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Audit - Evaluating Quality Care. Mrs M Somerville Director of Hospital & Community Learning Disability Services. Mr S Peover Permanent Secretary Department of Environment. Mrs Mairead Mitchell Assistant Director Service Improvement and Governance. Setting The Scene

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slide2

Mrs M Somerville

Director of Hospital & Community Learning Disability Services

slide3

Mr S Peover

Permanent Secretary

Department of Environment

slide4

Mrs Mairead Mitchell

Assistant Director Service Improvement and Governance

slide5

Setting The Scene

Muckamore Abbey Hospital

slide7

Background:

Population - 160,000

Staff - 3,500

Income - £145M

Service Locations - 50

slide8

A Centre of Excellence in the treatment and care of people with Learning Disabilities since the late 1950’s

slide9

What Do We Do?

  • We provide assessment and treatment services for people with learning disabilities who have an additional mental disorder:
  • Psychiatric Illness
  • Severe Challenging Behaviour
  • Co-existing complex neurological disorder
slide10

Main Services:

  • Specialist Psychiatric Medical and
  • Nursing Services
  • Clinical Psychology
  • Dental Services
  • Physiotherapy
  • Speech and Language Therapy
  • Orthotics
  • Social Work
  • Daycare
  • Podiatry
slide11

Muckamore Abbey Hospital

  • Opened in the late 1950s/ early 1960s
  • Provides a regional specialist service for people with Learning Disabilities
  • Max Patients 1980s - Over 800
  • Currently 290 Patients
  • Staff - 620
slide12

Strategic Direction :

  • Resettlement of Long Stay
  • patients to the Community
  • Reduction of Inpatient Bed Capacity
  • Assessment and Treatment Services
in the midst of change
In the Midst of Change:
  • Redevelopment of Hospital Services
  • Reprovision of Children’s Services
  • Review of Public Administration
slide14

Quality Agenda

  • Continuous Quality Improvement
  • Patient/Carer Involvement
  • Standards/targets
  • Development of a multidisciplinary audit tool
  • Awards
how did we get here
How Did We Get Here
  • Standards – Uniprofessional
  • Process for Review and Monitoring.
  • How the information was being used.
  • How could this be improved.
how it was done contd
How it was done (contd)
  • Multidisciplinary Review Group
  • Looked at gaps
  • Involved internal and external staff
  • Ownership
how it was done contd18
How it was done (contd)
  • Disseminate Standards
  • Consultation
  • Ensure staff understood them
  • Pilot
how it was done contd19
How it was done (contd)
  • Feedback from Pilot
  • Evidence
  • Monitoring Process
  • Implementation
where are we at now
Where Are We At Now
  • Audit Timetable
  • Multi-Disciplinary Auditors
  • Steering Group
  • Process for Ensuring Actions Completed
principles underpinning the standards
Principles Underpinning The Standards
  • Patient Involvement
  • Staff Involvement
  • Multi-Disciplinary
  • Quality of Care
  • Reflect Legislative Standards
challenges
Challenges
  • Setting Standards
  • Keeping Focused
  • Time
  • Software
improvements
Improvements
  • Learning Disability Audit Tool
  • Integrated into Practice
  • Measure Improvements
  • Monitoring Tool
slide24

Ms J McKay

Resource Nurse

slide26

EQC was developed following a review of all standards in the hospital.

Hospital Core Standards

Nursing Standards

Day-care Standards

EQUATE

EQC

Evaluating Quality Care

slide27

EQC is an all inclusive tool used to measure the Core Standards of the Hospital

It is a multidisciplinary / multidepartmental audit of the quality of care provided to patients

slide28

What does EQC do?

  • It provides a measurable audit of the core standards of the hospital
  • It provides a measurable audit of the quality of care provided to patients
  • It’s a practical step in the process of quality assurance
  • It raises questions in many specific areas re. the quality of care
  • It provides a series of pointers to areas which need attention
  • It acts as an agent of change
  • It’s a facilitator for best practice
slide29

What does EQC do?

  • provides an audit of all aspects of patient care by allowing specific audits e.g.
    • Safety
    • Leisure
    • Mental Health Order
    • Written records

It encompasses the entire treatment and care provided to the patient

slide30

Themed Questions

Themed questions allow audit tools to be created specifically relating to each department, e.g.

  • Nursing
  • Allied Health Professions
  • Hotel Services
  • Estates
  • Pharmacy

Other themes allow audits to be completed in relation to specific areas , e.g.

  • Safety
  • Facility Management
  • Care plans
  • Mental Health
  • Leisure
audit questions
Audit Questions
  • 3 types of questions
  • General - pertaining to the hospital
  • Facility specific
  • Patient related
  • All questions include auditors advice
safety audit
Safety Audit
  • Examples of areas audited
  • Hospital and professional policies
  • Infection control
  • Adverse incidents
  • Fire procedures
  • Faults
  • Major incident plan
  • Staff training
  • Emergency equipment
  • Drug storage / information
  • Quick reference information in care plan
  • Ward issues, i.e. staff available during meal times, special obs, bathroom guidelines
  • COSHH
slide33
ARE POLICY FILES ASSESSIBLE?

