Spreadsheet: 991533d9-c4c8-48e8-9652-2cd11f89c63a
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Example Good Practice | Unnamed: 3 | SECAmb self-assessment evidence | Unnamed: 5 | Unnamed: 6 | Rating | Unnamed: 8 | Unnamed: 9
 |  |  | Lead | Discussion | Gaps | Rating for each point
1 | Strategy |  |  |  |  |  |  | Comments | Score
1a | Does quality drive the trust's strategy | Quality is embedded in the Trust‟s overall strategy |  | The Trust's Quality Account sets out key quality priorities, which are linked to the Trust's strategic objectives and service developments, as articulated in the Integrated Business Plan.  The objectives from the Trust's Quality Account are integrated into the Annual Business Plan, to ensure the delivery of these is monitored in year.  These priorities reflect local priorities, and are supported by our commissioners.  The Trust considers patient and public feedback provided via complaints, compliments and PALS enquiries.  Reports are provided bi-monthly to the Trust Board and quarterly to the Trust's commissioners.  The Trust Board and committee governance framework facilitates a focus on quality at all appropriate levels of the organsiation. | Work being undertaken to incorporate the Quality Account Priorities into the ABP/Directorate Plans but not complete yet. | amber | Amber / Green |  | 0.5
 |  | The Trust‟s strategy comprises a small number of ambitious Trust-wide quality goals covering safety, clinical outcomes and patient experience which drive year on year improvement |  | The Trust's Quality Account sets out three quality priorities: 1. To increase the number of registered paramedics who attend seriously injured or ill patients; 2. To reduce the number of patients transported to hospital by ambulance by utilising registered paramedics with specialist skills who can provide care closer to home or at home; 3. To improve the quality of patient care by linking the documented evidence of care delivered to the patient outcome.  The CQUIN payments also focus on improving quality and achievement of these targets result in a financial payment to the Trust.
 |  | Quality goals reflect local as well as national priorities, reflecting what is relevant to patients and staff |  | The identified quality goals are linked to local and national priorities as follows:  Priority 1 - Links in to NAO, NCEPOD and Royal College of Surgeons reports around trauma care; Priority 2 - Focus on reducing conveyance, in line with recommendations set out in Taking healthcare to the patient and the Next Stage Review; Priority 3 - Improving quality of evidence, supporting the direct relationship betewen actual and evidenced patient care, linking to national audits.  Local priorities include developing the workforce to focus on particular demographics for the SEC area, as well as delivering operational performance at a PCT level. | Delivery of PCT level performance;  Staff survey - action plan in place to improve understanding of priorities and Trust operational model.
 |  | Quality goals are selected to have the highest possible impact across the overall Trust |  | The three priorities identified within the Quality Account cover a broad scope of the Trust's operations:    Priority 1 - relates to the treatment of the most seriously ill / injured patients by the most qualified clinician; Priority 2 - relates to the majority of calls received by the Trust - improving the patient experience by providing the most appropriate care, and minimising unnecessary conveyanced; Priority 3 - providing an assurance mechanism to assess the quality of care.
 |  | Wherever possible, quality goals are specific, measurable and time-bound |  | The priorities, as set out in the Quality Account include specific descriptors, and an identified lead.  The delivery of these is monitored through the ABP, in line with the agreed milestones. | Inclusion of the quality priorities to be incorporated into the ABP with identified leads. | amber
 |  | Overall Trust-wide quality goals link directly to goals in divisions/services (which will be tailored to the specific service) |  | The Annual Business Plan links to directorate objectives, supported by underpinning directorate plans. | Mapping of quality priorities to underpinning directorate plans.
 |  | There is a clear action plan for achieving the quality goals, with designated lead and timeframes |  | The Quality Account clearly identifies the organisational Lead and Executive Sponsor, and high-level timescales for the identified quality priorities. | Required to map Quality Account priorities into ABP and then embed these within individual directorate plans. | amber
 |  | Applicants are able to demonstrate that the quality goals are effectively communicated and well-understood across the Trust and the community it serves |  | The Trust's quality priorities are articulated in the Quality Account, which was signed off by the Board and published on 30 June 2010, and is available on the Trust website.    In addition, quality goals are communicated via the Strategic Commissioning Board, that has a quality agenda.  Quality goals are highlighted to stakeholders through the intranet, internet, staff bulletin and through the local media.  The Trust's Organisational Development process is designed to assist managers throughout the organisation to understand their role and responsibilities in the communication of quality priorities.  The performance management framework within the organisation cascades delivery of the priorities from the Annual Business Plan. | Staff survey - action plan in place to improve understanding of priorities and Trust operational model.  Review of performance management framework to ensure full cascade of responsibilities throughout organisation.  Minutes of Committee meetings to be more accessible through the new website   Processes for sharing of information (such as through minutes of meetings) between working groups to be formalised
 |  | The Board regularly tracks performance relative to quality goals |  | The Quality Account and corporate dashboard reports quality and are monitored and commented on by the Board.  The priorities from the Quality Account are being built in to the Annual Business Plan/Directorate Plans.   The priorities articulated within the Quality Account clearly link to the Trust's Service Development Enablers (SDEs) and Service Developments  The Corporate Dashboard monitors achievement of clinical performance indicators which demonstrate achievement of aome of the quality goals.   Quality measures for Patient Transport Service have been agreed with commissioners. | Regular updates on the Quality Account priority areas to be provided to the Board
1b | Is the Board sufficiently aware of potential risks to quality? | The Board regularly assesses and understands current and future risks to quality and is taking steps to address them |  | All risks on the corporate risk register are reviewed by the Board at every public Board meeting (every two months).  Action plans are set out to mitigate risks to an acceptable level, or to remove these. |  |  | Amber / Green |  | 0.5
 |  | The Board regularly reviews quality risks in an up-to-date risk register |  | All risks on the corporate risk register are reviewed by the Board at every public Board meeting (every two months)
 |  | The Board risk register is supported and fed by quality issues captured in directorate/service risk registers |  | The corporate risk register is constructed from those risks identified in the directorates.  Strategic risks are also presented to the Board via the Board Assurance Framework.  Both the BAF and the corporate risk register are integrated, ensuring quality issues are reflected in both documents.
