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Issue 21 Assurance and Winter 2013 Accreditation News

of our dementia dashboard and standards and consultancy Highlights from 2013 support, which make up the assurance programme.

2013 has been a year for consolidation The standards development team, as always, has continued and reflection following the significant to develop and maintain our programmes of standards. The changes in 2012. This year we said main achievement was the publication of the International goodbye to Ruth Wright, a long term Accreditation Programme for healthcare organisations 2013. client manager, who has left us for Updated using a patient pathway approach, and the modules as the pleasures of retirement which we a framework, we are excited by the end product which is a step hope she is embracing. In the summer, forward from the 2010 standards. Other programmes completed we were shocked by the sudden death of Julie Hyde, our in 2013 were the domiciliary standards and the oncology Accreditation Awards Panel chairman, which is a great loss to standards. The primary care standards are out for consultation, us. Her legacy will remain in the many structures and processes and work is very much underway on revising the hospice and implemented during her tenure and the memory of her ‘matter care home standards for completion in the first half of 2014. of fact’ approach to life. Alan Corry Finn has now taken on the chairmanship. Regulation and inspection As a result of the Francis, Keogh and Berwick reports there has Celebrating success been notable change in the regulation and inspection of health At our Top Hospitals ceremony in May, Guy’s and St Thomas’ and social care organisations in hospital was the winner of the dementia care award for their the UK this year. CHKS have been progress in implementing a trust wide dementia strategy and vocal in promoting both our In this issue the impact made on the culture of their organisation. How to data services and accreditation support those who suffer from dementia remains a top priority programmes as approaches n Highlights from 2013 across health services, with a G8 Dementia Summit being which can provide an evidence n New chairman for held in London this December, and it will continue to be a key based framework, support the the CHKS Accreditation programme for CHKS. We also congratulated Cappagh National understanding of risk, and give Awards Panel Orthopaedic Hospital, Ireland and Ygia Polyclinic, Cyprus on the necessary assurance that their CHKS continuous quality awards through accreditation health and social care services n ISQua Conference 2013 practice and learning. are providing a high quality n Standards developments service. We remain in contact We are excited to have several new clients this year including with both the CQC and Royal n Organisations accredited ambulance trusts and a primary care service in Ireland, a specialist Colleges through the health and n 2013 UKAS assessment neurological care home, and haematology and oncology services social care accreditation forum n Surveyor up-date in hospitals in the south of England. Alongside dementia, our and believe there are some event: 5 March 2014 assurance programme now includes maternity and we hope exciting opportunities ahead. to grow our customer base further in this area. We have been n Surveyor Selection working with Barking, Havering, and Redbridge NHS Trust to Moyra Amess, Event 2013 implement their dementia care programme with the support Associate Director, CHKS n Farewell to Amy Lewis Highlights continued...

New chairman for the CHKS Accreditation Awards Panel

In September, Alan Corry Finn was appointed Chairman of the CHKS Accreditation Awards Panel. Alan is currently the “I was delighted to be asked to chair the Panel and am looking Director of Primary Care & Older People’s Services & Executive forward to working with CHKS and other very experienced panel Director of Nursing at Western Health and Social Care Trust, members who are committed to maintaining and improving a role he has held since 2007. Alan is a CHKS surveyor and has standards of health and social care internationally. I would also participated in surveys in England, Scotland, and Portugal. like to pay tribute to Julie Hyde the previous chair, who sadly died He is also Chairman of the Northern Ireland Hospice Council very suddenly, for her absolute commitment and hard work in of Management, and a reviewer with the Northern Ireland the role.” Regulation and Quality Improvement Authority Alan Corry Finn, Chairman, CHKS Accreditation Awards Panel

ISQua Conference 2013 Other highlights included: ‘The hospital on trial’ where the audience participated as the jury in the case of a patient who had been given a drug to which she was allergic and subsequently The International Society of Quality in Healthcare’s 30th died; a new highly integrated approach to the care of patients Conference was held in October in the beautiful city of with co-morbidities and complex health needs and the use of the Edinburgh. Over 1200 delegates from 73 countries attended ‘bow-tie’ approach to risk management. to see and hear over 250 speakers and 370 posters.

