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Supporting Guidance Standard 3.1

Health and Care Standards

Supporting Guidance

Standard 3.1  Safe and Clinically Effective Care

 

What is the Standard about?

Clinical care, treatment and decision making, should reflect evidence based and best practice to ensure that the risk of inappropriate or unnecessary treatment and care is reduced to the lowest possible level. There is an extensive range of best practice guidance, some national, some professional and it is also a developing field with new technologies and ways of working. The pace of change can be very rapid.

This standard is about:

  • Keeping up with evolving practice and providing an efficient and effective response to promote safe and clinically effective care;
  • Having systems and processes to comply with safety and clinical directives in a timely way, including alerts.
  • Making sure that non-compliance or variance from best practice is properly recorded and audited and any risks identified are managed appropriately.
  • Providing services in Welsh, as for many Welsh speakers language this is an integral element of their care.  It is also about treating Welsh speakers with dignity and respect and ensuring that they receive accurate assessments and appropriate care.

 

Who is it for?

All healthcare services in all healthcare settings.

In relation to the standard criteria (in bold) the following key questions need to be considered:

People are safe and protected from avoidable harm through appropriate care, treatment, information, support and early detection of risks.

  • How do you protect people from avoidable harm?
  • What risk management systems do you have in place to ensure safe and clinically effective care?
  • What actions are taken to manage any risk identified?

People are supported to protect their own and their families’ health.

  • How do you support people to maintain and protect their own and their family’s health?
  • How do staff promote and protect the physical, mental health and wellbeing of service users?
  • How do you encourage self care and promote understanding of the risks of antibiotic misuse and over use?
  • Do you signpost to mental health helplines such as C.A.L.L and Samaritans when appropriate?
  • Does your health board provide appropriate information and actively encourage the eligible population to take up screening services?
  • Do you include highlighting the benefits to mental health of the Five Ways to Wellbeing?
  • Do you promote the ‘Add to your Life' Health Check for 50+?
  • Is the All Wales Obesity Pathway implemented across your health board?
  • Is smoking cessation included in all relevant care pathways? What is the referral mechanism?

Welsh speakers are able to use the Welsh language to express themselves and information is communicated effectively.

  • Do  Welsh speakers or learners wear a ‘Iaith Gwaith’ or ‘Dysgu Cymraeg’ badge to show that they can speak Welsh?
  • Do you know who the Welsh speakers are in your team so that they can matched with Welsh speaking patients / service users?
  • Do you ensure that wards or departments have a bilingual environment and is welcoming for Welsh speakers?  For example are there Welsh language reading material / Welsh language radio and television services available?
  • Do you have a Welsh Language Officer?  Do they provide effective help and advice.  Every LHB / Trust must have one.

Practice evolves to reflect new evidence and provides an efficient and effective response to promote safe and clinically effective care.

  • What risk management systems do you have in place to ensure safe and clinically effective care?
  • What governance arrangements do you have in place for managing concerns raised regarding the safety and/or clinical effectiveness of care?
  • What have you learned through the governance arrangements that have resulted in improvements?
  • How are you monitoring that these improvements are sustained?
  • How do you ensure systems take action on the finding from National Clinical Audit and Outcome Reviews?

Systems and processes comply with safety and clinical directives in a timely way, including alerts.

  • How do you hear about these?
  • How do you assess their relevance to you?
  • Who is accountable for implementation?
  • How do you disseminate and communicate with relevant parties?
  • How do you act on them? 
  • How do you know that action is taken within set timescales and outstanding actions are managed?
  • How do you know that you have an effective system for monitoring compliance? 
  • What have you learnt from monitoring these and what changes have you made as a result?
  • How does the board gain assurance that compliance is being managed effectively?
  • How do you ensure compliance with MHRA and Patient Safety Alerts

Systems ensure non-compliance or variance from best practice is properly recorded and audited and any risks identified are managed appropriately.

  • How do you record non-compliance with and variance from evidence-base and best practice?
  • How do you audit and record non-compliance?
  • How are outstanding actions managed/escalated?
  • What actions are taken to manage any risk identified
  • How are these actions monitored to ensure the risk is managed?
  • What oversight do the board have where there is non-compliance?

People receive a high quality, safe and effective service whilst in the care of the NHS which is based on agreed best practice guidelines including those defined by condition specific Delivery Plans, National Institute for Health and Care Excellence (NICE), NHS Wales Patient Safety Solutions, and professional bodies.

  • How do you hear about and receive best practice including guidance from Welsh Government Improving Patient Safety Team, and Medicines and Healthcare Products Regulatory Agency (MHRA),
  • How do you assess their relevance to you?
  • How do you disseminate and communicate with relevant parties?
  • How do you act on the guidance?
  • How do you know that appropriate action is taken in a timely manner?
  • How do you monitor that the appropriate action is embedded and sustained?
  • What is your commitment to overall continuous quality improvement?
  • Is guidance considered in forward planning, incorporated into local plans and discussed with partner organisations?
  • Is your approach to NICE guidance implementation reactive (making use of guidance when needed, for example as a response to a patient complaint or incident) bureaucratic (good systems are in place but they have little impact on overall quality of care) or proactive (always considering evidence based guidance as an integral part of everything your Health Board does)?

Practice keeps up to date with best practice, national and professional guidance, new technologies and innovative ways of working.  

  • Does staff education and training encourage a positive view of evidence based guidance?
  • How do you ensure that NICE Highly Specialised Technology Appraisals are implemented?

 

Legislation and Guidance

 

Good Practice Guides

 

Useful Contacts