 |  | The risk register covers potential future external risks to quality (e.g. new techniques/technologies, competitive landscape, demographics, policy change, funding, regulatory landscape) as well as internal risks |  | External risks are identified through horizon-scanning, via all directorates, and reported in the risk register, in addition to internal risks.  An example of this is the risk to funding from the Olympics, which, following review by the Olympic Event Working Group, has been included on the Trust's risk register.
 |  | There is clear evidence of action to mitigate risks to quality |  | Action points and control measures are identified to reduce / mitigate risk to an acceptable level, or to remove the risk to the organisation.  Bulletin and Reflections newsletter highlight action undertaken to mitigate risks to quality.  Examples of action undertaken include close-scrutiny items, such as sickness absence, reviewed at the Workforce Development Committee, and CIPs, reviewed at the Finance & Business Development Committee.  Team Briefing Folders are provided to operational staff with regular updates on quality issues.
 |  | Proposed initiatives are rated according to their potential impact on quality (e.g. clinical staff cuts would likely receive a high risk assessment) |  | Where projects that impact on the Trust are identified, they are contained on the risk register and consideration given to their risk assessment (e.g. CAD, Olympics)  The Trust uses a robust assessment framework to assess risks, based on impact and likelihood.
 |  | Initiatives with significant potential to impact quality are supported by a detailed assessment that could include: - „Bottom-up‟ analysis of where waste exists in current processes and how it can be reduced without impacting quality (e.g. [NAME]) - Internal and external benchmarking of relevant operational efficiency metrics (of which nurse/bed ratio, average length of stay, bed occupancy, bed density and doctors/bed are examples which can be markers of quality) - Historical evidence illustrating prior experience in making operational changes without negatively impacting quality (e.g. impact of previous changes to nurse/bed ratio on patient complaints) |  | Business cases relating to initiatives that have a potential to impact on quality are reviewed at Board level (e.g. Front Loaded Service Model, Make Ready, Single Point of Access).  The High Performance model employed in the Trust, which includes plans to improve the Unit Hours Utilisation (UHU) rate focuses on detailed analysis of call volume, with a view to reducing unnecessary waste in the system and maximising productivity.  Similarly, the FLSM initiative considers how the Trust can improve the quality of response provided, based on comprehensive analysis of trends relating to patient calls and conditions.
 |  | The Board is assured that initiatives have been assessed for quality |  | The Trust adopts the five-case model for all business cases.  Scrutiny is given to all initiatives to consider the implications and risks to quality, with a benefits realisation considered for each programme of work. | Formalise processes for tracking benefits realisation via Programme Board.
 |  | All initiatives are accepted and understood by clinicians |  | There are formal mechanisms in place to transmit messages relating to initiatives, such as via the staff bulletin, through team briefings etc.  The Trust has identified the need to improve management capacity to deliver key messages, focussing on the recipient of the information to improve understanding.  This is being supported through the Organisational Development plan.   Champions for different initiatives support peer to peer understanding e.g. stroke champions. | Organisational Development plan in place to improve management capacity to transmit messages regarding the Trust's strategic direction through the organisation
 |  | There is clear subsequent ownership (e.g. relevant clinical director) |  | The job descriptions for the Medical Director and Director of Professional Standards & Innovation clearly set out responsibilities around delivering quality.    There is ownership for these initiatives supported by Programme Board, and other committees and groups within the Trust's governance structure, such as the Medical Group.  The Trust seeks external support and buy-in on quality initiatives, such as through Deanery meetings, engaging with commissioners, and with university and deanery groups to discuss quality issues around new clinical initiatives.  Working groups monitor the work of the Medical directorate and Professional Standards and Innovation to ensure that ownership for clinical quality is achieved. The working groups also report into the RMCGC to ensure good governance structures are maintained.
 |  | There is an appropriate mechanism in place for capturing front-line staff concerns, including a defined whistleblower policy |  | The Trust has a whistleblowing policy in place, and there is a whistleblowing hotline that is promoted regularly through the staff bulletin.  There are mechanisms in place for informal reporting of concerns through the management structure.  [NAME] and non-clinical incidents and near misses are reported formally through the "IR1" incident reporting process, and trends analysis of these incidents is undertaken and reported.  The NHS Staff Survey is also a mechanism for capturing concerns from staff, and the Trust has implemented an action plan to address areas highlighted within the staff survey. | Development of the HR dashboard, including measures relating to concerns.  Staff Survey action plan.
 |  | Initiatives‟ impact on quality is monitored on an ongoing basis (post-implementation) |  | A benefits realisation plan is in place for all service developments.  This is monitored through individual Programme Boards and reported through the Trust's governance framework. | OD strategy and Comms strategy need to  be refreshed to focus on cumulative impact of change initatives.
 |  | Key measures of quality and early warning indicators identified for each initiative |  | Business objectives are agreed for each Service Development and Service Development Enabler as part of business case development and planning.    Initiatives have identified key performance indicators that are monitored and reported to Programme Boards with some feeding through to the Corporate Dashboard where they are reported with a RAG rating.  Subjective and objective measures of risks in relation to initatives.
 |  | Quality measures monitored before and after implementation |  | Where possible baseline data is used to establish the status quo prior to implementation and to be able to demonstrate that change has made improvement   For example, conveyance rates for PPs were measured prior to and post implementation, ROSC data shows quality measures before and after the introduction of Protocol C.  As part of the introduction of Make Ready, infection control rates for vehicles and premises are measured before and after.
 |  | Mitigating action taken where necessary |  | The "Five case" model has been adopted for business cases, includign a benefits realisation, and an objective assessment of what measures are going to be and what improvements are going to be for each initiative. | Adopted this approach for more recent service developments, however historically this approach was not adopted for previous initiatives and can't be done retrospectviely.
