Mandatory Health Day Information

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Mandatory Health Training
Some of our courses are mapped to the UK Core Skills Training Framework, therefore we thought it might be useful to provide you with some content from the guide for further information. This information has been taken from the Skills for health website, use the link below to reach the relevant page and to download the pdf version of this guide.
http://www.skillsforhealth.org.uk/services/item/676-statutory-mandatory-cstf-download-form
Statutory/Mandatory Subject Guide Version 1.4.2
About Skills for Health Skills for Health is the Sector Skills Council for Health. It helps the whole UK health sector develop a more skilled and flexible workforce. Skills for Health’s proven solutions help improve not just productivity but also the quality of health and healthcare. If you would like further information about how Skills for Health might support you with the implementation of this framework or other workforce development issues please visit: http://www.skillsforhealth.org.uk
CopyrigUK Core Skills Training Framework Statements of Support
Provision of statutory mandatory training represents a major investment by healthcare employers. We recognise that there has been strong regional and national interest and demand for guidance in this area of provision in order to make the best use of this investment, prevent unnecessary duplication and to help ensure the quality and consistency of training given.
NHS Education for Scotland have been working with Health Boards on supporting their mandatory training needs for over two years. Our aim is to ensure that the NHS Scotland workforce has the appropriate level of knowledge and skill to carry out their duties safely and maintain a safe and healthy working environment. Working with Skills for Health to develop the UK Core Skills Training Framework has made a valuable contribution to these endeavours. We anticipate the toolkit being used within Health Boards to benchmark and re-evaluate current activity and we also envisage piloting the practical implementation of the User Guide in clinical settings. Dr Stuart Cable, Assistant Director of Educational Development, NHS Education for Scotland
The National Association of Healthcare Fire Officers welcomed the request by Skills for Health to be involved in the development of the UK core skills training framework. Any document that strives to improve, develop and set out objectives and training outcomes has to be endorsed. The framework will assist healthcare organisations to achieve statutory compliance with regards to fire safety training.
The Infection Prevention Society welcomes the UK core skills training framework developed by Skills for Health. The Infection Prevention Society acknowledges that this framework does not attempt to cover all aspects of infection prevention and control. However following the framework can assist organisations in reviewing and developing their training arrangements.
The Health and Safety Executive welcomes the UK core skills training framework developed by Skills for Health. The framework does not attempt to cover all health and safety risks and may go further than the minimum you need to do to comply with the law. However, following the framework will help organisations review and develop their training arrangements and make health and safety improvements in their business.
The National Back Exchange has welcomed the opportunity to work with Skills for Health in developing the UK Core Skills Training Framework. We recognise that this framework builds upon other developments which have had benefit in establishing common guidance and which have been well received by healthcare organisations. While the National Back Exchange recognises that this framework does not attempt to cover all aspects of moving and handling the use of the framework can assist organisations in reviewing, planning and developing their training in moving and handling arrangements.
Resuscitation Council (UK): We are pleased to indicate that the information provided in the Resuscitation subject included in this framework has been supported by the Resuscitation Council (UK).
Royal College of Paediatrics and Child Health: We are pleased to indicate that the information provided in the Safeguarding Children’s subject included in this framework has been supported by the Royal College of Paediatrics and Child Health.
Contents
Introduction
Core Skills Subjects and Organising Structure
Subject 1: Equality, Diversity and Human Rights .
Subject 3: Health, Safety and Welfare
Subject 4: NHS Conflict Resolution (England)
Subject 5: Fire Safety
Subject 6: Infection Prevention and Control
Subject 7: Moving and Handling
Subject 8: Safeguarding Adults
Subject 8a: Preventing Radicalisation
Subject 9: Safeguarding Children (Version 2)
Subject 10: Resuscitation
Subject 11: Information Governance
Introduction
Purpose of Document This document sets out a framework for use by healthcare organisations to help guide and standardise the focus and the delivery of key statutory and mandatory training skills. The intention in providing this framework is that healthcare organisations will be able to review their current arrangements for defining and delivering training in relation to the identified subject areas, and through the adoption of the framework align their approaches. Where such alignment is undertaken it should then have benefits for healthcare organisations in ensuring consistent approaches, promote quality and delivery of training which, through the use of learning outcomes, should be more educationally focused and valued.
It is expected that the adoption of this framework will help promote organisational and system wide efficiencies by encouraging the health sector to recognise training which meets recognised standards and in doing so help contribute towards preventing unnecessary duplication.
Subject 1: Equality, Diversity and Human Rights
1.1 Context Statement Equality is about creating a fairer society where everyone has the opportunity to fulfil their potential. Diversity is about recognising and valuing difference in its broadest sense. Human rights are the legal rights and freedoms that individuals can expect to enjoy, can exercise and are based on core principles such as dignity, fairness, equality, respect and autonomy. Equality, Diversity and Human Rights are entirely relevant to day-to-day life and provide the framework which protects the freedom for individuals to control his/her own life, prevent discrimination and set expectations for enabling fair and equal services to and from public authorities.
The health sector has a responsibility to ensure delivery of services and workforce management which fully demonstrate and reflect the principles of equality, diversity and human rights. It is through the active and effective understanding of Equality, Diversity and Human Rights that the health sector will be able to recruit and retain a workforce that is more reflective of and sensitive to the population it seeks to serve.
1.2 Current Legal or Relevant Expert Guidance
Legislation – UK Wide • Equality Act 2010 • Human Rights Act 1998
Legislation – Northern Ireland • Employment Equality (Sex Discrimination) Regulations (Northern Ireland) 2005 • Employment Equality (Sexual Orientation) Regulations (Northern Ireland) 2003 • Northern Ireland Act 1998 • The Employment Equality (Age) Regulations (Northern Ireland) 2006 • The Equality Act (Sexual Orientation) Regulations (Northern Ireland) 2006
Legislation – Wales • Government of Wales Act • Wales Public Sector Duties
Key Guidance – England • Department of Health Human Rights in Healthcare • NHS Constitution • NHS England (2015), Accessible Information Standard • NHS England (2015), NHS Workforce Race Equality Standard • NHS England (2015), The Equality Delivery System • NHS England (2015), Monitoring Equality and Health Inequalities: A Position Paper
Key Guidance – Northern Ireland • Section 75 of the Northern Ireland Act 1998 A Guide for Public Authorities
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Key Guidance – Wales • Equality information: A guide for listed public authorities in Wales • Assessing Impact and the Equality Duty – A guide for listed public authorities in Wales • Equality Objectives and Strategic Equality Plans (SEPs)
Expert Organisations • Equality and Human Rights Commission (England, Wales) • Equality Commission for Northern Ireland • NHS Employers • The NHS Centre for Equality and Human Rights
1.3 Target Audience All staff, including unpaid and voluntary staff.
1.4 Key Learning Outcomes The following learning outcomes reflect a minimum standard which should be incorporated into equality, diversity and human rights education and training for all staff groups.
