Assuring the Care of Older People in Acute Hospitals in Nhsscotland

Assuring the Care of Older People in Acute Hospitals in NHSScotland

Methodology Review April 2013: Version 0.13

Background

1Healthcare Improvement Scotland was launched on 1 April 2011. This independent health body was established by section 10A of the National Health Service (Scotland) Act 1978 and marks a change in the way the quality of healthcare across Scotland will be supported nationally.

2Our organisation has key responsibility to help NHSScotland and independent healthcare providers to:

• deliver high quality, evidence-based, safe, effective and person-centred care, and
• scrutinise services to provide public assurance about the quality and safety of that care.

3Our work programme supports Scottish Government priorities, in particular those arising from the Healthcare Quality Strategy for NHSScotland. Our work encompasses all three areas of the integrated cycle of improvement with patient focus and public involvement at the heart of all that we do.

4The integrated cycle of improvement involves:

• developing evidence-based advice, guidance and standards for effective clinical practice
• driving and supporting improvement of healthcare practice, and
• providing assurance about the quality and safety of healthcare through scrutiny and reporting.

5On Monday 6 June 2011 Ms Nicola Sturgeon, the Cabinet Secretary for Health, Wellbeing and Cities announced that Healthcare Improvement Scotland would carry out a new programme of inspections. These inspections are to provide assurance that the care of older people in acute hospitals is of a high standard.

6The methodology for the inspection programme was agreed in November 2011 with the first inspection commencing in February 2012. There was a commitment in the original methodology to undertake a review of the inspection methodology by December 2012.This revised methodology has been developed and evolved to take into account the very complex and sensitive nature of the care for older people in acute hospitals. It also takes account of the experience of the inspections to date. The Whittle Review Group is therefore, recommending this methodology, which has been developed followingrecommendations arising from the review of the older people’s inspection methodology.

Introduction

7The purpose of this document is to inform the public and NHS boards of the methodology used by Healthcare Improvement Scotland to carry out its inspections regarding the care of older people in acute hospitals. A partnership approach between Healthcare Improvement Scotland and NHS boards will be used throughout the process, consistent with the integrated cycle of evidence, improvement and scrutiny.

8NHS boards will be measured against a range of standards, best practice statements and other relevant national documents. Relevant documents are listed in Appendix 2.

9The inspections will take a person-centred approach, focusing on up to threeof the following areas:

• treating older people with compassion, dignity and respect
• dementia and cognitive impairment
• nutritional care and hydration.
• falls prevention, and

• pressure ulcer care.

10Based on recommendations from the Francis Inquiry report, the inspection teams will also over time consider aspects of the recommendations relevant to Scotlandin relation to Older People in Acute Care.

Principles

11The following principles will underpin our approach, in improving care for older people:

11.1Supporting the delivery of person-centred, safe and effective care. Safe, effective and person-centred care can only be delivered when it is supported by appropriate procedures and management arrangements. The inspections will consider the systems and processes that NHS boards have in place support their staff to in delivering care for older people to ensure the outcomes are good.

11.2A focus on outcomes, considering service delivery to the end users of the services. Inspection will be delivered with a clear focus on the experience of those for whom the service is provided, ensuring that NHS boards are complying with standards.

11.3The purpose of improvement. There will be an explicit expectationthat the outcomes of the inspection will contribute to the improvement of the service being inspected. This should guide the focus, method, reporting and follow-up of inspection. The reports will recognise good performance through areas of strength and seek to address any failure appropriately through areas for improvement. Inspection should aim to generate data and intelligence that enable NHS boards to judge the progress they are making and priorities for improvement.Inspection should encourage innovation and diversity to secure sustainable improvement.

11.4Proportionate to risk. Over time, Healthcare Improvement Scotlandwillchange the frequency of inspection according to the performance ofthe NHS boards.Consistent with the Crerar principles, good performers should undergo less inspection, so that resources are concentrated on areas of greatest risk.

11.5Healthcare Improvement Scotlandwill encourage rigorous self-assessment by NHS boards. Healthcare Improvement Scotlandwill assess and as appropriate challenge the outcomes of NHS boardsself-assessments and take them into account in the inspection process.

11.6Healthcare Improvement Scotland will use evidencefrom a range of sources. The evidence will be used to assist us in informing our inspection. All evidence whether quantitative or qualitative, should be validated and credible.

11.7Healthcare Improvement Scotland will be open about its processes, willing to take any complaints about its processes seriously, and able to demonstrate a robust quality assurance process.

11.8Healthcare Improvement Scotland will ensure that its scrutiny activities demonstratevalue for money, and are subject to regular audit and benchmarking.

11.9Healthcare Improvement Scotland willcontinually learn from experience in its scrutiny work, in order to become increasingly effective. This will be done by assessing the impact on the NHS boards ability to improve and by sharing best practice with other scrutiny bodies.