2 | Capabilities and culture
2a | Does the Board have the necessary leadership and skills and knowledge to ensure delivery of the quality agenda? | The Board is assured that quality governance is subject to rigorous challenge, including full NED engagement and review (either through participation in Audit Committee or relevant quality-focussed committees and sub-committees) |  | The Trust's Audit Committee and Risk Management and Clinical Governance Committee consider the quality agenda (agendas, minutes).  These committees are chaired by NEDs, and have NED membership, alongside Director and senior management representation.  They scrutinise and review quality issues and escalate to the Board accordingly (Board agenda, minutes).  In addition, there are specific KPIs on the corporate dashboard that are reviewed at each Board meeting, as well as progress for delivery of business cases. |  |  | Green
 |  | The capabilities required in relation to delivering good quality governance are reflected in the make-up of the Board |  | The Trust's Medical Director is a doctor, the Director of Professional Standards & Innovation is a Consultant Paramedic, and the Director of Workforce Development is a nurse.  Other Board members have relevant skills and expertise that ensure  that quality governance is a priority at Board level, and this is given scrutiny by the Non Executive Directors.  [NAME] (of Committees) are regularly reviewed to ensure their skill set matches the requirements for the committees they are chairing.  The skills set of the relevant Executive is considered in relation to leading on Service Developments.
 |  | Board members are able to: - Describe the Trust‟s top three quality-related priorities |  | The Trust has developed a Quality Account, that has been signed off by the Board.  This identifies three key quality priorities for the Trust, which are embedded in the Trust's CQUIN programme, and delivery is monitored through the Trust's annual business plan.  The corporate dashboard includes metrics relating to quality and these are scrutinised at every Board meeting.  Board minutes and RMCGC minutes highlight Board challenge around data.  The Trust uses the internal audit processes to scrutinise and gain assurance on quality issues, as well as considering information from third parties such as regulators and registration  bodies. | Ensure continued Board engagement in future development of Quality Account -       Corporate Dashboard currently doesn't include Trust's quality priorities - work underway to include this.
 |  | Board members are able to: - Identify well- and poor-performing services in relation to quality, and actions the Trust is taking to address them, |  | The Corporate dashboard includes information on the Trust's performance on national quality initiatives (Clinical Performance Indicators) and benchmarking information is shared when available.  The Trust has identified "close-scrutiny" items, such as sickness absence management, and have action plans in place to address these, that are reported regularly through the Trust's governance framework. | Benchmarking data with comparator performance information needs to be further developed.  Staff survey action plan in place
 |  | Board members are able to: - Explain how it uses external benchmarks to assess quality in the organisation (e.g. adherence to NICE guidelines, recognised Royal College or Faculty measures). |  | Within the Professional Standards & Innovations and Medical directorates national/local clinical guidelines (such as NICE/NSF's etc) are reviewed and appropriate action implemented in the Trust.  This is reported to the RMCGC.  Mechanisms to cascade information on clinical guidelines through team briefing folders are in place.  The Trust's Pathways Sub Group, and the Clinical Governance and Innovations Working Group discusses and reviews adherence to measures.  The national report on ambulance service Clinical Performance Indicators enables the Trust to benchmark externally and to address any areas of underperformance.  This has recently been further supplemented with further audit work undertaken on specific indicators.
 |  | Board members are able to: - Understand the purpose of each metric they review, be able to interpret them and draw conclusions from them |  | The corporate dashboard is discussed at each Board meeting, with challenge from NEDs and Exec Directors regarding specific measurements and indicators. | Work is underway to formalise the link between the Quality Account and corporate dashboard.
 |  | Board members are able to: - Be clear about basic processes and structures of quality governance |  | The Director of Professional Standards & Innovation led a Board discussion on the development of the quality account.  This is further supported by external assurances in the document.  The Quality Account has been developed in line with appropriate guidance, and has been scrutinised by external groups. Issues are escalated through the Trust's governance framework.
 |  | Feel they have the information and confidence to challenge data |  | The Board challenge data received, both at Board and Committee level, as evidenced in minutes of meetings etc.  An example of this relates to interrogation of sickness absence figures, which were reported through two different sources, therefore giving different figures.  Agreement to report from a single data source was discussed at the WDC.  In relation to operational performance, a paper was presented to the Board outlining data validation processes.
 |  | Be clear about when it is necessary to seek external assurances on quality e.g how and when it will access independent advice on clinical matters. |  | An example of external assurance being sought is the independent review of ROSC rates that was undertaken nationally.
 |  | Applicants are able to give specific examples of when the Board has had a significant impact on improving quality performance (e.g. must provide evidence of the Board‟s role in leading on quality) |  | Example from Board:  A SUI highlighted a quality issue in relation to handover between the Trust and a receiving hospital, where a patient's care was compromised.  This resulted in Board level scrutiny and discussion, with an action plan being developed to improve handover between the Trust and receiving hospitals, to minimise excessive delays.  The Board continues to scrutinise this aspect of the process and requests remedial action to be taken where appropriate.
 |  | The Board conducts regular self-assessments to test its skills and capabilities; and has a succession plan to ensure they are maintained |  | There is a Board level development programme that is undertaken by an external organisation.  This is based on 360 analysis and peer review, and a Board competency framework has been developed.  The Board has developed a comprehensive organisational development programme to identify and develop its leaders of the future.  In addition, key individuals have been placed on external development programmes and have tailored personal development plans. | Succession planning for specific roles is not formalised.
 |  | Board members have attended training sessions covering the core elements of quality governance and continuous improvement |  | The Board development programme has been based on providing competencies and skills in relation to recognised good practice, such as Lean.  Individual members of the Board have attended external sessions in relation to these areas.  The Trust's principles of High performance that are embedded across the organisation are based on principles of continuous improvement.