The learner will:
a) understand the terms of Equality and Diversity and Human Rights and how they are applied within the context of the health sector
b) understand how a proactive inclusive approach to equality and diversity and human rights can be promoted
c) understand the purpose and benefits of monitoring equalities and health inequalities
d) understand the benefits that an effective approach to equality and diversity and human rights can have on society, organisations and individuals
e) understand how legislation, organisational policies and processes can empower individuals to act appropriately and understand people’s rights
f) know how to treat everyone with dignity, courtesy and respect and value people as individuals
g) know what to do if there are concerns about equality and diversity practices, including how to use any local whistle blowing policy procedures and other related policies such as Bullying at Work and Dignity at Work
For Wales only:
h) understand the Public Sector Equality Duties
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1.5 Proposed Frequency of Refresher Training or Assessment
Proposed Refresher Period It is recommended that equality and diversity refresher training for all staff groups should take place at a maximum of every 3 years. Where staff are changing roles and have more direct accountability for Human Resources, staff management and service delivery, they may need to undertake refresher and/or receive specific training ahead of any scheduled update. Wherever possible, such training should also coincide with a much broader review of the organisational approach to equality, diversity and human rights.
Organisational Implications: Each healthcare organisation will need to determine the required refresher training periods, ensuring that any agreed training schedule is incorporated into their local policy.
Refresher training will be indicated for all staff if there is a change in Equality, Diversity and Human Rights Legislation nationally or an organisation has amended its policy locally.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
1.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators who are involved in the delivery of Equality, Diversity and Human Rights education or training have the appropriate experience, background and qualifications to deliver training to a satisfactory standard. For guidance, this may include the following:
• A current and thorough knowledge of Equality, Diversity and Human Rights legislation and an understanding of its application and effective practice within a healthcare setting. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities. • A relevant qualification in Equality, Diversity and Human Rights such as, for example, the Institute of Leadership and Management Level 4 Award in Managing Equality and Diversity in an Organisation. • Awareness of the Competency Framework for Equality and Diversity Leadership and how this might be appropriately applied within the context of any education/training role. Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic observation.
1.7 Relevant National Occupational Standards
Relevant National Occupational Standards • SCDHSC0234: Uphold the rights of individuals • SS01: Foster people’s equality, diversity and rights • SCDHSC0045: Lead practice that promotes the safeguarding of individuals
Subject 3: Health, Safety and Welfare
3.1 Context Statement Given the complexity of the purpose, structure and type of activity delivered in healthcare environments, there is a diverse range of potential risks to the health and safety of staff. The law requires employers to provide whatever information, instruction and training is needed to ensure, so far as is reasonably practicable, the health and safety of its employees. Employers are required to provide employees with relevant information on potential risks to their health and safety in the workplace, and how these risks can be minimised.
The provision of effective health and safety training will help to avoid the cost and distress that accidents and ill health cause. Of particular importance, is the need to develop a positive health and safety culture where healthy working becomes second nature to everyone.
3.2 Current Legal or Relevant Expert Guidance
Legislation – UK Wide • Health and Safety at Work etc Act 1974 • Management of Health and Safety at Work Regulations 1999 • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 • The Control of Substances Hazardous to Health Regulations 2002 • The Health and Safety (Training for Employment) Regulations 1990 • The Health and Safety (Display Screen Equipment) Regulations 1992 • The Provision and Use of Work Equipment Regulations 1998
Legislation – Northern Ireland • Management of Health and Safety at Work Regulations (Northern Ireland) 2000
Key Guidance – England • NHS Employers / Health and safety • The NHS Health, Safety and Wellbeing Partnership Group (2013), Workplace health and safety standards • Health and Safety Executive, Health and social care services
Expert Organisations • The Health and Safety Executive (HSE) • The Health and Safety Executive for Northern Ireland • The Care Quality Commission (England)
3.3 Target Audience All staff, including unpaid and voluntary staff.
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3.4 Key Learning Outcomes The following learning outcomes reflect the minimum standard that should be incorporated into general health and safety training.
The learner will:
a) understand the organisation’s commitment to delivering services safely
b) understand the importance of acting in ways that are consistent with legislation, policies and procedures for maintaining own and others’ health and safety
c) know the organisation’s arrangements for consulting with employees on health and safety matters
d) be able to locate the organisation’s health and safety policy and the arrangements for implementing it
e) understand the meaning of hazard, risk and risk assessment
f) be able to recognise common work place hazards including:
o electricity
o slips and trips, falls
o chemicals and substances
o stress
o physical and verbal abuse
o traffic routes
o display screen equipment (DSE), workstations and the working environment.
g) understand how any identified risks might be managed through balanced and appropriate preventive and protective measures
h) understand how they could apply and promote safe working practices specific to their job role
i) know the actions they should take to ensure patient safety
j) understand the importance of reporting health and safety concerns
k) know the reporting processes used and how the organisation uses the information gathered to help manage risks
l) know how to raise health and safety concerns
m) understand individual responsibilities in reporting incidents, ill health and near misses.
NB: Additional learning outcomes and practical experience should be added, where appropriate, to take into account the capabilities, knowledge, experience and prior training of workers.
Based upon risk assessment, training needs analysis, type of role, location and service need, the learning outcomes stated should be supplemented by specific job and site training as necessary to ensure competence in safe working practices and compliance with legal requirements.
Employers should ensure that vulnerable workers such as young people at work and learners undertaking work experience receive appropriate training, to protect their health and safety.
Managers and supervisors should receive additional health and safety training as appropriate to support them in their role and health and safety responsibilities.
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3.5 Proposed Frequency of Refresher Training or Assessment
Proposed Refresher Period Health and Safety law does not mandate defined time schedules for refresher periods but consensus from health care regions who have developed their own frameworks indicate that general health and safety refresher training for all staff groups should take place at a maximum of every 3 years.
Organisational Implications: Each healthcare organisation will need to determine their position in relation to alignment with the recommended refresher periods, particularly for those staff groups exposed to frequent health and safety risks and ensuring that any agreed training schedule is incorporated into local policy.
Organisations should have a programme of health and safety audits in place. The outcomes and implications of audits should be used to ensure that key policies and practices are being monitored and implemented appropriately, and they inform training priorities.
