Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services

Tags: NHS Highland, NHS board, arrangements, clinical governance, operational unit, effectiveness, assessment, audit committee, clinical governance committee, NHS QIS, operational units, organisation, Local Report, performance assessment, risk management, clinical governance and risk management, management team, performance, business continuity plan, emergency plans, Board committees, Scottish Environmental Protection Agency, clinical effectiveness, clinical director, business continuity, Raigmore Hospital, quality improvement, Scotland NHS National Services Scotland Scottish Government Health Directorates, NHS boards, NHS Quality Improvement Scotland, Background NHS Quality Improvement Scotland, performance management, Equality and diversity, service improvement, peer review, Audit Scotland, governance committee
Content: NHS Highland Local Report ~ June 2010 Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services
NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity Impact Assessment, please see our website (www.nhshealthquality.org). The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer. © NHS Quality Improvement Scotland 2010 First published June 2010 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. Information contained in this report has been supplied by NHS boards/NHS organisations, or taken from current NHS board/NHS organisation sources, unless otherwise stated, and is believed to be reliable on publication. www.nhshealthquality.org = Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 2
Contents
1 Setting the scene
4
2 Summary of findings
6
3 Detailed findings against the standards
8
Appendix 1 ­ Glossary of abbreviations
25
Appendix 2 ­ Review process
26
Appendix 3 ­ Details of review visit
27
Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 3
1 Setting the scene This report presents the findings from the clinical governance and risk management (CGRM) peer review to NHS Highland. This review visit took place on 11 March 2010, and details of the visit, including membership of the review team, can be found in Appendix 3. Further information about the local NHS system can be accessed via the website of NHS Highland (www.nhshighland.scot.nhs.uk). Background NHS Quality Improvement Scotland (NHS QIS) was set up by the Scottish Parliament in 2003 and leads the use of knowledge to promote improvement in the quality of healthcare for the people of Scotland and performs three key functions: providing advice and guidance on effective clinical practice, including setting standards; driving and supporting implementation of improvements in quality; and assessing the performance of the NHS, reporting and publishing the findings. In addition, it also has central responsibility for patient safety and clinical governance across NHSScotland. The National Standards for Clinical Governance & Risk Management: Achieving Safe, Effective, Patient-focused Care and Services were published in October 2005. These standards are being used to assess the quality of services provided by NHSScotland. The national standards for clinical governance and risk management were first reviewed during 2006­2007. Peer review visits to all NHS boards in Scotland were conducted between May 2006 and May 2007 to assess performance against the standards. Local reports for each NHS board were published during the review cycle and a national overview of the key findings and recommendations was published in October 2007. NHS QIS has subsequently agreed with the Scottish Government that it will review the national standards for clinical governance and risk management at a strategic level, in each NHS board, every 3 years. Review process The review process has three key phases: preparation prior to the performance assessment review, the review visit, and report production and publication following the visit. (See flow chart in Appendix 2 for further detail.) A quality improvement tool is used by each review team to assess performance against the standards. The quality improvement tool enables the review team to assess how an NHS board is achieving each standard through the cycle of development, implementation, monitoring and reviewing. These four key stages represent the continuous improvement cycle through which each NHS board can ensure that all patients receive safe, effective, patient-focused care and services. The most appropriate performance assessment statement is agreed by the review team to describe an NHS board's current position against each core area. This allows an overall performance assessment statement to be arrived at for each of the standards, which indicates the NHS board's level of achievement for each standard. The agreed overall performance assessment statement for each standard will be added together for each NHS board and this information will feed into the NHSScotland health, efficiency, access and treatment (HEAT) targets, set by Ministers, in June 2010. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 4
Each review team is led by an experienced reviewer, who is responsible for guiding the team and ensuring that team members are in agreement about the assessment reached. Links with other organisations Clinical governance and risk management is part of a shared agenda. During this review process, we have focused on working more effectively in partnership with the following organisations that monitor other aspects of healthcare in order to inform the assessment process: Audit Scotland Chief Scientist Office NHS Education for Scotland NHS National Services Scotland Scottish Government Health Directorates, and Scottish Health Council. We have agreed that the following areas will not be reviewed by NHS QIS as they are already being reviewed as follows: Criterion 1c.5: Scottish Health Council (patient focus and public involvement assessment) Criterion 3a.2: Scottish Health Council (patient focus and public involvement assessment) Criterion 3a.5: Chief Scientist Office (research governance assessment) Core area 3e: NHS National Services Scotland (information governance assessment) We have also agreed an operational protocol with Audit Scotland which sets out broad principles for collaborative working, primarily between NHS QIS and Audit Scotland, covering issues such as the sharing of information, communication and liaison, and avoiding the duplication of work which relates specifically to Audit Scotland's national reporting. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 5
2 Summary of findings A summary of the findings, including strengths and recommendations, from the review is illustrated in this section. Overall performance is rated using the four assessment categories. The most appropriate category is agreed by the review team to describe the NHS board's current position against each core area ­ indicated by the shaded areas below. A detailed description of performance against the standards is included in Section 3.
CGRM standards
Development
Assessment category Implementation Monitoring
Standard 1: Safe and effective care and services
Core area 1a
Core area 1b
Core area 1c
Standard 2: The health, wellbeing and care experience
Core area 2a
Core area 2b
Core area 2c
Standard 3: Assurance and accountability
Core area 3a
Core area 3b
Core area 3c
Core area 3d
Reviewing
Strengths The NHS board has: embedded the culture of quality improvement across the organisation, particularly in the areas of clinical governance, fitness to practise and performance management. developed clearly devolved systems and governance arrangements at operational level to ensure local solutions are established specific to local needs.
Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 6
Recommendations The NHS board to: demonstrate that there is cross system learning from the good practice activity under way in operational units, particularly within clinical effectiveness. ensure there is a documented, planned and systematic approach to evaluation demonstrating that the changes made to governance arrangements are as a result of a coordinated review of current arrangements. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 7
3 Detailed findings against the standards Standard 1: Safe and effective care and services Standard statement Care and services are safe, effective, and evidence-based. Overall performance assessment statement: The NHS board is monitoring the effectiveness of its arrangements to control risk, continually monitor care and services and work in partnership with staff, patients and members of the public. Core area: 1(a) Risk management Performance assessment statement: The NHS board is monitoring the effectiveness of its risk management arrangements across the organisation. NHS Highland has robustly implemented its arrangements for risk management and is monitoring how effective these are across the organisation. The risk management policy, first published in 2005, is regularly updated and provides a framework to assist staff to reduce and control risks across the organisation. The risk management steering group takes the lead role in providing reassurance to the Board that systems, processes and procedures relating to risk management are operating effectively. It is responsible for the development and implementation of both the risk management policy and the corporate risk register, reporting annually on its effectiveness to the audit committee and the Board. NHS Highland is made up of four community health partnerships (CHPs) and Raigmore Hospital, Inverness, referred to as operational units, which each have local clinical governance and risk management groups. These groups have responsibility for operational delivery of risk management. Their remit is to ensure that risk management procedures are followed across the operational unit and oversee the development of local risk registers and action plans. Each of the clinical governance and risk management groups has a named link person within the clinical governance support team to ensure co-ordination and information sharing across the organisation. The corporate risk register forms NHS Highland's risk management framework, containing risks that have been assessed as being threats or potential threats to the achievement of the NHS board's objectives. The risk management steering group reviews the corporate risk register on a quarterly basis. Risks are allocated a specific review date of 3 or 6 months depending on the risk rating. Operational risk registers exist for each operational unit and are reviewed on a regular basis. Risk can be escalated using the risk escalation policy. All risks are accompanied by action plans that are regularly monitored and reported on. The review team noted that NHS Highland's internal audit programme includes a number of reviews of the effectiveness of the governance arrangements, including risk management. For example, the 2008­2009 review of primary care dental clinical governance arrangements identified that not all risks on the risk register had been assigned a risk owner, rating or action plan. This audit programme ensured that the risk register was Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 8
updated and is now monitored regularly by the dental clinical governance and risk management group to ensure continued progression. It was also noted that the corporate team hosted a risk workshop to undertake a high level, detailed review of the risk management arrangements. This workshop was attended by members of the Board and a range of individuals from across the organisation with a responsibility for risk. The NHS board stated that a key focus was to highlight what was considered important for embedding risk management. This included linking strategic risk management objectives to recently agreed corporate objectives of the organisation. In terms of health and safety, the NHS board's health and safety committee meets quarterly and is jointly chaired by the chief operating officer and the full-time staff-side health and safety representative. A health and safety policy has been fully rolled out and contains details on communication and consultation processes. This is supported by action plans to ensure progress in specific areas, such as work related stress and violence and aggression. The NHS board has benchmarked its performance against the Health and Safety Executive's `Corporate Health & Safety Performance Index for the Public Sector' and has now embarked upon an improvement programme. This includes progressing with a revised health and safety policy and implementation strategy and implementing newly purchased performance monitoring and audit software. It was clear that risk management is well embedded at the operational level and the wide availability of training was also noted. The review team was also pleased to note the increased levels of governance in place at local levels across the NHS board. The organisation should ensure that changes are made to systems over a sustained period of time based on systematic and documented evaluations, evidencing that all aspects of the risk management arrangements have been considered. This will then ensure that NHS Highland is well placed to demonstrate a position of a self-sustaining cycle of review and continuous improvement. Core area: 1(b) Emergency and continuity planning Performance assessment statement: The NHS board is implementing its emergency and continuity planning arrangements across the organisation. NHS Highland has strong emergency planning arrangements in place that are subject to robust monitoring and evaluation. There is an overarching major incident and emergency plan for the organisation, supported by a suite of major incident plans in place at each receiving hospital. These plans are routinely tested through annual exercises and responses to live incidents, with changes made as required. The NHS board is building on its experiences in emergency planning to complete implementation of comprehensive arrangements for business continuity. All hospital sites have service continuity plans in place and a contingency planning format that is standardised across all hospitals and CHPs. The NHS Highland emergency planning and service continuity group is the strategic forum that has a role to shape and inform the NHS board's emergency and business continuity agenda in line with the obligations of the Civil Contingencies Act 2004. The group meets on a quarterly basis, chaired by the chief operating officer and attended by a wide range of staff from across the organisation. This includes representatives from each of the CHPs, the head of communications, the head of facilities management, and head of public engagement. The group reports to the NHS board's risk management steering group. At each meeting, individual operational units provide an update on activity within Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 9
their area, including details of planned live and table top exercises, the outcome of any exercises and any incident that has occurred. The group considers any evaluation reports together with issues and recommendations that arise and actions them as appropriate to the general manager or head of services. NHS Highland is a member of the Highlands and Islands strategic co-ordinating group and the Strathclyde emergencies co-ordination group. These are multi-agency groups with representatives from all emergency services, local authorities, Scottish Water, Scottish and Southern Energy and the Scottish Environmental Protection Agency. There is also a Highlands and Islands emergency planning group that has representation from partner organisations and is a tactical group that meets on a quarterly basis. The role of the group is to continue to promote the integration of emergency planning procedures across its membership and share the results of experiences/lessons learned from training, exercises and actual incidents across the Highlands and Islands. The roles and responsibilities of partner organisations are detailed within the NHS Highland major incident and major emergencies plan, alongside details of the multi-agency response to specific incidents such as the handling of radiation casualties, chemical incidents and subsequent decontamination procedures. Emergency plans are subject to an annual review and each operational unit undertakes an exercise annually to test plans. It was also stated that plans are reviewed to take account of any changes in risks or learning points from operational experience or exercising. All