2b | Does the Board promote a quality-focused culture throughout the Trust? | The Board takes an active leadership role on quality |  | Patient experience and quality are key agenda items for every Board meeting (Board agendas, minutes).  The Board actively reviews KPIs for clinical performance, SUIs and patient outcomes.  NEDs chair and are members of key committees that review quality. |  |  | Green
 |  | The Board takes a proactive approach to improving quality (e.g. it actively seeks to apply lessons learnt in other Trusts and external organisations) |  | The Board actively seeks to learn from external organisations, both within and external to the NHS.  An example of this process is a comprehensive review paper that was discussed by the Board on the Mid-Staffs enquiry and the learning outcomes that were applicable for the Trust have been incorporated into the Trust's plans and governance framework - e.g. patient complaints being reported at Board level.  As part of the Board development programme, case study examples of other organisations, both within and external to the NHS, are reviewed, and learning for SECAmb considered.
 |  | The Board regularly commits resources (time and money) to delivering quality initiatives |  | The Board has agreed a dedicated CQUIN programme with its commissioners, focussing on three key quality improvement areas.  Delivery of this plan is reviewed on a monthly basis with the commissioners.  Business cases for the Trust's Service Developments and Service Development Enablers are approved at Board level.
 |  | The Board is actively engaged in the delivery of quality improvement initiatives (e.g. some initiatives led personally by Board members) |  | The Board were involved with the creation/production of the Quality Account document which was published on the 30th June 2010.  Each Service Development and Service Development Enabler have an Executive sponsor.  Clinical Performance Indicators are reported to the Trust Board by the Medical Director.
 |  | The Board encourages staff empowerment on quality |  | The Trust has appointed staff champions to lead on key clinical initiatives, such as Stroke.  Our Professional Standards & Innovations directorate actively supports staff in developing clinical innovations to improve patient outcomes (such as the EZIO intra-osseous driver).     Engagement with regional developments such as Brighton Drug & Alcohol Teams ensure the Trust feeds in to both local priorities as well as national initiatives.  The Trust has identified staff leading on national clinical initiaitves such as HART, Emergency Preparedness, Stroke.  The national Royal College of Paramedics group is chaired by a member of SECAmb staff.
 |  | Staff are encouraged to participate in quality / continuous improvement training and development |  | SECAmb is committed to Key Skills training, to underpin the quality in people approach.  This is provided on a rolling 18 month programme for all staff.   External courses in universities are promoted to staff, as well as the opportunities of one-off specialist training sessions (e.g. burns trauma course at [NAME] East Grinstead).  This ensures a comprehensive programme of training is available to staff.  Continuing Professional Development can be accessed at 6 partner universities.  The Trust's training records evidence involvement in courses both internally and externally to the Trust.  Training records evidence involvement and linked to ESR.    Staff representatives are included on working groups across the Trust.  Senior operational staff have undertaken an external, SHA-supported training programme, including project management skills, continuous improvement etc. | IPDR process being further developed to provide more robust training needs analysis for individual members of staff.  Work to capture external courses for non-clinical staff.
 |  | Staff feel comfortable reporting harm and errors (these are seen as the basis for learning, rather than punishment) |  | SECAmb has adopted both a formal and informal process for staff regarding near misses, untoward incidents and critical failures.  The formal process is reported through the IR1 and SIRI process, and this information is actively published through the organisation.  The Trust also has a confidental whistle-blowing hotline, and reporting system, that is accessible to all staff.
 |  | Staff are entrusted with delivering the quality improvement initiatives they have identified (and held to account for delivery) |  | Monitoring of the delivery of the CQUIN programme and the Quality Account are undertaken through the Annual Business Plan process.  Initiatives champions are charged with, and supported in, delivery of specific clinical quality initiatives, e.g. DH Violence against Women & Children project. | Work in progress re: inclusion of the quality priorities in the ABP/directorate plans.
 |  | Internal communications (e.g. monthly news letter, intranet, notice boards) regularly feature articles on quality |  | The Trust has a number of internal communications methods including a weekly bulletin, quarterly magazine and intranet. Clinical quality features heavily in all of these mechanisms as well as more formal internal comms mechanisms such as clinical instructions, that are cascaded through Team Briefing folders.  Performance against CPIs is reported regularly and staff feedback on clinical quality is also published. Articles highlighting best practice case studies are regularly communicated to highlight quality and commend staff.   Similarly, the Trust publishes Reflections - a publication for all staff aimed at improving quality through reflective practice, highlighting incidents where care provided could be improved and ensuring that learning from those incidents is disseminated throughout the Trust, leading to improved practice.  Clinical information is made available to all staff via the noticeboards in stations. | Development of a CPI comms plan to include promotion of CPI audits and routine publication of outcomes (using audit data and internal dashboard).   Increase routine communications on clinical quality e.g promotion of clinical dashboard out to all staff, increase number of articles in internal comms channels etc.