Refresher training will be indicated for all staff if there is a change in health and safety legislation nationally or where local risk management assessment identifies new risks, or if there is a change in working practices and procedures and where skills need updating.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
3.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators that are involved in the delivery of Health and Safety education or training have the appropriate qualifications, experience, knowledge and skills to deliver training to a satisfactory standard. For guidance, this may include the following:
• A current and thorough knowledge of Health and Safety, including risk assessment & management and an understanding of its application and practice within a healthcare setting. • Knowledge and experience of health and safety risks in their own organisation. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities • A relevant qualification in Health and Safety. • Membership of a professional organisation, for example, the Chartered Membership of IOSH (www.iosh.co.uk) (this might be particularly required for any external trainers providing training on behalf of the organisation). Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic observation.
Subject 4: NHS Conflict Resolution (England)
4.1 Context Statement It is important that staff feel safe in their working environments. Violent behaviour not only affects them personally but indirectly it has a negative impact upon the standard of service and the delivery of patient care. In terms of tackling violence against staff, Conflict Resolution Training (CRT) is a key preventative tool. It forms part of a range of measures introduced to make the NHS a safer place to work. Clearly, it is not sufficient to react to incidents after they occur; ways of reducing the risk of incidents occurring and preventing them from happening in the first place must be found.
The detail in this subject reflects the Conflict Resolution Training guidance as provided by NHS Protect (2013).
4.2 Current Legal or Relevant Expert Guidance
England • NHS Protect (2013), Conflict Resolution Training: implementing the learning aims and outcomes • NHS Protect (2014), Meeting needs and reducing distress: Guidance on the prevention and management of clinically related challenging behaviour in NHS settings • Care Quality Commission: The fundamental standards / safety
Expert Organisation • NHS Protect NB. NHS Protect will be decommissioned during 2017. A new organisation to tackle fraud, bribery and corruption within the health service in England will be known as the NHS Counter Fraud Authority (NHSCFA).
4.3 Target Audience Frontline NHS staff and professionals whose work brings them into direct contact with members of the public – under legislation it is employer’s responsibility to ensure that these individuals and roles are risk-assessed in relation to violence and aggression.
4.4 Key Learning Outcomes The learning aims and associated outcomes are based on de-escalation techniques. The aims address the way one communicates, patterns of behaviour, recognition of warning signs, impact factors and preventative strategies. At the end of the training learners should be able to:
a) explain the role of the Security Management Director and Local Security Management Specialist
b) describe the common causes of conflict and identify the different stages of conflict
c) learn from their own experience of conflict situations to develop strategies to reduce the opportunity for conflict in the future
d) describe two forms of communication
e) indicate the level of emphasis that can be placed on verbal and non-verbal communication during a conflict situation
f) understand the impact that cultural differences may have in relation to communication
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g) identify the causes of communication break down and the importance of creating conditions for communication to succeed
h) utilise three communication models that would assist in dealing with different levels of conflict
i) recognise the behavioural pattern of individuals during conflict
j) recognise the warning and danger signals displayed by individuals during a conflict situation including the signs that may indicate the possibility of physical attack
k) identify the procedural and environmental factors affecting conflict situations and recognise their importance in decision making
l) understand the importance of keeping a safe distance in conflict situations
m) summarise the methods and actions appropriate for particular conflict situations bearing in mind that no two situations are same
n) explain the use of ‘reasonable force’ as described in law and its limitations and requirements
o) identify the range of support, both short and long-term, available to those affected by a violent incident
p) understand the need to provide support to those directly affected by a violent incident and the wider organisational benefits of this.
NB: It is crucial that employing organisations deliver the appropriate level of CRT to meet the needs of staff at their organisation. For example, the clinical and environmental factors affecting conflict for ambulance services or mental health services will be different to those experienced within the in-patient setting.
Even within each type of health organisations there may be different factors coming into play such as location, demographics and geography. Therefore, in addition to delivering the core learning outcomes organisations will need to make a risk assessment of the CRT needs of their staff. In some cases this may result in training with additional learning outcomes to meet and mitigate the identified risks.
CRT provides staff with important de-escalation, communication and calming skills to help them prevent and manage violent situations. However, there are some incidents which may involve challenging behaviour that is clinically related, one common characteristic being where the individual involved in the incident may have some degree of cognitive impairment and their communication may be temporarily or permanently impaired.
NHS organisations and providers of NHS services may therefore choose to include clinically related challenging behaviour awareness as part of a combined course with CRT or incorporate it as part of other training initiatives, such as those addressing staff training needs around dementia.
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4.5 Proposed Frequency of Refresher Training or Assessment The frequency of delivering refresher CRT will be determined by local needs, although it is recommended that, from the viewpoint of retention of knowledge and personal safety, they should not be more than three years from the time of delivery of the previous training.
In cases where new employees have already received CRT from other NHS providers or commissioners the prior learning may be recognised if the training has followed NHS Protect guidance. In such cases a risk-based approach should be made of the employee’s present needs before determining whether their prior learning is sufficient for their new role.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
4.6 Suggested Standards for Training Delivery It is appropriate that the delivery method for CRT takes into account the needs of learners to ensure that maximum benefit and value is obtained. While not exhaustive, these may include access to resources such as classrooms, literature, audio visual facilities and appropriately qualified trainers. Studies have shown that CRT benefits best from delivery in a classroom setting, although the overriding aim must be that learners achieve all of the learning outcomes and any additional ones appropriate for their role and setting established by the risk assessment.
The duration of CRT courses will vary considerably and their length will depend upon the number of additional learning outcomes identified through a risk assessment of CRT needs. However, all NHS CRT courses will need to be long enough to provide sufficient time to ensure that the core learning outcomes and those identified in the risk assessment are fully met. CRT can be delivered as a standalone course, although there are benefits to it being integrated as part of a more holistic approach to communication, customer care and engagement with service users as these are transferable skills.
Each learning outcome serves a specific purpose in the process of de-escalating potential conflict and preventing violence. If the outcomes are not addressed adequately on the course because there has been insufficient time allowed for the information to be fully disseminated and understood this provides little or no value to learners.
NHS Protect (2013) recommends that the core learning outcomes require five hours of contact time to be effective and that the successful delivery of the learning outcomes is considered when determining class sizes. Research has shown that this should be no more than 20 delegates and the Health and Safety Executive have endorsed this approach. E-learning may be appropriate to support the delivery of knowledge aspects of CRT but should not be a substitute for the recommended contact time.
