organisation.
• To ensure that policy changes and government initiatives are included in the training

programme.

• To monitor the trusts on their implementation of Vulnerable Adults policies and

Deprivation of Liberty requests. On-going As required Monthly Performance report

14 Deliverable Key Process Key Outputs/ Dates/ Frequency

Liaison with the Care Quality Commission

• To support the information sharing systems with the CQC, Suffolk County Council, the

Fire Service and Environmental Health, reporting to the CCG.

• Liaison with CQC on quality improvement visits to identify contractual quality issues.
• To notify the CQC on changes to the Accountable Officer for Controlled Drugs

Monthly Performance Report On-going As required

Patient Safety – identifying risks and learning from incidents that occur

Patient safety and serious incident reporting

• To identify to the CCG early warnings of clinical areas of concern, through the

monitoring of serious incidents requiring investigation (SIRI).

• To highlight areas with a low level of incident reporting, developing an early warning

system.

• Review of reporting and audit results
• Arrangements in place to monitor quality issues and safety.
• Monitor Serious Incidents Requiring Investigation (SIRIs) and never events with

regard to CCG requirements; manage day to day reporting and coordination from

• providers. Ensure timeframes and deadlines for SIRI root cause analysis submission

are met via provider contracts and supply for clinical review.

• Ensure learning from SIRIs and never events across pathways is disseminated.
• Ensure reporting to the National Reporting and Learning System is undertaken by

providers, or the CNO office as necessary on behalf of the CCG. Monthly Performance Reports On-going On-going Monthly performance Report As required As required Infection Control

• Surveillance reports on MRSA and C diff.
• Production of root cause analysis on all positive cases of MRSA and C diff. working

with all relevant providers.

• Advice to GP practices and care homes on infection control best practice providing

assurance to the CCG.

• Quality improvement visits for infection control to GP practices, support to practices

in the completion of self audits as part of the Health and Social Care Act Monthly As required Monthly As required Undertaking Clinical investigations and overseeing serious case reviews

• Monitoring of serious incidents requiring reporting (SIRIs) to act as an early warning

system to identify areas of concern.

• To maintain a Risk Register, updated monthly, identifying the key risk areas and

action plans to reduce risks.

• To lead on the lines of accountability for patient safety including regular reporting to

the national reporting and learning systems. Monthly Performance Reports On-going

15 Deliverable Key Process Key Outputs/ Dates/ Frequency

Accountable Officer for Controlled Drugs

• The Chief Nursing Officer is identified as the Accountable Officer for Controlled Drugs,

they will ensure that there are a range of measures relating to the monitoring of the safe use and management of controlled drugs

• To provide assurance that provider organisations have in place systems to ensure

that CD regulations are being complied with, including their storage and safe destruction and disposal. On-going

Patient Experience – complaints, advice and guidance enquiries

Complaints

• To maintain a database on the investigation into complaints. To include comparisons

with previous years activity.

• To identify improvements following review of the complaint.
• To support practices with the implementation of the national guidance for complaint

management, by training sessions to improve practice.

• To liaise with the Health Service Ombudsman.

Monthly Performance Report As required Advice and guidance enquiries

• To maintain a database of all contacts with the PALS service, reporting on the types
• f enquiries, including how to register with a GP when new to the area.
• To give advice and assistance for patients including prisoners who have

concerns/issues with appointments, delays or treatments.

• To act as an advocate for patients – e.g. to make a complaint, to claim for exceptional

funding, NHS continuing Healthcare or patients on the Special Allocation Scheme. Monthly Performance Report On-going On-going As required Provider Patient Experience development

• To facilitate the patient experience strategy group to involve users with the re-design

process.

• To develop Community Conversations with Children and Young People.
• Support patient involvement to influence service re-designs, developing local

standards.

• PALS acts as catalyst for change and improvement, it is an early warning system when

there are gaps in service provision. On-going On-going On-going On-going

16 Deliverable Key Process Key Outputs/ Dates/ Frequency Supporting the provision of quality clinical by Service Providers, including primary care services

Monitoring Quality Standards

• Review of Quality Accounts giving assurance to CCGs that actions are implemented by

monitoring.

• To ensure a mechanism is in place to share confidential and sensitive information.

Monthly Performance Reports Undertaking Quality Improvement visits (QIV)

• Quality improvement visits and the subsequent implementation of actions through
• bservational audits.
• To agree a QIV plan for all providers.
• Ensure providers have appropriate clinical governance arrangements in place.

Monthly Performance Reports On-going On-going Ensure quality information can be sourced from clinical services to be used effectively in clinical commissioning

• Monitoring processes in place to comply with national and local clinical standards
• To ensure that quality KPIs are part of the contract with all providers

Monthly Performance Report As required Caldicott Guardian

• The Chief Nursing Officer has the function as the senior nominated person as the

Caldicott Guardian, to ensure that organisations adheres to the Caldicott principles.

• The Guardian plays a key role in ensuring that NHS, Councils with Social Services

Responsibilities and partner organisations satisfy the highest practical standards for handling patient identifiable information.