3 | Structures and Processes
3a | Are there clear roles and accountabilities in relation to quality governance? | Each and every board member understand their ultimate accountability for quality |  | As part of the Board schedule of work, all Board members have received a briefing on the quality account.  The Board has identified nominated leads for Caldicott Guardian, SIRO, Patient Champion, medicines management and safeguarding. Responsibility for quality is included in all Job Descriptions at Board level. |  |  | Green
 |  | There is a clear organisation structure that cascades responsibility for delivering quality performance from „Board to ward to [NAME] (and there are specified owners in-post and actively fulfilling their responsibilities) |  | The Job Descriptions for the Medical Director, Director of Professional Standards & Innovation and their respective Assistant [NAME] and Heads of Department include appropriate references to responsibilities for delivering quality.    The Professional Standards & Innovation directorate has departments relating to professional standards, as well as aligned to various quality inititatives.    All Board members have references to quality responsibilities within their job descriptions and this is reflected in Director's objectives, which are monitored through the Annual Business Plan.
 |  | Quality is a core part of main Board meetings, both as a standing agenda item and as an integrated element of all major discussions and decisions |  | Quality is embedded throughout Board agenda, included on the agenda frameworks for Board and Committees, and evidenced through the minutes of meetings.  Corporate dashboard, and directorate dashboards report on key indicators, and the ABP reports progress against key service developments and service development enablers. | No standing agenda item on quality - currently integrated throughout agenda.
 |  | Quality performance is discussed in more detail each month by a quality-focused board sub-committee with a stable, regularly attending membership |  | Quality performance and initiatives are discussed by the Risk Management & Clinical Governance Committee (RMCGC agenda, minutes).  Membership of the RMCGC is monitored, and non-attendance is followed up by the Chair, with individual attendance standards required at 75%.
3b | Are there clearly defined, well understood processes for escalating and resolving issues and managing performance? | Boards are clear about the processes for escalating quality performance issues to the Board |  | The Scheme of Delegation sets out the responsibilities that are delegated from the Board.  Committees and Working Groups have agreed Terms of Reference, which set out their responsibilities and scope.  Individual staff can raise quality issues through IR1, which are reviewed, considered and as appropriate reported via the risk register. (e.g incorrect administration of drugs |  |  | Amber / Green |  | 0.5
 |  | Processes are documented |  | There is formal documentation setting out the IR1 process, and the Risk Register procedure.    Committee and Working Group Terms of Reference set out the responsibilities for reporting for those groups.                                We have achieved NHSLA Level 1 compliance.
 |  | There are agreed rules determining which issues should be escalated |  | The Trust's governance framework sets out which issues should be discussed by the Board and relevant Committees/Working Groups in accordance with their agenda frameworks (as set out in the Scheme of Delegation).
 |  | Robust action plans are put in place to address quality performance issues. With actions having: - Designated owners and time frames |  | Issues relating to quality performance are discussed at the Board (minutes), with an identified lead allocated, and subsequent monitoring undertaken.  Where appropriate, longer-term actions are embedded in the Trust's existing monitoring processes, such as the Annual Business Plan and associated Directorate Plans.
 |  | Robust action plans are put in place to address quality performance issues. With actions having: - Regular follow-ups at subsequent Board meetings |  | Where issues relating to quality performance are identified, appropriate action plans are developed, monitored and reported to the Trust Board, or relevant Committee.
 |  | Learnings from quality performance issues are well-documented and shared across the Trust on a regular, timely basis, leading to rapid implementation at scale of good-practice |  | The Trust publishes Reflections - a publication for all staff aimed at improving quality through reflective practice, highlighting incidents where care provided could be improved and ensuring that learning from those incidents is disseminated throughout the Trust, leading to improved practice.  In addition, the Trust has a professional standards department, that ensures learning is cascaded throughout the organisation and that quality performance issues are addressed in a timely fashion.
 |  | There is a well-functioning, impactful clinical and internal audit process in relation to quality governance, with clear evidence of action to resolve audit concerns |  | The Trust has an Annual Clinical Audit Plan, which includes topics for re-audit.  This is managed by the Clinical Quality & Audit Sub Group (Terms of Reference, minutes), which reports to the Clinical Governance & Innovations Working Group (Terms of Reference, minutes) to the RMCGC.
 |  | Continuous rolling programme that measures and improves quality |  | The Trust participates in the national ambulance clinical performance indicator audits, focussing on improving performance on a defined set of indicators.
 |  | Action plans completed from audit |  | As a result of the outcome of audits, plans are identified and put in place to deliver improvements and address any identified issues.
 |  | Re-audits undertaken to assess improvement |  | The national clinical audit programme is a rolling programme, with items being re-audited twice a year.  In addition, the Trust has undertaken an independent audit, to assess the organisations improvement against these indicators.
 |  | A whistleblower/error reporting process is defined and communicated to staff, and staff are prepared if necessary to blow the whistle |  | The Trust has in place a Raising Concerns at Work Policy (Whistle-Blowing Policy), which sets out the process whereby staff can raise concerns.  This includes promotion of a phone number for the "Whistle-blowing hot line", which is also promoted through the Trust bulletin.  The hotline is monitored on a regular basis, and issues that are raised through this process are dealt with in accordance with the Trust policy.
 |  | There is a performance management system with clinical governance policies for addressing under-performance and recognising and incentivising good performance at individual, team and service line levels |  | The clinical dashboard enables managers to look at clinical outcome measures by team as well as individualy. This is monitored through normal line management processes and also through the annual appraisal process. This can be evidenced by looking at staff annual appraisals. | Clinical governance policies for addressing under performance and incentivising good performance at all levels need to be formalised.