4.7 Relevant National Occupational Standards
Relevant National Occupational Standards • Ento WRV6: Promote a safe and positive culture in the workplace • FMH5: Minimise the risks to an individual and staff during clinical interventions and violent and aggressive episodes
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Subject 5: Fire Safety
5.1 Context Statement Since the publication of the fire safety Regulatory Reform (Fire Safety) Order 2005, the provision of fire training has become a legal requirement for all employees within the UK. Fire safety in the healthcare environment is particularly challenging since many people in healthcare environments will require some degree of assistance from healthcare staff to ensure their safety in the event of a fire (Department of Health 2013).
Fire within a healthcare setting can have a significant impact and consequences which can include property loss, injury and potential loss of life. High levels of fire safety awareness and knowledge by the healthcare workforce is essential if safe healthcare environments are to be maintained and the distressing consequences that can be caused through fire are to be prevented.
Within the UK, healthcare is provided in a wide range of environments, and it is essential that dependent upon the nature of the environment, which might be categorised as either simple or complex, that the relevant guidance related to fire safety management is used to help assess and address potential fire safety risks.
5.2 Current Legal or Relevant Expert Guidance
Legislation – England and Wales • The Regulatory Reform (Fire Safety) Order 2005
Legislation – Northern Ireland • The Fire Safety Regulations (Northern Ireland) 2010
Legislation – Scotland • The Fire Safety (Scotland) Regulations 2006
Legislation – Wales • The Smoke-free Premises etc. (Wales) Regulations 2007
Expert Guidance – England • Department of Health policy on fire safety in the NHS in England: Managing Healthcare Fire Safety (HTM 0501), Second edition April 2013 • DCLG (2006), Fire safety risk assessment: healthcare premises
Expert Guidance – Wales • Working Together In Partnership (2007), Concordat Between The Welsh Assembly Government’s Department For Health And Social Services and the Chief Fire Officers’ Association Wales
Expert Organisation • National Association of Healthcare Fire Officers (NAHFO)
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5.3 Target Audience Fire Safety training is a legal requirement for all staff. The learning outcomes stated in the Core Skills Training Framework are taken from the Firecode and specify the generic training needed by all staff without exception.
Adequate fire safety information and instruction is required for all staff on induction.
5.4 Key Learning Outcomes The following learning outcomes reflect the minimum standard which should be incorporated into fire safety training for all levels, and reflects in England the Department of Health policy on fire safety in the NHS in England: Managing Healthcare Fire Safety (HTM 05-01), Second edition April 2013.
The learner will:
a) understand the characteristics of fire, smoke and toxic fumes
b) know the fire hazards in the working environment
c) be aware of the significant findings of relevant fire risk assessments
d) understand how to practice and promote fire prevention
e) be aware of basic fire safety and local fire safety protocols including staff responsibilities during a fire incident
f) know the means of raising the fire alarm and the actions to take on hearing the fire alarm
g) know instinctively the right action to take if fire breaks out or smoke is detected
h) be familiar with the different types of fire extinguishers, state their use and identify the safety precautions associated with their use
i) understand the importance of being familiar with evacuation procedures and associated escape routes.
NB: In addition learners should take part in practical training sessions which include evacuation techniques and where appropriate, use of firefighting equipment.
Dependent upon role, location and service need the learning outcomes stated should be supplemented by specific job and site training. This should include, for example, local fire procedures, escape routes, refuges, evacuation aids and fire alarms and any other aspects as deemed necessary based upon localised fire risk assessment, training needs analysis and policy.
Similarly, staff involved in particular roles such as telephone operators, estates and working in environments such as operating theatres may need more specific training to fulfil their responsibilities in effective fire prevention and management.
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5.5 Proposed frequency of Refresher Training or Assessment All staff should on commencement of employment receive local site specific fire induction training, and within a month of starting employment undertake any established corporate fire induction training.
All staff should receive regular updated fire safety training and instruction. The duration and frequency of the training should be determined by a training needs analysis. This should take account of the fire risks present in the premises, the numbers and dependency of people at risk, and the responsibilities of staff in a fire emergency. The outcomes of the fire risk assessment and the resulting determination of training requirements should be formally recorded and periodically reviewed.
Organisational Implications: Staff who are involved in the direct care of patients, who may need to help evacuate others, should receive training more frequently than those who may only be required to evacuate themselves, this needs to be based upon current local risk assessment.
Refresher training will be indicated if there has been a change in Fire Safety Legislation nationally, an organisation has amended its policy, or the local fire risk assessment identifies a new or changed risk, all staff affected will need to be updated to reflect any changes.
Assessment of Competence
Assessing the effectiveness of training is important but often difficult to carry out with certainty. The Fire Safety Manager in conjunction with healthcare Fire Safety Advisers should, on a regular basis (but normally no less than every two years), devise methods of testing staff.
It is likely that the practical performance of staff at training sessions and during rehearsals of the fire emergency action plan will offer the best indication of the effectiveness of a programme and the degree to which staff have assimilated instruction (Department of Health 2013).
5.6 Suggested Standards for Training Delivery It is the responsibility of the Trust Board (or equivalent), in consultation with the Fire Safety Manager/Advisor to determine how a suitable programme of fire safety is developed and implemented, and provide assurance that it meets the legislative requirements.
The employing organisation should be assured that Learning Facilitators who are involved in the delivery of fire training are competent in fire safety in the healthcare environment and have the appropriate qualifications, experience or background to deliver training to a satisfactory standard. The Firecode stipulates that:
“Staff delivering training should have the necessary competence, and if called upon to do so, should be able to demonstrate their competence.”
For guidance, this should include the following:
• A relevant fire safety qualification e.g. IOSH, the Fire Protection Association Advanced Fire Safety Management, Membership of Institute of Fire Engineers, Loughborough Post Graduate Certificate in Fire Safety Management, CFPA Diploma or extensive fire service experience (Local Authority or MoD) and/or relevant fire service experience. and
• A thorough knowledge of Fire Safety in a healthcare setting, including legislation and the application of the Firecode. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities Within complex healthcare environments such as hospitals, the requirements are that face-to-face training should be delivered by the designated Authorised Person1. Where the delivery of any training in complex buildings is supported
1 Authorised Person (Fire) who is usually the Fire Adviser for the trust.
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by designated Fire Wardens/coordinators, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic review.
Where staff work in non-complex buildings, for example, a medical centre, walk in centre or doctors surgery and the treatments provided within the premises are non-invasive, Fire training may be delivered by a person with lesser experience and qualifications than identified above. However, training should follow the guidance in the DCLG guide for healthcare premises (see 5.2). In these cases, the organisation should ensure that they have put in place a quality assurance mechanism to ensure an accurate and effective delivery.
