1. Quality and Patient Safety: Clinical Governance and QPS Audit 9 th February 2012 Ms. Maureen Flynn National Lead for Clinical Governance Development Quality and Patient Safety Directorate Ms. Edwina Dunne Director Quality Patient Safety Audit Quality and Patient Safety Directorate

2. Quality and Patient Safety Directorate Our role Listening to service users, patients and members of the public. Supporting implementation of standards. Risk management. Clinical audit. Managing when things go wrong. Safety and quality initiatives.

3. ‘Litzlberg am Attersee’ Gustav Klimt 1914-1915

4. Knowledgeable patients, receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes. Vision Source: Commission on Patient Safety and Quality Assurance (2008)

5. Corporate and Clinical Governance? “The main lesson I take form the problems at Mid-staffs is that in future, we must never separate quality and financial data. They are always two sides of the same coin.” (Secretary of State for Health, England)

6. Clinical Governance Clinical governance is defined today as: –A framework through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they have delivered. For health care staff this means: –Specifying the clinical standards you are going to deliver and showing everyone the measurements you have made to demonstrate that you have done what you set out to do. “Corporate accountability for clinical performance” (The Scottish Office, 1997)

7. Vision for Clinical Governance Development Each individual, as part of a team: –knows the purpose and function of leadership and accountability for good clinical and social care; –knows their responsibility, level of authority and who they are accountable to; –understands how the principles of clinical governance can be applied in their diverse practice; –consistently demonstrates a commitment to the principles of clinical governance in decision making A culture of trust, openness, respect and caring is evident among mangers, clinicians, staff and patients Clinical governance is embedded within the overall corporate governance arrangements for the statutory and voluntary health and personal social services in realising improved outcome for patients.

8. New Documents

9. Principles for Good Clinical Governance

11. Collaborative Initiatives in Progress…. Clinical leadership –Clinical directors/directorates –Leadership and quality in healthcare (HSE programme in partnership with RCPI) National clinical programmes. Supporting mangers –Alignment with standards (e.g. HIQA Mental Health Commission) –Engaging with the work of the Special Delivery Unit. Embedding clinical governance in: –Annual controls assurance process –Service/grant aide agreement –Performance management. Open disclosure pilot project. Patient safety culture survey methodology.

12. “My job is to make sure that patients are safe and well cared for…and I have no other”. (Colin Ovington, Director of Nursing and Midwifery, Mid Staffordshire Trust, 2011) Three elements of quality Patient care (clinical outcome) Patient experience Staff experience. The Clinical Governance..Mantra

13. “Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives - choice, not chance, determines your destiny.” (Aristotle, 384 BC – 322 BC)

14. Quality and Patient Safety Audit Ms. Edwina Dunne Director Quality Patient Safety Audit Quality and Patient Safety Directorate

15. Embedding Clinical Governance in Corporate Governance Processes “The resonance of the two terms is important, for if clinical governance is to be successful it must be underpinned by the same strengths as corporate governance; it must be rigorous in its emphasis, accountable in its delivery, developmental in its thrust and responsive in its connotations” (Scally and Donaldson, 1998)

16. Quality Patient Safety Audit QPSA as part of the HSE assurance framework provides independent internal assurance for healthcare services on compliance to standards, policies and procedures. This assurance adds value to our services by building trust and confidence… “that we are delivering high quality safe services for all our patients and clients” (National Service Plan, 2012).

17. Assurance Is confidence, based on sufficient evidence, that internal controls are in place and are operating effectively, and that objectives are being met. (NHS Internal Audit Standards) Assurance “Gap” –The risk committee prompt! –The assurance framework in the HSE had three levels of assurance (1,3, and 4). –No internal independent assurance for healthcare services. –The controls assurance process did not formally include clinical and social care services.

18. HSE, Assurance Framework 2010 QPSD

19. QPS Audit Established in 2010 based on feasibility study and research on models - national and other jurisdictions (private & public). Auditors recruited 16 internally and trained internally, auditor training, action learning, learning sets, team work. SOP adopted from internal audit (NHS) and internal audit collaboration. Audit requests sought from the Regional Director of Operations (RDO) level up.

20. Level 2. Assurance (QPS Audit) Provides independent assurance by testing the self assessment (Level 1) on the level of compliance to which standards/guidelines for health care activity are met across the system. Identifying reasons why they are not met. Make recommendations to implement change to achieve the required standard/best practice. Follow-up audits will monitor the implementation of the recommendations.

21. QPSA Progress… Each audit team consists of 2 – 3 auditors using the Standard of Practice. QPSA anticipated commencing 20 Audits in 2011 (overachieved Audits = 21). Audit target for 2012 = 24 50% QPSA audits with service user involvement Controls Assurance Process (CAS) 2011, required all managers to sign for “Reasonable Assurance” to include clinical and social care responsibilities and accountabilities. CAS 2012 - will refine this process to include assurance interviews.

22. Cross Section of Audits Audit of risk assessment for violence and aggression in Acute Mental Health Units. Audit of compliance with Correct Site Surgery policy. Audit of implementation of recommendations from the Hayes Report (2010) in AMNCH in the areas of OPD and Radiology. Audit of Self Employed Community Midwives (SECM) compliance with Memorandum of Understanding relating to the provision of Home Birth Services to Eligible Expectant Mothers (2011). Audit of national ambulance service appropriate Hospital Access Protocol for Trauma.

23. Distribution of Audit Requests (30) 2011

24. 2011 Recommendations by Headings (% of overall)

25. QPSA in Challenging Times New pro-active service/ innovation in QPSD that is working for patient safety and quality. Is providing assurance that the controls for managing Healthcare risks are effective (making risk management real). Is Identifying area of excellence/good practice, acknowledge and share at senior management team, board and across the services internally and externally. Is Identifying areas of weakness and making recommendations to address. Is improving the quality and reliability of information, used as basis for clinical and social care decision making. Is embedding clinical governance in corporate governance equal to finance as part of Controls Assurance Process. Do you have evidence?.......YES