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Christine Morris Associate Director of Governance October 2018
Safety Triangulation Accreditation Review Christine Morris - - PowerPoint PPT Presentation
Safety Triangulation Accreditation Review Christine Morris - - PowerPoint PPT Presentation
Safety Triangulation Accreditation Review Christine Morris Associate Director of Governance October 2018 Sept 2016 What Did Staff Say? Patients are at the centre of it all of it - we should be assuring them We spend a huge amount
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What Did Staff Say?
- Patients are at the centre of it all of it - we should be assuring them
- We spend a huge amount of time collecting data - is it used ?
- We don't need more resources - just need to work smarter
- Not always convinced the data is accurate
- There is lots of duplication
- Lots of audits, not always with a clear pathway
- Doesn't feel like everything is gathered in a single place
- Various instances where things are being done but not fed upward
- Individual systems exist, but without an overarching strategy
- Lack of visibility and shared learning (both positive and negative)
- Assurance needs to tie into accountability
- Are the right people doing the right bits?
- Only helps ward managers a small amount in terms of doing the day job
- Estates is sometimes on periphery and should be integrated
- Some audits are "done at" departments rather than with them
- There’s a disconnect - things that would help elsewhere but not being used
- RAG rating and dashboards often provide more reassurance than assurance
- No standardised template for action plans, but there is probably a "popular one"!
- Can end up with a complex set of actions/plans, a bit like a "house of cards"
- Not always clear how the lessons learned process works
- Examples of good action plans but process means they aren't always owned at
ward level
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Our Framework for Excellence will provide assurance
- n the standards of care across Lancashire Teaching
- Hospitals. The system will empower staff by
providing a framework and clear standards. These standards will be used to work in partnership with peers to provide evidence that is credible, reliable,
- pen and honest, allowing areas to benchmark and
eliminate variation and provide a platform for continuous improvement.
Our Vision
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Our framework will be:
- Consistent with achieving an outstanding rating in line
with the CQC standards
- Align with LTH core ambitions and values
- Patient and family focussed
- Credible, measureable and relevant to all staff and the
work they do
- Flexible to allow for local variation
- Responsive, dynamic, action focused
Key Principles
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Ward / Department Manager Ensure the outcomes
- f the review are
actioned Place the results of the review on the ward governance meeting agenda Agree actions and collectively resolve areas requiring improvement Matron / Professional Leads
- Undertake STAR
monthly review
- Monthly reporting
to Divisional Nurse / Midwifery / AHP Director Divisional Nurse/Midwifery/AHP Director
- Ensure improvement
actions for areas / repeated shortfalls are addressed appropriately
- Quarterly reporting
to Divisional Governance Boards
- Reporting to Safety
and Quality Committee
Quality Assurance Matron Quarterly Report to the Quality Deliver Group Quality Assurance Team Support
Roles and Responsibilities
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Triangulation
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- Undertaken by the Matron or Professional Lead
- Completed by 26th of each month
- Recorded on the Audit Management and Tracking
(AMaT) system
- Focus on fundamental standards that underpin a safe
and effective environment for patients and staff
STAR Monthly Reviews
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14 questions - one from each of the following domains:
- Well Led
- Quality Improvement
- Staff Health and Well Being
- Infection Prevention and Control
- Safeguarding Vulnerable adults
- Medicine Management
- Performance Data
- Environment
- Documentation
- Listening to Patients
- Harm Free Care
- End of Life
- Acutely Unwell
- Discharge
4 categories
- Documentation
- Environment
- Staff Feedback
- Patient Feedback
STAR Monthly Reviews
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Clinical areas
- Wards
- Inpatients
- Outpatients
- Therapies
- Clinics
- Satellite units
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STAR Monthly Review Scoring
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STAR Reviews Monthly Reporting
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STAR Monthly Review Trust Wide
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STAR Visit Process
- Undertaken at least every 6 months by:
- Quality Assurance Matron / member of Quality Assurance Team
(to ensure consistency of standards)
- Ward / Departmental Manager
- Matron
- Layperson or peer assessor from a different clinical area
- Recorded on the Audit Management and Tracking (AMaT) system
- Focus on fundamental standards that underpin a safe and effective
environment for patients and staff
- Opportunity to benchmark against others providing a similar service
- Will include the same questions asked in the STAR Monthly
Review
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STAR Visit Process
- 15 step challenge (on the way to the area)
- Checking
- training records
- risk assessments
- departmental minutes
- audits
- Discussion with patients, carers and staff
- Observation of environment and care given
- Review of documentation
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STAR Accreditation Visit Scoring and Revisits
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4 Categories
- Documentation
- Environment
- Staff Feedback
- Patient Feedback
Feedback
- High level and any patient safety /
immediate issues addressed before leaving the ward
- Quality Assurance Matron - written
feedback within 48 hours
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Where are we now ?
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Additional Support
Will include but not limited to:
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MIAA – Baseline Review
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