The fire safety training programme should include practical sessions and fire drills to supplement classroom instruction. Elearning can be used to support Fire Training but is not acceptable as the sole means of training.
5.7 Relevant National Occupational Standards
Relevant National Occupational Standards • GEN96: Maintain health, safety and security practices within a health setting • SS03: Promote, monitor and maintain health, safety and security in the workplace
Subject 6: Infection Prevention and Control
6.1 Context Statement The risk of infection within a healthcare setting poses a significant risk to patients, carers and staff. Without effective infection prevention and control approaches, infection can cause distress, harm, and impair the quality of life and healthcare experiences. Infection frequently requires additional costly resources to treat. Therefore, prevention of infection has to be a key priority for all staff groups working within a healthcare setting. Consequently, ensuring that all staff have high levels of infection prevention and control awareness, supported through an effective education and training approach, should form a central feature of any infection prevention and control strategy.
6.2 Current Legal or Relevant Expert Guidance
Legislation – UK Wide • Health and Safety at Work etc Act 1974 • The Control of Substances Hazardous to Health Regulations 2002
Legislation – England • Health Act 2009 • Health and Social Care Act 2008 • Public Health (Control of Disease) Act 1984 • The Health Protection (Notification) Regulations 2010
Legislation – Scotland • Public Health etc. (Scotland) Act 2008 • Public Services Reform (Scotland) Act 2010
Key Guidance – England • Department of Health (2015), The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance • Loveday HP et al (2014), epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England, Journal of Hospital Infection 86S1 (2014) S1–S70 • NHS, Infection. Prevention. Control. • NICE (2011), Healthcare-associated infections: prevention and control, Public health guidance [PH36] • NICE (2014), Infection prevention and control: Quality Standard QS61 • NICE (2017), Healthcare-associated infections: prevention and control in primary and community care, Clinical guideline [CG139]
Key Guidance – Northern Ireland • The Northern Ireland Regional Infection Prevention and Control Manual • Public Health Agency Northern Ireland
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Key Guidance – Scotland • Health Protection Scotland (2017), Compendium of Healthcare Associated Infection Guidance • Health Protection Scotland (2017), National Infection Prevention and Control Manual • NHS Education for Scotland HAI Education for Infection Prevention and Control
Key Guidance – Wales • National Infection Control Policies for Wales • NHS Wales. Healthcare Associated Infection Wales
Expert Organisations and Resources • Healthcare Infection Society • Health Protection Scotland • Infection Prevention Society • International Resource for Infection Control • Public Health England • Public Health Wales • World Health Organization
6.3 Target Audience Level 1: All staff including contractors, unpaid and voluntary staff.
Level 2: All healthcare staff groups involved in direct patient care or services.
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6.4 Key Learning Outcomes Learning outcomes are divided into two levels. Each level reflects a level of expected knowledge, skill and understanding. The appropriate level of training is dependent upon role, work context and local risk assessment. Level 1 learning outcomes reflect a basic standard which should be incorporated into infection prevention and control training for all staff, including contractors and volunteers. Level 2 learning outcomes reflect a further standard which should be incorporated into infection prevention and control training for all healthcare staff and other staff groups who provide direct patient care.
Level 1: All staff, including contractors and unpaid and voluntary staff.
The learner will:
a) know how individuals can contribute to infection prevention and control
b) have knowledge of and demonstrate the standard infection prevention and control precautions relevant to their role which may include:
o Hand Hygiene
o Personal Protective Equipment (PPE)
o Management of Blood and Body Fluid Spillage
o Management of Occupational Exposure (including sharps)
o Management of the Environment
o Management of Care Equipment.
c) recognise and act when their personal fitness to work may pose a risk of infection to others.
Level 2: All healthcare staff providing direct patient care and other relevant staff, based upon role and local risk assessment (Level 1 outcomes plus the following).
The learner will relevant to their role:
a) be able to describe the healthcare organisation’s and their own responsibilities in terms of current infection prevention and control legislation
b) know how to obtain information about infection prevention and control within the organisation
c) understand what is meant by the term healthcare associated infections
d) understand the chain of infection and how this informs infection prevention and control practice
e) demonstrate an understanding of the routes of transmission of micro-organisms
f) understand individual roles and responsibilities for the three levels of decontamination
g) use single use items appropriately
h) be able to conduct a risk assessment in respect of ensuring infection prevention and control
i) explain different alert organisms and conditions that pose an infection risk
j) describe how to safely manage patients with specific alert organisms.
Where applicable to the role Apply appropriate health and safety measures, standard precautions for infection prevention and control in obtaining specimens from individuals.
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NB: It is to be noted that, in some healthcare settings, Level 2 learning outcomes may not be relevant for some clinical roles e.g. Community Healthcare. It is the organisation’s discretion to agree on which learning outcomes are relevant and, therefore, required.
6.5 Proposed Frequency of Refresher Training or Assessment It is recommended that refresher training for infection prevention and control training should be a maximum of:
• All staff (Level 1 Outcomes): every 3 years. • All healthcare staff providing direct patient care (Level 2 Outcomes): every year. Organisational Implications: Each healthcare organisation will need to determine their position in relation to alignment with the recommended refresher periods, particularly for those staff groups exposed to greater risks and ensuring that any agreed training schedule is incorporated into local policy.
Additional refresher training will be indicated for all staff if there is a change in infection prevention and control guidelines nationally or where the organisation has amended its policy locally. Organisations should have a programme of quality assurance including audit and feedback. The audit findings should be used to ensure that key policies and practices are being reviewed, implemented and inform training priorities.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant, practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member or learner does not meet the required level of current knowledge and understanding and practice through pre-assessment, they should complete the refresher training and any associated assessments required.
6.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators involved in the delivery of Infection prevention and control education or training have the appropriate qualifications, experience or background to deliver training to a satisfactory standard. For guidance, this may include the following:
• A relevant professional/healthcare registered qualification e.g. nurse. • Ability to demonstrate significant experience/knowledge of infection prevention and control issues and an understanding of their issues and practice within a healthcare setting. • Recent participation in advanced practice CPD developments in infection prevention and control. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities Where the learning facilitator is a designated practitioner in infection control and prevention, then they should be working towards demonstrating the Outcome competences for practitioners in infection prevention and control as suggested by Infection Prevention Society. Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic review.
