Quality
Framework
2013-2018
Supplemental
Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
Staffordshire and Stoke on Trent Partnership Trust
Quality Framework 2013-2018
Supplemental
Robin Sasaru, Quality Team Manager
Simon Kent, Quality Team Manager
Contents
1.
Drivers for quality ................................................................................................ 3
2.
Defining Quality ................................................................................................. 10
3.
Using the best approach for quality ................................................................... 13
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
1. Drivers for quality
While there are many national and regional drivers for quality, this section references
the drivers that relate primarily to the overarching Quality Framework. Strategies that
sit under this framework will make reference to the drivers for that particular area.
Quality is central to the Staffordshire and Stoke on Trent Partnership Trust
vision:
“We deliver personalised care of the highest quality, with the best possible outcomes
for users and carers, empowering them to remain independent”
Our values and goals run through the core of our Quality Framework ensuring that
quality care and safety is at the heart of everything we do for our people and their
families. We put quality first.
The Trust’s Strategic Organisational Goals:
we will provide high quality and safe services which provide an excellent
experience and best possible outcomes
we will work with partners, users and carers to deliver integrated services
simply and effectively
our organisation will develop and deliver sustainable innovative services that
support independence
our workforce will be empowered and supported to deliver care in a way that
is consistent with our values
we will make excellent use of our resources and improve levels of efficiency
across our services
The Trust’s Organisational Development Strategy contains three organisational
objectives that are aligned to quality:
Create a culture where individuals are empowered to fulfil their roles and
support the Trust’s vision.
Develop our leaders to be ambitious, innovative, empowered role models for
other staff.
Support the continuous improvement of the Partnership Trust so that it is
effective, efficient and delivers quality safe care that meets the needs of the
population it serves.
The Partnership Trust is determined to continue to be a beacon and leader of
enlightened Equality, Human Rights and Inclusion policies and practices in
Staffordshire. The trust’s three equality objectives are closely related to the quality
agenda.
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
The shared agendas of the Staffordshire Strategic Partnership outlines a
commitment from partner agencies with regard to ensuring that Staffordshire will be
a safe, healthy and aspirational place to live.
The NHS Next stage review (2009) led by Lord Darzi, published “high quality care
for all”. This document advocated that quality should be the prime focus and driving
force for the NHS over the next decade. It also provided a general definition of
quality under Safety, Effectiveness and Experience. “High quality care for all”
introduced a Quality Framework as the national strategy for quality improvement.
The Partnership Trust has already responded to this Quality Framework in its
2011/12 Quality Account.
Figure 3: The Quality Framework and the Partnership Trust response 1
Quality Framework: guidance for community services (2009) is best practice
guidance that sets the direction for implementing the national Quality Framework
within community services. The guidance describes evidence-based interventions,
which will help make every service as good as the best. Whilst they are designed
principally for front-line staff and clinical team leaders, commissioners will use them
to inform service specifications, and with the indicators in the Quality Framework,
1
Transforming Community Services: Quality Framework: Guidance for Community
Services, Department of Health, 24 Jun 2009. Access via
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalas
set/dh_101426.pdf
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
track improvement. Through the implementation of the framework the Partnership
Trust aims to:
improve people’s experience of health and social care
enables and drives a culture of continuous improvement
embed quality as the organising principle driving the Trust agenda
promote accountability across all stakeholders
Equity and Excellence: Liberating the NHS (2011) and the subsequent Health
and Social Care Act 2012 affirmed the desire to ensure that health services in
England “achieve quality and outcomes which are among the best in the world” and
identified a number of reforms that relate to the quality agenda, in particular:
Putting service users at the centre of care; “no decision about me without me”
Creation of an NHS outcomes framework which will span the three areas of
quality (Safety, Effectiveness, Experience)
Establishment of Local / National Healthwatch, Health and Wellbeing Boards,
Clinical Commissioning Groups and a National Commissioning board
Strengthening the roles of the Care Quality Commission, the National Institute
for Health and Clinical Excellence, and Monitor.