The final plenary session was from Sir Harry Burns, Chief Medical Moyra Amess, Carlos Hiran Goes de Souza and Ann al Dahma Officer for Scotland, who described the effect of social changes were lucky enough to be there. Ann gave a short presentation on the health of a nation. His description of the microbiology of on Accreditation Online and Carlos, as an ISQua committee a cuddle left us all with a warm nurtured feeling and a sense that member, was part of the International Review Panel. this had been one of the best ISQua conferences.

With so many Many of the presentations can be found at on the ISQua presentations it was website. www.isqua.org. difficult to decide Next year the conference is in Rio de Janeiro…we can’t wait! what to go to but the choice was aided by the grouping into nine thematic tracks covering, for example, patient safety, health information technology, governance leadership and health Join the policy and measuring service and performance outcomes. In debate! addition, there were a number of sessions dedicated to quality in social care for older persons and advances in population health.

Keep up to date with the latest developments at CHKS by Our appetites were whetted by the first plenary session given following us on Twitter and join us on LinkedIn where you can by Atul Gawande, a Boston surgeon, who demonstrated how contribute to some of our discussions. monitoring the use of the WHO surgical checklist and increasing the availability of basic equipment such as pulse oximeters, @Insightfromchks items which we take for granted in the UK, can save millions of lives globally.

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Developing our standards

International Standards 2013 and experience from his managerial days at the Pembrokeshire Ambulance service which included emergency and general transport services. Tom also represented Pembrokeshire on We are delighted to announce the publication of the new the Welsh Ambulance Policy Advisory Group (WAPAG). The CHKS International Accreditation Programme for healthcare recommendations of this group led to the formation of the All organisations, 2013. The standards have been rebuilt using Wales Ambulance NHS Trust in 1998. Furthermore in 2008 Tom the modules developed to assess corporate management and was requested by the Health Commission Wales to work with leadership, risk and patient safety and patient focused care, the Welsh Ambulance Services Trust to develop their new long which allow the organisation to follow the patient’s pathway term Strategy. Overall feedback on the standard for ambulance from referral through to treatment and discharge, keeping the services was very positive. The standard has been fully revised patient at the very heart of the process. In addition, modules as part of the complete review of the 2010 International from other programmes, including oncology, addiction and Accreditation Programme with the assistance and feedback from maternity have been included in the redeveloped standards. both clients and Mr. Woods.

The standards apply to most healthcare services, not just whole CHKS congratulate both Beaumont Private Ambulance Service, hospitals, however they are structured. This provides flexibility to in Castlebar, Co. Mayo and Lifeline Ambulance Service, Leixlip, Co. enable organisations to opt for certain services to be accredited Kildare on the dedicated hard work undertaken with unyielding on an individual or multiple basis. Significantly, the standards are time restraints on both, to achieve a positive outcome. CHKS applicable to healthcare organisations whether they are provided are delighted to publicise that both services have achieved full by a private organisation or if they are publically funded. accreditation with CHKS.

These latest standards address our main development concerns around patient safety, the patient’s experience of care, Organisations accredited by the CHKS Accreditation professional competence, clinical governance, leadership and teamwork. Furthermore, although the standards continue to Awards Panel during July – December 2013 include those essential elements concerning systems, processes n Action on Addiction, and environment, we have focused on outcomes and the n Alliance Medical Diagnostic Imaging, Limerick, Ireland* standards require information from participating organisations n The Beacon Oncology Centre, Taunton and NHS on issues such as the percentage of staff trained in a particular Foundation Trust, UK* skill. We will continue to engage with clients to gain feedback as n Beaumont Private Ambulance Service, Co Mayo, Ireland we continue to develop the standards. n Cara Lodge (Matt Talbot Adolescent Centre), Co Cork, Ireland n Centro Hospitalar de Lisboa Central EPE (Hospital Sao Jose and Hospital Santo Antonio dos Capuchos), Portugal – Ambulance Service Standards Corporate Services: Management and Leadership Department, Technical Department and Support & Logistics Department. Since the introduction of the 2010 International Accreditation Clinical Services: Pathology Service* Programme, CHKS has offered a specialist standard for use by n Cuan Mhuire Addiction Centres, Ireland* ambulance service providers. Due to changes in the health n Keech Hospice Care, Luton insurance requirement in the Republic of Ireland (ROI) the n HCA International Ltd Cancer Network, UK* first opportunity to actually use the standards for two clients n HCA International Ltd (Leadership and Corporate Management) UK* in the ROI came late in 2012. n HCA International Ltd (Risk and Patient Safety), UK* n Hospital da Prelada, Portugal The Ambulance Service Standard proved to be very focused n Lifeline Ambulance Service Ltd, Co. Kildare, Ireland on the specialist requirements for the ambulance services. It n Princess Cruise Lines Ltd (Medical Centers), USA* was an added bonus for the clients as well as the two Client n The Priory Corporate Group, * Managers, Stuart Lonie and Geraldine Reynolds, when Mr. Tom n Tabor Lodge Addiction Treatment Centre. Co Cork, Ireland Woods accepted the request to act as one of the survey team n VHI Swiftcare Clinics, Dublin and Cork, Ireland* for both surveys. Tom brought with him a wealth of knowledge (* also certificated to ISO 9001:2008) 3