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6.7 Relevant National Occupational Standards
Relevant National Occupational Standards • Gen1: Ensure personal fitness for work • Gen2: Prepare and dress for work in healthcare settings • IPC2.2012: Perform hand hygiene to prevent the spread of infection • IPC6.2012: Use personal protective equipment to prevent the spread of infection • IPC1.2012: Minimise the risk of spreading infection by cleaning, disinfecting and maintaining environments • IPC4.2012: Minimise the risk of spreading infection by cleaning, disinfection and storing care equipment • IPC8.2012: Minimise the risk of spreading infection when transporting and storing health and care related waste • IPC3.2012: Clean, disinfect and remove spillages of blood and other body fluids to minimise the risk of infection • IPC7.2012: Safely dispose of healthcare waste, including sharps, to prevent the spread of infection
Subject 7: Moving and Handling
7.1 Context Statement Healthcare settings can pose significant moving and handling challenges and risks. Work-related musculoskeletal disorders, including manual handling injuries, are the most common type of occupational ill health in the UK (Health and Safety Executive 2011). Given the nature, type and frequency of moving and handling activities undertaken the risks of injury to staff and patients are considerable and need to be minimised. As part of health and safety at work requirements, employers are expected to provide training on key health and safety risks and this has been supplemented with additional guidance covering the specific activity of moving and handling.
7.2 Current Legal or Relevant Expert Guidance
Legislation • Health and Safety at Work etc Act 1974 • Lifting Operations and Lifting Equipment Regulation (LOLER), 1998 • Management of Health and Safety at Work Regulations, 1999 • Provision and Use of Work Equipment regulations (PUWER), 1998 • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), 2013 • The Health and Safety (Miscellaneous Amendments) Regulations 2002 • The Manual Handling Operations Regulations 1992
Key Guidance – Scotland • Scottish Government (2014), The Scottish Manual Handling Passport Scheme
Key Guidance – Wales • All Wales NHS Manual Handling Passport & Information Scheme
Key Organisations • The Health and Safety Executive (HSE) • National Back Exchange
Key References • Health Safety Executive, The Manual Handling Operations Regulations 1992 (as Amended 2002) • Health Safety Executive, Manual handling at work: A brief guide • ISO Technical Report 12296 Ergonomics – Manual Handling Of people in the Health Care Sector • The Guide to the Handling of People (HOP 6 edition). Backcare: London • Ruszala, S et al. (2010), Standards in Manual Handling, (3rd edition). National Back Exchange: Towcester
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7.3 Target Audience Level 1: All staff, including unpaid and voluntary staff.
Level 2: Those staff groups, including unpaid and voluntary staff, whose role involves patient handling activities.
7.4 Key Learning Outcomes Level 1
The learner will:
a) be able to recognise manual handling risk factors and how injuries can occur
b) understand employers and employees responsibilities under relevant national Health & Safety legislation including most recent versions of the Manual Handling Operation Regulations
c) understand their own responsibilities under local organisational policies for Moving and Handling
d) know where additional advice and information can be sought relating to Moving and Handling issues
e) be able to use an ergonomic approach to manual handling and other work tasks leading to improved working posture
f) understand principles of good back care to promote general musculo-skeletal health
g) understand the principles of safer handling
h) know the factors to be included in undertaking a dynamic risk assessment prior to undertaking a moving and handling activity
i) understand how the organisation uses its risk management processes to inform safe systems of work
j) be able to choose suitable risk control strategies, resources and support available to facilitate good practice following a risk assessment appropriate to the staff member’s role.
Load Handling Staff
Staff involved as part of their duties in the moving and handling of inanimate loads, will require principle-based practical instruction on strategies and approaches for safely moving and handling inanimate loads, relevant to their role in the organisation.
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Level 2: Patient Handling Staff In addition to the learning outcomes listed for all employees, staff identified as being involved in patient handling activities will be required to meet the following additional outcomes.
The learner will:
a) know how to provide patients with the best quality care using appropriate, safe and dignified moving and handling strategies
b) understand normal human movement patterns as a prerequisite to moving and handling people
c) understand how multidisciplinary team communication and risk assessments ensure the safe handling of patients.
Staff involved as part of their duties in the moving and handling of patients will require principle-based practical instruction on strategies and approaches for safely moving and handling patients, relevant to their role in the organisation:
o chair moves and transfers
o bed/trolley/table moves and transfers
o mobility
o managing the falling/fallen patient
o use of equipment available within the organisation, e.g. profiling beds, patient hoists and slings, bathing aids, sliding and transferring systems, small handling aids to promote independence.
Training should be supported with practical instruction and competence assessment by work place supervisors in the use of any mechanical aids provided for undertaking Moving and Handling tasks.
NB: Additional learning outcomes, or specific training, may be necessary to meet the particular needs or function of individual organisations. These should be determined by local risk assessment and policy.
7.5 Proposed frequency of Refresher Training or Assessment
Proposed Refresher Training Periods Given the potential range of individual local factors and risks that might have an impact upon moving and handling activities it is difficult to set defined refresher periods for all staff groups. Rather the organisation should have monitoring and a programme of audit in place to check that individual employees are moving and handling people safely. The need for updating skills or refresher training will be determined by the monitoring and assessment of the individual’s competence, outcomes of any local audits and whether there are any other changes to tasks, equipment, environment or new developments in moving and handling policy and practice.
One of the implications arising from this is that staff who are monitored and demonstrate currency of knowledge and practice as relevant in their workplace will not need to undertake refresher training unless there are changes in the circumstances as indicated above.
If organisations determine an agreed refresher training period, then this needs to be incorporated into local policy.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant, practical assessment, the required level of current knowledge, understanding and practice as appropriate to their work setting then this can be used as evidence that knowledge and skills have been maintained, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training.
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• Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
7.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators that are involved in the delivery of Moving and Handling education or training are physically capable of demonstrating good practice in all aspects of moving and handling and have the appropriate qualifications, experience or background to deliver training to a satisfactory standard. For guidance, this may include the following:
Key Requirements: • A current and thorough knowledge of Manual Handling including risk assessment & management and an understanding of its application and practice within a healthcare setting. • A relevant professional/healthcare qualification e.g. nurse, physiotherapist, occupational therapist, ergonomist, radiographer, ambulance paramedic or be able to demonstrate extensive experience of load handling or working within a health or social care setting. • Completion of an approved back care advisor course based on the National Back Exchange Inter-professional Curriculum (or proof of a similar course) leading to a recognised qualification in Back Care Management. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities
Desirable: • Membership to the National Back Exchange will be one of the criteria that organisations might use when looking for evidence that trainers have access to current best practice and continued professional development. • Awareness of and the incorporation of the National Back Exchange Standards In Manual Handling – Training Guidelines. Organisations should ensure that they have a designated Competent Person to oversee the delivery of Moving and Handling Training. Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in a place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic review.
