Joe Wolfe and Trevor Nesirky introduce the first in a series of articles designed to support service providers in preparing for registration and inspection by the Health Information and Quality Authority. This part focuses on preparing the management foundation and structures and ensuring that effective governance is in place, providing practical advice, rather than academic comment. It draws on reports of HIQA inspections of Older Persons’ Services and from experience of working with service providers in that area who have undergone the HIQA inspection process. Further articles will focus on preparing staff, conducting self.assessments and audits, building evidence for inspections and preparing for follow.up visits.
Introduction
The Health Information and Quality Authority (HIQA) is the statutory authority with responsibility for setting standards for health and social care services and for ensuring that such standards are met. HIQA is responsible for the registration and inspection of residential services for people with disabilities under the Health Act (2007). The Authority published its National quality standards: Residential Services for people with disabilities in 2009. Statutory regulations for the application of the residential standards to the disability sector are anticipated in the coming months, and Minister of State Kathleen Lynch has urged HIQA to commence inspections as soon as possible. The regulations will provide further detail to organisations on what is expected of them.
The publication of the HIQA standards, and the statement of intent with regard to the registration and inspection of residential services, have been warmly welcomed by people with disabilities, their families and representative bodies such as Inclusion Ireland and by staff and managers within services.
The National Standards consist of 19 standards covering the following areas/themes:
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Quality of Life
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Staffing
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Protection
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Development and Health Rights
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The Physical environment and Governance and management.
Although it is not yet clear how the registration and inspection process will be applied to disability services, many lessons can be learned from how HIQA have implemented a similar process in residential services for older persons.
Governance and management
HIQA places considerable attention on governance and management during registration and inspection, and this is
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evident in all their published reports. This is not surprising because, nationally and internationally, poor governance has been associated with poor quality of service provision and poor outcomes for service users (Report of the Commission on Patient Safety 2008, HSE 2010).
A central component of the HIQA standards and the requirements on services is that they are well governed. A number of key requisites for people leading organisations to consider are:
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Are the people charged with managing your service ‘fit persons’ and how can you (and they) demonstrate that they are?
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Have you a clear management structure in place, known to all?
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Have you an effective complaints system in place?
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Have you effective policies, procedures and guidelines?
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Have you a system of quality assurance in place?
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Have you a system in place for reducing, responding to and monitoring adverse events?
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Have you effective communication structures in place throughout the organisation?
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Have you the necessary management meetings in place, working effectively?
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Have you effective processes in place with regard to staff recruitment, staff induction, staff development and performance management?
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Have you effective systems in place from a safety perspective?
The following are questions for senior managers to consider with regard to governance, under the key requisites:
‘Fit persons’ in charge of management
HIQA require all those involved in the running of the service to demonstrate that they are fit to carry out their respective roles. This applies to the provider (the person with overall responsibility), the person in charge of the service (the person with day.to.day responsibility) and other managers involved in aspects of the service. The Board and CEOs of organisations need to ask themselves:
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Does each manager have a thorough understanding of the standards and can they demonstrate to inspectors how they are implemented and monitored in the areas under their responsibility?
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Will each manager have a thorough understanding of the regulations (once passed in law) and will they be able to demonstrate to inspectors how they implement and monitor the regulations in the areas under their responsibility?
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Can the organisation demonstrate how it has prepared its managers for the ‘fit persons’ process’?
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Has each service manager/area developed a purpose and function document, specific to their area, which clearly sets out that area’s purpose and function?
A clear management structure, known to all
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Does an up.to.date organisational chart demonstrating the organisation structure exist and is it visible/available to all?
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Do service users, service.user representatives and families understand the management structure?
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Are staff clear on the management structure, reporting relationships and reporting channels?
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Do rosters clearly demonstrate who is in charge on a day to day basis?
An effective complaints system
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Are all service users, families and staff familiar with the complaints procedure? (This needs to be checked regularly.)
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Are all complaints managed in accordance with the procedure?
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Is a log of all complaints kept, with any actions taken, their investigation and their outcome?
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Is there a monitor/audit/evaluation of the complaints log on a regular basis, records kept of this? Can the lessons learned from these processes be demonstrated?
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Are there proactive processes in place that seek the views of key stakeholders?
Effective policies, procedures and guidelines
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Are relevant documents available, as required by the standards and regulations?