• Acting as the 'conscience' of an organisation, the Guardian actively supports work to

enable information sharing where it is appropriate to share, and advises on options for lawful and ethical processing of information. The Caldicott Guardian also has a strategic role, which involves representing and championing Information Governance requirements and issues. On-going On-going On-going

Support Innovation by the development of Clinical Standards

Development of Clinical Standards

• To review and monitor HMSR data from acute providers and report concerns to the

CCG.

• To review and act upon the quality monthly reports from all providers, developing an

early warning system for quality

Monthly Performance Report

17 Deliverable Key Process Key Outputs/ Dates/ Frequency

Keep up to date with national and local initiatives

• To monitor other external bodies reports, to ensure action plans in place, to improve

clinical practice.

Monthly Performance Report

Use expert skills and knowledge to inform and develop improvements

• Professional Safeguarding Children advice and expert clinical guidance to primary

care and to other agencies

• Advisor on Vulnerable Adults and the Deprivation of Liberty.
• Infection Control specialist.
• NHS Continuing Healthcare for Adults and Shared Care for Children

On-going On-going On-going On-going

Providing expertise and interpretation of national guidance

Managing the provision of Adult NHS Continuing Healthcare

• To negotiate cost effective packages of care for patients eligible for NHS Continuing

Healthcare , based on assessed need

• To provide education and training in line with national guidance on NHS Continuing

Healthcare, to partners, the public and public organisations.

• To implement the national policy, including an appeals process and the management
• f retrospective reviews.
• Funded Nursing Care, to manage the database for the Care Homes with Nursing in

the CCG, to complete the checklist on new admissions and annual reviews including full continuing care assessments as required.

On-going As required On-going On-going

Managing the provision of Children’s NHS Continuing Healthcare and Shared Care

• Management and monitoring of shared care funding for children with complex cases

through the County Panel.

• To negotiate cost effective packages of care for patients eligible for NHS Continuing

Healthcare and Shared Care, based on assessed need.

• To authorise placements of care packages, in and out of county, on your behalf
• To maintain a database on individual children’s spend, including CAMH funding.
• To monitor and challenge invoices to ensure that correct processes are in place

Quarterly reports on cases and expenditure. On-going On-going On-going On-going

18 Deliverable Key Process Key Outputs/ Dates/ Frequency

Manage the funding of individual funding requests

• To maintain a database of requests for individual funding for general acute, children,

mental health and equipment.

• To clinically review all requests, discuss with relevant clinicians
• To facilitate a West Suffolk CCG panel to review requests
• Panel minutes to CCG Chair, to include decision and costing
• To manage on behalf of the CCG the appeals process.

On-going On-going As required As required Primary Care Research Network

• To provide an opportunity for patient s to access research in the CCG.
• To ensure that research is linked to the clinical priorities of the CCG
• To maintain a database of research
• Working with practices and provider services to increase the level of research in

those areas where little research has taken place.

• Report on the research activity, on both contracted practices and non-contracted.

On-going On-going On-going Annual report Administration of the End of Life Project

• Administrative support to the End of Life project for the implementation and

maintenance of the Suffolk Palliative website and the End of Life Register

• Development and maintenance of the End of Life Register.
• To monitor and record the use of Patient held palliative care records (the yellow

folder). Quarterly reports On-going On-going

Emergency Planning and Business Resilience Compliance with: Civil Contingencies act 2004 S.46 Health & Social Care Act 2012 Department of Health Emergency Planning Guidance

• To enable the CCG to comply with its statutory duties under the Civil Contingences Act
• To support the CCG in developing steps for securing that it is properly prepared for

dealing with a relevant emergency

• To lead on the development and implementation of policies, procedures and practices

that determines emergency planning priorities for Suffolk’s NHS organisations.

• Provide specialist advice, guidance and training to the health economy in Suffolk
• Develop and embed service continuity management in provider organisations, providing

advice and guidance to ensure a co-ordinated response with partner organisations.

• To ensure contracts with provider organisations contain relevant emergency

preparedness, resilience and response elements. On-going

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Appendix B: Responsibilities that do not fall within this function

Function Responsibility

Completion of Incident forms Relevant Provider Initial response to complainants Relevant Provider Personnel performance reports Relevant Provider

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Appendix C: Structure

Chief Nursing Officer VSM (1 WTE) Executive Assistan t (1 WTE) Designated Nur se Safeguarding Children (1 WTE) Designated Doctors Safeguarding C hildren M&D (0.6 WTE) Head of Clinical Qu ality & Patient Experience (1WTE)

CHIEF NURSING OFFICER STRUCTURE

Clinical Quality Contract Lead (1WTE) Head of Patient Safety & Clinical Effectivene ss (1 WTE)

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Appendix D: Running costs Chief Nursing Officer £,000 Ipswich & East Suffolk CCG West Suffolk CCG Total Total Costs Staff Costs Database Costs Cost per registered head