Using the elements of the EiC framework

Quality of care review guidance
Healthcare Improvement Scotland

Excellence in Care (EiC) framework

  • Fundamentals of care

  • Communication

  • Compassion

  • Person-centred care

  • Maintaining Quality

  • Planning for Quality

  • Improving Quality

  • Safety

  • Evidence & standards

  • Workforce

  • Culture

  • Staff wellbeing

  • Leadership

  • Learning

  • Assurance

  • Governance

 

Using the elements of the EiC framework to inform a QoC review:

  • Examples of quality and safety indicators for each element of the EiC framework and potential sources of information (fact finding, observational and discussion) are provided below. This list is not exhaustive, and consideration of the scope and the remit of the QoC review should be taken into account when identifying relevant quality and safety indicators.

  • Using local knowledge and expertise, a number of other relevant speciality specific quality and safety indicators may need to be considered for inclusion.

  • Consider which of the elements of the EiC framework are most appropriate to inform the questions being asked within the QoC review, the best way to gather the required information and how this will be triangulated.

  • It is not essential to use all of the elements, professional judgement and the scope of the QoC review will determine which elements to use.

  • Note that some areas of practice will impact a number of different elements of the EiC framework at the same time.

  • The HIS QA framework has informed our consideration of how to apply the elements of the EiC Framework for care assurance purposes (see Excellence in Care elements mapped to quality assurance framework and Healthcare Improvement Scotland quality assurance framework).

Fundamentals of care

Example quality and safety indicators

  • SPSP and CAIR dashboard data such as Inpatient Falls rate, Food Fluid & Nutrition measures, Early Warning Scores and Pressure Ulcer rates
  • Waiting times –inpatient and out patient services
  • Length of stay, number of delayed discharges
  • Caseload size and complexity
  • GIRFEC assessments.

Fact finding

  • CAIR and/or local dashboard data – workforce and quality measures
  • Key performance indicators held on local and national dashboards e.g. Discovery.

Observational

  • Observe the person in receipt of care within the clinical area/community setting noting their needs, have these been met? For example hydration, nutrition, safety, communication, child development, inactivity and deconditioning, comfort and analgesia.

Discussion

  • Show me examples of documentation related to risk assessment, care planning and care delivery covering the fundamentals of care recorded by the multi-disciplinary team
  • What audits do you currently undertake, how have you responded to results?
  • What improvement work have you identified/progressing?

Person centered care

Example quality and safety indicators

  • Care plan and bundle audits (SPSP)
  • Waiting times – inpatient and outpatient services
  • Length of stay, number of delayed discharges
  • Trauma informed care
  • Anticipatory care planning
  • Therapeutic Indicators.

Fact finding

  • Local dashboard
  • Key performance indicators held on local and national dashboard e.g. Discovery.

Observational

  • Review examples of care planning (for example birth plan) and “Getting to Know Me”/”My World Assessment” documents to see how care is individualised. Does this match with what you observe?
  • Can you give examples of when you have observed patients and families being treated with dignity and respect? (or not).

Discussion

  • Speak to person/child in receipt of care about their experience. Ask about the person/child experience and how it feels being cared for in this area. Consider questions such as:
    • Do you feel safe?
    • Do you feel listened to with understanding and compassion?
    • Are services working well together to support you to achieve your goals?
    • Has clear and understandable information been provided, helping you to make the right decisions?
    • Is care supporting you to achieve the goals that are important to you?

Compassion

Example quality and safety indicators

  • Care opinion, patient experience team, complaints or adverse events
  • Trauma informed care.

Fact finding

  • Local dashboard.

Observational

  • How are staff interacting with person/child in receipt of care and families in person and on the phone?
  • Staff interactions with one another throughout the day and during huddles/handovers.

Discussion

  • Ask staff about how they feel about the escalation processes and how they work in practice.

Communication

Example quality and safety indicators

  • Care opinion, patient experience team or advocacy, complaints or adverse events
  • Continuity of care.

Fact finding

  • Risk assessment process and feedback measurement
  • Use or uptake of interpretation and translation services.

Observational

  • Observations of safety huddles and team handovers
  • The use of escalation processes and staff feedback
  • Observations between staff, staff and people in receipt of care.