agreed emergency plans are posted on the intranet and made available to staff. In the event of a live incident, plans are in place in relation to media management with a system of on-call communications officers to ensure a professional open and honest approach to the media. Arrangements are also in place for the dissemination of public health information following liaison and consultation between the communications manager and director of public health. This includes plans on how to communicate with a diverse range of groups and ensures a consistent message is passed to the public. The review team noted that the NHS board has a business continuity management plan that was approved by the emergency planning and service continuity group in March 2010. This, supported by a business continuity plan, also approved in March 2010, builds on the previous plans that were in place across the NHS board area. The NHS board has appointed a business continuity manager to provide specialist knowledge and expertise in this area. This post will work to ensure continued progression in standardising the business continuity plans across the organisations and incorporating the results of the business impact analysis to these. The review team encourages the continued development of arrangements for business continuity management, ensuring decisions are signed off by key committees and the Board. The NHS board should ensure that there is a process in place to demonstrate a coordinated and documented approach to considering the effectiveness of arrangements for both emergency and business continuity planning, thereby evidencing a continuous cycle of review and improvement. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 10
Core area: 1(c) Clinical effectiveness and quality improvement Performance assessment statement: The NHS board is monitoring the effectiveness of its arrangements for clinical effectiveness and quality improvement across the organisation. NHS Highland has robust arrangements in place for ensuring clinical effectiveness across the NHS board area and these are subject to regular monitoring and evaluation. Clinical effectiveness activity is closely linked to the clinical governance arrangements with the clinical governance committee taking a lead role in overseeing the development, implementation and evaluation of both clinical effectiveness and clinical governance. The clinical effectiveness strategy was updated following consultation and resubmitted to the clinical governance committee for approval in August 2009. The strategy affirms NHS Highland's commitment to providing services in a safe, evidence based and patient focused way, outlining key responsibilities of committees and groups in taking the agenda forward. The NHS board reported that direct health services was responsible for the operational management of NHS Highland, including overseeing the arrangements for clinical effectiveness. However, it was also reported that the organisation is currently in a transition period allocating responsibilities to the newly established Highland operational group and the clinical governance forum, following a recently completed review of decision-making and accountability arrangements across NHS Highland. The role of the clinical governance forum is to manage the development and implementation of the clinical effectiveness activity across NHS Highland, paying specific attention to co-ordinating the activity under way in each of the operational units. The operational unit's clinical governance and risk management groups have a specific responsibility to develop a local programme of multidisciplinary clinical effectiveness activity including clinical audit, patient feedback and service evaluation based on local and national priorities and the local delivery plan. They also have a remit to review the outcome of clinical effectiveness activities and ensure recommendations are taken forward, resulting in improvements to services delivered and patient care and that good practice is shared across NHS Highland. It was reported that the clinical effectiveness strategy is supported by the annual clinical effectiveness work programme. This programme is based on national and local priorities and is subject to a prioritisation process from the clinical effectiveness team. There is a central log of all projects approved by the operational unit's clinical governance committee and/or clinical governance forum. This log is used by the clinical effectiveness team to allow improved monitoring of project work for example by priority, geographical area and professional grouping for example, allowing targeting of effort by the clinical effectiveness team. The prioritisation schedule for the clinical effectiveness team is reviewed on an annual basis and agreed by the clinical governance forum. The NHS board stated that the clinical effectiveness team also emphasises the importance of using information gained to support service delivery improvements, which has led to redesigning of documentation. Each project is required to have an enquiry form, project proposal form and action plans completed after the project that state how the necessary changes will be implemented and monitored. Training has also been developed to support this approach. The NHS board reported that the service improvement group has identified the top 10 priorities for service improvement based on national programmes and priorities. This includes the three national improvement programmes: 18 weeks referral to treatment programme, long term conditions collaborative programme and the mental health collaborative programme. The services improvement group leads and co-ordinates these Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 11
programmes and is a formal subgroup of the corporate team chaired by the chief operating officer. There are various local projects under way that are directed by this group and closely linked to the clinical governance and risk management annual work programme. NHS Highland has empowered its staff to contribute fully to the clinical effectiveness work programme. Operational units have protected learning time or half days for audit purposes on a monthly basis. This involves GP practices closing for an afternoon to allow staff to be free from clinical duties to attend development, training and education sessions in line with a locally developed protected learning time programme, based on locally identified needs. Within Raigmore Hospital the half days allow the directorates to have dedicated time to undertake audit and review practice. For example, within the medical directorate, there has been a proactive plan of audit based on local priority areas of morbidity and mortality. Results of evaluations and the necessary actions are built into the clinical governance and risk management work programme and monitored by the clinical governance forum. The review team considered the nursing and midwifery record-keeping and care planning audit to be a good example of staff empowerment driving the agenda for clinical effectiveness from the bottom up. This audit aimed to improve the standards of record-keeping across NHS Highland's nursing and midwifery team. The audit has been improved year on year and has now led to the development of a tool to be rolled out into other areas of the organisation such as occupational therapy, nutrition and dietetics and physiotherapy. The review team was pleased to note the quality and patient safety framework which was drafted by the NHS board in advance of the Scottish Government publication of the national quality strategy. NHS Highland has undertaken significant work over the last year to redefine its aims, objectives and vision for patients and communities to provide `quality care to every patient, every day'. This vision has informed the draft quality and patient safety framework that is based on three key areas: patient safety; patient experience; and clinical effectiveness, which includes clinical outcomes, audit and service evaluation. This will be supported by a clinical dashboard that is currently in development. At the time of the visit, it was reported that the framework and dashboard had been considered by a number of key groups including the clinical governance committee, clinical governance forum, Scottish Patient Safety Programme senior leadership group, area nursing and midwifery advisory committee and maternity services committee and was due for approval at the next Board meeting. It is clear that NHS Highland has a robust approach to continually evaluating the services it provides and that there is a high level of clinical effectiveness and quality improvement activity under way across the organisation. It has demonstrated a series of projects that will continue to contribute to improving the services that NHS Highland provides. The review team encourages the NHS board to demonstrate that evaluations are conducted in a planned and co-ordinated way across the organisation. This will demonstrate that changes are made to the arrangements as a result of a systematic approach which then re-enter the cycle of continuous improvement and evaluation. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 12