3c | Does the Board actively engage patients, staff and other key stakeholders on quality? | Quality outcomes are made public (and accessible) regularly, and include objective coverage of both good and bad performance |  | We publish quality outcomes via a number of different mediums including the website, media releases, annual report, quality account and during public engagement events such as our Shaping the future of your ambulance service events and Open Day/AGM.  The Quality Account is one example of where we are publicly reporting on both good performance/quality and areas that require improvement.  Clinical performance indicator audit data is reported to the DOCCs group nationally.  Patients and the public were also engaged in the development of the Trust's Quality account, via the six LINks within the patch.  The Corporate [NAME] includes a number of indicators relating to quality, and reports on areas of good performance, as well as under-performance. | From Oct 2010: new website will include an area on clinical quality, including CPI data, other outcome data, CQC ratings etc. This data will be published regularly whether good or bad to ensure as much transparency of information for the public as possible. |  | Green
 |  | The Board actively engages patients on quality, e.g.: - Patient feedback is actively solicited, made easy to give and based on validated tools |  | The Trust commissions patient and public satisfaction research on a two-yearly basis, with results being made available in the annual report and on the Trust website.  In addition, the Trust holds an annual series of stakeholder engagement events, entitled “Shaping the future of your ambulance service”, to which patients and the public are invited to provide feedback on trust plans, including the development of new quality initiatives, such as care pathways.  The Board reviews feedback from the above two initiatives as well as other patient and public involvement sessions on a regular basis. Patients and members of the public are invited to become members of working groups and project teams to ensure ongoing patient involvement in service developments. In addition questions are invited from the public at each public Board meeting (Board agenda / minutes); some of which have been on clinical quality. | Development of patient stories (both negative and positive) to be shared at each public Board meeting; governors and, where appropriate members, to meet with Board members when authorised as an FT; increase third manning of Board members to interact with patients first hand.
 |  | The Board actively engages patients on quality, e.g.: - Patient views are proactively sought during the design of new pathways and processes |  | Patient/public workshops over the last two years have included themes on Foundation Trust status (which yielded some elements of our constitution, e.g. number of public members, membership age; new Trust website testing; consent and capacity policy; input into a feasibility study for a research project (use of oxygen in MI patients); introduction of paramedic practitioners in Medway (in conjunction with the PCT).  Many of the Care Networks, for example Stroke, have patient representatives to ensure that patients are able to feed into the develoment of new pathways.
 |  | The Board actively engages patients on quality, e.g.: - All patient feedback is reviewed on an ongoing basis, with summary reports reviewed regularly and intelligently by the Board |  | Feedback from patients (complaints, compliments, PALS and Shaping the Future) is regularly reviewed, with comprehensive reports provided to the RMCGC, and summary reports provided to the Trust Board.
 |  | The Board actively engages patients on quality, e.g.: - The Board regularly reviews and interrogates complaints data |  | A Patient Experience report is presented and reviewed at every public Board meeting (bi-monthly), and complaints summary data is included on the corporate dashboard.
 |  | The Board actively engages patients on quality, e.g.: - The Board uses a range of approaches to „bring patients into the Board room‟ (e.g. face-to-face discussions, video diaries, ward rounds, patient shadowing) |  | The Trust commissions patient and public satisfaction research on a two-yearly basis, with results being made available in the annual report and on the Trust website.  In addition, the Trust holds an annual series of stakeholder engagement events, entitled “Shaping the future of your ambulance service”, to which patients and the public are invited to provide feedback on trust plans, including the development of new quality initiatives, such as pathways.  The Board has a patient representative with speaking rights at the table for all public Board meetings.   The Board reviews feedback from the above two initiatives as well as other patient and public involvement sessions on a regular basis. In addition questions are invited from the public at each public Board meeting (Board agenda / minutes); some of which have been on clinical quality.
 |  | The Board actively engages staff on quality, e.g.: - Staff are encouraged to provide feedback on an ongoing basis, as well as through specific mechanisms (e.g. monthly „temperature gauge‟ plus annual staff survey) |  | Every quarter a temperature check is undertaken amongst a random sample of staff - questions include ones on clinical quality. In addition the Board reviews the annual NHS staff survey feedback and monitors the resulting action plan via the Workforce Development Comittee (Agenda / minutes). Staff feedback is also invited at Shaping the Future events attended by Board members; again, the Trust Board reviews feedback from these events and builds it into future planning. | Board visit programme by ODA to be developed, with a focus on clinical quality.  Staff feedback re clincial quality to be built into CPI comms plan to ensure that it is collected, reviewed and acted upon consistently.
 |  | The Board actively engages staff on quality, e.g.: - All staff feedback is reviewed on an ongoing basis with summary reports reviewed regularly and intelligently by the Board |  | In addition to the NHS Staff survey that is undertaken annually, the Trust has developed a process whereby quarterly "temperature" checks are undertaken, to assess staff feedback on key issues.  Feedback from these is provided to the Trust Board.  A "Shaping the Future" report is provided to the Board with recomendations for the future. the recomendations are developed as a result of staff, patient and public suggestions at the events. These recomendations are built into the ABP and then monitored at subsequent Shaping the Future events.
 |  | The Board actively engages all other key stakeholders on quality, e.g.: - Quality performance is clearly communicated to commissioners to enable them to make educated decisions |  | Stakeholders including NHS partners, commissioners and third sector organisations are invited to attend "Shaping the Future" events to provide feedback on Trust plans, many of which relate to improving clinical quality. Board members attend each event and there is opportunity for Q&A with Board members.  The Trust recently developed its first Quality Account and ensured patient/public involvement via Local Involvement Networks (LINks).   LINks were invited to comment on the draft document and will be consulted in the ongoing development of SECAmb quality accounts.  Regular meetings on quality are held with commissioners ([NAME], minutes). The Quality Account has been shared with commissioners and HOSCs throughout SEC. CPI information and care pathways developments are discussed regularly at commissioning meetings. There is also patient representation at commissioning meetings.