Maintaining quality (Often called Quality control)

Monitoring performance in real time and taking action to reduce variation

Example quality and safety indicators

  • SPSP and CAIR dashboard
  • Data from other sources –qualitative and quantitative.

Fact finding

  • What are the indicators of quality and safety telling you, what are the data signals, intelligence around how assured you are that the service is delivering safe and effective person-centred care (outcomes)
  • Are there clear escalation processes for when additional support is required? ie when the data is signalling concerns –who is advised and what support is available.

Observational

  • What data do the local team have access to- quantitative and qualitative? How informed are the team?
  • How are they using the data to drive improvement? Where is the evidence?
  • Are they working in a culture which enables them to make any required changes at a team level? Psychologically safe.

Discussion

  • Do the team know what good looks like/work towards a standard they have agreed?
  • How frequently do teams access data about the quality of their care e.g the CAIR dashboard and what happens as a result?
  • How are they using the data to drive improvement? Where is the evidence?
  • Are they working in a culture which enables them to make any required changes at a team level? Psychologically safe.

Planning for quality (Often called Quality planning)

Choosing priorities for improvement and designing intervention to deliver improvements

Example quality and safety indicators

  • Board data for Scottish Government targets such as waiting times
  • SPSP, CAIR and local dashboards.

Fact finding

  • How is the service performing in relation to Scottish Government/Board targets?
  • Demand for service/any signals in the data e.g. referrals, waiting times, quality measures
  • What are the indicators of quality and safety telling you, what are the elements of the EiC Framework that you need to plan to support improvement? (Data signals in the system).

Observational

  • Is the service set up appropriately to deliver the goals/purpose of the service-capacity, flexibility during periods of increased demand?
  • Which quality indicators are being used- what are the team working on, QI culture evident?

Discussion

  • What do people in receipt of care want from the service?
  • What does the service want to deliver?
  • Which quality indicators are being used- what are the team working on, QI culture evident?

Improving quality (Often called Quality improvement)

Small iterative tests of change to improve quality of care and outcomes

Example quality and safety indicators

  • QI qualifications within the area such as ScLIP, SiFS, ScIL or local training programmes
  • QI team support
  • Examples of QI testing and learning.

Fact finding

  • What are the elements of care that need to be reviewed and improved upon to support the delivery of safe and effective care – how will we know there has been an improvement?

Observational

  • What QI work is happening locally?
  • What support is available for the team?
  • Who in the team is involved in QI work?
  • How is learning from tests of change communicated/shared at team level and wider?

Discussion

  • What QI work is happening locally?
  • What support is available for the team?
  • Who in the team is involved in QI work?
  • How is learning from tests of change communicated/shared at team level and wider?

Workforce

Example quality and safety indicators

  • CAIR dashboard such as establishment variance, predictable absence allowance and supplementary staffing use (bank and agency/overtime and excess)

  • Staffing Level Tool (SLT) run.

Fact finding

  • Identify any establishment variance, duration of and any mitigating actions being put in place to address staffing gaps

  • Use of supplementary staffing and the breakdown by category – agency, bank, excess hours – placement of supplementary staffing –to ensure Safe Delivery of Care

  • Sickness absence - long and short term - themes

  • Date of last Staffing Level Tool (SLT) run, was the Common Staffing Method used - how were the results communicated to the teams, have they been implemented?

Observational

  • Is Real Time Staffing system and process robust – is there recording of mitigations, severe and recurring staffing risks with feedback to staff?

  • How are recurring staffing risks captured and triangulated with quality and patient outcomes/ staff well-being?

  • Using the Professional Judgement of the nurse/midwife/team lead in charge of each shift, is the identified skill mix for safe staffing being met? If not, what mitigation in place?

  • Are there documented and well understood processes for how to deal with surge capacity/additional beds/complexity within caseload and caseload size? What is observed regarding patient placement, maintenance of dignity, potential harm?

  • Use of supplementary staffing and the breakdown by category-agency, bank, excess hours – placement of supplementary staffing – to ensure Safe Delivery of Care.

Discussion

  • How are recurring staffing risks captured and triangulated with quality and patient outcomes/ staff well-being?