Standard 2: The health, wellbeing and care experience Standard statement Care and services are provided in partnership with patients, carers and the public, treating them with dignity and respect at all times, and taking into account individual needs, preferences and choices. Overall performance assessment statement: The NHS board is monitoring the effectiveness of its arrangements to provide services that take into account individual needs, preferences and choices. Core area: 2(a) Access, referral, treatment and discharge Performance assessment statement: The NHS board is monitoring the effectiveness of its arrangements with a partnership approach to access, referral, treatment and discharge across the organisation. NHS Highland has fully implemented systems for access, referral, treatment and discharge across the NHS board area and is now monitoring their effectiveness. There are wellestablished partnership working arrangements in operation with a range of stakeholders, including two single outcome agreements that have been in place for the last 2 years. The review team was pleased to note the level of evaluation activity under way across the organisation within the operational units, allowing it to deliver local solutions to local issues. There are various policies in place across the NHS board to support access to services and provide patients, carers and the public with the necessary information to inform its decisions. A patient information policy was approved in 2007 which provides advice on developing and producing new patient information as well as detailing why people need information about health and healthcare interventions. The policy has recently been subject to a consultation and evaluation exercise which has led to some amendments. These include changing the title to written information for patients' policy and further encouragement for staff to use high quality information available from charities and support groups. NHS Highland accessibility guidance has been recently approved. This provides information about improving accessibility for all patients, carers and communities making contact with the NHS board. It has been developed to ensure that staff have the knowledge and resources to provide sensitive services that recognise and respond to individual needs. The NHS board has also appointed an accessibility information officer to develop easy read leaflets and ensure that appropriate information is available in an accessible format for people with learning disabilities. At the time of the visit, NHS Highland had two joint access and discharge policies in place to cover the Highland Council and the Argyll and Bute Council areas. The review team noted the joint review under way within the Argyll and Bute CHP, with Argyll and Bute Council, focused on managing delayed discharges. This review has led to the creation of a new joint admission, transfer and discharge policy to be implemented in both council areas. The review team was pleased to note that the joint policy was nearing finalisation and formal sign-off prior to its implementation and encourages continued progress with this. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 13
The joint leadership and performance group oversees partnership working between NHS Highland and Highland Council. Its remit includes providing a forum for leadership and direction as well as scrutinising the effectiveness and performance of the arrangements. One of the main points of focus of the group is to monitor the community care balanced scorecard to ensure the organisations are performing against the targets and ensure good outcomes across a range of joint working agreements. This balanced scorecard has been developed to incorporate a range of Health, Efficiency, Access and Treatment (HEAT) and single outcome agreement targets. There are similar scorecards in place within CHPs to allow local monitoring of performance benchmarking across the region and tracking of achievements. There are similar arrangements in place within Argyll and Bute with the Argyll and Bute health care strategic partnership that provides a forum to co-ordinate strategic working between the Local Authority and the NHS board. This partnership manages all issues relating to joint service planning, service design and integration of services and is regularly monitored by the NHS board. In addition to the activity under way to monitor the effectiveness of the joint working arrangements, the NHS board is taking forward an integrated approach to the three national improvement programmes. This requires NHS Highland to consider how effective its arrangements for access, referral, treatment and discharge are. As part of the 18 week referral to treatment collaborative, NHS Highland has focused on redesigning patient pathways for high volume surgical procedures, managing referral and improving patient focused booking. Within the long term conditions collaborative, there has been a significant volume of work carried out on anticipatory care, particularly with regards to the roll-out of anticipatory care patient alert forms. In terms of the `mental health collaborative, there has been a major service improvement in developing an under70s service in Raigmore Hospital, which offers services to younger people with possible dementia. The NHS board reported that diagnoses are more complex in this age range and the creation of this service has made the process substantially quicker and smoother. Each of the three collaborative programmes has a steering group that guides the various projects and regularly reports to the NHS board's service improvement group. The service improvement group provides strategic direction, co-ordination and regularly evaluates the effectiveness of the projects on service delivery and subsequently reports to the Board. NHS Highland has demonstrated that it regularly considers its performance across access, referral, treatment and discharge, particularly through its commitment to national improvement programmes. It has developed performance management mechanisms to ensure that there can be continual monitoring of performance against key targets and outcomes, and has devolved these to local operational units where possible. The review team encourages the NHS board to continue to develop a whole system approach to evaluation, thereby allowing the organisation to demonstrate a systematic cycle of continuous review and improvement across the whole of NHS Highland. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 14
Core area: 2(b) Equality and diversity Performance assessment statement: The NHS board is implementing its arrangements for equality and diversity in accordance with legislation, national guidance and best practice across the organisation. NHS Highland is in the process of implementing robust arrangements for equality and diversity across the organisation. It was reported that the NHS board's overarching approach is to mainstream equality and diversity across its functions, working closely with community groups to share and align priorities. The NHS board has equality schemes in place for race, disability and gender that are reviewed on an annual basis in line with legislative requirements. The NHS board reported that while there are no policies in place specifically in relation to age, faith, or sexual orientation, they are incorporated into the work programmes and included in the NHS board's equality and diversity impact assessment (EQIA) processes. It was noted that the process of establishing a single equality scheme, that will cover all six strands of Fair for All as well as poverty/deprivation, social origin and other aspects that may make an individual vulnerable to health inequalities, was under way at the time of the visit. There is an NHS Highland equality and diversity steering group that prioritises strategic and policy work, as well as providing operational guidance across the NHS board. The group reports annually on progress to the Board. The NHS board also works with its community planning partners across Highland and Argyll and Bute to lead the Highland community planning partnership equality group. This group develops an annual work programme based on priorities identified through consultation with equalities groups as well as reflecting the single outcome agreement priorities. The community planning equalities group is reported to have had continuous engagement with equalities groups over several years and contracted independent consultants in 2007­2008 to survey the