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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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Mrs M Somerville

Director of Hospital & Community Learning Disability Services

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Mr S Peover

Permanent Secretary

Department of Environment

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Mrs Mairead Mitchell

Assistant Director Service Improvement and Governance

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Setting The Scene

Muckamore Abbey Hospital

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Population - 160,000

Staff - 3,500

Income - £145M

Service Locations - 50

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

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  • What Do We Do? with Learning Disabilities since the late 1950’s

  • 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

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  • Main Services: with Learning Disabilities since the late 1950’s

  • Specialist Psychiatric Medical and

  • Nursing Services

  • Clinical Psychology

  • Dental Services

  • Physiotherapy

  • Speech and Language Therapy

  • Orthotics

  • Social Work

  • Daycare

  • Podiatry

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Muckamore Abbey Hospital with Learning Disabilities since the late 1950’s

  • 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

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  • Strategic Direction : with Learning Disabilities since the late 1950’s

  • Resettlement of Long Stay

  • patients to the Community

  • Reduction of Inpatient Bed Capacity

  • Assessment and Treatment Services

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In the Midst of Change: with Learning Disabilities since the late 1950’s

  • Redevelopment of Hospital Services

  • Reprovision of Children’s Services

  • Review of Public Administration

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  • Quality Agenda with Learning Disabilities since the late 1950’s

  • Continuous Quality Improvement

  • Patient/Carer Involvement

  • Standards/targets

  • Development of a multidisciplinary audit tool

  • Awards

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Achievements: with Learning Disabilities since the late 1950’s

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How Did We Get Here with Learning Disabilities since the late 1950’s

  • Standards – Uniprofessional

  • Process for Review and Monitoring.

  • How the information was being used.

  • How could this be improved.

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How it was done (contd) with Learning Disabilities since the late 1950’s

  • Multidisciplinary Review Group

  • Looked at gaps

  • Involved internal and external staff

  • Ownership

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How it was done (contd) with Learning Disabilities since the late 1950’s

  • Disseminate Standards

  • Consultation

  • Ensure staff understood them

  • Pilot

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How it was done (contd) with Learning Disabilities since the late 1950’s

  • Feedback from Pilot

  • Evidence

  • Monitoring Process

  • Implementation

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Where Are We At Now with Learning Disabilities since the late 1950’s

  • Audit Timetable

  • Multi-Disciplinary Auditors

  • Steering Group

  • Process for Ensuring Actions Completed

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Principles Underpinning The Standards with Learning Disabilities since the late 1950’s

  • Patient Involvement

  • Staff Involvement

  • Multi-Disciplinary

  • Quality of Care

  • Reflect Legislative Standards

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Challenges with Learning Disabilities since the late 1950’s

  • Setting Standards

  • Keeping Focused

  • Time

  • Software

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Improvements with Learning Disabilities since the late 1950’s

  • Learning Disability Audit Tool

  • Integrated into Practice

  • Measure Improvements

  • Monitoring Tool

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Ms J McKay with Learning Disabilities since the late 1950’s

Resource Nurse

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EQC with Learning Disabilities since the late 1950’sEvaluating Quality Care

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

Hospital Core Standards

Nursing Standards

Day-care Standards



Evaluating Quality Care

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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

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What does EQC do? Standards of the Hospital

  • 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

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What does EQC do? Standards of the Hospital

  • 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

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Themed Questions Standards of the Hospital

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

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Audit Questions Standards of the Hospital

  • 3 types of questions

  • General - pertaining to the hospital

  • Facility specific

  • Patient related

  • All questions include auditors advice

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Safety Audit Standards of the Hospital

  • 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


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ARE POLICY FILES ASSESSIBLE? Standards of the Hospital

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)


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


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


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

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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


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


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

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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

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Audit Team PATIENT ?

  • Multidisciplinary team

    • Nursing

    • Day Care

    • Social Work

    • Administration

    • Estates

    • Dietetics

    • Hotel Services

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Auditors PATIENT ?

Competence, training and behaviour of the auditor is crucial

Auditors selected for their

  • Integrity

  • Professional competence

  • Tact

  • Perseverance

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Audit Training PATIENT ?

  • 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

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Audit Training PATIENT ?Being an auditor

  • Explanations

    • staff and patients

    • collecting quality related facts on patient care NOT staffs professional competence

  • Attitude

  • Respect

  • Visitor

  •  disruption

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Audit takes place PATIENT ?


the all facilities

Pts satisfaction


Copies of audits to

all depts – master and


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

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By Department PATIENT ?

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%

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Ward 1 PATIENT ?

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All Departments PATIENT ?

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Action Plan PATIENT ?

Pass mark 100% Score 60%


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

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Reviewing EQC PATIENT ?

  • 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

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Benefits PATIENT ?

  • 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

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Where are we now? PATIENT ?

  • 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

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Patient Satisfaction Survey PATIENT ?

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

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    Patient Satisfaction Survey PATIENT ?

    • Use different methods of gathering responses

    • 2 versions of survey

    • Input from all patients required

    • pertinent questions only

    • short snappy feedback

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    Patients Question Set PATIENT ?

    Are you happy with the meals?




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    Mrs K Murray PATIENT ?

    Deputy Manager

    Day Care

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    User Involvement PATIENT ?

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    Patient Forum PATIENT ?

    • Regular meetings

    • Agenda - open to everyone

    • Informative

    • Issues

      • Staff

      • Patients

  • Solutions

  • Empowerment

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    Communication Difficulties PATIENT ?

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

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

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    Overcoming Communication Difficulties PATIENT ?

    • Knowing patients

    • Sensory aids

    • Makaton signs / symbols

    • Objects of reference

    • Visual cues

    • Speech & language Therapy

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    Focus Group PATIENT ?

    • 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

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    Patient Focus Group PATIENT ?

    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

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    Hospital Redevelopment Focus Group PATIENT ?Phase 1

    • Current patients within the hospital

    • Former Patients

    • Male and female patients

    • Age range 27 – 45

    • Independent facilitator

    • 2 members of the Project Team

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    • The purpose of the meetings were to PATIENT ?

    • Share experiences / opinions on Muckamore Abbey Hospital

    • Give ideas on what would make the hospital better

    • Feedback to the planners on the new building

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    • One person at a time would speak PATIENT ?

    • 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

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    • The general layout of the new buildings PATIENT ?

    • 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

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    • They try and want to do things PATIENT ?

    • 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

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    EQC Patient Satisfaction Survey PATIENT ?Focus Group

    • Independent facilitator

    • Selection process

    • Speech & Language Therapy

    • EQC Auditor

    • Evaluation of process

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    Mrs E Steele PATIENT ?

    Assistant Director of Hospital Services

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    EQC as a Management Tool PATIENT ?

    Mrs E Steele

    Assistant Director of Hospital Services

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    • Individually in wards / departments PATIENT ?

    • 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

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    • Hospital as a whole PATIENT ?

    • 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

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    • 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

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    Patient Satisfaction Survey all disciplines have ownership

    • Reflects the overall audit

    • Covers all the basics

    • Encompasses areas important to the patients

    • Potential to be a strong powerful voice