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Quality Improvement Plan for restrictive practices – Disability ServicesHealth Information and Quality Authority

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Restrictive Practice Thematic Programme

Quality Improvement Plan

Designated Centres for People with Disabilities


About the Health Information and Quality Authority (HIQA)

The Health Information and Quality Authority (HIQA) is an independent statutory authority established to promote safety and quality in the provision of health and social care services for the benefit of the health and welfare of the public.

HIQA’s mandate to date extends across a wide range of public, private and voluntary sector services. Reporting to the Minister for Health and engaging with the Minister for Children and Youth Affairs, HIQA has responsibility for the following:

Setting standards for health and social care services — Developing person-centred standards and guidance, based on evidence and international best practice, for health and social care services in Ireland.

Regulating social care services — The Office of the Chief Inspector within HIQA is responsible for registering and inspecting residential services for older people and people with a disability, and children’s special care units.

Regulating health services — Regulating medical exposure to ionising radiation.

Monitoring services — Monitoring the safety and quality of health services and children’s social services, and investigating as necessary serious concerns about the health and welfare of people who use these services.

Health technology assessment — Evaluating the clinical and cost-effectiveness of health programmes, policies, medicines, medical equipment, diagnostic and surgical techniques, health promotion and protection activities, and providing advice to enable the best use of resources and the best outcomes for people who use our health service.

Health information — Advising on the efficient and secure collection and sharing of health information, setting standards, evaluating information resources and publishing information on the delivery and performance of Ireland’s health and social care services.

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National Care Experience Programme — Carrying out national service-user experience surveys across a range of health services, in conjunction with the Department of Health and the HSE.

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Introduction The aim of thematic inspections is to help drive quality improvements in specific aspects of care and support. These thematic programmes will focus primarily on the National Standards for Residential Services for Children and Adults with Disabilities (2013). This Quality Improvement Plan is specifically designed for use in the thematic inspections of restrictive practices in designated centres for people with disabilities.

This document should be used in conjunction with the self-assessment questionnaire for restrictive practices. Once your service has completed the self-assessment questionnaire, this plan provides an opportunity for the service to target areas for improvement under each of the eight themes. This quality improvement plan is not required to be submitted to the Office of the Chief Inspector. It should be used by the centre to focus on what improvements are needed and how they will be progressed and monitored. The quality improvement plan should be made available to an inspector upon request as it will demonstrate initiatives being undertaken in relation to reducing and eliminating the use of restrictive practices in the centre.

Service providers are encouraged to read the guidance document accompanying this thematic programme as it will provide useful information on meeting the standards.

*Please Note: This quality improvement plan is a template produced by the Office of the Chief Inspector. You are not required to use this template and are free to use an alternate tool or template to create a quality improvement plan. However, please ensure that your plan incorporates the main elements as set out in this template.

Figure 1: Themes in the National Standards for Residential Services for Children and Adults with Disabilities (2013)

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Section 1 - Capacity and capability

This section focuses on the overall delivery of the service and how the provider is assured that an effective and safe service is provided. Delivering improvement depends on services having capability and capacity in four key areas.

This includes how the provider:

makes sure there are effective governance structures with clear lines of accountability so that all members of the workforce are aware of their responsibilities and to whom they are accountable

ensures that the necessary resources are in place to support the effective delivery of quality care and support to people using the service

designs and implements policies and procedures to enable centres run effectively

uses information as a resource for planning, delivering, monitoring, managing and improving care.

Section 2 - Quality and safety

The focus of this section is about the lived experience of the people using the service.

This includes how people:

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make choices and are actively involved in shaping the services they receive

are empowered to exercise their rights, achieve their personal goals, hopes, and aspirations

receive effective person-centred care and support, at all stages of their lives

are able to live in a safe, comfortable and homely environment have food and drink that is nutritious are protected from any harm or abuse.

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Quality Improvement Plan

Section 1 – Capacity and Capability

Dimension: Capacity and capabilityTheme: Leadership, Governance and Management

Please outline your key achievements relevant to restrictive practices under the Leadership, Governance and Management theme within the last year

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Outline where there is room for improvement under the Leadership, Governance and Management theme

Standard number

*5.___

Standards assessed as requiring a Quality Improvement Initiative

*Please place the standard number requiring a Quality Improvement initiative into the box on

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the leftCopy and paste this box if you require additional plans for each standard

Area(s) identified as requiring improvement

Priority levelHigh/Medium/Low

Actions to be taken

Person responsible

Resources needed

Possible constraints

Measures of success

Timeframe

Progress review date(s)

Standard number Standards assessed as requiring a Quality Improvement Initiative

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*5.___ *Please place the standard number requiring a Quality Improvement initiative into the box on the left

Copy and paste this box if you require additional plans for each standard



Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe


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Dimension: Capacity and Capability

Theme: Use of Resources

Please outline your key achievements relevant to restrictive practices under the Use of Resources theme within the last year

Outline where there is room for improvement under the Use of Resources theme

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Standard number

6.1

Standard assessed as requiring a Quality Improvement Initiative

Yes No



Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe


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Dimension: Capacity and capability

Theme: Responsive Workforce

Please outline your key achievements relevant to restrictive practices under the Responsive Workforce theme within the last year

Outline where there is room for improvement under the Responsive Workforce theme

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Standard number

*7.___


*Please place the standard number requiring a Quality Improvement initiative into the box on the left

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Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe


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Dimension: Capacity and Capability

Theme: Use of Information

Please outline your key achievements relevant to restrictive practices under the Use of Information theme within the last year

Outline where there is room for improvement under the Use of Information theme


Standard number

8. ___






Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe

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Section 2 - Quality and Safety

Dimension: Quality and SafetyTheme: Person-centred Care and Support

Please outline your key achievements relevant to restrictive practices under the Person–centred Care and Support theme within the last year

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Outline where there is room for improvement under the Person–centred Care and Support theme

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Standard number

*1.___






Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe

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Dimension: Quality and SafetyTheme: Effective Services

Please outline your key achievements relevant to restrictive practices under the Effective Services theme within the last year

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Outline where there is room for improvement under the Effective Services theme

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Standard number

*2.___






Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe

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Standard number

*2. ___






Actions to be taken

Person responsible

Resources needed


Measures of success

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Timeframe


Dimension: Quality and SafetyTheme: Safe Services

Please outline your key achievements relevant to restrictive practices under the Safe Services theme within the last year

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Outline where there is room for improvement under the Safe Services theme

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Standard number

*3.___






Actions to be taken

Person responsible

Resources needed


Measures of success

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Timeframe


Standard number

*3.___






Actions to be taken

Person responsible

Resources needed


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Measures of success

Timeframe


Dimension: Quality and SafetyTheme: Health and Wellbeing

Please outline your key achievements relevant to restrictive practices under the Health and Wellbeing theme within the last year

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Outline where there is room for improvement under the Health and Wellbeing theme

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Standard number

*4. ___






Actions to be taken

Person responsible

Resources needed


Measures of success

Timeframe

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To be completed at the end of the Quality Improvement Plan cycle

Standards assessed as requiring improvement

Measures of success Status(completed/in progress)

Progress notes

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