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Are these documents user friendly?
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Is there an effective document control system with regard to development, approval, implementation, review and audit?
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Are there records of staff sign.off for all documents?
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If agency staff are employed, is policy induction addressed with these staff?
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Are the correct editions of the various documents available in all areas?
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Is there a simple process in place to test whether documents are being implemented effectively?
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Is there a method for checking that staff are aware of the key elements of core policies, particularly those relating to safety, protection and risk?
A system of quality assurance
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Is there a group driving quality assurance within the service, representative of all stakeholders?
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Is there a written strategy for implementing quality assurance?
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Is there a schedule of self.assessment against the standards?
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Is there a separate audit schedule for the core audits required by HIQA?
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Are all audit reports collated in one centrally accessible area, with corrective action plans completed?
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Is there demonstration of the quality assurance circle being completed— acted on by audit/self.assessment recommendations?
(These aspects will be dealt with in more detail in further articles in this series.)
A system for reducing, responding to and monitoring adverse events?
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Is there a process in place for capturing, reporting and responding to adverse events?
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Are adverse events most likely to occur in the service settings identified and are risk management approaches in place to reduce and minimise these?
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Is there analysis of adverse events on a regular basis (with documentary evidence kept) and demonstration of
improvements made in response to this analysis?
Effective communication structures throughout the organisation?
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What communication structures are in place within the organisation and how do these address general communication, information sharing, information transfer to/from service users, staff, families, managers, the board and other key stakeholders, communication in emergencies, on.call arrangements?
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Is there a regular review of communication and its effectiveness throughout the organisation, which can be demonstrated to inspectors?
Effective management meetings
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Can it be shown that there are meetings at the various management levels of the organisation and that these are effective as a tool for management?
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Are meetings chaired effectively and do those chairing the meetings have the required skills?
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Do the relevant meetings take place as planned?
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Does each meeting have a clearly defined purpose (set out in a terms of reference document); occur in accordance with the planned schedule and in accordance with the agenda; have clear relevant minutes maintained; and clearly set out actions and responsibilities for implementing actions, with timescales attached?
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Is an early focus of each meeting to review implementation of previous recommended actions?
Effective procedures on staff recruitment, induction, development and performance management
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Do all staff files have clear records of the interview process, 2.3 references, a record of application for Garda clearance, records of relevant qualifications and copies of registrations with the staff member’s professional body (if relevant)?
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Are staff files well organised and stored securely?
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Is there an induction policy and package, and are clear records kept which documenting that all staff have received the relevant induction as defined by policy?
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Are there records of an up.to.date analysis of staff training needs (based on service user needs)?
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Is there a concise summary record of all training provided to staff?
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Is there a record of required training and a plan outlining how this is to be met in a reasonable timescale?
. Is there an effective performance management system in place? Is it being implemented effectively? Can this be demonstrated to inspectors?
Effective systems for risk assessment and safety
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Are key risks within your organisation identified, with documented controls in place to minimise and manage them?
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Are there effective systems in place with regard to fire safety?
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Are there effective systems in place with regard to health and safety, with up.to.date and accessible records?
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Are there clear processes in place with regard to child /adult protection, including policies and training, with clear reporting, screening and investigation processes that are subject to regular audit and scrutiny?
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Is there a policy and process with regard to risk assessment of the environment, of clinical risk and of risk to service users and staff (including positive risk)?
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Is there a clear process in place for determining staffing levels and is this based on assessed service user needs?
If any restrictive practices are in place, are they based on policy and best practice, and are they prescribed and subject to rigorous review?
Conclusion
For the first time in Ireland, service provision in the health and social care sector will soon have a transparent, rigorous inspection process. The improvement in the quality of residential services for older persons is very evident, from reading various reports, because of the introduction of registration and inspections in that area. If a similar approach is utilised in residential services for persons with a disability, it is highly likely that we will see similar improvements in certain disability services. This is a very welcome development that can only benefit people with disabilities, their families, staff in services and service providers alike.
There are clear variations nationally in the quality of services, in the rate of implementation and in the degree and quality of self.assessments being conducted. Some services are quite far along the path of implementation and self.assessment, while others are only beginning their journey. It is hoped that this article will be a practical support to organisations in assessing and developing the governance of their services and in preparing for the registration and inspection process with HIQA.
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