11.10Healthcare Improvement Scotland will escalate matters of concern to NHS Boards and other appropriate organisations as required to ensure timely intervention and improvement.

Comments are closed.

Inspection Methodology Overview

12The focus of the team will be on inspecting the quality of care provided for older people while they are in an acute hospital. We will include the issues that matter most to patients such as privacy, dignity, compassion and respect. Increasingly, the focus will be on unannounced inspections. The frequency and intensity of inspection may vary according to the risks and scope of the inspection.

13The inspection team will:

• check to make sure that systems are in place to effectively manage thecare for patients
• gain the views of patients on the care they receive
• assess and comment upon the standards of care achieved over the period of the inspection
• identify strengths and areas for improvements within each hospital, and
• escalate or, if the health and wellbeing of patients is at risk of harm, interveneif staff do not follow the NHS board policies and procedures, best practice statements or national standards.

14We will not comment on the fitness to practice of the staff delivering healthcare, including competence, professional conduct and clinical decision-making. Responsibility for these issues will remain with the organisations which regulate the professions or the employing NHS boards.

15We will undertake inspections to all acutehospitals across NHSScotland, to assess compliance with standards, best practice statements and other national documents.

16The inspections will incorporate evidence gathered from:

• self-assessments
• documentary evidence, including case note reviews, and
• observational information.

17The team will also draw on the material contained in NHS board improvement plans. NHS boards will take into account the findings from inspection reports in reviewing progress against objectives and milestones.

The Stages

18The inspections will follow four stages:

• self-assessment
• onsite inspection
• reporting, and
• follow-up.

It is envisaged that the start to end of the inspection process (ie. from inspection through to final publication) may take up to 8 weeks.

Self Assessment: Stage 1

19NHS boards will providea short andfocused self-assessment prior to inspection. This will cover the areas set out in the areas for inspection and identify areas of strength but also areas where NHS boards acknowledge that they have further work to do. At this stage, NHS boards will begin compiling their improvement action plan. These improvement action plans will belong to the NHS board and NHS boards will be expected to start implementing these prior to the inspection, based on their self-assessment return.

20The principal purpose of the self-assessment is to provide a framework for the NHS boards to establish their own performance in relation to the care they are providing for older people. Once completed, the self-assessment should inform the NHS board of the key areas for improvement and allow them to develop a plan to drive the improvements in advance of any inspection. The submission of the self-assessment to Healthcare Improvement Scotland allows the inspection teamto review the information and use it to inform the planning of the inspection.

The self-assessment will be considered in the context of the following points:

• validation of how selected policies and procedures are put into practice at an operational level, when the NHS board has stated that it is meeting the standards
• exploring and further investigating the issues the NHS board has highlighted in its self-assessment as needing improvement, and
• exploring areas where the inspection teamthink the self-assessment submission is lacking.

21The self-assessment should be completed robustlyby the NHS board in the context of its own arrangements for the care of older people, recognising where it has scope for improvement. The elements of the self-assessment that have been tested during the inspection will be included in the report.

Onsite Inspection:Stage 2

22The onsite inspection itself will be subject to a number of stages:

22.1on-site observational inspection, including meeting/talking with staff, patients and carers,

22.2case note review, and

22.3analysis of evidence gathered.

All inspection team members will take notes and complete the relevant documentation throughout the inspection process.

Reporting: Stage 3

23Reporting will include the following stages:

23.1drafting of report

23.2quality assurance review, and

23.3issue to the Senior Inspector and Head of Quality of Care for quality assurance and subsequent to that final sign-off by the Director of Scrutiny and Assurance.

24Throughout this period Healthcare Improvement Scotland will continue to liaise with the NHS board to ensure that the evidence is up-to-date and factually accurate and queries are identified and pursued, prior to the clearance draft report being issued to the NHS board Chief Executive.

25All draft reports will be considered by the Senior Inspector, Head of Quality of Care, and the Director of Scrutiny and Assurance.

26All draft versions of reports will be water-marked as 'embargoed clearance draft: private and confidential'

27NHS boards will, normally, be given 10working days to respond to the factual accuracy check.

28A final and embargoed version will be issued to the NHS board prior to publication. The NHS board will be notified in advance of the publication date.

29All reports will be published on our website on the publication date. If a report is delayed by more than 5 working days, a statement will be placed on our website indicating why there has been a delay. NHS boards will be responsible for publishing their own improvement action plans on their website.

Follow-up: Stage 4

30The inspection will be followed up as appropriate depending on the findings. Though, all NHS boards will be expected to produce a report on progress six months following the publication date of the original inspection report.