7.7 Relevant National Occupational Standards
Relevant National Occupational Standards • SCDHSC0223: Contribute to moving and positioning individuals • CHS6: Move and position individuals • CHS5: Undertake agreed pressure area care.
Subject 8: Safeguarding Adults
8.1 Context Statement All citizens have a right to live their lives free from violence, harassment, humiliation and degradation. Ensuring independence, well-being and choice is also a key element of this right (The Association of Directors of Social Services, 20052). Adults with capacity also have the right to make decisions, even if they are perceived as unwise. They may make decisions that put their right to privacy, autonomy and family life ahead of their right to live and to be free from inhuman or degrading treatment. There are safeguards for those people who lack capacity and sometimes complex work is needed to weigh up whether action should be taken in the public interest or where the person concerned is being coerced.
The health sector can make a positive contribution towards safeguarding those that might be less able to protect themselves from harm, neglect or abuse. Central to effective safeguarding management are trustful and supportive relationships, based upon dignity and respect, between patients, their families and healthcare staff. There are however, distressing examples where this has failed as documented in the Francis Report (20133), the Cavendish Review (20134) and findings of Serious Case Reviews where there have been major concerns about adult protection or system failures. Healthcare organisations therefore have a responsibility to be active and responsive in ensuring people’s dignity and rights and meeting statutory duties to safeguard adults. This requires a systematic approach, effective leadership at all levels and an organisational culture where care and compassion are valued.
The aims of adult safeguarding are5:
• To prevent harm and reduce the risk of abuse or neglect to adults with care and support needs. • To safeguard individuals in a way that supports them in making choices and having control in how they choose to live their lives. • To promote an outcomes approach in safeguarding that works for people resulting in the best experience possible. • To raise public awareness so that professionals, other staff and communities as a whole play their part in preventing, identifying and responding to abuse and neglect. Six key principles underpin all adult safeguarding work:
• Empowerment – Personalisation and the presumption of person-led decisions and informed consent • Prevention – It is better to take action before harm occurs • Proportionality – Proportionate and least intrusive response appropriate to the risk represented • Protection – Support and representation for those in greatest need • Partnership – Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse • Accountability – Accountability and transparency in delivering safeguarding.
2 The Association of Directors of Social Services (2005) Safeguarding Adults. A National Framework of Standards for good practice and outcomes in adult protection work, London. 3 Francis R (2013), Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, London: The Stationery Office. 4 Cavendish C (2013), The Cavendish Review: An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. 5 Department of Health (2014), Care and Support Statutory Guidance
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8.2 Current Legal or Relevant Expert Guidance
Legislation – UK Wide • Data Protection Act 1998 • Equality Act 2010 • Freedom of Information Act 2000 • Human Rights Act 1998 • Public Interest Disclosure Act 1998 • Safeguarding Vulnerable Groups Act 2006 • Counter-Terrorism and Security Act (2015) • Serious Crime Act (2015)
Legislation – England and Wales • Care Act 2014 • Children and Families Act 2014 • NHS Act 2006 • Mental Capacity Act 2005 • The Mental Capacity Act Deprivation of Liberty Safeguards
Legislation – Wales • Social Services and Wellbeing (Wales) Act 2014
Legislation – Northern Ireland • Safeguarding Vulnerable Groups (2007 Order)
Legislation – Scotland • Adult Support and Protection (Scotland) Act 2007 • Adults with Incapacity (Scotland) 2000 • Freedom of Information (Scotland) Act 2000
Key Guidance – England • Bournemouth University & Learn to Care (2012), National Capability Framework for Safeguarding Adults and supporting workbooks: Safeguarding Vulnerable Adults (Staff Group A Workbook) and Safeguarding Adults at risk of harm (Staff Group B Workbook) • Care Quality Commission, Safeguarding People • Department for Constitutional Affairs (2007), Mental Capacity Act 2005: Code of Practice • Department of Health (2017), Care and Support Statutory Guidance • Department of Health (2011), Building partnerships, staying safe: The health sector contribution to HM Government’s Prevent strategy: guidance for healthcare organisations • Department of Health (2011*), Safeguarding Adults: The role of health service managers and their boards • Lampard K and Marsden E (2015), Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile • NHS England (2017), Prevent Training and Competencies Framework • NHS England (2015), Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework
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• NHS England (2015), Safeguarding Policy • NHS England (2015), Managing Safeguarding Allegations Against Staff Policy and Procedure
Key Guidance – England and Wales • HM Government (2015), Channel Duty Guidance: Protecting vulnerable people from being drawn into terrorism • HM Government (2015), Revised Prevent Duty Guidance for England and Wales Key Guidance – Northern Ireland • Department of Health, Social Services and Public Safety (2015), Adult Safeguarding: Prevention and Protection in Partnership Key Guidance – Scotland • Adult Support and Protection Code of Practice (2014) • The Scottish Government (2015), Revised Prevent Duty Guidance for Scotland
Key Guidance – Wales • Health Inspectorate Wales (2010), Safeguarding and Protecting Vulnerable Adults in Wales • NHS Wales Governance e-Manual | Safeguarding Vulnerable Adults
8.3 Target Audience • Level 1: All staff, including paid and voluntary staff • Level 2: Staff with professional and organisational responsibility for safeguarding adults, able to act on concerns and to work within an inter- or multi-agency context
8.4 Key Learning Outcomes
Level 1 The learner will:
a) understand the term safeguarding adults
b) understand the nature and scope of harm to and abuse of adults at risk
c) be able to recognise a range of factors which feature in adult abuse and neglect
d) understand the importance of demonstrating dignity and respect when providing healthcare services
e) understand how healthcare environments can promote or undermine people’s dignity and rights and the importance of individualised, person centred care
f) know how to apply the basic principles of helping people to keep themselves safe
g) know how to support people to think about risk when exercising choice and control
h) know the local arrangements for the implementation of multi-agency Safeguarding Adult’s policies and procedures
i) know and explain what to do if abuse of an adult is suspected; including how to raise concerns within local whistle blowing policy procedures
j) be aware of relevant legislation, local and national policies and procedures which relate to safeguarding adults
k) understand the importance of sharing information with the relevant agencies
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l) know the actions to take if they experience barriers in alerting or referring to relevant agencies
m) be aware of the risk factors for radicalisation and know who to contact regarding preventive action and support for those who may be at risk of, or are being drawn into, terrorist related activity.