The NHS Outcomes Framework sets out the national outcome goals that the
Secretary of State for Health will use to monitor the progress of the NHS
Commissioning Board. The NHS Commissioning Board will commission the National
Institute for Health and Clinical Excellence (NICE) to develop Quality Standards
which will set out the evidence-based characteristics of a high quality service for a
particular clinical pathway or condition. These standards will, where appropriate, look
across several or all five domains of the NHS Outcomes Framework.
The framework recognises the importance of aligning outcomes for health and
social care, developing a shared accountability where appropriate. Further
alignment of outcomes is stated as desirable in future years, as a means of
encouraging collaboration and integration.
The Department of Health has also published Transparency in Outcomes: a
Framework for Quality in Adult Social Care. This framework is based on being
clear about what high quality looks like in adult social care, agreeing a data set which
supports councils and communities to understand progress and to hold their
organisations to account and making information on the quality of social care and
outcomes achieved available for the public, service users, carers, commissioners
and managers. There are three key elements in the framework:
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
1. The National Data Set for Adult Social Care – a single, agreed set of data
requirements which encompasses all routine social care information derived
from council sources. In the first year this will be made up of the existing
Referrals, Assessments and Packages of Care (RAP) data, Adult Social Care
Combined Activity Return (ASC-CAR) data, Abuse of Vulnerable Adults (AVA)
data and other data returns;
2. A set of outcome-focused measures of performance that will allow councils
and citizens to interpret the raw data and paint a picture of what social care is
achieving locally; and
3. A ‘Local Account’ – a self-assessed account of the quality and outcome
priorities which the council has chosen, in consultation with its partners, and
the progress it has made in achieving them during the past year.
The Vision for Social care (2010) and Think local act personal (2010)
emphasises a system that helps people to live their lives the way they want to,
supported by the staff who work with them. The approach aims to free the front line
from bureaucratic constraints and support local organisations to focus on the quality
of care and the outcomes achieved for people using services and their carers,
without the focus on targets. A particular example of this is the Making It Real2
(2012) key themes and criteria, based on a public commitment to improving quality in
social care. The key themes are based on “I” statements, which emphasise quality
as dependent on service user requirements.
The National Quality Board (NQB) is a multi-stakeholder board established to
champion quality and ensure alignment in quality throughout the NHS. The Board is
a key aspect of the work to deliver high quality care for service users. The NQB
2012 draft paper Maintaining and improving quality from April 20133 highlights
the nature and place for quality in a changing healthcare system, the different parts
of the system together with the corresponding roles, responsibilities and expected
values and behaviors to put service users and the public first.
The NQB 2010 Review of early warning systems in the NHS presents lessons to
be learned from investigation and review of NHS organisations (notably the Francis
Enquiry into Mid-Staffordshire NHS Foundation Trust) and makes clear that
safeguarding patients is the responsibility of every organisation and every member of
staff. In addition, a further report from a Public Inquiry is anticipated in early 2013 4
2
See http://www.thinklocalactpersonal.org.uk/
3
Quality in the New Health System Maintaining and improving quality from April 2013. A
draft report from the National Quality Board. 16th August 2012. Access via
https://www.wp.dh.gov.uk/publications/files/2012/08/Quality-in-the-new-system-maintainingand-improving-quality-from-April-2013-FINAL-2.pdf
4
www.midstaffspublicinquiry.com
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The Care Quality Commission (CQC) is the independent regulator of all health and
social care services in England. Its essential standards of quality and safety outline
the basic essential service quality that our organisation should always achieve.
There are numerous reports on the CQC website related to quality; high profile
cases such as the investigation into services at Cornwall Partnership NHS Trust, and
the closing of a care home in Haringey following inspection, present significant
learning opportunities for all care providers.
The Commissioning for Quality and Innovation (CQUIN) scheme is a key driver
to ensure Boards maintain a focus on the delivery of a quality service. The scheme
allows commissioners to retain a proportion of a Trust’s income. The Trust is
required to meet a series of pre-agreed quality markers to obtain that portion of the
funding, and this allows both parties to ensure quality is integrated into the
development and delivery of care.