  • Using the Professional Judgement of the nurse/midwife in charge of each shift, is the identified skill mix for safe staffing being met? If not, what mitigation in place?

  • Are there documented and well understood processes for how to deal with surge capacity/additional beds/complexity within caseload and caseload size? What is observed regarding patient placement, maintenance of dignity, potential harm?

Evidence & standards

Safe, consistent care is delivered by a skilled workforce utilising evidence and best practice

Example quality and safety indicators

  • Board data for Scottish Government targets such as waiting time targets
  • CAIR dashboard data such as QMPLE Score and QMPLE Student Feedback measures
  • Annual Review, professional development and relevant registration (NMC, HCPC)
  • GIRFEC/GIRFE/UNCRC/Pathway 4 (CfSD - Discharge without delay).

Fact finding

  • How are speciality specific standards used within the service?
  • Are there any gaps in the use of evidence/best practice standards to inform local procedures?
  • What are the local processes for raising awareness of updated standards/best practice? How are these then implemented?

Observational

  • What planning for quality improvement work is being driven by service specific standards? What progress being made?

Discussion

  • How are speciality specific standards used within the service?
  • What are the local processes for raising awareness of updated standards/best practice? How are these then implemented?

Safety

Paramount to quality care, combining the reduction of risk and unnecessary harm while maximising the successful implementation of care

Example quality and safety indicators

  • SPSP, CAIR and/or local dashboard

  • Use of Mental Health Act –restraint, covert medication, capacity

  • Incident reporting systems

  • Care Opinion, Patient Experience Team, Complaints

  • Real Time Staffing and Escalation.

Fact finding

  • What harm has affected patients/near misses?

  • Adverse events/incidents - any patterns emerging in individual units/across the wider system?

  • Incident reporting systemreports- any themes emerging?

  • Complaints- any themes emerging?

  • Consider staffing data- Real Time Staffing recording and escalation, establishment variance, supplementary staffing use, skill mix, compliance with the guiding principles of HCSA (to provide safe and high-quality services, and to ensure the best health care or care outcomes for service users), how much time the Team Leader has to lead

  • SPSP data available- any themes emerging, mortality reviews and any learning?

Observational

  • What is the safety culture in this clinical area?

  • Infection Prevention and Control Procedures- what audits are undertaken (any themes), are improvement plans fully implemented?

  • Medicines safety and storage processes, omissions/errors

  • Consider staffing data- Real Time Staffing recording and escalation, establishment variance, supplementary staffing use, skill mix, compliance with the guiding principles of HCSA (to provide safe and high-quality services, and to ensure the best health care or care outcomes for service users), how much time the Team Leader has to lead.

Discussion

  • Consider staffing data- Real Time Staffing recording and escalation, establishment variance, supplementary staffing use, skill mix, compliance with the guiding principles of HCSA (to provide safe and high-quality services, and to ensure the best health care or care outcomes for service users), how much time the Team Leader has to lead.

Leadership

Importance of co-designing improvements to co-produce the outcome with people in receipt of care and the team who deliver it

Example quality and safety indicators

  • Time to Lead
  • TURAS – training and appraisal.

Fact finding

  • Consider duration/experience of Team Leader in a leadership role and their preparation/training and support available within the role
  • What protected leadership/management time is available (agreed as per local governance arrangements) and how is it utilised? If unable to protect the agreed leadership time, then risk and mitigations should be recorded
  • How often do the team get a one to one/supervision opportunity to discuss current workload and any support requirements?
  • What is the system for annual appraisal and is it effective?

Observational

  • How are decisions that impact on the team made and then communicated?
  • What protected leadership/management time is available (agreed as per local governance arrangements) and how is it utilised? If unable to protect the agreed leadership time, then risk and mitigations should be recorded.

Discussion

  • Consider duration of Team Leader in a leadership role and their preparation/training and support available within the role
  • How often do the team get a one to one/supervision opportunity to discuss current workload and any support requirements?
  • What is the system for annual appraisal and is it effective?
  • How are decisions that impact on the team made and then communicated?