Advice to auditor: See policy files – (1) Operational policy file and (2) Policy manual specific to the dept. These must be assessible to all staff at all times (available in seniors office in day-care depts)

IS THERE A NAMED ROOM / BED PLAN ?

Advice to auditors: see plan – 2 storey buildings require a copy upstairs and downstairs – see both

IS INDUCTION TRAINING GIVEN FOR NEW TEAM MEMBERS ?

Advice to auditors: See induction booklet belonging to the 2 most recent staff to join the team. This must be completed and signed. Hotel Services – evidence of induction on staffs individual training cards

ARE ALL DRUGS STORED ACCORDING TO POLICY (inc controlled drugs) ?

Advice to auditors: Check drug cupboards are locked and controlled drugs are kept in a cupboard within the locked drug cupboard

slide34
ARE ACTIONS IN CASE OF FIRE KNOWN TO STAFF?

Advice to auditor: Ask 2 random staff what to do in the case of a fire: sound alarm, call switchboard by dialling 6666, on hearing alarm evacuate all patients, leave the building by the nearest safest root, close all doors, report to assembly point, check all present by role call

IS THE TEMPERATURE CHECKED TWICE DAILY AND RECORDED IN THE REPORT BOOK ?

Advice to auditors: see day and night reports for the previous week

ARE ALL ELECTRICAL DEVICES SAFE AND RECOREDE ACCORDING TO THE ELECTRICITY AT WORK ACT ?

Advice to auditors: Check dates on tags have not expired, check 3 pieces of electrical equipment in the facility.(Check steriliser in Podiatry)

slide35
IS THE QUICK REFERRENCE INFORMATION COMPLETED FOR THE PATIENT ?

Advice to auditors: Check care plan of 5 randomly selected patients. Check quick reference information section on ‘buff’ personal details sheet, this should have information that a new staff starting the ward that day would immediately require to keep the patient safe, i.e. prone to choking, absconding, special diets, behaviour, mental health, allergies, alerts, epilepsy, level of observations, etc

audit team
Audit Team
  • Multidisciplinary team
    • Nursing
    • Day Care
    • Social Work
    • Administration
    • Estates
    • Dietetics
    • Hotel Services
auditors
Auditors

Competence, training and behaviour of the auditor is crucial

Auditors selected for their

  • Integrity
  • Professional competence
  • Tact
  • Perseverance
audit training
Audit Training
  • ½ - 1 days training including
    • EQC document
    • being an auditor
  • Most training occurs during hands on experience carrying out audits
  • All new auditors paired with experienced auditor
  • Auditors don’t wear uniform
audit training being an auditor
Audit TrainingBeing an auditor
  • Explanations
    • staff and patients
    • collecting quality related facts on patient care NOT staffs professional competence
  • Attitude
  • Respect
  • Visitor
  •  disruption
eqc process

Audit takes place

in

the all facilities

Pts satisfaction

Audit

Copies of audits to

all depts – master and

individual

Action Plan to Facility Manager & SNM(When applicable)

  • Action Plan audit report prepared
  • Core Group
  • SNM

EQC Steering Group monitor actions & review & update tool

EQC Process

Audit dates arranged

72 Hrs

  • Audit Reports prepared
  • Individual
  • Hospital

Audit of Action Plan

6 weeks

slide41

By Department

Ward 1 September 2006  

Admission/Transfer/Discharge 100%

Care Plan 70%

Environment 95% 

Facility Management 89%

Leisure & Education 100%

Medical Notes 100%

Multidisciplinary Care 100%

Patient Charter 96%

Patient Needs 100%

Safety 78.5%

Overall Score 93%

slide44

Action Plan

Pass mark 100% Score 60%

DO STAFF RECEIVE MANDATORY TRAINING?

Comments: Training cancelled because of staff shortages

Notes: staff unable to attend

Action to be taken: Discuss with management

Completed: No

Completion date: Feb 07

Assigned to: Charge Nurse

slide45

Reviewing EQC

  • EQC is a working tool
  • Continual review by Multidisciplinary steering group using
    • Feedback from wards / departments
    • Feedback from individuals
    • Feedback from auditors
    • Other groups in hospital e.g. Senior Management Team
benefits
Benefits
  • One audit tool for the hospital
  • Individualised action plans for each dept
  • Direct impact on patient care
  • Direct impact on the quality of care all services provide
  • One point of contact for all reports and audits
  • Up to date audits
  • Flexibility
  • Precise and measurable standards
  • Use of up to date technology e.g. PDA’s and Quasar2

It is also

  • A model for other areas interestedin developing such an initiative
where are we now
Where are we now?
  • Annual audit completed including
    • audits of action plans
    • areas of improvement identified
    • staff identified areas of improvement within own practice
    • report presented to management
    • individual reports to each ward / department
    • report of areas still requiring action
  • EQC tool reviewed and updated
  • Dates arranged for 2nd annual audit
  • Liaising with depts to include updated standards
  • Patients question set piloted
patient satisfaction survey
Patient Satisfaction Survey

To allow the patients have an input into the audit, many of the questions reflect what has been asked in the wards / depts.