 |  | The Board actively engages all other key stakeholders on quality, e.g.: - Feedback from PALS and LINKs is considered |  | Feedback from LINKs and HOSCs was sought and included in the Trust's Quality Account.  The Trust has fostered good relationships with the six LINks within the area, and attends meetings and responds to enquiries on request.  PALS feedback, along with feedback from complaints, is incoporated into the Patient Experience report provided to the SECAmb RMCGC and Trust Board (bimonthly) and commissioners (quarterly).  LINks and their participants are invited to the Trust's 'Shaping the future' events and are encouraged to become members of the Trust and to become as involved as they are able to be.
 |  | The Board actively engages all other key stakeholders on quality, e.g.: - For care pathways involving GP and community care, discussions are held with all providers to identify potential issues and ensure overall quality along the pathway |  | Urgent Care networks have representation from the GP community, acute sector and the community sector. Care pathways are agreed and developed through these routes.Executive Board members, staff from the Business Development Team and operational managers attend all urgent care network meetings throughout SEC.  On larger projects, for example, the implementation of NHS Pathways, which will have an impact on the way that urgent care is managed within primary care, GPs are engaged on an individual basis, through bespoke events, at PBC cluster meetings and LEC meetings. These discussions focus on improving the patient experience and ensuring high clinical quality. Project teams in each local PCT area have representation of community services and community Trusts have been individually engaged around this programme. |  |  | green
 |  | The Board actively engages all other key stakeholders on quality, e.g.: - The Board is clear about Governors‟ involvement in quality governance |  | Governors will be involved in quality governance through the business development process, ie, shaping what the Trust plans to do the following year, through Shaping the Future events and through quarterly monitoring of the Corporate Dashboard which will be provided to the Governors for information. As governors will be key in patient and public engagement their feedback on quality will also be invaluable.  Governors will  be provided with time on the public Board agenda to rasie any concerns to the Trust Board and to update them on the work they are carrying out. | Consider Governor oversight of the Quality Account |  | green
4 | Measurement
4a | Is appropriate quailty information being analysed and challenged? | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Key relevant national priority indicators and regulatory requirements |  | The Trust has in place a Corporate [NAME], which is reviewed by the Board on a monthly basis.  Tolerances are set for indicators included on the dashboard, and are regularly reviewed.  For indicators where tolerances are Amber or Red, an exception report is provided.  The dashboard includes national priority indicators for example response time targets and STEMI. |  |  | Amber / Green |  | 0.5
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Selection of other metrics covering safety, clinical effectiveness and patient experience (at least 3 each) |  | The corporate dashboard is linked to Trust's strategic objectives, and includes indicators on safety (5 indicators), clinical effectiveness (7 inidcators) and patient experience (4 indicators).
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Selected advance warning indicators |  | UHU levels provide the Tust with advance warning indicators as if the UHU levels are not on target this informs potential difficulties around performance as well as finance. | Tolerances for advance warnings should be developed.
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Adverse event reports |  | Adverse events are discussed at private Board meetings as and when necessary. All SIRIs are reported to the Board in summary form through the corporate dashboard. A trend analysis and summary is also reported to the Board annually.
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Measures of instances of harm (e.g. [NAME]) |  | The number of staff injuries and assaults are reported through the corporate dashboard.
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Monitor's risk ratings (with risks to future scores highlighted) |  | Financial risk ratings are included in the Trust's dashboard, with monthly information, year to date information, and a full year forecast provided.
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Where possible/appropriate, percentage compliance to agreed best-practice pathways |  | Thrombolysis and pPCI are two indicators that are reported on a percentage compliance basis. However, this is not routine for all agreed best practice pathways. This information is mostly monitored through the clinical networks. | % compliance to pathways is not formally recorded although this information is analysed at clinical network meetings. This information should also be reviewed by the Board
 |  | The Board reviews a monthly dashboard of the most important metrics. Good practice dashboards include: - Qualitative descriptions and commentary to back up quantitative information |  | The exception reports that accompany the Corporate [NAME] provide qualitative descriptions for targets that are not being met.   Patient stories have been included on the public Board agenda to provide qualitative information around service performance and clinical quality.
 |  | The Board is able to justify the selected metrics as being: - Linked to Trust‟s overall strategy and priorities |  | The indicators contained within the corporate dashboard are mapped to the Trust's strategic objectives.  The metrics contained within the dashboard are reviewed on a six-monthly basis to ensure they are fit for purpose. | Work is underway to report the quality priorities set out in the Quality Account with the dashboard.
 |  | The Board is able to justify the selected metrics as being: - Covering all of the Trust‟s major focus areas |  | The indicators contained within the corporate dashboard are mapped to the Trust's strategic objectives.  The metrics contained within the dashboard are reviewed on a six-monthly basis to ensure they are fit for purpose.
 |  | The Board is able to justify the selected metrics as being: - The best available ones to use |  | The corporate dashboard provides the Board the opportunity to monitor and benchmark SECAmb performance with other ambulance trusts for clinical quality indicators and response times. There are no other nationally collected metrics.   The Trust intends to increase the monitoring of outcome measures following targeted work with local acute Trusts. | Outcome measures that are dependent upon acute provider data will be progressed in order to ensure that the entire patient journey is being reviewed.
 |  | The Board is able to justify the selected metrics as being: - Useful to review |  | The metrics that are monitored through the dashboard inform strategic decisions around service delivery and areas for close scrutiny. This enables the Board to assure themselves of good clinical quality and achievement of performance targets.
