Sandwell and West Birmingham NHS Trust Occupational Health and Wellbeing service Accredited July 1 st 2011

Webinar – SEQOHS accreditation Brief service overview Reasons for going for accreditation Reservations Practical tips – preparing evidence Practical tips – inspection Domain specific evidence, problems and solutions What we are planning next 3 key learning points / tips

Service overview Teaching trust with 7000 WTE staff, 2 acute sites OH&W part of workforce division Main base at one site, clinic rooms at other site 5 days per week Self / management referrals Daily clinics, telephone advice line In house committee, policy and divisional work appointments in last 12 months Acute Trust and 4 main external contracts

Service overview - Staffing Consultant led WTE equivalent consultant Hierarchical nursing structure - nurse manager, senior nurse, 4.45 WTE band 6, 1 band 5 General manager Health and Wellbeing facilitator Administrative staff Physiotherapist External counselling service – contract with us External alternative therapist

Why we went for SEQOHS accreditation - Awareness that good practices not always present, formalised or documented – hoped process would spotlight any gaps to improve care Looking to the future – increasing need to demonstrate good and evidence based practice Increasing business culture- how can we assure customers and patients about quality and continue income generation Priority in last 12 months of promoting profile within Trust – good publicity

Reservations New process – no-one to ask! How good is “good enough” Extra work / cost Need to ensure that any changes we made were for good of service and patients not just for accreditation Need to remember that SEQOHS is not an endpoint in service development

Practical Tips – preparing evidence (Chris Ritchie, general manager) Set up Regular Meetings with Lead Staff Use of an Excel RAG rated Spreadsheet Manual Folder with Index Retain Electronic evidence folder Update SEQOHS database only when internal electronic evidence is complete

Other practical tips for preparation Staff involvement Trust involvement Internal coms useful Set aside time for uploads Set aside time to respond to inspectors’ comments online and react to them Dialogue with inspectors on the website Dialogue with SEQOHS office

Practical tips – inspection day preparation Final staff briefing reminding where policies, documents etc could be found easily Check as to whether our clinic rooms on the other site would be visited too – not clear initially Checked most up to date forms / leaflets on display and manuals etc for equipment to hand Networked laptop and projector set up in quiet room for inspectors’ use Hard copies of evidence and selected personal files, training records etc laid out Cleaners, catering and parking arranged, directions sent

Structure of visit Business as usual in the morning – staff doing clinics etc as normal. Management team free Inspectors arrived 9am Management team met inspectors 9.30 Presentation about the service – staffing, main activities, contracts, in house work, planned developments Inspectors went through each domain and each standard, commented on the electronic evidence

Structure of visit ctd Inspection of hard copy evidence – eg someone’s training certificate for audio competence, calibration records, Trust policies, web information Questions on future plans to address any gaps Premises toured to demonstrate facilities Inspectors spoke to admin staff and asked how they did selected procedures, eg how would they go about transferring records across site

Structure of visit ctd Spoke to available nurses and asked about departmental policies Detailed – looked at key register, all equipment, toilets, locks, manuals, calibration records, info on display Lunch with inspectors Inspectors had approx 1.5 hours alone to write report Entire OH team and manager invited by us to attend “the verdict” Inspectors presented a detailed report commenting on our strengths, weaknesses and areas for improvement

Hints for the day Think about rota-ing, who it is most appropriate to have free to talk Involve the whole team – make it a special occasion, good for morale within our team Check if Trust have policy on external accreditation visits and follow it Ensure you have read and actioned the comments online from inspectors so there are no surprises

Future plans (Tracy Lees, nurse manager) A1.3: Verification of EAPs qualification & supervision. ACTION: Currently looking into guidelines, what is required & what other Trusts do B1.1: Extend audit of all clinical encounters ACTION: - to include general nurse clinics, Health Assessments, processing blood test results etc

Future plans ctd C1.2: Systematic approach to identifying and tracking specific training ACTION: Expand training matrix to incorporate competency assessments. Update nurse training gaps. Develop Standard Ops Procedure C2.4 Written protocols need to be consistent to guarantee quality and reproducibility of test procedures ACTION: the protocol reviewed was incomplete, to be completed to the same standard as the immunisation protocol which was deemed comprehensive. Other protocols to be updated to the same standard.

Future plans ctd G1.1 Recruitment & Sickness Absence policies require review ACTION: already in review process, new policies should be available in November 2011 Additions oWorking with Tempus to improve cohort data collection systems to aid SEQOHS accreditation oUsing SEQOHS as a platform to raise profile of service locally and nationally. Interview already given to the Nursing Standard oMonthly review of SEQOHS domains by Senior Management Team to ensure standards are maintained and kept updated oTeam congratulated by having a celebratory lunch

Evidence examples- Domain D Mostly assessed by inspection on the day Local EIA (Equality Impact Assessment) Customer Survey – specific question on privacy and dignity All departmental risk assessments – COSHH, sharps, slips and trips etc Calibration records, technical sheets etc Records of fridge checks and training delivered to nurses on cold chain with register of attendance and signatures of understanding Vaccines order trail and delivery notes Anaphylaxis training records, equipment checks Medicines management policy (Trust)

Domain D issue Problem – facilities across two sites, less scope to alter things at one site Example – clinic rooms at other site have no disabled toilet Solution – Insert step in booking process where disabled clients are booked at the Sandwell site, alter appt letter to clients and upload as evidence

Evidence examples -Domain E Survey monkey used to administer questionnaire to customers Trust sickness absence policy External SLAs /contracts (without financial detail) Records of meetings held with clients (when) and minutes/summaries of meetings held with them) Management referral form example

Domain E issues Immediate problem – misunderstanding of terminology – Be aware that “customer questionnaire” means business clients not patients! Problem – no SLA or equivalent documented with host Trust Solution – Supply the information that goes to Trust management regularly, and ask HRD to sign a one page summary of what we do currently in the Trust and how they moniter it

Evidence examples -Domain F List of leaflets (revision of all leaflets for patients in the 12 months prior to inspection) Consultant attendance at Union meeting within Trust introduced to get worker feedback, selected minutes from other Trust committees Brief role description added to picture board in reception and uploaded Personal file KSF framework which staff sign at their appraisal and includes equality and diversity as a core skill Consent forms and procedures footer for feedback. Item added to staff meeting agenda to review feedback from this and comment cards and action monthly.

Domain F issues Problem – no easy evidence available for what we think is best practice within consultations. Solution – good practice points written, circulated and displayed in clinic rooms. Problem – no formal confidentiality training for clinical staff as professional expectation Solution -Confidentiality training delivered in staff meeting with records of attendance / understanding submitted with training slides

Domain G3/4 evidence and issues Local audits submitted (needlestick management and records keeping standards) and evidence of registration with the updated national back pain survey Problem – No particular agreed standards with host Trust for waiting times etc Solution – KPIs agreed with Trust (using NHS plus standards as a starting point) and other customers and COHORT data used to measure performance against these quarterly, reports submitted and later used as evidence

3 key learning points / tips 1.The process of accreditation is worthwhile and beneficial, not just the end result – it will shed light on every corner of your service and make you see it with new eyes. 2.Don’t overcomplicate things or re-invent the wheel, share practice 3.Talk to the SEQOHS office, to other services and to the inspectors throughout the process