Transcript Webinar – SEQOHS accreditation

Sandwell and West Birmingham NHS Trust Occupational
Health and Wellbeing service
Accredited July 1st 2011
Webinar – SEQOHS accreditation
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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
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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 8.30-4.30
Self / management referrals
Daily clinics, telephone advice line
In house committee, policy and divisional work
10200 appointments in last 12 months
Acute Trust and 4 main external contracts
Service overview - Staffing
• Consultant led - 1.2 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
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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
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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.
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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
o Working with Tempus to improve cohort data collection
systems to aid SEQOHS accreditation
o Using SEQOHS as a platform to raise profile of service
locally and nationally. Interview already given to the
Nursing Standard
o Monthly review of SEQOHS domains by Senior
Management Team to ensure standards are maintained
and kept updated
o Team 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
• E-mail 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