mechanisms in place for involving community and user groups. This supported a review of involvement within the partnership equality and diversity work programme. Feedback is given regularly to communities and groups consulted, through community engagement events, newsletters and attending community meetings. The EQIA toolkit used in NHS Highland has been widely rolled out and covers all six strands of Fair for All. Guidance on completing impact assessments is reviewed on an annual basis and amended as required. All new policies are required to be assessed for impact prior to approval by the Board. Training on completing EQIAs has been widely rolled out and specific guidance issued for staff who write Board papers. It was noted that completed impact assessments are published on the internet. There is a wide variety of information on equality and diversity available to staff within NHS Highland. Staff are encouraged to be involved in the development of equality schemes and identify areas where organisational change is required. It was reported that approximately 1,400 staff have attended face to face training on equality and diversity and several hundred have completed an e-learning course entitled `Same Difference'; the review team commends this progress. There is a specific equalities and diversity section on the intranet that hosts information available for download to support staff in working with patients. It also includes contact details for further information and advice. Furthermore, the NHS board has circulated guidance to provide practical pointers to staff to support the identification and response to individual needs. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 15
NHS Highland reported that after participating in the NHS Health Scotland equality and diversity benchmarking exercise in 2008­2009, it identified a need to establish an internal performance assessment tool. At the time of the visit, this tool was being rolled out across the organisation, allowing for robust data gathering which will in turn support the NHS board to monitor its effectiveness in equality and diversity. The review team noted the equality and diversity action plan which provides a framework for operational monitoring and noted that progress as at February 2010 was to start analysing the data going forward. It was also noted that in the February 2010 meeting of the equality and diversity steering group, a paper was presented outlining the intended approach to evaluating the effectiveness of equality and diversity arrangements and developing an improvement plan. At the time of the visit, the organisation demonstrated it was in the process of completing stage three of this approach; assessing the data gathered. The review team encourages the NHS board to continue to progress with the remaining four stages outlined in this paper which will culminate in an improvement plan, thereby demonstrating existing arrangements have been evaluated to allow for improvements to be made to the systems in place. The review team also encourages the NHS board to incorporate robust evaluation mechanisms into the single equality scheme to ensure the organisation can demonstrate a proactive and systematic approach to evaluation, review and continuous cycle of improvement. Core area: 2(c) Communication Performance assessment statement: The NHS board is monitoring the effectiveness of its arrangements for improving the way that staff communicate and engage with each other, patients and the public across the organisation NHS Highland has evaluated its communication strategy for 2006­2009 and, at the time of the review visit, was in the process of ratifying a new communication framework for the period 2010­2012. Both the draft framework for communication and the existing communication strategy cover internal and external communication and are supported by communication action plans. The action plan for the existing strategy addressed the action required, timescales for completion and progress and success measures. Progress has been monitored predominantly by the communication subgroup and by way of reports to the staff governance committee and the Board. A review of the action plan confirmed that the majority of the actions had been completed. This was then replaced by the changing for the better communication and engagement plan. The changing for the better communication and engagement plan is being used to support the NHS board in implementing and achieving its re-defined strategic aim to provide `quality care to every patient, every day' to deliver better health, better care and better value. This detailed action plan includes preparing presentations, an easy guide to changing for the better, changing the format of Board papers to reflect corporate objectives, updating training materials and organising workshops. Progress against this plan is reported to the Board in the chief executive's monthly report. In order to develop the new communications framework, the NHS board has undertaken a number of evaluative pieces of work including a Board strategy day and various consultations. At the Board strategy day, it was agreed that to meet the changing needs of the service to support the better health, better care, better value aims, it was necessary to take further action to communicate a clear vision to staff, patients and the public. In 2009, the responsibility for communication was also transferred from the planning and performance team to the human resources directorate. The director of human resources is Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 16
now the executive lead for communications and patient focus and public involvement, allowing closer links with the staff governance agenda. The NHS board has also carried out a series of questionnaires to gain insight and feedback on internal communication arrangements. Targeted surveys have been sent to partners of NHS Highland: including the Scottish Ambulance Service; local authorities; the University of the Highlands and Islands; Northern Constabulary and Strathclyde Police; key communicators, including executive and non-Executive Directors; general mangers; locality managers and clinical directors; the public; and staff through the staff survey in 2008. The results of these findings have been presented to the staff governance committee, the public partnership forum and the Board, and have been used to inform the development of the communication framework. The draft framework was presented to the Board in February 2010 when the principles and approach were approved. However, it was noted that there was to be a further period of engagement, consultation and feedback prior to implementation across the NHS board area. This demonstrates that the NHS board considers evaluation to be an important element in the development of its new strategy, allowing time to accumulate appropriate feedback and demonstrate learning from existing arrangements. The review team also noted that a range of internal communication methods had been modified since the last review visit. For example, after consultation with staff, the monthly staff magazine `Team Update' is now mainly distributed electronically. The `In Touch' magazine is no longer provided as it was not considered to be adding value and articles are now incorporated into the `Team Update'. The communications team has also been expanded to enable each operational unit to have a dedicated communication manager or officer to ensure there are locally based individuals to respond to locally based issues. The review team was also pleased to note the use of information technology to enable participation across the NHS board area including video-conferencing of the NHS Highland Annual Review to five sites across the NHS board. NHS Highland has demonstrated a responsive approach to internal communication. The arrangements in place have been subject to regular changes to ensure they fulfil the needs of the organisation. The review team encourages the NHS board to demonstrate that reviews are undertaken in a planned, documented and systematic manner, thereby showing that there is a continuous cycle of review and improvement. The review team is pleased to note the organisation's approach to investing in new technology and encourages NHS Highland to harness this to increase levels of consultation and involvement as it implements its new communications framework. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 17