  • EQUATE satisfaction survey
  • Question set developed with symbols
  • Piloted in wards
  • Asked for feedback from patients
      • symbols
      • language
      • too long / too many questions
  • Survey reviewed
patient satisfaction survey49
Patient Satisfaction Survey
  • Use different methods of gathering responses
  • 2 versions of survey
  • Input from all patients required
  • pertinent questions only
  • short snappy feedback
slide50

Patients Question Set

Are you happy with the meals?

Yes

Ok

No

slide51

Mrs K Murray

Deputy Manager

Day Care

patient forum
Patient Forum
  • Regular meetings
  • Agenda - open to everyone
  • Informative
  • Issues
      • Staff
      • Patients
  • Solutions
  • Empowerment
communication difficulties
Communication Difficulties

50 – 90% of people with Learning Disabilities have some communication difficulties

4 out of 5 people with severe Learning Disability have no effective speech

overcoming communication difficulties
Overcoming Communication Difficulties
  • Knowing patients
  • Sensory aids
  • Makaton signs / symbols
  • Objects of reference
  • Visual cues
  • Speech & language Therapy
focus group
Focus Group
  • A focus group is a group of individuals selected and assembled to discuss and comment on, from personal experience, a chosen topic that is the subject of the discussion
  • Business case for patient use of computers
  • Hospital Re-development
  • EQC Patient Satisfaction Survey
patient focus group
Patient Focus Group

Contribution to the development of Patient Satisfaction Survey

  • 2 groups consulted
  • Original Satisfaction Survey viewed / explained
  • Questions felt to be limited
  • Suggestions made & new questions developed
  • Wording too complicated
  • Patients happy to be consulted and involved
hospital redevelopment focus group phase 1
Hospital Redevelopment Focus GroupPhase 1
  • Current patients within the hospital
  • Former Patients
  • Male and female patients
  • Age range 27 – 45
  • Independent facilitator
  • 2 members of the Project Team
slide60

Liaising directly with patient

  • Liaising directly with patient’s consultant
  • Liaising directly with carers
  • Liaising directly with relatives
slide61

The purpose of the meetings were to

  • Share experiences / opinions on Muckamore Abbey Hospital
  • Give ideas on what would make the hospital better
  • Feedback to the planners on the new building
slide62

One person at a time would speak

  • When not speaking we would listen to each other
  • The room would be seen as a safe place to speak and share ideas and opinions
  • No statement would subsequently be attributed to a specific person without his / her consent
slide63

The general layout of the new buildings

  • Internal space
  • Dining arrangements
  • Food
  • Management / personnel in the new hospital
  • Smoking policy and access to personal lighters
  • Values and attitudes in the new service
  • Signage on access roads
  • Unsupervised time within the grounds
  • Privacy
  • Education, work and day care service
  • Good day and bad day experience
  • Communication within the new units
slide64

They try and want to do things

  • They try and want to understand you
  • They care and want to care for you
  • They listen to you
  • Come to you when you feel sad
  • Give you reason for the decisions and treatments being offered to you
eqc patient satisfaction survey focus group
EQC Patient Satisfaction SurveyFocus Group
  • Independent facilitator
  • Selection process
  • Speech & Language Therapy
  • EQC Auditor
  • Evaluation of process
slide66

Mrs E Steele

Assistant Director of Hospital Services

slide67

EQC as a Management Tool

Mrs E Steele

Assistant Director of Hospital Services

slide68

Individually in wards / departments

  • Baseline for a manager in wards / departments
    • New manager
    • New ward / department
  • Shows how areas are performing
  • Early warning of underperformance
  • Highlights good practice – which then can be shared with other areas
slide69

Hospital as a whole

  • Overview of hospital
    • provides trends
    • allows comparisons
  • Can target a particular theme throughout hospital, i.e. safety, environment, Care plan
  • Recurrent issues / areas of concern - EQC can provide an evidence base, changes are implemented and a further audit will evidence if the changes have made a difference
slide70

Provides a fair broad base for all issues – all areas have the same audit by trained auditors using the same criteria

  • All aspects of care are covered
  • Imbedded as part of a way of life in the hospital,
  • i.e. introduction of a new policy - EQC can measure its effectiveness and how the policy is implemented
  • Checklist for Senior Managers
slide71

Steering group is a Multidisciplinary group, meaning that all disciplines have ownership

  • All reviews and updates discussed therefore keeping all up to date
slide72

Patient Satisfaction Survey

  • Reflects the overall audit
  • Covers all the basics
  • Encompasses areas important to the patients
  • Potential to be a strong powerful voice
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