The CQUIN system incentivises quality improvement and innovation over and above
that required within the commissioned service. At its best, the CQUIN scheme
should be much more than payment linked to meeting quality markers, it is intended
to be one of the ways to have shift in focus to a continuous improvement culture
amongst commissioners and providers and commissioning for quality. CQUIN
schemes represent an investment by commissioners in quality improvement and
innovation.
The National Patient Safety Agency (functions now transferred to the NHS
commissioning board) was set up in response to a recognition that the same things
go wrong again and again5. The agency set up a National Reporting and Learning
System, the world’s most comprehensive database of patient safety information, to
identify and tackle important patient safety issues at their root cause.
The Monitor Quality Governance Framework was introduced into the assessment
process for Foundation Trusts in 2010. A Quality Governance assessment is now
part of the Foundation Trust application process, and there is a requirement for the
Boards of both new and existing NHS Foundation Trusts to self-certify with regards
to quality governance. Monitor is looking for evidence that:
boards accurately understand the quality of the care their organisation provides
boards are able to assess and mitigate risks to quality
quality is seen as a responsibility of the entire board, not only the medical and
nursing directors
trusts are committed to continuous quality improvement, and have put in place
the tools to address poor performance
5
Organisation with a memory. Department of Health 2000
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Our Commissioners (Primarily the Clinical Commissioning Groups and the NHS
Commissioning board) each have priorities for quality improvement, which will
influence this framework’s supporting strategies and workstreams.
Perhaps most importantly, our service users are a key driver for quality:
it is predicted that there will be an increase in population age and health need
support for carers will become increasingly important
Involvement of service users and carers is essential for quality
Our evolving model for quality will learn from a local and national knowledge base,
taking into account any conclusions, recommendations and findings from reports
such as the Mid Staffordshire NHS Foundation Trust Public Inquiry, which is due to
be published in 2013, and the Care Quality Commission Winterbourne View report
(July 2011).
Figure 4: Other drivers and the strategies / policies that will reference them
Other drivers for quality
Patient Safety Function of the NHS
Commissioning Board (formerly National
Patient Safety Agency)
Commissioning for Quality and Innovation
NHS institute: (including productive series)
National Institute for Health and Clinical
Excellence
National Advisory Group on Clinical Audit &
Enquiries and the Healthcare Quality
Improvement Partnership
NHS constitution
Safety express
NHS Litigation Authority
Patient Environment Action Teams
Safety Thermometer
Customer Service Excellence
Equality Delivery System
Quality, Innovation, Productivity and
Prevention (QIPP)
Commissioning for Quality and Innovation
Payment Framework
Strategies / Policies that
will reference them
Risk Management
Risk Management
Transformation,
Effectiveness
Effectiveness
Clinical Audit
Safety, Effectiveness,
Experience, Transformation
Safety, Effectiveness,
Experience, Transformation
Safety, Effectiveness,
Experience, Transformation
Safety, Experience
Safety, Effectiveness
Experience
Effectiveness, Experience
Effectiveness, Experience,
Transformation
Effectiveness, Experience
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
Other drivers for quality
Making it real – Think local act personal
National Quality Board (e.g. “Review of early
warning systems in the NHS”)
Staffordshire & Stoke on Trent Adult
Safeguarding Interagency Adult Protection
Procedures
OFSTED and Joint Children and Young
Peoples Services inspections e.g. looked after
children and children with disabilities
inspections.