Standard 3: Assurance and accountability Standard statement NHSScotland is assured and the public are confident about the safety and quality of NHS services. Overall performance assessment statement: The NHS board is reviewing and continuously improving its arrangements to promote public confidence about the safety and quality of the care and services it provides. Core area: 3(a) Clinical governance and quality assurance Performance assessment statement: The NHS board is reviewing and continuously improving its arrangements to co-ordinate clinical governance and quality assurance arrangements across the organisation. NHS Highland has continued to display a positive clinical governance and quality assurance culture that is well embedded throughout the organisation. The NHS board has demonstrated a cycle of continuous review and improvement activities to further enhance and refine its arrangements for clinical governance. The clinical governance strategy sets out the vision of how the NHS board intends to develop and deliver its clinical governance arrangements across the organisation. The NHS board reported that the strategy had been reviewed and signed off by the clinical governance committee in August 2009 to reflect the delivery of NHS Highland's corporate objectives for 2009­2010 and support the development of the clinical governance forum. The clinical governance committee has the lead role in providing assurance to the Board that there are effective systems in place and regularly submits reports on the operation of the clinical governance arrangements to the Board. The clinical governance committee has an annual Work Plan that is regularly monitored and reports performance on this within the annual report. There is also a clinical governance and risk management annual work programme, which is monitored on a quarterly basis by the clinical governance committee and more regularly by the recently established clinical governance forum. The clinical governance forum is chaired by the medical director and is responsible for overseeing the development and implementation of clinical governance and patient safety, providing assurance to the corporate team that systems, processes and procedures are in place to deliver continuous quality improvement across the operational units. The clinical governance forum has a remit to ensure local and Highland-wide delivery of the six clinical governance principles upon which NHS Highland's strategy is based, namely patient focus, clinical effectiveness and research, safety, learning organisation, partnership and reducing inequalities. It is closely aligned with the operational units and receives progress reports on implementation of the annual work programme from each of the operational unit's clinical governance and risk management groups. Its link to the operational units is further strengthened through membership of the clinical directors and lead nurse from each operational unit. After reviewing the strategy, the NHS board reported that there was a need for a more coordinated approach towards clinical governance at operational levels. The new strategy Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 18
includes the requirement for clinical governance and risk management groups at each CHP, Raigmore Hospital and within dental services. These groups report to their management team and are chaired by either the clinical director or the general manager. The specific remit and membership of each group has been developed by the individual operational units to ensure that they meet their particular needs in relation to clinical governance and risk management. However, this is based on a template that ensures membership of the group is comprised of staff that are able to consider a broad range of issues. Broadly the remit of these groups is similar to that of the overarching board-wide clinical governance committee, to oversee the development and implementation of clinical governance and risk management within the units and provide re-assurance to the management team of the unit that systems, processes and procedures are in place to deliver clinical governance. The review team was pleased to note the introduction of a rolling programme of operational unit presentations at each meeting of the clinical governance committee. This allows the clinical governance committee to perform in-depth scrutiny into the arrangements at each of the operational units, challenge arrangements and identify areas for good practices or areas of difficulty for wider dissemination across the organisation. It was also reported that these presentations help to inform the annual clinical governance work plan for the year. NHS Highland also reported that annual reports from each of the Board committees are submitted to the audit committee. These reports include a specific declaration that systems of control within their respective area are considered to be operating effectively. It was stated that following evaluation, the NHS board changed the format of these reports to improve their effectiveness by adding a section outlining the key focus points for the next year. This allows the audit committee to gain an overarching view of the effectiveness of the systems and processes in place for clinical governance and acts as a further quality assurance mechanism across the NHS board area. The committees and groups described above are further supported by the clinical governance support team. Each operational unit has a link manager within the clinical governance support team who provides a wide range of management information and reports which support quality assurance and improvement activities at all levels of the NHS board. In 2008, the team undertook an evaluation of the clinical governance and risk management arrangements within the operational units. This included gaining feedback from key stakeholders on the current systems with a view to using this information to improve the arrangements to better suit the needs of NHS Highland. It was noted that the results of this evaluation had been reported to the clinical governance committee and the recommendations were included within the annual clinical governance work programme for 2009­2010. The review team also noted that the chair and chief executive undertook a review of the functioning and effectiveness of the CHP and Raigmore Hospital governance committees. As part of this, agendas and papers were reviewed and each committee was attended by the chair and chief executive where brief discussions on effectiveness were held. The outcomes of these reviews were reportedly discussed at Board development sessions in March and May 2008. The Board concluded that the broad framework of governance was satisfactory, with strengthening required in some areas. The subsequent actions were approved at the June 2008 Board meeting. The review team also noted that there is a clinical governance and risk management evaluation plan that details the proposals for the evaluation of various clinical governance and risk management systems and processes for the last 2 years and for the future 2 years. The NHS board stated that evaluation reports are accompanied by detailed action plans which indicate how the changes will be implemented and monitored. There is also a robust Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 19
programme of internal audit that includes a number of reviews of the effectiveness of the governance arrangements, including a 2008­2009 review of primary care dental clinical governance arrangements and in 2009­2010 a planned review of complaints management. It was also noted that internal audit has assisted the clinical governance committee in assessing its effectiveness by developing an online questionnaire that was circulated to several key groups of staff including non-executive directors, operational unit clinical directors, lead nurses and general managers and chairs of committees and groups accountable to the clinical governance committee. The review team was pleased to note the quality of the report produced and encourages the board to progress with its recommendations. It is evident that NHS Highland considers continuous review and improvement to be fundamental to the success of the organisation. It has been able to demonstrate that clinical governance is well embedded within the operational units and there is a rolling programme of planned and systematic evaluation. The review team encourages the board to continue with the commitment it has demonstrated in this area ensuring that the systems and processes in place continue to meet the NHS board's requirements. Core area: 3(b) Fitness to practise Performance assessment statement: The NHS board is reviewing and continuously improving its arrangements across the organisation to ensure its workforce is fit to practise. Since the last review visit, NHS Highland has continued to improve its arrangements to ensure its workforce is fit to practise and is now reviewing and continuously improving its arrangements across the organisation. The NHS Highland partnership forum, which consists of six standing subgroups, is the main implementation body for the staff governance agenda and reports to the staff governance committee. Each operational unit has a management team that is