Heartbeat: Self-assessment tool provides helicopter view of care
June 30, 2021
Ensuring that Care Quality Commission (CQC) domains are embedded into the ethos of all teams to give assurance that care is safe, effective and of a high standard every day not just when an inspection is due is an ambition of the senior leaders within iCares.
When thinking about how they could better embed the CQC domains, the iCares leadership team felt they needed to have a helicopter view of how care was being delivered within the directorate.
Denise Owen, Deputy Clinical Directorate Lead told us: “It was important that all teams were involved and owned the whole process of the CQC self-assessment, action plans and shared learning.”
Along with Mike Lewis, iCares Business Support, Denise developed an electronic self-assessment tool. The tool has tabs with definitions, each domain (safe, effective, caring, responsive, and well led), summary sheets with pie charts and an evidence page. Each domain tab has questions which the CQC lead selects the rating from a drop down list. The ratings are colour coded and automatically populate the pie chart which makes the tool very visual for teams to map progress going forward. Colleagues can also use the tool to identify three examples of good practice and three examples of actions they will take to improve their rating at the next audit.
Denise added: “Following a successful pilot with the continence team, the decision was made to roll out the tool to all teams within the directorate. An audit project plan was developed including identifying CQC leads from each team, training on the use of the tool, ongoing support, timescales to complete the audit, collation of data and quality assurance by the senior leadership team.
“Even throughout this pandemic, I feel that we have been able to maintain the momentum of the CQC assessments by identifying the CQC leads in each team who have agreed to be responsible for this audit for 12 months. They will receive a certificate after each self-assessment which they can use as evidence when registering with professional bodies.”
The leads are responsible for:
- Completing the tool on behalf of their team
- Gathering evidence to support the tool
- Presenting results to iCares directorate and their own teams
- Developing action plans with teams support and keep updated
- Doing an audit every three months
The self-assessment tool has been well received by colleagues who have commented:
“Thanks so much for creating something so easy to use, and genuinely useful to help recognise where we are brilliant, and where perhaps we need to tighten up some processes.”
“I have enjoyed working on this with the team and it definitely gives us actions.”
Audit results have been shared at the directorate quality and safety meetings. And overall summary sheets have been printed and displayed in prominent areas. Initially there were plans for quality assurance to take place in January and for the CQC leads to re-audit in February but due to the pandemic, this has been paused with a plan to restart in April.
“The tool has really given us a helicopter view of the CQC compliance for the whole directorate – which we have never had before,” added Denise.
The audit has given the teams an opportunity to:
- Have assurance around patient safety and quality
- Help improve patient care
- Plan 2021-2022 training to address some of the gaps identified
- Plan 2021-2022 QIHDs around service needs
- Provide leadership support around areas that require improvement
- Work with teams where gaps are identified
- Share good practice within the directorate and group
The tool has now been rolled out across PCCT.