Our Trust Level Quality Goals[1] 2015-17 - a 3 page summary

Service user and carer involvement

  • Each directorate and divisional business plan will specify local involvement development priorities
  • Each year we will host a service users’ and carers’ celebration event and an awards ceremony focused on how people who use our services are involved in both their own care and in service improvements
  • By October 2015 we will have co-produced a trust-wide “Framework for Carers” and an implementation plan
  • By December 2015 we will have increased the use of Advanced Directives by 100%
  • By January 2016 all clinical teams will have been audited against the Triangle of Care Standards and identified team priorities to improve carer engagement
  • By January 2017 all clinical teams will be able to demonstrate progress against the triangle of care standards.
  • By April 2016, a plan for increasing for co-produced service development and involvement opportunities, through the role of Service Development and Improvement Worker, will have been agreed
  • By April 2016, a plan for improving the use of real time feedback systems in capturing and responding to patient, service user and carer feedback will have been agreed

Recovery and person-centred care

  • By April 2017 we will have peer support workers across the mental health division, with at least 3 peer support workers or more within each locality
  • By April 2017, there will be a plan to roll out peer working within other specialties
  • By April 2017, there will be an established support workers’ training and supervision programme (including peer support workers), including sessions for all staff on ‘Using your Lived-Experience’ & ‘Using Advanced Statements’
  • By April 2017, the practice of co-produced service development will be developing and moving towards 50:50 involvement working on projects, with service users and/or carers employed for specified which can demonstrate how lived experience is shaping services
  • By April 2016, our mental health services will have developed our ‘recovery college without walls’ delivering a range of co-produced learning across the Trust, outlined within a prospectus, supported by individual learning plans and available to service users and carers across specialisms
  • By April 2017, mental health inpatient handovers will be explicitly recovery focused and will actively be reducing the use of restrictive practices
  • By September 2016, the Trust website and social media will support active engagement for all regarding recovery ideas and person centred practice
  • By April 2019, all staff being aware of ‘hope, control (as early as safe) and opportunity’ as the recovery and person centred rule of thumb, against which the quality of all interactions can be measured

By April 2016, all services will have made measurable progress in implementing person centred outcomes assessments that put service users in the driving seat of their own care

Quality Improvement (QI)

  • By January 2017, we will have trained 41 senior staff from across the Trust as quality improvement leaders, certified externally by experts from the North East Transformation System
  • By January 2017, we will have run at least 40 RPIWs within all clinical and corporate divisions
  • By January 2017, we will have run at least 5 Kaizen events
  • By January 2017, we will have run at least 6 other lean events (for example 3P and Share and Spread events)
  • By January 2017, we will have trained 36 managers and clinical leaders from across the Trust in core quality improvement skills and they will each have completed a QI project
  • By January 2017, we will have trained 40 admin staff from across the Trust in the basics of QI and they will each have completed a mini QI project
  • By April 2016, we will have trained two coaches, certified by NETS to deliver Certified Leader training to senior leaders across the Trust
  • By March 2016, we will have piloted the use of RPIWs as option for delivering CQUINs
  • By April 2017, quality improvement leaders across the organisation will be maintaining their skills in QI techniques by engaging in a range of activities including leading and sponsoring improvement events, mentoring trainees in the Trust’s Leading QI programme and teaching modules on all QI training programmes

CQC compliance

  • By January 2016, all teams will be able to demonstrate, how their day to day activities deliver on the CQC’s five key questions assessment framework and that the associated fundamental standards are embedded in. (For example, as part of routine discussions in team meetings structured around services being safe, caring, effective, responsive and well led)
  • Throughout 2015 a continuing programme of team support in delivering this target will be in place
  • Every month, there will be at least one detailed visit, jointly with governors, focused on the Fundamental Standards. Teams will be fully engaged with this process both as peer reviewers and as recipients of the findings of their own reviews
  • Every month, our CQC intranet pages will be refreshed with any relevant information staff need to help them comply with the requirements

Risk management and safety

  • In 2015, all directorates will assess their ‘risk appetite’ against the Board’s self-assessment and will have agreed monitoring arrangements in place to mitigate any escalated risks
  • There will be clear mitigation plans in place to address all environmental risks identified within clinical areas
  • Using the NHS Safety Thermometer maintain “harm free care” above 95%
  • We will ensure Duty of Candour is effectively implemented
  • Work with our partners in primary care and other secondary care settings to reduce harm

‘Learning the lessons’

  • We will publish a “Learning the Lessons” bulletin for staff at least four times a year
  • We will participate in patient safety research in conjunction with our research and development network
  • We will review our delivery against the “Sign Up for Safety” campaign annually
  • We will use feedback from our service users and carers to continually develop and improve services, using a range of sources including the Meridian patient experience real-time feedback tool, feedback and learning from PALS and complaints and the Service User and Carer Committee and its directorate and divisional sub groups
  • We will continue to review our incidents identifying recurring themes and share the learning through Thematic Reviews
  • We will share and spread the learning from improvement events via briefings, e-bulletins and websites
  • We will improve team learning following a serious incident by using Significant Event Reviews to investigate all Level 1 Serious Incidents

Clinical strategy
Each directorate level clinical strategy will:
  • Make clear how clinical experts and experts by experience have shaped the strategy
  • Include clear linkages to Trust values and strategic aims
  • Reflect the work done by the SLF in February 2015
  • Make explicit links to relevant national strategy, local health economy priorities, new market environments and contract requirements
  • Make use of recognised strategy development tools and processes
  • Have bespoke, measurable, goals linked to its supporting directorate business plan
  • Make explicit the links with service specifications and be based on evidence
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Core elements for all directorate level clinical strategies

Quality accounts

  • Our quality accounts will be accurate and transparent
  • Our published quality priorities will be negotiated with partners and governors
  • We will give accurate data about any improvements we have made and will be honest when we fail to make intended improvements
  • We will be able to demonstrate we have delivered on core indicators
  • We will be able to demonstrate we have delivered on local indicators
  • We will continue to work on making improvements and know how we can measure these
  • We will participate in all relevant national audits
  • We will use clinical audit to understand how we meet NICE guidance and standards
  • We will participate in national quality accreditation schemes

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[1] For further details of all these frameworks and for what staff and teams need to know, please contact Lorraine Brazier (on 01785 221677, or at ) to ask for a copy of the Trust document, “Provide high quality recovery focused services - Our first strategic aim: what it means for staff and teams”