operationally responsible and accountable, through the chief operating officer, for ensuring that local governance arrangements are in place, as well as a governance committee which is directly responsible to the Board. The staff governance committee has overall responsibility for ensuring that robust systems are in place for implementing the staff governance standards and monitoring the effectiveness of fitness to practise arrangements. Following each of its meetings, the committee produces an assurance report which includes details of the actions being progressed. The committee also produces an annual report detailing the effectiveness of staff governance systems. Key performance indicators (KPIs), which include HEAT targets, staff survey and staff governance self-assessment audits are the main tools used to monitor the effectiveness of staff governance systems. Annual reports are reviewed in detail by the audit committee which then reports to the Board on any issues. In addition, the operational units are required to produce a progress report on implementation of the staff governance standards. A comprehensive and robust checking system is in place to ensure that staff have the necessary qualifications, registrations and accreditations to fulfil the requirements of their role. The employment services department and the medical staffing department are responsible for ensuring that systems are in place to cover pre-employment checks. Many of the checks are the responsibility of the recruiting manager. Managers and professional leads have responsibility for ensuring that staff renew and update their registration status Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 20
with Professional bodies, with local policies in place to monitor this. The personnel team employs a workforce information officer whose role is to manage a central process that checks registrations due to lapse up to the end of the following month and to update the Scottish workforce information standard system. Workforce monitoring reports are produced monthly and are sent to appropriate managers and leads for their information and action. Evidence demonstrated that improvement decisions based on evaluation have been made in this area. The review team was pleased to note the example of improvements made to registration procedures and systems following a review of nursing, midwifery and allied health professional (NMAHP) registrations carried out by internal audit in 2009. This internal audit was consistent with the audit plan approved by the audit committee. A new policy for NMAHP registration monitoring has recently been approved. This will ensure a standardised process of registration monitoring is in place in each unit. Additionally, a number of developments and improvements to the workforce report were made in light of feedback and evaluation from managers and committees. The review team was pleased to note that clinical supervision is well established within the organisation. Policies and programmes are in place across the professional groups including; NMAHP, laboratory, pharmacy, dental and medical staff. Training has been carried out around one to one clinical supervision and other approaches have been developed depending on local need. The clinical supervision policy and framework has been evaluated through the use of a survey. The policy will be updated following a report on the outcomes of this survey. NHS Highland supports continuous Professional Development through its learning strategy action plan and learning plan. The combination of these documents was agreed in June 2008 at the learning and development subgroup and a revised format put in place. The NHS board considers the Knowledge and Skills Framework (KSF) to be an essential building block in ensuring that staff have the necessary knowledge and training to carry out their duties. Since the last review visit, the NHS board has continued to implement and embed the KSF framework throughout the organisation with training being systematically recorded and monitored through the AT-L Learning Management System. Committees and groups are in place to support and monitor the professional development of each professional group, with the current appraisal system for medical staff being made more robust to reflect recent guidance. NHS Highland was the first NHS board in Scotland to have a learning partnership agreement (December 2007) that supports the delivery of effective learning for employees. Within CHPs, some staff have half a day of protected learning time each month. NHS Highland has a strong commitment to ensuring that its workforce is fit to practise and has continued to embed and improve its arrangements. It has demonstrated that there is ongoing monitoring across a range of key areas and a cycle of internal audit is in place. There are robust arrangements in place to ensure that action is taken if a member of staff is identified as unfit to practise and a number of mechanisms to ensure continued development of staff. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 21
Core area: 3(c) External communication Performance assessment statement: The NHS board is monitoring the effectiveness of its external communication arrangements across the organisation. NHS Highland had in place a joint strategy for internal and external communication (2006­2009) which was evaluated through a number of formal and informal mechanisms. The results of the evaluation were used to inform the communication framework 2010­ 2012. It was reported that the communications framework is substantially different to the previous strategy and is more suited to the current needs of NHS Highland. It presents the NHS board's strategic aims in relation to communicating with its staff, patients and carers, local communities and other external audiences. The NHS board has a comprehensive suite of external communication methods which includes patient information leaflets, posters, the Highland HealthVOICES network, the NHS Highland website and various press releases. The NHS Highland website has been significantly developed and improved since the last review visit. It now includes feedback links to allow staff to respond to queries from patients or the public. There are two public partnership forums in operation across NHS Highland; the Highland HealthVOICES network, which is Highland wide and has 276 members from across the region; and the Argyll and Bute Public Partnership Forum that is assisting with the transition to NHS Highland and responding to local issues. Each forum has an annual action plan that informs their development and is regularly consulted on with regards to initiatives, policies and service development across NHS Highland. There are also five patient councils in place at Raigmore Hospital, Caithness General Hospital, Belford Hospital, Argyll and Bute Hospital and New Craigs Hospital. These councils are involved in a wide range of activities including supporting patient feedback surveys and service evaluation, being `ghost' patients, and attending health improvement groups in the hospitals. They have all been involved in the evaluation of the existing communication strategy through the completion of targeted questionnaires. The strategy has also been advertised in the local media to allow the general public to respond. In addition to the evaluation activity undertaken to inform the new communications framework, as described in core area 2c, the NHS board has conducted a range of informal evaluation activity. It was reported that the communications team has expanded to ensure there is a member of the communications team aligned to each operational unit to provide locally based responses to local issues. It was reported that this has improved relations with local communities and the media. It was also stated that the communications team has become more proactive regarding press releases and now ensures that positive news stories are circulated to the media on a daily basis. There has been a number of key service delivery changes that have enabled the NHS board to evaluate the effectiveness of its external communication methods. For example, within Argyll and Bute CHP, mental health services are being redesigned. This involved an extensive consultation process with a total of 38 meetings held across the CHP. It was reported that a total of 560 people attended these meetings and contributed to shaping the new service. Furthermore, the NHS board reported that after each patient or public engagement event, participants were asked to feedback on how it went to enable improvements to be made to future events. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 22
