introduction to the ccqi and the peer review process training presentation.pdf · lead reviewer...
TRANSCRIPT
Introduction to the CCQI and the peer review
process
Royal College of Psychiatrists’ Centre for Quality Improvement
(CCQI)
Engages directly with clinicians and other front line staff and managers
More than 90% of mental health services in the UK participate in one or more of these initiatives
22+ projects http://www.rcpsych.ac.uk/quality/quality,accreditationaudit.aspx
Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI)
Manages quality improvement national initiatives Supports services to take responsibility for improving
local mental health provision
Engages directly with clinicians, managers, front line staff and service users
Over 90% of mental health services in the UK participate
Community of Communities
4%
38%
5% 5%
18%
13%
17%
Addictions
Children and Young People HMP Addictions
Learning Disabilities Mental Health
NHS Personality Disorder HMP
Agree Standards
Self-Review
Peer-Review
Local Report Action
Planning
National Report
Annual Forum
Membership Annual Cycle
Service Standards and Criteria
Standards reflect underlying principles and values
Criteria expand the standard
Agreed best practice by expert consensus
Parameters to measure TC-ness
A benchmark for measuring improvement
Allows services to demonstrate quality
Standards and Criteria - Layout
This is the Standard – you need to complete the peer-review comment here
These are the criterion. You should aim to score these to help score the standard. You can list evidence in the space provided
This is optional only to be completed by the host community. Information should feed into discussions
Peer-Review Process
Encourages reflection Engage staff and service users in the process of
service development Validate and measure service improvement Focused action plans for development Evidence-based method to lead to improvements in
practice (Jamtvedt et al 2004)
Lead reviewer Peer-review team - 3-5 staff of different disciplines
from different TCs TC Specialist (Accreditation Visits only)
The Peer-Review Teams
Role of the Lead Reviewer
To ensure all parties are prepared for the review Maintain structure of the day i.e. timing etc. Enable and assist the peer-review team Support host TC Keep focused on task e.g. gathering evidence, writing
report Facilitate the process Provide guidance e.g. understanding standards etc. Write the report by providing a record of the experience
of the review, scores and findings
Role of the Peer-Reviewer 1
Introduce yourself to the community - help the community relax
Engage with the host community in reflective discussions about their practice based on their self-review
Chair one of the meetings – lead the discussion of the standards
Review the services performance against the standards and not against the practice of your own community
Role of the Peer-Reviewer 2
Highlight areas of achievement and support TC to think about areas for development
Enquire and comment on improvements from previous cycles
Contribute to the written record of the visit
Review and comment on the accuracy and clarity of the draft local report during the consultation stage
Preparing for and Managing the peer-review day
Preparing for the
review
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Before the Day (1)
• Check travel arrangements with your Community Project Lead
• Receive a review pack by email:
• Details of Lead Reviewer
• Contact details of Community
• Type of Visit and Areas of Focus
• Completed self-review workbook including timetable
• Last year’s report if applicable
• Peer reviewer Guidance
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Before the Day(2) • Read Community Details • Read and print self-review
• Identify Areas for Improvement and Areas for development e.g. standards not met or partly met,
• Identify Areas of Achievement and best practice • Focus on the chosen areas (if applicable) • Identify areas of interest
• Read last year’s report • Note action points • Measure progress since last year
• Look at the website
• Keep notes
• Receive a call from lead reviewer
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Exercise 1
• Read last year’s report • Note action points
• Read this year’s self-review
• Identify progress from last year • Identify standards not met or partly met • Identify Areas of Achievement and best practice • Identify areas of interest and any questions you may
have • Think of some questions for how you would engage a
struggling host community to discuss CS1, CS2 and CS3 – You’ll need these later on!
After reading the material and making notes, discuss your findings with the person next to you
Gathering Evidence
The review day
Where you gather evidence?
Self-review workbook
Service website
Tour and Lunch
Discussions and Interviews
Paperwork review
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Observation Testimony
Records What you read
?
