Sandwell and West Birmingham NHS Trust Occupational Health and Wellbeing service

Accredited July 1st 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 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

• 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, HealthAssessments, 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 reviewACTION: already in review process, new policies

should be available in November 2011

• Additionso Working with Tempus to improve cohort data collection

systems to aid SEQOHS accreditationo 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