NHS Highland has demonstrated that it regularly reflects on the effectiveness of its external communication arrangements. The review team noted the work of the NHS board to move to a new communications framework and encourages progress with this as a priority. The review team also encourages the NHS board to incorporate comprehensive monitoring mechanisms into the new framework. This will allow demonstration of a proactive and systematic approach to evaluating the effectiveness of the arrangements thereby showing a continuous cycle of review and improvement. Core area: 3(d) Performance management Performance assessment statement: The NHS board is reviewing and continuously improving its arrangements for performance management across the organisation. NHS Highland has robustly implemented its arrangements for performance management and regularly monitors and reviews these to ensure continuous improvement. The NHS board uses the balanced scorecard approach to measure its performance against key targets set out in the local delivery plan. The targets are also closely aligned to the 38 existing HEAT targets, each of which has an identified executive lead. The executive lead is responsible for developing an action plan, risk narrative and trajectory for the target. It was reported that the balanced scorecard is updated every 2 months. It is measured against the trajectory and an assessment made based on agreed percentage tolerances which give each target a red, amber or green status. Since the last review visit, the NHS board has developed balanced scorecards for each of the operational units which reflect their contribution to the overall NHS Highland target. The scorecard is considered at the operational unit's executive committee and its clinical governance and risk management group, where red targets are scrutinised to ensure actions are taken to improve the performance status. It was also noted that while the current balanced scorecards focus on the delivery of HEAT targets, it is the NHS boards' intention to develop the operational balanced scorecards to incorporate additional targets that the operational units wish to measure. The review team also commends the progress that the NHS board has made in establishing a community care balanced scorecard based around both HEAT and single outcome agreement targets. This is governed by the joint leadership and performance group within Highland, which includes the chair and chief executive of the Board, and the Argyll and Bute Healthcare and Strategic Partnership within the Argyll and Bute CHP. The minutes of these meetings are discussed at the NHS Highland Board meeting and at the Highland Council meetings. Since the last review visit, the NHS board has established an improvement committee as a subcommittee of the Board. This committee has evolved as a result of ongoing evaluation of the effectiveness of the previous performance review group and meets every 2 months to consider the balanced scorecard. The improvement committee has a remit to provide assurance to the Board on effective system performance and on the effectiveness of the performance management arrangements providing explicit clarity around responsibility for this area. It also has a duty to hold the operational units to account for their performance and promote good practice across the organisation. It was reported that after each meeting of the improvement committee, an assurance report is produced and submitted to the Board. The report clearly assigns the actions arising from the meeting, highlighting the committee's distinct role in relation to performance monitoring and governance. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 23
A review panel has been established as a component part of the improvement committee. This panel consists of the chair and vice chair of the Board, the chief executive, the chief operating officer, the Board medical director, chair of area clinical forum and the head of service planning. Operational units, represented by the general manager and chair of the executive committee, provide assurance reports for any of the targets within the balanced scorecard that are highlighted as `red'. At this point they also outline the work that is being undertaken to bring the target back in line with the trajectory as soon as possible. It was also reported that the NHS board was in the process of establishing a performance group. This group will be chaired by the chief operating officer and attended by operational unit general managers and have a more operational focus. The NHS board stated that the group will look at a set of KPIs on a monthly basis that cover a wide range of areas, but will initially focus on access and HEAT targets. It is envisaged that the range of KPIs will develop over time to include areas such as patient safety, and health and safety. There have been several reviews of performance management arrangements across NHS Highland including: an internal audit in 2007­2008; a review in 2008, which was the main driver behind establishing the improvement committee and the significant restructuring within the planning and performance directorate; and an ongoing review of the performance arrangements with Argyll and Bute. It was noted that during the review of the performance management arrangements within Argyll and Bute, the NHS board highlighted two areas of good practice that are now being rolled out across the organisation. This includes developing a CHP analyst role and using the intranet to make routine reports available. The CHP analysts will work with the CHPs and Raigmore Hospital to develop a suite of reports that will allow them to measure performance of areas such as community hospitals' bed occupancy and allow KPIs to be developed locally and enable operational monitoring of their contribution to national improvement programmes such as the 18 weeks referral to treatment programme. The NHS Highland information portal has also been established which will be a one stop shop for a number of routine reports from various sources. To further support this, the NHS board reported that it is currently in the process of developing additional KPIs, based on models established in England, that will be available on a weekly and/or monthly basis and will allow for reports to be tailored to local needs. Furthermore, NHS Highland has implemented and is monitoring robust performance management arrangements within the service level agreement with NHS Western Isles. There is a service level agreement monitoring committee in place that reports to the corporate management team within NHS Western Isles and the Raigmore Hospital management team in NHS Highland. Monthly meetings are held between the chairs and chief executives of both NHS boards, during which performance is discussed alongside weekly analysis of additions to both the outpatient waiting list and the inpatient waiting list in NHS Highland from the NHS Western Isles. The review team also noted the appointment of a corporate service level agreement performance and partnership manager to ensure continued joined-up working between the NHS boards. It is clear that there is a co-ordinated and systematic approach to performance management which is well embedded across NHS Highland. The NHS board has demonstrated that changes made to the arrangements are based on systematic evaluation which then re-enter a continuous programme of review and improvement. It has illustrated that it continues to consider the next steps required to ensure that the performance management arrangements are meeting the organisation's requirements and support the NHS board in demonstrating achievement of its objectives. Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 24
Appendix 1 ­ Glossary of abbreviations
Abbreviation
CGRM
clinical governance and risk management
CHP
community health partnership
EQIA
equality and diversity impact assessments
HEAT
health, efficiency, access and treatment
KPI
key performance indicator
KSF
knowledge skills framework
NMAHP nursing, midwifery and allied health professional
NHS QIS NHS Quality Improvement Scotland
Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 25
Appendix 2 ­ Review process = Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 26
Appendix 3 ­ Details of review visit The review visit to NHS Highland was conducted on 11 March 2010. Review team members Maureen Stevenson (Team Leader) Head of Clinical Governance ­ Development and Risk Management, NHS Dumfries & Galloway Peter Baxter Associate Medical Director, NHS 24 Alison McGilvray Public Partner, Forth Valley Elizabeth Middleton Non-executive Director, NHS Orkney Elizabeth Muir Clinical Effectiveness Co-ordinator, NHS Fife Hazel Robertson Finance and Performance Manager, The State Hospital Board for Scotland NHS Quality Improvement Scotland staff Anne Hanley Team Manager Deborah McIntyre Project Officer Jennifer Davies (Observer) Project Administrator Local Report (NHS Highland): Clinical Governance and Risk Management ­ June 2010 27

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