Provide high quality
recovery focused
services
Our first strategic aim:
what it means for staff and teams
2015-2017
Living
Our
Values
A summary of our approach to achieving our first strategic aim
Document development and contributors
This document is a summary of work developed by authors referenced in the
footnotes of each section. Most of these have involved separate consultations and
have been approved through a number of Board level committees. All authors have
been asked to comment on and amend the document and the respective strategic
goals. Executive Directors, Clinical Directors (as directorate quality leaders) and the
Head of Inclusions services have also been asked for their contributions. Eleven
iterations were produced through subsequent amendments until reaching this final
version which was approved by the Board’s Quality Governance Committee on 11th
June 2015 and ratified by the Trust Board on 25th June 2015.
Therèsa Moyes, Director of Quality and Clinical Performance, July 2015
1
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Contents
Document development and contributors ................................................................... 1
Who is this paper for and what is it about?................................................................. 4
What staff and teams need to know........................................................................ 4
What team leaders, managers, clinical and professional leads need to know ........ 4
What clinical directors need to know....................................................................... 4
How quality fits within the Trust’s strategy.................................................................. 5
Provide high quality recovery focused services ...................................................... 5
Frameworks for delivering our quality aim .................................................................. 6
Service Users and Carers Involvement Strategy .................................................... 7
We have five involvement pledges: ..................................................................... 7
Our involvement goals ........................................................................................ 8
What staff need to do .......................................................................................... 8
What teams need to do ....................................................................................... 8
Recovery and Person Centred Care Frameworks .................................................. 9
Our recovery and person centred goals ............................................................ 10
What staff need to do ........................................................................................ 10
What teams need to do ..................................................................................... 10
Quality Improvement (QI) Framework................................................................... 11
Our QI goals ...................................................................................................... 12
What staff need to do ........................................................................................ 12
What teams need to do ..................................................................................... 12
CQC’s Five Key Questions and Fundamental Standards ..................................... 13
Our CQC compliance goals .............................................................................. 14
What staff need to do ........................................................................................ 14
What teams need to do ..................................................................................... 14
Risk Strategy ........................................................................................................ 15
Our risk management and safety goals............................................................. 16
What staff need to do ........................................................................................ 16
What teams need to do ..................................................................................... 16
Learning the Lessons Framework......................................................................... 17
Our ‘learning the lessons’ goals ........................................................................ 18
What staff need to do ........................................................................................ 18
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“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
What teams need to do ..................................................................................... 18
Clinical Strategy .................................................................................................... 19
Our overarching clinical strategy goals ............................................................. 20
What staff need to do ........................................................................................ 20
What teams need to do ..................................................................................... 20
Quality Accounts ................................................................................................... 21
Links with ‘CQUINs’ and national standards ..................................................... 21
Our quality accounts goals ................................................................................ 22
What staff need to do ........................................................................................ 22
What teams need to do ..................................................................................... 22
Figure 1 - Our strategic overview ............................................................................... 5
Figure 2 - Eight enabling components for quality ....................................................... 6
Figure 3 - CQC's Fundamental Standards are embedded in the 5 key questions .... 13
Figure 4 - Our risk management framework ............................................................. 15
Figure 5 - Learning the Lessons Framework ............................................................ 17
Figure 6 - Clinical strategy word cloud ..................................................................... 19
Figure 7 - Core elements for all directorate level clinical strategies ......................... 20
Figure 8 - Quality processes and measurements ..................................................... 24
3
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Who is this paper for and what is it about?
This paper has been written so that the majority of staff can understand it and use it
for conversations within their teams and with their managers and leaders. The
Board knows that, in general, staff have a very good understanding of what quality
means, but that sometimes people focus on different aspects of quality and that
sometimes it can be difficult to know how different aspects link together so we can
demonstrate a shared understanding and a focus on continuously improving.
What staff and teams need to know
We don’t expect that all staff will have detailed knowledge about all the frameworks
here or about all the processes and measurements we use (most of which we’ve
included in a table at the back of this document), but everyone, irrespective of their
job role, should understand:








Why they need to put the service user central to everything
How to live, and challenge each other to live, the Trust values
How to use feedback and other information for continuous improvement
How to put ideas for improvement forward
How to raise concerns about quality
Why being able to give examples of what they and their teams are doing to
maintain and improve quality under each of the CQC’s five key questions is
important
What any professional bodies expect of them
That achieving the quality and other targets set by commissioners is an important
way for them to decide whether to continue paying for their service
What team leaders, managers, clinical and professional leads need to know






