Audit - Evaluating Quality Care

1. Audit - Evaluating Quality Care

2. Mrs M Somerville Director of Hospital & Community Learning Disability Services

3. Mr S Peover Permanent Secretary Department of Environment

4. Mrs Mairead Mitchell Assistant Director Service Improvement and Governance

5. Setting The Scene Muckamore Abbey Hospital

6. North and West Belfast Health and Social Services Trust Community and Hospital

7. Background: Population - 160,000 Staff - 3,500 Income - £145M Service Locations - 50

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

9. 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

10. Main Services: • Specialist Psychiatric Medical and • Nursing Services • Clinical Psychology • Dental Services • Physiotherapy • Speech and Language Therapy • Orthotics • Social Work • Daycare • Podiatry

11. 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

12. Strategic Direction : • Resettlement of Long Stay • patients to the Community • Reduction of Inpatient Bed Capacity • Assessment and Treatment Services

13. In the Midst of Change: • Redevelopment of Hospital Services • Reprovision of Children’s Services • Review of Public Administration

14. Quality Agenda • Continuous Quality Improvement • Patient/Carer Involvement • Standards/targets • Development of a multidisciplinary audit tool • Awards

15. Achievements:

16. How Did We Get Here • Standards – Uniprofessional • Process for Review and Monitoring. • How the information was being used. • How could this be improved.

17. How it was done (contd) • Multidisciplinary Review Group • Looked at gaps • Involved internal and external staff • Ownership

18. How it was done (contd) • Disseminate Standards • Consultation • Ensure staff understood them • Pilot

19. How it was done (contd) • Feedback from Pilot • Evidence • Monitoring Process • Implementation

20. Where Are We At Now • Audit Timetable • Multi-Disciplinary Auditors • Steering Group • Process for Ensuring Actions Completed

21. Principles Underpinning The Standards • Patient Involvement • Staff Involvement • Multi-Disciplinary • Quality of Care • Reflect Legislative Standards

22. Challenges • Setting Standards • Keeping Focused • Time • Software

23. Improvements • Learning Disability Audit Tool • Integrated into Practice • Measure Improvements • Monitoring Tool

24. Ms J McKay Resource Nurse

25. EQCEvaluating Quality Care

26. 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

27. 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

28. 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

29. 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

30. 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

31. Audit Questions • 3 types of questions • General - pertaining to the hospital • Facility specific • Patient related • All questions include auditors advice

32. 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

33. 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

34. 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)

35. 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

36. Audit Team • Multidisciplinary team • Nursing • Day Care • Social Work • Administration • Estates • Dietetics • Hotel Services

37. Auditors Competence, training and behaviour of the auditor is crucial Auditors selected for their • Integrity • Professional competence • Tact • Perseverance

38. 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

39. Audit TrainingBeing an auditor • Explanations • staff and patients • collecting quality related facts on patient care NOT staffs professional competence • Attitude • Respect • Visitor •  disruption

40. 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

41. 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%

42. Ward 1

43. All Departments

44. 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

45. 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

46. 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

47. 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

48. 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

49. Patient Satisfaction Survey • Use different methods of gathering responses • 2 versions of survey • Input from all patients required • pertinent questions only • short snappy feedback

50. Patients Question Set Are you happy with the meals? Yes Ok No