31The inspection team will follow-up on the progress made by the NHS board and hospital in relation to the findings. This will take place no later than 16 weeks after the inspection, although the exact timing will depend on the severity of the issues highlighted by the inspection and the impact on patient care. The nature of the follow-up activity may be determined by the nature of the risk presented to patients and willinvolve one or more of the following elements:

• an announced or unannounced inspection
• a targeted announced or unannounced inspection looking at specific areas of concern
• a meeting (either face to face or via telephone/video conference)
• a written submission by the NHS board on progress with supporting documented evidence, or
• another intervention deemed appropriate by the inspection team based on the findings of the initial inspection.

The Inspection

Overall Structure

32Ensuring that the care for older people is delivered with compassion, dignity and respect while they are in an acute hospital setting will form the core of every inspection. In addition inspectionsmay focus on dementia and cognitive impairment and nutritional care and hydration. If the evidence available indicates it is appropriate falls prevention and pressure ulcer care may also be considered as a part of the inspection.

33The inspection will incorporate four major elements.

33.1Pre-visit intelligence gathering

33.2On-site inspection, including observation of care and meetings with staff and patients

33.3Formal case note review

33.4Post inspection analysis and review

34Together these elements will assist in forming a comprehensive, fair, objective and reliable assessment of the quality of care afforded to older people in acute hospitals.

Pre-Visit Intelligence Gathering

35Healthcare Improvement Scotland will focus on the material generated in the self-assessment but also gather intelligence from a range of sources including, but not limited to:

35.1Healthcare Improvement Scotland intelligence data such as complaints from NHS boards and other inspection reports;

35.2Annual Review intelligence and data;

35.3Information and Statistics Division validated data;

35.4Scottish Public Services Ombudsman reports;

35.5Mental Welfare Commission Reviews;

35.6Information on patient experience

36Healthcare Improvement Scotland will, based on this information, produce a baseline assessment report to assist in guiding the inspection priorities and the focus.

On-site Observation Inspection

37The on-site inspection will typically last two/three days. The inspection will be focused on key areas set out earlier and will include:

37.1observational information gathered using the observation tool;

37.2structured interviews with staff;

37.3questionnaires for patients and their relatives;

37.4analysis of patient notes, assessments and care plans.

38All the evidence gathered will be fully documented.

39There will be a post on-site inspection feedback session.

Formal Case Note Reviews

40The inspection programme will also consist of a detailed review of case notes from a sample of records. This will allow a more comprehensive assessment of the journey of care for patients between hospital and the community or home.

41The inspection reports will detail both areas of strength in relation to the care of older people and where there are areas for improvement. The inspection team may gather strong evidence that a hospital or NHS board is doing well in relation to some practices, ways of working or outcomes for patients. When these are found, these will be reported as an area of strength in the report.

42Areas for improvement mean that a hospital or service is not meeting recognised standards or following best practice and there is concern about the impact this is having on the patients using the hospital. Wherever possible, the areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board:

• must take action when they are not meeting the recognised standards.
• should take action where improvements cannot be directly linked to the recognised standards, but where these improvements will lead to better outcomes for patients.

Healthcare Improvement Scotland expects that all the areas for improvement will be addressed and any changes implemented.

Reporting of the Inspection Findings

43The draft inspection report will be considered by the Senior Inspector, Head of Quality of Care and the Director of Scrutiny and Assurance. Any issues will be discussed with the inspection team.

44A key test in considering the draft report will be the extent to which it meets the principles set out earlier in this methodology. The Director of Scrutiny and Assurance and the Chief Executive will seek the advice of the Executive Team as appropriate prior to further circulation of the report and, in particular, the clinical advice of the Executive Clinical Director and the professional staff in their Directorate.

45The Director of Scrutiny and Assurance, the Head of Quality Care and the lead inspector will be available to meet with the Chief Executive or representatives of the NHS board to discuss the findings.

46Following review, and with any proposed points of clarification or amendment, the draft report will be sent back to the lead inspector for issue to the NHS board Chief Executive. This report will be water-marked as ‘embargoed clearance draft: private/confidential’.

47NHS boards will be required to consider the immediate findings and to highlight areas of factual inaccuracy in a response form. The NHS board Chief Executive will be given the opportunity to submit and agree the factual accuracy of the draft report before publication. The NHS board Chief Executive will return the report sign off form and improvement action plan to Healthcare Improvement Scotland within 10 working days from receipt of the report.

48Reports will be published on our website and available in a range of accessible formats on request. We will also produce a number of other reports, including bi-annual summary reports of themes.

The Inspection Team

Core Inspection Team

49The core inspection team will consist of a lead inspectorand up tothree Healthcare Improvement Scotland inspectors and a project officer.

50The team will also be enhanced by seniorpractising healthcare professionals in NHSScotland.

51In addition, there will be two ‘public partners’ on each inspection.