Everything that staff need to know
How to inspire teams and individual staff members to deliver continuously
improving quality
How to ensure staff use available feedback and other information to support
improvements
How to address quality concerns rapidly and escalate when necessary
How to be clear with staff about what you expect when quality is not good enough
How the elements in the table at the back provide assurance that teams are
delivering high quality person centred services
What clinical directors need to know




Everything that everyone else needs to know
How to ensure directorate quality priorities are the right ones
How to ensure quality is prioritised in teams and discussed in the directorate
How to use relevant support available from corporate services
4
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
How quality fits within the Trust’s strategy
Providing high quality recovery focused services is everyone’s responsibility. It
ensures we demonstrate that we really do put people who use our services at the
centre of everything we do.
Figure 1 - Our strategic overview
Provide high quality recovery focused services
What our quality aim means is simple:

Through the five behaviours of our charter, every employee of the Trust is
responsible for working well with people who use our services, and with those
who care for them, to focus on their personal goals and outcomes and for
using feedback and other information to keep improving our services.
 This way services will be safe, caring, responsive and effective. They will be
well led, ensuring our emphasis is on a continuing journey of improvement.
Our quality aim does not stand alone from our other four strategic aims. It is linked
to all of them. This paper summarises what staff’s personal and team based roles
are in providing quality services and directs readers to where they can find any
further information they may need to help them understand these roles.
5
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Frameworks for delivering our quality aim
The Trust relies on eight enabling components to achieve its quality aim. The eighth,
quality reporting is the requirement we have to report on quality every year through
something called the “Quality Accounts” or “Quality Report”. These reports follow a
standardised format so they can be compared with similar reports from other Trusts.
All the components are highlighted below and a brief summary of each follows 1, with
a table explaining our goals for each component and what staff and teams need to
do to meet them.
Service Users
and Carers
Involvement
Strategy
Recovery
Framework
Clinical
Strategy
Provide high
quality
recovery
focused
services
Quality
Improvement
Framework
CQC's
fundamental
standards
Learning the
Lessons
Framework
Risk Strategy
Quality
Accounts
Figure 2 - Eight enabling components for quality
1
In the Word version of this document, each circle also contains a hyperlink to take readers directly to
the relevant section. Simply press the “Ctrl” button as you click on the text in the circle.
6
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Service Users and Carers Involvement Strategy2
The purpose of this strategy is to ensure we all benefit from the experience of those
who come into contact with our services. The main aim of this strategy is to improve
services by ensuring that everyone who uses our services is fully involved in their
own care and the work of the Trust in ways which are meaningful to them.
Service users and their carers are ‘Experts by Experience’ and recognised as true
partners who can help to shape and improve the Trust’s services. This strategy
describes how we work in partnership with our service users and carers to develop
and improve services. Service users and carers who become involved say that their
involvement has “turned our lives around and improved our self-esteem and
confidence.” They feel that they have made a significant difference to how health
services are being delivered.
By learning from the personal experiences of service users and carers, we can
ensure that any service developments are responsive to their needs. In addition, the
benefits to service users can be therapeutic and contribute to recovery, by increasing
confidence and self-esteem, and also having more information about the availability
of services and understanding the limitations the Trust has in delivering some of
them.
We have five involvement pledges:
By involving service users and carers in discussions and joint working with front line
staff and service management, we pledge to:





Keep the Trust focussed on its core role and values. The care, treatment,
support, involvement, recovery and well-being of people who use its services
Be honest and open in all service development and change at all levels
Promote a culture of involvement where all participants; staff, service users
and carers are making a positive difference to services
Use everyone’s input to challenge thinking and continuously improve services
Harness everyone’s enthusiasm to help service progress.
Carers are often the only constant in a service user’s life. In
2015 we signed up to ‘The Triangle of Care’3 as part of our
commitment to deliver better carer engagement and support.
The model is supported by six nationally accepted standards
which we are working towards.
2
Service User and Carer Involvement Strategy 2011-2016
3
Triangle of Care or contact jane.landick@sssft.nhs.uk or lesley.crawford@sssft.nhs.uk
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“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our involvement goals
 Each directorate and divisional business plan will specify local involvement
development priorities
 Each year we will host a service users’ and carers’ celebration event and an
awards ceremony focused on how people who use our services are involved
in both their own care and in service improvements
 By October 2015 we will have co-produced a trust-wide “Framework for
Carers” and an implementation plan
 By December 2015 we will have increased the use of Advanced Directives by
100%
 By January 2016 all clinical teams will have been audited against the Triangle
of Care Standards and identified team priorities to improve carer engagement
 By January 2017 all clinical teams will be able to demonstrate progress
against the triangle of care standards.
 By April 2016, a plan for increasing for co-produced service development and
involvement opportunities, through the role of Service Development and
Improvement Worker, will have been agreed
 By April 2016, a plan for improving the use of real time feedback systems in
capturing and responding to patient, service user and carer feedback will have
been agreed
What staff need to do
 Nominate people for our service
users and carers awards
 Include service user and carer
experience objectives at appraisals
 Know what feedback systems the
trust has so you can encourage
people to give real feedback on their
experiences and it can make a
difference to future service delivery
 Share feedback with PALS
 Attend Carer Engagement Standards
training
 Identify and work with carers at the
earliest opportunity
 Make sure people are introduced to
their service and are provided with a
range of relevant information
 Make sure people who want to tell
their story have support to do so
 Understand and use the feedback
you get about people’s experiences to
work together to improve services
What teams need to do
 Share examples of good practice in
service user and carer involvement
and engagement
 Use people’s good and bad examples
of care to improve services
 Set team objectives for service user
and carer involvement and
engagement
 Support the attendance of service
users and carers at key meetings at
team, division/directorate and trust
level meetings
 Promote peer working and service
development and improvement roles
to ensure that people who use your
services are central to improvements
 Make commitments to focus on
carers’ needs, in line with the Trust’s
commitment to the Triangle of Care
Standards
 Support local initiatives for Listening
and Responding to patient, service
user and carer feedback received.
 Regularly reflect on how you can
demonstrate the team is “Living Our
Values” charter
8
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Recovery4 and Person Centred Care5 Frameworks
Recovery, defined as personal recovery, can include but is not dependant on clinical
recovery. For some of the people who use our services the same principles apply
within a model of person centred care. Key to both is the enhancement of
opportunities for achievement of personal dreams, hope, wishes, and control
wherever possible. Recovery and person centred care provide approaches to
supporting and making tangible the Trust’s core values. They offer ways of ensuring
people’s humanity and potential is honoured and supported and reconnect staff with
the very reason they entered their professions - to help people move forward with
their lives.
Across the organisation there are pockets of excellent recovery and person centred
focused practice, often championed individually, but not generalised across the
organisation. Through cross organisational discussion, the desire is to be nationally
informed about these approaches and locally driven through co-production.
Our framework builds on current excellent practice, and seeks to employ approaches
which have been found nationally to affect organisational change, namely increasing
lived experience in the workforce (eg by employing peer support workers) and coproduction (ie moving to 50:50 expert by study and expert through lived experience,
working on service development) and co-produced learning (ie lecturer with
someone with lived experience, producing and delivering learning to participants
comprised of service users, carers and workers).
Delivery of the frameworks spans three years. They are integrated within divisional
and directorate business plans so that delivery varies according to local service user
and carer need. Delivery is about working from the ground up, moving to a position
where the Trust fully integrates recovery focused and person centred working as
becoming the expected 'way we do things here', with individual workers owning the
key elements of these approaches as measures of all we do. Our aim is that our
focus on recovery and person centredness will become an identifiable quality of the
Trust, incorporated within our strategic overview model and brand.
Leadership for delivering the recovery framework sits equally between the Trust’s
Director of Psychological Services and her partner with lived experience, who
shared:
“A number of aspects stood out for me including feelings of empowerment, connectedness, hope, relationships
and many more. I may not have termed those aspects in that way previously, but as I have become more
involved and gained a richer understanding of the nature of this approach, those words encapsulate the essence
of what recovery means to me and what I hope is achieved through the recovery approach.”
4
5
Contact Rachel.Lucas@sssft.nhs.uk or Danni.Cook@sssft.nhs.uk
Contact Gwen.Moulster@sssft.nhs.uk
9
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our recovery and person centred goals