Independent Safeguarding Authority
Leading Improvement in Patient Safety (LIPS)
Starting Out: Common Induction standards
www.skillsforcare.org.uk
Professional body standards (e.g. Nursing and
Midwifery Council code of conduct)
National Institute for Health Research
NHS Operating Framework
The CARE campaign
www.thecarecampaign.co.uk
Being open: communicating patient safety
incidents with patients, their families and
carers
Health and Wellbeing Boards and
commissioners (CCGs)
Department of health Guidance for NHS trusts
on the NHS friends and family test
The Shipman Inquiry
The Bristol Inquiry
The Victoria Climbié inquiry
The safe and secure handling of medicines: a
team approach (Royal Pharmaceutical society
of Great Britain)
Patient and Public Involvement in Health: The
evidence for policy implementation
(Department of Health)
Patient Involvement and Public Accountability:
A report from the NHS future forum
Whistle blowing policy
Strategies / Policies that
will reference them
Effectiveness, Experience
Safety, Effectiveness,
Experience
Safety
Safety
Safety
Safety
Effectiveness
Safety, Effectiveness
Effectiveness
Safety, Effectiveness,
Experience
Safety
Safety
Safety, Effectiveness,
Experience
Experience
Safety
Safety, Effectiveness,
Experience
Safety
Safety, Effectiveness
Safety, Effectiveness,
Experience
Safety, Effectiveness,
Experience
Safety, Effectiveness,
Experience, Quality
Assurance Programme
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Staffordshire and Stoke on Trent Partnership NHS Trust Quality Framework Supplemental
2. Defining Quality
In order to clearly define a framework for quality, a clear and trust wide definition of
“quality” must be agreed that encompasses health and social care. This section aims
to pull some of the key health and social care descriptions of quality into one agreed
definition, on which the framework itself can build on.
The NHS has worked around a shared definition of quality set out by Lord Darzi6 with
three elements:
Safety: The first dimension of quality must be that we do no harm. This means
ensuring the environment is safe and clean, reducing avoidable harm such as
reducing the number of preventable pressure ulcers and reduced injury as a result of
a fall. It also means safeguarding vulnerable people from harm.
Experience: Quality of care includes quality of caring. This means providing
personalised care, treating people with compassion, dignity and respect. It can only
be improved by analysing and understanding service user’s satisfaction with their
own experiences.
Effectiveness: This means understanding success rates from different treatments
for different conditions. Assessing this will include clinical measures such as
mortality or survival rates, complication rates and measures of clinical improvement.
Just as important is the effectiveness of care from the service user’s own perspective
– for instance improvement in pain-free movement after an operation, or returning to
work after treatment. Effectiveness extends to people’s well-being and ability to live
independent lives, receiving personalised care through assessment and support
planning processes.
All three of these elements must be present at the same time to ensure high quality –
delivering on just one or two is not enough.
The Social Care Institute for Excellence (SCIE) describes excellence in social care:
“Excellence in social care is rooted in a whole-hearted commitment to human rights,
and a continuous practical application of that commitment in the way that people who
use services are supported. People who use services are demonstrably placed at
the heart of everything that an excellent service does.” (A definition of excellence for
regulated adult social care services in England, SCIE 2010)
6
High Quality Care for all: NHS next stage review final report. Department of Health June 2008.
Access via
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0
85825
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SCIE identifies four essential elements of excellence in social care:
having choice and control over day-to-day and significant life decisions
maintaining good relationships with family, partners, friends, staff and others
spending time purposefully and enjoyably doing things that bring them
pleasure and meaning.
the organisational and service factors which enable the above three outcomebased elements to be achieved and sustained.
SCIE differentiates between Essential (i.e. “good enough”) and Excellent services,
and describes how focussing on outcomes for the individual and attempting to
enable individuals to have the greatest possible control over their own life, means
that the service will be doing an excellent job.
Standardisation is a recognised way to quality in many industries. It is important
that the need for standardised processes and consistency of approach based on
evidence and best practice in care is not omitted in order to emphasise the need for
flexible and patient centred services. These are two sides of the same coin.
Quality is everyone’s business. It is not the responsibility of any one part of the
system, it is a collective endeavour. Quality requires collaboration at every level of
health and social care. It includes working together for a common purpose,
appreciating each others contribution.
Our ultimate aim is to improve outcomes for our service users. Even in health and
social care, services that are evidence-informed, highly skilled and sometimes
technically complex, an underlying principle that only the customer can define
quality drives many definitions of this term. Service users expect high quality service
in line with best practice, and monitoring this requires objective and measurable
standards.