Culture

Impacts staff wellbeing, patient safety, embedding quality improvement and innovation in day to day practice

Example quality and safety indicators

  • Staff feedback such as iMatter, Joy in Work

  • Board data for Scottish Government reporting such as whistleblowing

  • Information from previous Reviews

  • PDWR/Appraisal

  • Staff professionalism

  • PSDS Safety Culture Cards.

Fact finding

  • Is there a clear vision for the service?

  • Are staff aware of how they contribute towards that vision? If appropriate, are individual objectives available?

  • iMatter survey and improvement plan.

Observational

  • Are teams encouraged to problem solve and innovate within clear boundaries?

  • Is psychological safety evident - do people express concerns openly?

  • How do individuals deal with differences of opinion?

Discussion

  • Are staff aware of how they contribute towards that vision? If appropriate, are individual objectives available?

Staff wellbeing

Essential for the delivery of compassionate, person centred care

Example quality and safety indicators

  • CAIR dashboard such as Predictable Absence Allowance, Establishment Variance measures
  • iMatter, Joy in Work
  • TURAS - Appraisal and Training.

Fact finding

  • What development opportunities have the team engaged in recently- clinical skills, leadership development?

Observational

  • Do staff feel supported by their immediate team and wider leadership and know where to go for support on both clinical and operational issues?
  • Are these clear lines of delegation for decision making which are known by everyone in the team, with clear lines of escalation for issues?
  • Do staff get their breaks? What are their break facilities like? o What wellbeing activities are readily available for staff including access to spiritual care team?

Discussion

  • What opportunities are there to access Clinical Supervision, Values Based Reflective Practice sessions, other methods of supporting reflective practice?
  • Do staff feel supported by their immediate team and wider leadership and know where to go for support on both clinical and operational issues?
  • Are these clear lines of delegation for decision making which are known by everyone in the team, with clear lines of escalation for issues?
  • Do staff get their breaks? What are their break facilities like?
  • What wellbeing activities are readily available for staff including access to spiritual care team?
  • Do the team undertake de-brief activities after particularly challenging periods/episodes of care delivery?
  • Application of NHS Scotland Workforce Policies.

Assurance

Verifying whether the team/system have effective approaches to managing quality of care

Example quality and safety indicators

  • Local dashboards.

Fact finding

  • Who undertakes local assurance processes?

  • Are assurance processes available at different levels of the organisation and are there clear escalation processes?

  • Is the frequency of assurance processes sufficient to pick up early signals within the system?

  • Is the scope of local assurance processes sufficient to meet your needs? Consider the domains of care quality -patient experience, safety, effectiveness, efficiency, sustainability.

Discussion

  • What local systems currently provide assurance of high-quality, safe and person-centred care- e.g. audits, walk rounds, scrutiny of quality information at governance meetings.

Governance

Shared governance emphasises the perspective of staff, shared decision making and professional accountability therefore aligning governance with culture and staff wellbeing

Example quality and safety indicators

  • Risk Assessment and Escalation processes
  • Visible and effective governance
  • Child protection/Adult support and protection.

Fact finding

  • Is there a process to flag signals in the data and identify areas for improvement activity and additional support?
  • Are there standardised risk escalation processes and are they effective?
  • Is there a feedback loop for staff who have escalated risk?
  • Who reviews quality and workforce measures for this service? Who else?

Observational

  • Are there standardised risk escalation processes and are they effective?

Discussion

  • Is there a feedback loop for staff who have escalated risk?
  • Who reviews quality and workforce measures for this service? Who else?

Learning

Consider if there is evidence of a culture of continuous learning across the system

Example quality and safety indicators

  • Clinical Supervision
  • TURAS – Appraisal and Training
  • QI qualifications within the area such as ScLIP, SiFS, ScIL or local training programmes
  • Hot/Cold debriefs
  • Protected learning time
  • TURAS learning

Fact finding

  • How do the team/wider system share learning from adverse events/incidents, near misses, positive care experiences?
  • Identify if there is a system in place to ensure staff receive the required training for their role with the time and resources to support this

Discussion

  • What opportunities are there to access Clinical Supervision, Values Based Reflective Practice sessions, other methods of supporting reflective practice?
  • What system is in place to ensure staff receive the required training for their role with the time and resources to support this?
  • What time available to engage with Leading Excellence in Care Education and Development Framework?