 By April 2017 we will have peer support workers across the mental health
division, with at least 3 peer support workers or more within each locality
 By April 2017, there will be a plan to roll out peer working within other
specialties
 By April 2017, there will be an established support workers’ training and
supervision programme (including peer support workers), including sessions
for all staff on ‘Using your Lived-Experience’ & ‘Using Advanced Statements’
 By April 2017, the practice of co-produced service development will be
developing and moving towards 50:50 involvement working on projects, with
service users and/or carers employed for specified which can demonstrate
how lived experience is shaping services
 By April 2016, our mental health services will have developed our ‘recovery
college without walls’ delivering a range of co-produced learning across the
Trust, outlined within a prospectus, supported by individual learning plans and
available to service users and carers across specialisms
 By April 2017, mental health inpatient handovers will be explicitly recovery
focused and will actively be reducing the use of restrictive practices
 By September 2016, the Trust website and social media will support active
engagement for all regarding recovery ideas and person centred practice
 By April 2019, all staff being aware of ‘hope, control (as early as safe) and
opportunity’ as the recovery and person centred rule of thumb, against which
the quality of all interactions can be measured
 By April 2016, all services will have made measurable progress in
implementing person centred outcomes assessments that put service users in
the driving seat of their own care
What staff need to do
What teams need to do
 Regularly reflect on your own life Set objectives to develop peer
experience and its impact on both
working and co-production
your current practice and your
 Talk together about how recovery
own health and wellbeing
and person centred approaches
challenge traditional practice and
 Actively seek to offer hope, control
and opportunity in every
require effort and courage
interaction with those using
 Support and challenge each other
services
to reduce power imbalances and
 Seek to constructively challenge
actively use the concepts behind
yourself and others to reduce
recovery and person centred
power imbalances wherever
practice in team discussions to
possible and to recognise the
measure the quality of all
ongoing process of questioning
interventions provided
and learning in sustaining
 Recognise the whole team needs
recovery focused or person
emotional support – whether ‘peer’
centred practice
or professional
 Be aware of any commissioning
targets related to recovery or
person centred care planning
10
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Quality Improvement (QI) Framework6
To continually improve the ways we can deliver the best experiences for people who
use our services, the Board approved a long term plan to introduce a well-tested
approach to “Lean” in healthcare that creates added value for service users and
carers and that puts change in the hands of front-line staff. Our quality improvement
(QI) approach is that of the Virginia Mason Production System7 (VMPS). Our QI
framework is strongly aligned to our values and strategic direction. It explicitly puts
staff, service users and carers at the heart of the system, ensuring that task and
process redesign are critically analysed so that changes really can focus on
measurable improvements. It allows the different skills of all staff to be maximised in
an organisation that believes that any task or existing form and function can be
improved and should be challenged.
A large proportion of our QI work is in managing Rapid Process Improvement
Workshops (RPIWs) and in delivering these with teams where opportunities for
improving services have been identified within directorate business plans. We have
established a comprehensive rolling programme of both RPIWs and Kaizen
(continuous improvement) events. Our QI team provides inspirational resources,
bespoke training, tools and the knowledge to enable teams to expedite changes to
add value and remove waste, thereby creating capacity to provide a high-quality,
recovery-focused environment for our service users.
Our long term aim is that decisions and responsibilities for improvement are handed
to those best equipped for the task – the staff themselves. Key to the Virginia Mason
Approach is the development of our Staff Charter which is an agreement between
staff and the Trust on how we will keep quality service delivery central. Staff need to
believe that they will be authorised to make changes and it needs to be clear that
senior staff will take a clearly structured and actively facilitative role to enable them
to do so, breaking down any corporate barriers to change. Our Charter, highlighting
five key behaviours needed to demonstrate we live our values8, was launched at the
2014 AGM after several months of consultation with staff, service users, carers and
partners. It is closely aligned to the NHS Constitution and is summarised in the
bubbles under the strategy triangle shown earlier in figure 1.
6
Contact Katy.Morris@sssft.nhs.uk
https://www.virginiamason.org/VMPS
8 http://www.sssft.nhs.uk/images/LOV/LivingOurValuesCharterA4.pdf
7
11
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our QI goals
 By January 2017, we will have trained 41 senior staff from across the Trust as
quality improvement leaders, certified externally by experts from the North
East Transformation System
 By January 2017, we will have run at least 40 RPIWs within all clinical and
corporate divisions
 By January 2017, we will have run at least 5 Kaizen events
 By January 2017, we will have run at least 6 other lean events (for example
3P and Share and Spread events)
 By January 2017, we will have trained 36 managers and clinical leaders from
across the Trust in core quality improvement skills and they will each have
completed a QI project
 By January 2017, we will have trained 40 admin staff from across the Trust in
the basics of QI and they will each have completed a mini QI project
 By April 2016, we will have trained two coaches, certified by NETS to deliver
Certified Leader training to senior leaders across the Trust
 By March 2016, we will have piloted the use of RPIWs as option for delivering
CQUINs
 By April 2017, quality improvement leaders across the organisation will be
maintaining their skills in QI techniques by engaging in a range of activities
including leading and sponsoring improvement events, mentoring trainees in
the Trust’s Leading QI programme and teaching modules on all QI training
programmes
What staff need to do



