Trust Board papers - University Hospital Southampton NHS ...

The Clinical accreditation Scheme (CAS) has been developed as a key element in the trust’s clinicalassurance programme.The Clinical Accreditation Scheme offers a comprehensive method for providing standardisedassurance about quality of care at ward level which staff and patient workshops have identified asuseful to them. The purpose of the clinical accreditation scheme (CAS) is to use existing sources ofquality assurance that will enable each ward/department to be accredited according to set measures ofquality. This will ensure that the standards of expected care are communicated effectively to all staffdelivering care at ward level.The clinical accreditation scheme is being delivered in 2 parts: the clinical quality dashboard (CQD)which is now operational in all relevant clinical areas, and the implementation of the scheme itself. Overthe following 14 months all relevant wards and clinical departments will undergo clinical accreditationassessment. This involves a retrospective review of clinical metrics in 4 KPI domains and a panel visit tothe clinical area, including PPI reps and peers. The CAS implementation plan can be summarised asfollows:• Phase 1 – Clinical Quality Dashboard development• Essence of care - benchmarks to be included in the accreditation process• ‘15 steps challenge’ adapted to facilitate CAS reviews (including PPI reps)• 4 Domains to cover all essential aspects of care:– Patient safety– Patient experience– Ward Environment– Staff Experience/Workforce• Phase 2 – Pilot of CAS on 4 wards between June- July 2012 (2 now fully accredited)• Phase 3 – Full roll out commenced November 2012• 4 levels of accreditation• Exemplar• Full with no conditions• Full with conditions• ReferA CAS research project is underway led by researchers from the University of Southampton. 3 wardswill undergo accreditation (intervention) and 3 will act as a control until after the research study hasbeen completed. Staff are being asked to complete questionnaires at three key points in order to assessthe value of the clinical accreditation process in improving quality, patient experience and safety KPIsand staff engagement.3.7 Supporting CarersThe trust has undertaken several listening events and audits of carer’s experience of acute hospitalcare. A key theme in carer feedback relates to the provision of information and signposting. Working inpartnership with Southampton City Council and Carer’s Together, the trust has piloted a carer’sinformation trolley on the Medicine for Older People’s Unit and this is now rolled out to other clinicalareas.The trolley is staffed by Carers Together volunteers and cited in different locations around the trust 6days per week. One of these sessions incorporates a specific “Memory Clinic” to support carers ofpatients with dementia, facilitated by the trust’s new Admiral Nurse Specialist. Further initiatives tosupport carers include carer support assessment proformas, which will be implemented in the followingquarter.4 Summary and ConclusionThis report has summarised patient feedback from a variety of sources (part 1) and demonstrated thatmajority of patients continue to rate their experiences of care and treatment at UHS positively. Part 2 ofthe report details progress against some of the trust’s key improvement programmes which reflect thekey themes which have emerged form patient feedback. Trust board members will note the 3 areas ofperformance which require continued focus; communication, sharing mixed gender facilities (evenwhen they are not) and hospital food, although some improvements are noted in October since thechange of the Medirest Steamplicity menu.11