There are many phrases that people think of when considering the definition of
“quality”:
Right people at the right time
Getting it right first time
With realistic expectations
Getting the right services for them based on sound clinical evidence
Goal based, personalised and planned with the consent and involvement of
service user
Delivered consistently by experienced skilled competent caring and motivated
staff
Sufficiently flexible to responding to changing need.
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Care delivered in the best place (e.g. at home or as close to home as possible
whilst ensuring safety and effectiveness)
Using the most appropriate medication and equipment
Cost effective
Leading to the best possible outcomes
With minimum risk of adverse outcomes
Problems, issues, incidents and concerns are recognised and addressed as
they arise, lessons are learned and changes made to improve services and
reduce risk of recurrences
Safe discharge from services
Effective and appropriate ongoing or long term support services where
needed
Minimising for as long as possible the need for more intensive services
Maximising ability to care for oneself and enjoy activities of daily living for as
long as possible
Minimising the risk of future unplanned or emergency services
care that people approaching the end of life receive is aligned to their needs
and preferences
While there may be different definitions and descriptions of quality, everyone in our
trust should have the same understanding of quality. Our view of quality uses Safety,
Effectiveness and Experience as a common starting point. We recognise that
minimum levels of quality in these areas require a swift response, and that a culture
of continuous improvement means that our minimum levels of quality will constantly
increase.
In summary, quality refers to our service user and carer requirements; expressed in
terms of safety, effectiveness, and experience; and ultimately focussed on
outcomes. We therefore subscribe to the definition put forth by Darzi as follows:
High quality care is where; service users are in control,
have effective access to treatment or care, are safe, and
where illnesses are not just treated, but prevented.
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3. Using the best approach for
quality
Using the underlying simple principles7 from a variety of methodologies, our
approach to Quality includes a focus on:
understanding the problem with a particular emphasis on what the data says
understanding the processes and systems within the organisation –
particularly the service user pathway and whether these can be simplified
analysing the demand, capacity and flows of the service
choosing the tools to bring about change, including leadership and clinical
engagement, plus staff and service user participation
evaluating and measuring the impact of a change
While there are many approaches to quality improvement, across healthcare, social
care, and industry, they are often based on similar principles and a common body of
tools for improvement. Drawing on work by the NHS Institute for Innovation and
Improvement8, our common approach to quality improvement is:
define quality first
identify the process
beware of the exclusive promotion of one approach to quality improvement
think about who the “customer” is
understand the people – the individuals working in the system and their
behaviours
get data about quality before you start
recognise the importance of whole system leadership
Our approach to quality includes individual behaviours as well as improvement of
systems and processes.
We also recognise the need to involve service users in quality assurance and quality
improvement.
7
Quality Improvement Made Simple: Identify, Innovate, Demonstrate, Encourage.
The Health Foundation - Inspiring Improvement. 6th September 2010. Access via
http://www.health.org.uk/public/cms/75/76/313/594/Quality_improvement_made_sim
ple.pdf?realName=uDCzzh.pdf
8
Quality Improvement: Theory and practice in healthcare. NHS institute for innovation and
improvement. Access via
http://www.institute.nhs.uk/index.php?option=com_joomcart&main_page=document_product_info&pr
oducts_id=403&cPath=67
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There are clear synergies between the approaches outlined above and the
organisation’s social care Quality Framework:
Figure 5: social care Quality Framework diagram
Only the customer can define quality; learn what is important to customers
Define and refine standards
Measure how well we are meeting these standards
Take action to address unmet standards
Monitor customer satisfaction
Continuous quality improvement is a philosophy that intends that most things can be
improved and is the scientific method of improvement in everyday work. Plan-dostudy-act cycles and quality circles are examples of techniques that embrace this
philosophy of quality as a journey not a destination.
In line with the overall direction of the framework, it is important to support, develop
and share local team based improvement initiatives. This highlights the importance
of developing a culture supporting the testing of quality improvement initiatives at a
local level.
Staff and service users are the best source of information about quality of services.
This means that the organisation must always acknowledge of the role of staff and
service users, and respond to concerns and suggestions.
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