Submit ideas for quality
improvement to the Everyday
Lean Ideas page on the QI
website www.qit.sssft.nhs.uk
Access the training available,
either Leading Quality
Improvement (for managers and
clinicians) or First Steps in Quality
Improvement (for any member of
staff)
Support colleagues taking part in
improvement activities – attend
the RPIW report outs on Friday
afternoons
What teams need to do




Participate in improvement
activities, such as RPIWs and
Kaizen events
Lead your own improvement
activities within teams, using the
resources available from the QI
Team www.qit.sssft.nhs.uk
Discuss with managers your ideas
for improving the quality of
services
Support team members who are
leading their own quality
improvement projects
12
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
CQC’s Five Key Questions and Fundamental Standards9
The CQC is an independent regulatory body that makes sure hospitals, care homes,
dental and GP surgeries, and all other care services in England provide people with
safe, effective, compassionate and high-quality care. The CQC monitors and
inspects services against a standard framework, taking action where improvement is
needed. During an inspection the CQC will:





gather the views of people who use services and observe care
talk to managers and members of staff at all levels
check that the right systems and processes are in place
judge the quality and safety of service by asking five key questions of services;
are they safe? caring? effective? responsive? and well led?
look for evidence that the service at least meets the “fundamental standards” (the
minimum legal requirements shown in the diagram below)
Services will be rated as “Outstanding, Good, Requires Improvement or
Inadequate”. Inspection reports and performance ratings are published on their
website. If the CQC’s concerns are
not addressed within specified
timeframes this could result in
them suspending or cancelling
the provider’s registration,
therefore, not being able to
Safe
provide services.
Well-Led
Responsive
Fit and proper persons: directors
Person-centred care
Dignity and respect
Need for consent
Safe care and treatment
Safeguarding service users from abuse
and improper treatment
Meeting nutritional and hydration needs
Premises and equipment
Receiving and acting on complaints
Good governance
Staffing
Fit and proper persons employed
Duty of candour
Requirement to display a performance
assessment
Effective
Caring
Figure 3 - CQC's Fundamental Standards are embedded in the 5 key questions
9
Contact Sara.Reeve@sssft.nhs.uk for further information and visit our CQC intranet pages at:
http://nww.intranet.sssft.nhs.uk/The-Knowledge-Bank/Sections/Directorates-andServices/Performance/CQC-information.aspx
13
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our CQC compliance goals




By January 2016, all teams will be able to demonstrate, how their day to day
activities deliver on the CQC’s five key questions assessment framework and
that the associated fundamental standards are embedded in. (For example,
as part of routine discussions in team meetings structured around services
being safe, caring, effective, responsive and well led)
Throughout 2015 a continuing programme of team support in delivering this
target will be in place
Every month, there will be at least one detailed visit, jointly with governors,
focused on the Fundamental Standards. Teams will be fully engaged with this
process both as peer reviewers and as recipients of the findings of their own
reviews
Every month, our CQC intranet pages will be refreshed with any relevant
information staff need to help them comply with the requirements
What staff need to do




Understand the legal requirements
of the Fundamental standards
Discuss with your manager if you
are unclear
Raise any quality or compliance
concerns
Make suggestions for improving
quality
What teams need to do




Ask how do we know we provide
safe, caring, effective, responsive
and well led services? What
evidence can we use to prove
this?
Audit your own practice
Participate fully in a quality
standards visit
Invite members of another team to
visit your service and give honest
feedback
14
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Risk Strategy10
The Trust is committed to leading the organisation in the delivery of quality services
through the continual development and implementation of robust integrated
governance structures and processes. To achieve success in the delivery of quality
it is essential that governance themes, assurance and risk are aligned to the Trust’s
strategy and that its strategic objectives are delivered in a coherent way. Risk
management is a systematic approach to minimising exposure to risk by operating a
suite of risk management policies, procedures and practices that work in unison to
identify, analyse, evaluate, address and monitor risk. Our risk strategy lays out the
Trusts systematic approaches to risk management.
The risk management processes laid out within the risk strategy support the Trust in
achieving its strategic objectives whilst ensuring that the best use is made of public
funds. The processes are shown in the figure below:
Communicate and Consult
Establish
Context
Identify
Risks
Analyse
Risks
Evaluate
Risks
Objectives
What can
happen?
Review controls
Evaluate risks
Likelihood
Rank risks
Treat Risks
Identify options
Stakeholders
Criteria Define
key elements
How can it
happen?
Select best
responses
Consequence
Develop plan
Level of risk
Implement
Monitor and Review
Figure 4 - Our risk management framework
The purpose of the risk strategy is to create within the Trust a positive risk culture
that encourages staff consistently to use its risk management policies and
procedures and its Assurance Plan and Risk Register in order to:





10
Identify and control risks which may adversely the Trusts operations and
affect its statement of internal control
Compare risks with each other using consistent risk scoring and grading
Where possible, eliminate, transfer or reduce risks to an acceptable level
Otherwise ensure the Trust openly accepts the remaining risk
Ensure that issues and concerns raised by internal and external audit and
external assessment are addressed and resolved
Contact Liz.Lockett@sssft.nhs.uk
15
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our risk management and safety goals





In 2015, all directorates will assess their ‘risk appetite’ against the Board’s
self-assessment and will have agreed monitoring arrangements in place to
mitigate any escalated risks
There will be clear mitigation plans in place to address all environmental risks
identified within clinical areas
Using the NHS Safety Thermometer maintain “harm free care” above 95%
We will ensure Duty of Candour is effectively implemented
Work with our partners in primary care and other secondary care settings to
reduce harm
What staff need to do




Ensure that all risks are reported
and recorded within the team risk
register
Follow best practice guidelines
that promote “harm free care”
Report any incident you witness
(even if you are not sure of the
criteria) on the Trust’s web-based
system, Safeguard
When incidents do occur ensure
that the service user/carer is
offered an apology
What teams need to do



Review the team level risk register
on a monthly basis ensuring the
key controls are in place to
mitigate risk
Review the Safety Thermometer
data on a monthly basis and
consider what interventions can
be taken to achieve “harm free
care”
Review on a monthly basis any
incidents that triggered Duty of
Candour and share learning from
these incidents within the team
16
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Learning the Lessons Framework11
Following a Trust level self-assessment of safety culture using the Manchester
Patient Safety Framework (MaPSaF), a task group was set up to consider ways to
further improve learning from serious incidents which could be incorporated into a
learning framework alongside existing approaches. The figure below is a summary
of the framework that was approved by the Board in October 2014. It incorporates
both existing and new approaches the task group agreed to test out over the
following year. The processes involved in the existing elements of the central box
were also subject to improvements during a Rapid Process Improvement Workshop
(RPIW) in December 2014.
The following diagram shows the main opportunities for learning from incidents.
National evidence and benchmarking
(Board level learning)
A. Best
practice
benchmark
reviews
against
evidence,
including
national
reports
B. Annual
report/s on
SI's, including
data from all
embedded
activities
Themes from SI's and safety data
(QGC/Trust level learning)
D. Thematic
reviews,
supported by
literature
searches
E. Annual safety
culture
assessments
(MaPSaF)
Serious incident
investigations (directorate
level learning)
F. Cluster analyses
C. "Sign up for
Safety"
G. Trust-wide
"share & spread"
and other
learning events
H. Root
cause
analysis
(RCA)
I. Significant
event
analysis
(SEA)
J. Guided
team level
feedback and
SI
improvement
planning
K. Whole
team
Kaizen
events,
linked to QI
Figure 5 - Learning the Lessons Framework
11
Contact Theresa.Moyes@sssft.nhs.uk
17
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our ‘learning the lessons’ goals







We will publish a “Learning the Lessons” bulletin for staff at least four times a
year
We will participate in patient safety research in conjunction with our research
and development network
We will review our delivery against the “Sign Up for Safety” campaign
annually
We will use feedback from our service users and carers to continually develop
and improve services, using a range of sources including the Meridian patient
experience real-time feedback tool, feedback and learning from PALS and
complaints and the Service User and Carer Committee and its directorate and
divisional sub groups
We will continue to review our incidents identifying recurring themes and
share the learning through Thematic Reviews
We will share and spread the learning from improvement events via briefings,
e-bulletins and websites
We will improve team learning following a serious incident by using Significant
Event Reviews to investigate all Level 1 Serious Incidents
What staff need to do


Read the learning lessons bulletin
and implement relevant learning in
practice
Participate in team learning events
and share experience from
practice and ideas for improved
practice
What teams need to do


