Atrium Clinic Quality Assurance and clinical governance Policy

Updated May 25 SI

 

Introduction

 

The aim of the Atrium Clinic and Therapy Centre is to provide a quality service. This quality assurance policy outlines our belief and commitment to ensure that ongoing quality improvement is integral part of our organisation.

We recognise that clinical excellence is underpinned in our operational policy through the strategies and processes we employ to assure safer working and higher standards. Our work requires us to collaborate closely with the existing clinical governance structures of organisation clients and our referrers to protect our clients and improve our practices as part of a whole system and integrated approach to service delivery.

Clinical governance relies on the integration of best practice across our operational polices and strategy areas where we can evidence the outputs from our education and training, staff management and clinical activity review through  record checks, clinical supervision, reflective practice, staff reviews, the monitoring of clinical effectiveness where CORE provides feedback from clients on their experience, our performance against indicators or wellbeing recovery (CORE) and data on our integrative working, risk management and escalation  and quality of service reports (including case studies and client feedback/complaints), to improve the quality and safety of our services.

 

Our approach to case management as one element in the clinical governance activity, means that we include spot checks, informal case management advice to clinicians through the working day, ledger audits for sessions booked, risk escalation processes being followed…….and feedback to clinicians can be found in email advice and supervision notes on CORE. Training records and clinical supervision dates can also be accessed by request.

The purpose of the Quality Assurance policy is to ensure such continuous improvement though self-evaluation and action planning. The Quality Assurance Policy and associated procedures outlined with this document, will involve all employees, and the management of the process will be though the existing organisational structure.

 

Our quality is achieved through our quality assurance framework which ensures that all aspects of our work are underpinned by policies and processes that guide our best practice.

Individual Responsibilities

To meet the high standards of Clinical delivery within Atrium, we will, as an organisation ensure

• Our customers and clients are treated in a polite and friendly way.
• The needs of our customers are carefully identified and understood.
• We only make promises which can be kept.
• Each task is completed correctly and on time.
• We communicate effectively with our customers and colleagues in the client’s interest and with their consent.
• We participate in all trainings and updating to ensure we understand the processes that deliver quality to our clients.
• Implementation is monitored to ensure staff understand and comply and that all aspects of the procedures are effective.
• Feedback is regularly sought from commissioners and clients regarding the quality of their experience of Atrium services. This feedback is evaluated by the relevant management team and used to improve the quality of our services.

 

Quality Assurance Framework Implementation

Atrium Clinic has in place a range of systems and procedures that combine to provide a quality assurance framework.

 

• Quarterly and Annual self-assessment by service pathway against quality objectives and priorities.
• Peer and student observation and co-working for continual teaching, learning and improvement.
• Clinical and case supervision for individuals and by peer and pathway groups.
• Consultant practitioner review and staff development plans alongside upkeep of annual CPD and training records.
• Accredited services for training and learning, re assessed annually.
• Probation and buddying for new consultant/self employed staff during and after induction and beyond.
• Community of practice portal (COP) for updating, community learning and information sharing.
• CORE record ongoing audit by the Atrium quality assurance clinical manager and administration team who inducts new staff into client system, reports on data quality to managers, procedure compliance, flags safeguarding concerns to corroborate with clinical supervision evidence and implementation of coaching for improvement cycle.
• Case management monitoring through safeguarding consultations, case reviews
• Client and stakeholder feedback collation from surveys and postintervention feedback to review the work.
• A customer/client complaints policy, with complaints and issues of concern investigated by the management team and reported to commissioner.
• Student and staff induction programmes

 

 

Quality Improvement

A cycle of review, evaluation, planning, and reporting is in place to identify priority areas for continuous improvement and development.

The review cycle arises from:

• The Atrium Clinic mission and values statement
• The Clinic’s Strategic Plan and priorities
• Annual Quality Improvement and Development Plan (arising from the ongoing Self-Assessment process) and quarterly progress reports
• Specific pathways of clinical services and specific commissioner-led guidance.
• Observation and case supervision – action planning and coaching process in monthly management meetings and reviews
• Staff Reviews and Development Planswith ongoing feedback
• Sharing of good practice through team meetings, peer and community supervision, networking and learning
• Use of feedback – commissioner and client feedback, complaints and positive feedback including from social media.
• Client outcome tracking, monthly reporting
• Use of national, local and internal benchmarking data to identify priority areas for improvement
• Peer Review and development, working with partner providers and commissioners to share good practice.

 

Actions

 

The results of Quality review as stated above, will be used to:

 

• Plan for improvement within Atrium Clinic
• Highlight issues that need consideration by Atrium Clinic
• Feedback to all staff action taken to improve the quality of service delivery to our clients
• Identify new initiatives and solutions that will improve the quality of service we can provide for our clients.