Triangulate the Information
Collecting Evidence
Collect information Supporting evidence Record areas for improvement List Areas for Development discussed Areas of Achievement or best practice Comment on Improvements
Informal Time
Get to know each other better
Important for learning and sharing
Increase understanding of the service as a whole
Meet other members of the community
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Observation Host community plan observation
Awareness of the standards
Remember:
Do not contribute to the discussions
Do not take notes during the observation
Evidence Portfolio Review Host community prepare
documents to evidence standards and criteria
Host community available to talk through documents
All review team to read documents provided
Discuss the documents in relation to relevant standards and criteria
Remember: Take Notes Focus Discussion Action Points
Meetings
Meetings with clients only, staff only and whole community Discuss self-review Focussed discussions on the standards Share ideas and experiences Identify Areas for Improvement and Action points Identify Areas of Achievement and best practice Measure progress since last year Keep notes Lead will keep record of evidence for the standards
and relevant discussion
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Review team meetings
Important to note important discussions, no need to minute
take Time to collectively think about the evidence you have seen
on the review day Think about progress made during the year Highlights any areas that need to be asked again or where
more information is needed for clarification Share thoughts about the visit Writing the report
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Exercise 2
Peer-review Experience – in groups play the role of
the host community/peer-review team (you will then swap round after the break)
Peer-review team - Use the self-review workbook to guide your
discussions around the standards Host community – either answer as the community in the self-
review workbook or your real community
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Writing the report
Scoring
Check the self-review score Discuss all the evidence for the standard which was
available on the review day Agree a score for each standard that was discussed 2 = Standard met 1 = Standard partly met 0 = Standard not met 9 = Not applicable (this will be very rare)
Provide Evidence
Combine comments from the review day Lead reviewer takes a lead Provide evidence and comments for all standards Make sure the evidence matches the score Be supportive – the magic ‘however’ Comment on standards where the community
demonstrates good practice or where they have acted on recommendations from the previous year
Provide Evidence
Example of clear evidence provided for a score of 2
There is written record of attendance for all therapeutic sessions in the timetable
2
Written records of attendance for all therapeutic sessions are kept. Case notes indicate daily attendance. There is a signing in & out book for all staff & client members and visitors. Client members keep an attendance register; there is also a handover book.
Make Recommendations/Areas for Improvement
For scores with 0 or 1, always provide a clear and achievable recommendation
Sometimes the community may meet a standard but there are still issues that need to be highlighted
Suggest recommendations even if the community meets the standard
A Bad Recommendation
Problems and their solutions are discussed in the community before action is taken. The discussion is regarded as a learning opportunity Source Staff and Resident Testimony, observation, group notes Guidance Staff and residents should be able to give examples and describe the outcomes of these events. Specialists should give evidence for the score
1
Lack of trust
Staff team should continue to support one another in holding on to what is good practice.
A Good Recommendation
Staff and client members provide written material about the community which is informative for prospective client members, referrers, and other related professionals Guidance Written material should be written by or with members of the community and clearly describe the TC model as lived by members of the community. Information is specific to potential members, referrers etc and is separate to the resident handbook that may be available when members join the TC
1
Members would like to see greater description about the therapeutic process itself in the introductory format
This is insufficient. New residents come with lack of knowledge and understanding of the principles of a TC.
Recommendation
Review and revise all written material about the community, making it informative for prospective client members, referrers, and other related professionals. The TC could set up a formal working party of staff and residents to do this.
Areas of Achievement and Areas for Improvement
At the end of each section, include areas of achievement and areas for improvement for the section
More general suggestions, not specific recommendations
All areas for improvement and recommendations from the community’s previous report are listed at the front of the review workbook for ease of reference.
Any Questions?
Exercise 3
In pairs, write comments, areas of achievement and
areas for development for the standards discussed in exercise 2
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What then?
Lead Reviewer types up report and sends to C of C
C of C sends to peer-review team
Peer-review team has 1 week to comment on the draft report
Key Elements
Preparation, Preparation, Preparation
Understand the TC
Read the Self-review
Read the Previous report
Core Competencies
This training and the subsequent peer-reviewer role provide a way for developing your organisational related Core Competencies
Org
anis
atio
nal
rel
ated
co
mp
eten
cies
10
Recognises importance of the environmental setting & external environment
• Uses ‘daily living’ as opportunities for learning - ‘opportunity-led work’ • Acknowledges the symbolic nature of the environment • Understands ‘corrective emotional experience’, primary care and
therapeutic adaptation • Political / social awareness - can challenge status quo
11 Understanding of organisational dynamics
• Can understand and acknowledge issues of authority, power, leadership • Can understand the varied reasons for organisational anxiety, the defences
which operate to avoid this and one’s own role in managing this • Aware of own valency - the tendency to take up a familiar defensive role in
a group context
12 Participant observer
• Can observe self and others without being compelled to act before reflecting
• Can wait, think, talk with others before acting • Capacity to learn from direct experience - capacity to explore and be
vulnerable - not defensive / avoidant
13 Recognises the primary task
• Boundaried - able to acknowledge one’s own place in the organizational structure
• Clarity about one’s role - engages directly in the key tasks defined in their job description and its relation with the primary task of the community
The C of C Project Team
Sarah Paget Programme Manager [email protected] Josie Thorne Deputy Programme Manager [email protected]
Natalie Fildes Project Worker [email protected] Salima Rashid Project Worker [email protected]