Review on a monthly basis
learning disseminated to the team
Review on a monthly basis
feedback received about the team
through PALS, service user and
carer feedback, incidents etc.
Identify any themes and take
steps to improve practice based
on the feedback received
18
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Clinical Strategy12
In February 2015, members of the senior leadership forum (SLF) used the Trust’s
overarching strategy to work collaboratively across clinical and corporate
directorates to agree what clinical strategy should include. Many ideas were
generated that have since been summarised into the ‘word cloud’13 below,
highlighting how tightly clinical strategy needs to be linked to our quality aim:
Figure 6 - Clinical strategy word cloud
It was agreed that each directorate will have its own clinical strategy that is tightly
linked to its business plan, and that all directorate clinical strategies will include (at
least) four common core themes:




Driving quality and performance improvement
Building better clinical leadership relationships
Responding to locally-driven needs
Taking our services into other markets where we can make a positive
difference
12
Contact Alison.Bussey@sssft.nhs.uk
A word cloud is an image composed of words in which the size of each word indicates its frequency
or importance
13
19
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our overarching clinical strategy goals
Each directorate level clinical strategy
will:
 Make clear how clinical experts
and experts by experience have
shaped the strategy
 Include clear linkages to Trust
values and strategic aims
 Reflect the work done by the SLF
in February 2015
 Make explicit links to relevant
national strategy, local health
economy priorities, new market
environments and contract
requirements
 Make use of recognised strategy
development tools and
processes
 Have bespoke, measurable,
goals linked to its supporting
directorate business plan
 Make explicit the links with
service specifications and be
based on evidence
What staff need to do
 Ask to see your directorate or
divisional clinical strategy and
business plans
 Raise questions with your
managers to help you understand
why and how goals have been
arrived at
 Ensure your personal objectives
set at your next appraisal link to
your directorate clinical strategy
Driving quality and
performance improvement
Building better clinical
leadership relationships
Clinical strategy
core elements
Responding to locallydriven needs
Taking our services into
other markets where we can
make a positive difference
Figure 7 - Core elements for all directorate level
clinical strategies
What teams need to do
 Discuss your directorate or
divisional clinical strategy and
business plan
 Agree and set team level
objectives in line with them
20
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Quality Accounts14
Our ‘Quality Accounts’ relate to our fourth strategic aim but are also an expression of
how we are working on our quality aim. They are our annual report to the public
about the quality of the services we deliver and an opportunity for us to offer up our
approach to quality for scrutiny, debate and reflection by the public. Some of the
content of the Quality Accounts is mandated by Monitor and/or by The NHS (Quality
Accounts) Amendment Regulations 2012, however other parts are determined
locally and shaped through the feedback we receive. Within the Quality Accounts
we are required to:





Provide a review of performance against the priorities for improvement as
identified in the previous year’s Quality Accounts
Set out our quality priorities for the forthcoming year
Provide a series of prescribed statements of assurance from the Trust Board
Provide a report on performance against a set of core indicators using data made
available by the national ‘Health and Social Care Information Centre’
Present an overview of the quality of care delivered by the
Trust against a number of local indicators as well as
performance against relevant indicators set out in Monitor’s
Risk Assessment Framework.
Links with ‘CQUINs’ and national standards
Each year we present a summary of our key quality improvement achievements and
challenges. We also set out our quality priorities for the year ahead, ensuring that we
maintain a balanced focus on the three key domains of quality: Safety; Effectiveness;
and Experience. Our quality priorities are chosen following a process of reviewing
current services, consultation with our key stakeholders and most importantly
through listening to the views of people who use our services. They are expected to
be aligned with our Commissioning for Quality and Innovation (CQUIN) schemes.
CQUINs provide an incentive framework, enabling commissioners to reward quality
by linking a proportion of our income to the achievement of quality improvement
goals. Some are nationally required and some are agreed in partnership with
commissioners. CQUINs could also be informed by assessment of our services
against NICE15 guidance or standards, which are derived from the best available
evidence and developed with professionals, service users and organisations. In our
accounts, we report on our participation in national quality accreditation schemes,
such as those organised by the Royal College of Psychiatrists, and national audits,
some of which are based on NICE guidance. Both these processes are ways for us
to receive independent feedback on how we meet accredited standards and offer
opportunities for us to understand how we can continue to improve.
14
Available on the Trust website. For more information, contact Liz.Lockett@sssft.nhs.uk
National Institute for Health and Care Excellence. See: http://www.nice.org.uk/article/pg1/chapter/2Using-NICE-guidance-and-related-quality-standards-in-provider-organisations
15
21
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
Our quality accounts goals
Each year:
 Our quality accounts will be accurate and transparent
 Our published quality priorities will be negotiated with partners and governors
 We will give accurate data about any improvements we have made and will
be honest when we fail to make intended improvements
 We will be able to demonstrate we have delivered on core indicators
 We will be able to demonstrate we have delivered on local indicators
 We will continue to work on making improvements and know how we can
measure these
 We will participate in all relevant national audits
 We will use clinical audit to understand how we meet NICE guidance and
standards
 We will participate in national quality accreditation schemes
What staff need to do