Other developments

2013 UKAS Assessment

CHKS Assurance and accreditation is required to undergo a office review. Conducted on 1st August 2013, this review was full survey every three years and a yearly surveillance visit undertaken by the same UKAS Assessment Manager. Three (similar to the one undertaken by CHKS client organisations), partial compliance actions were noted at the feedback session. to ensure we continue to meet the requirements as set out by A time frame of 20 working days to provide evidence to UKAS and particularly ISO 17021:2011. demonstrate full compliance was agreed. The required evidence was provided within the timeframe. We were very pleased to hear A witnessed assessment (where a UKAS Assessment Manager on 16th September 2013 that all actions were closed and that observes CHKS undertaking a surveillance visit) took place the Unit’s accreditation was maintained. A full survey against on 22nd July 2013. During the assessment one issue of partial ISO 17021:2011 is required during 2014. compliance was noted which was then discussed at the head

Surveyor Selection Event 2013 Surveyor update day Book your place! (or Os portugueses estão a chegar) 2014

In July this year we held a surveyor selection and training event 5 March, London - as well as our general updates, we will in Birmingham with 12 attendees, four of whom were from provide all surveyors with a digital information pack which will Portugal. With the heat wave the UK was experiencing it felt at include Capita developed training information on: times as if we were delivering the event in Portugal itself. n Data Protection Awareness A new selection process had been developed with a greater n Fraud Prevention Awareness emphasis on Accreditation Online (AO) and the surveyor’s role n Information Security Awareness within the survey process. Three facilitators, Stuart, Geraldine and Trudie guided the attendees through a selection of scenarios and As professionals who work with CHKS client information, it is training sessions over the course of three days. appropriate and important for good information governance that surveyors have the same training and development opportunity in As with previous selection events some sessions were graded by this area. We look forward to seeing as many surveyors as possible the facilitators and this year also saw the introduction of a written on the day. Visit www.chks.co.uk/events to book your place. final examination.

Feedback from the attendees stated that from their point of view Farewell to Amy Lewis the training was a success (most evaluations falling into the good/ excellent category). One attendee said: “The schedule for the Many of you will know Amy, who has been our Scheduling and three days was very well structured to reflect a perfect mixture of Office Manager for the past four ½ years. Amy first joined CHKS extremely useful and illuminating training sessions.” as a ‘temp’ in June 2008, but left later that year to join the CQC. She returned in 2009, and since then has managed our London We are pleased to advise that all candidates achieved the desired office, client managers, surveyors and survey schedules with great pass mark, demonstrated the necessary skills and were all efficiency. Amy will be joining a company in Shoreditch, London, eligible to become new surveyors. So finally, ‘welcome on board’ to take up a position as senior administrator and PA. We will miss to the 2013 candidates and we hope you all enjoy your surveying her very much and would like to take this opportunity to thank experience. her for her valuable contribution over the years and wish her every success and happiness for the future.

To find out more, please contact us T: + 44 (0)1789 761600 E: [email protected] or visit www.chks.co.uk