 |  | The Board dashboard is backed up by a pyramid of more granular reports reviewed by sub-committees, divisional leads and individual service lines |  | The Board agenda framework sets out the information the Board reviews, and this is underpinned by the agenda frameworks for the Audit Committee, Risk Management & Clinical Governance Committee, Workforce Development Committee and Finance & Business Development Committee. For some committees there are working groups (again with agenda frameworks) that  report to the committees and action recomendations made at committee level. Relevant reports and actions are discussed at directorate meetings where necessary.  Information and reports receive further review and scrutiny at Committee level, with summary reports being provided to the Trust Board, and issues escalated as required.
 |  | Quality information is analysed and challenged at the individual consultant level |  | Clinical Team Leaders have responsibility to analyse and challenge clinical staff on  their performance. This is done through routine appraisal meetings as well as staff supervision within staff bases. | As appraisal levels are not yet 100% it is difficult to evidence challenge occurring for all staff. Staff appriasals for oeprational staff need to be rolled out fully.
 |  | The Board dashboard is frequently reviewed and updated to maximise effectiveness of decisions; and in areas lacking useful metrics, the Board commits time and resources to developing new metrics |  | The Corporate [NAME] is reviewed on a six-monthly basis, to ensure that appropriate KPIs are being monitored and reported.    Engagement in development of and revision of existing metrics is sought from Board members. | The Trust is working towards increasing the number of outcome measures monitored by the Board
4b | Is the Board assured of the robustness of the quality information? | There are clearly documented, robust controls to assure ongoing information accuracy, validity and comprehensiveness |  | The Trust uses info.secamb as an electronic tool for generating reports and for data analysis. The data provided within this data warehouse is regularly audited to ensure its accuracy. | The Trust needs to ensure that data accuracy reported through the committee/ working group structure. |  | Amber / Green |  | 0.5
 |  | Each directorate/service has a well-documented, well-functioning process for clinical governance that assures the Board of the quality of its data |  | Clinical governance within the Operations directorate is addressed through the managment meetings which are supported by clincal leads. These meetings are minuted and evidence of service change as a result of learning from clinical events can be evidenced. | Need to ensure that clinical governance can be evidenced throughout all services.
 |  | Clinical audit programme is driven by national audits, with processes for initiating additional audits as a result of identification of local risks (e.g. incidents) |  | The Trust has a Clinical Audit Annual Plan, which sets out the audits to be undertaken in year.  The Trust is an active participant in the national ambulance audit programme.  Where local risks are identified additional audits may be requested through the Clinical Quality & Audit Sub Group that reports to the Clincial Governance & Innovations Working Group to the RMCGC.
 |  | Electronic systems are used where possible, generating reliable reports with minimal ongoing effort |  | info.secamb is available to all staff within the Trust and commissioners. The data warehouse provides staff with access to Trustwide, team based, individual based clinical quality and response time information. The system is realtime and generates routine reports as well as can be responsive to specific requests for information.
 |  | Information can be traced to source and is signed-off by owners |  | Information about clinical quality, patient data and response times can be attributed to an individual. All patient report forms are signed by members of staff.
 |  | There is clear evidence of action to resolve audit concerns |  | Evidence can be seen both in the change in metrics identified on the corporate dashboard for some audit concerns, staff sickness for example, and evidence of action taken can be seen within working group papers, changes in policies, L&D programme content and team briefing folder updates.
 |  | Action plans are completed from audit (and subject to regular follow-up reviews) |  | Audit action plans are followed up through the Clinical Quality & Audit Sub Group. | Need to review action plans on a more routine basis.
 |  | Re-audits are undertaken to assess performance improvement |  | Re-audits are undertaken throughout the year for the clinical quality performance indicators. This has enable the Trust to evidence ongoing improvement in most areas. The development of the annual audit plan also includes a review of the previous years audits to assess need for reaudits to be undertaken.
 |  | There are no major concerns with coding accuracy performance |  | AMPDS, the Trust's triage software, uses different clinical coding to the national data set. There are no concerns about how this works although it is recognised that it does not match to that national clinical codes which makes comparison of acute/ GP and SECAmb information difficult. Patient Care Records are scanned onto the system and there is not 100% compliance for all records. | Ensure ongoing audit and improvement of PCRs uploaded onto info.secamb.
4c | Is quality information being used effectively? | Information in quality reports is displayed clearly and consistently |  | The Trust's Quality Account document is available on the website and on the NHS Choices website.  (Hard copies are also available upon request). |  |  | green
 |  | Information is compared with target levels of performance (in conjunction with a R/A/G rating), historic own performance and external benchmarks (where available and helpful) |  | The Corporate [NAME] reports KPIs in relation to target performance (using a RAG rating), as well as considering historic performance and trends..  External benchmarks are used for response time targets and clinical quality indicators.
 |  | Information being reviewed must be the most recent available, and recent enough to be relevant |  | Information contained within the Corporate [NAME] reports on the previous month's performance.  Realtime reporting for performance and other metrics is available and is reported where appropriate.
 |  | On demand data is available for the highest priority metrics |  | SECAmb has an excellent system for accessing key quality performance information through the web-based info.secamb system.  Response time and clinical quality information (through the clinical dashboard) is available through this system.
 |  | Information is humanised/personalised where possible (e.g. unexpected deaths shown as an absolute number, not embedded in a mortality rate) |  | SIRIs are reported as whole numbers rather than percentages. Where SIRIs require closer scrutiny the patient journey is described.
 |  | Trust is able to demonstrate how reviewing information has resulted in actions which have successfully improved quality performance |  | The 'Incident Review Group' was established for when issues/ trends around clinical quality have been identified through normal procedures. An example would include an incident where there were a number of drug errors for anaphalaxis during treatment. The Incident Review Group produced aid memoirs which were then sent to staff. There have been no further instances of this incident occurring;  this is monitored through routine review of drug errors and SIRIs.
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