Understand and participate in
quality improvement activities,
including clinical audits, NICE
standards reviews, national quality
accreditation schemes and QI
activities (see p11-12)
Consider what the key quality
indicators mean to you in your role
and how you can have a direct
impact on improved outcomes for
service users and carers
Input anything you are required to
correctly on the clinical information
and other systems within 24 hours
Alert your manager whenever you
have difficulties in achieving this
Report any technical problems
that prevent you inputting data
with the health informatics service
(HIS) immediately
What teams need to do



Review all team level data about
national and local quality
indicators at least once a month to
ensure it is correct and that all
team members are inputting
everything they need to
Review the progress made
against the quality goals and the
positive impact this has on service
users and carers
Ensure that progress is being
made against any CQUIN or audit
you are contributing to
22
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams
CQC’s 5
questions.
Processes we use to
understand and improve
Measurements and feedback
we use to understand and
improve


Safety culture assessments
Learning from incidents
framework
Thematic reviews
Personalised risk
assessments and safety
plans
Environmental risk
assessment
Central Alerting System
(CAS)

National Institute for Health
and Care Excellence
(NICE) guideline
implementation
The outcomes framework
Care clustering
Clinical audit

Recovery strategy
Triangle of Care
Care planning
Involvement in lean/quality
improvement (QI)
processes
Service Users and Carers
Committee (SUaC) of the
Board
Directorate level
engagement groups

QI processes – such as
rapid process improvement
workshops (RPIWs),
Kaizens, 3Ps, everyday
lean ideas (ELIs)

Bespoke targets and actions
developed by teams
Commissioning for Quality
and Innovation (CQUIN)
schemes

Quarterly confirmation of
CQUIN target achievements
from commissioners
Are we:
Safe?




Effective?




Caring?






Responsive?

(This also links to
our third strategic
aim, “Innovate
through cooperation and co- 
production”)








Manchester Patient Safety
Framework (MaPSaF )
Statistical Process Control
(SPC) charts for incident
types by team/ward
Completed improvement
plans from serious incidents
(Sis)
Ward level incident
dashboards
Safer staffing benchmarking
Completed clinical audit
improvement plans
Prescribing observatory for
mental health (POMH)
audits
Meridian survey scores –
team level and Trust level
National community mental
health (CMH) survey
The Friends and Family
Test (FFT)
Feedback from experiences
of participating in QI
workstreams
23
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams



Clinical audit
SI’s
Complaints, compliments,
feedback via patient advice
and liaison services (PALS)
Service users’ and carers’
surveys
Quality visits (internal and
external)

Sign off of completed
improvement plans

QI processes and events

Bespoke measures
developed by teams

Quality Impact
Assessments (QIAs) of
Cost Improvement
Programmes (CIPs)

Risk ratings associated with
identified risks and delivery
of risk mitigation plans

Clinical Directors (CD’s) &
deputies
Professional leads
Lead clinicians for specific
projects and clinical audits
Process owners for QI
activities and workshops
Ideas generation from all
staff
Staff charter (and the “wills”
and “won’ts”)

Appraisals – achievement of
personal quality objectives
linked to strategy
Staff survey analysis
Care Quality Commission
(CQC) regulations, Mental
Health Act (MHA), Mental
Capacity Act (MCA) and
Deprivation of Liberty
Safeguards (DoLS)
Quality standards visits &
governor involvement
Quality Governance
Committee (QGC) and
related sub groups and
structures
Directorate level quality and
assurance groups
Policies and SOP’s
The assurance framework
Risk registers



Well led?
(This also links to
our fourth
strategic aim,
“Deliver
regulatory,
financial,
performance and
quality standards
- through robust
mechanisms of
assurance and
the liberation of
clinicians to
improve test and
enhance
services”)




















CQC inspection reports –
completion of any
improvement requirements
Quality accounts
Contract quality measures
and processes
Internal audits of various
processes
External audits of quality
accounts
CIP QIA executive
challenge sessions
Performance reviews
Use of Performance Plus
(P+)
Figure 8 - Quality processes and measurements
24
“Provide high quality recovery focused services” - Our first strategic aim: what it means for staff and teams