Level 2 (Level 1 outcomes plus the following)6 The learner will:
a) understand how to support people to keep safe
b) be able to respond to safeguarding alerts / referrals
c) be able to identify and reduce potential and actual risks after disclosure or an allegation has been made
d) be able to develop protective strategies for those that decline services
e) understand the levels or thresholds for investigating in response to a safeguarding referral and the requirements of gathering initial information
f) be able to apply local and national policy and procedural frameworks when undertaking safeguarding activity
g) know what legislation is relevant to undertaking safeguarding activity
h) be able to support service users and carers to understand safeguarding issues to maximise their decision making
i) understand when to use emergency systems to safeguard adults
j) be able to maintain accurate, complete and up to date records
k) understand how best evidence is achieved
l) know the purpose of Safeguarding Adults investigations and be able to apply the duties and tasks involved
m) understand the roles and responsibilities of the different agencies involved in investigating allegations of abuse.
6 The descriptions of target audience and associated learning outcomes at Level 2 are mainly derived from Staff Group B in the National Capability Framework for Safeguarding Adults developed by Bournemouth University & Learn to Care. Background information on relevant theories, concepts and models and a number of learning activities and tools to support reflective practice can also be found in the Staff Group B Workbook (Bournemouth University & Learn to Care, 2012).
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8.5 Proposed Frequency of Refresher Training or Assessment
Proposed Refresher Training Periods It is recommended that Safeguarding refresher training for all staff should take place on induction to ensure awareness of local procedures and at a maximum of every 3 years.
Organisational Implications: Each healthcare organisation will need to determine the required refresher training periods, ensuring that any agreed training schedule is incorporated into their local policy.
Refresher training will be indicated for all staff if there is a change in Safeguarding legislation nationally or an organisation has amended its policy locally.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment, including where relevant, practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
8.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators that are involved in the delivery of Safeguarding education or training have the appropriate, experience, background and qualifications to deliver training to a satisfactory standard. For guidance, this may include the following:
• Advanced knowledge and understanding of adult Safeguarding and its application and practice within a healthcare setting. • Awareness of diversity and cultural issues. • Familiarity with key issues related to the use/misuse of physical restrain, deprivation of liberty safeguards, the Mental Capacity Act and the Care Act. • Familiarity with the interfaces between dignity, safeguarding, serious incidents, whistle blowing, complaints, and patient feedback routes. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic review.
8.7 Relevant National Occupational Standards
Relevant National Occupational Standards • SCDHSC0024: Support the safeguarding of individuals • SCDHSC0035: Promote the safeguarding of individuals • SCDHSC0045: Lead practice that promotes the safeguarding of individuals
Subject 8a: Preventing Radicalisation
8a.1 Context Statement This subject is derived from the NHS England Prevent Training and Competencies Framework (2017):
Prevent is part of the Government counter-terrorism strategy CONTEST and aims to reduce the threat to the UK from terrorism by stopping people becoming terrorists or supporting terrorism.
Prevent focuses on all forms of terrorism and operates in a ‘pre-criminal’ space’. The Prevent strategy is focused on providing support and re-direction to individuals at risk of, or in the process of being groomed /radicalised into terrorist activity before any crime is committed. Radicalisation is comparable to other forms of exploitation; it is a safeguarding issue that staff working in the health sector must be aware of.
Radicalisation is a process by which an individual or group adopts increasingly extreme political, social, or religious ideals and aspirations that reject or undermine the status quo or undermine contemporary ideas and expressions of freedom of choice.
The Prevent Duty 2015 requires all specified authorities including NHS Trusts and Foundation Trusts to ensure that there are mechanisms in place for understanding the risk of radicalisation. Furthermore, they must ensure that health staff understand the risk of radicalisation and how to seek appropriate advice and support.
Healthcare staff will meet, and treat people who may be vulnerable to being drawn into terrorism. The health sector needs to ensure that healthcare workers are able to identify early signs of an individual being drawn into radicalisation.
Staff must be able to recognise key signs of radicalisation and be confident in referring individuals to their organisational safeguarding lead or the police thus enabling them to receive the support and intervention they require. Ref: NHS England (2017), Prevent Training and Competencies Framework
8a.2 Current Legal or Relevant Expert Guidance
Legislation – UK Wide • Equality Act 2010 • Human Rights Act 1998 • Counter-Terrorism and Security Act (2015)
Key Guidance – England and Wales • NHS England (2017), Prevent Training and Competencies Framework • HM Government (July 2015), Revised Prevent Duty Guidance for England and Wales • HM Government (2011), Prevent Strategy • HM Government (2011), Counter-terrorism strategy (CONTEST) • Department of Health (2011), Building Partnerships, Staying Safe: guidance for healthcare organisations
Key Guidance – Northern Ireland • Department of Health, Social Services and Public Safety (2015), Adult Safeguarding: Prevention and Protection in Partnership Key Guidance – Scotland • The Scottish Government (2015), Revised Prevent Duty Guidance for Scotland
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8a.3 Target Audience • Basic Prevent Awareness: All clinical and non-clinical staff that have contact with adults, children and young people and/ or parents/carers. This will include for example receptionists, transport staff and phlebotomists. This is the same target group as for Safeguarding Adults and Safeguarding Children at Levels 1 & 2. • Awareness of Prevent: All staff who could potentially contribute to assessing, planning, intervening and evaluating the needs of an adult or child where there are safeguarding concerns. This will include for example; GPs, mental health practitioners, front line ambulance staff and chaplaincy staff. This is the same target group as for Safeguarding Adults and Safeguarding Children at Level 3. This target group for Awareness of Prevent also includes: ➢ Named professionals (named doctors, named nurses named health visitors, named midwives (in organisations delivering maternity services), named health professionals in ambulance organisations and named GPs for Organisations commissioning Primary Care) ➢ Designated Professionals (designated doctors and nurses, lead paediatricians, consultant/lead nurses, Child Protection Nurse Advisers (Scotland).
Prevent Leads In addition to Basic Prevent Awareness and Prevent Awareness, there is also a level of competence relevant to organisational Prevent Leads in both commissioner and provider organisations. The competencies for Prevent Leads are outside the scope of the Statutory/Mandatory CSTF, but can be found in the NHS England Prevent Training and Competencies Framework.
NB. The Prevent Training and Competencies Framework was developed in conjunction with the 2014 Intercollegiate document7 in order to ensure a consistent approach to training and provide parity between the expectations to safeguard both children and adults with care and support needs.
7 Royal College of Paediatrics and Child Health (2014), Intercollegiate Document, Safeguarding children and young people: roles and competences for health care staff
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8a.4 Key Learning Outcomes8
Basic Prevent Awareness The learner will:
a) understand the objectives of the Prevent strategy and the health sector contribution to the Prevent agenda
b) know own professional responsibilities in relation to the safeguarding of adults, children and young people at risk
c) understand the vulnerability factors that can make individuals susceptible to radicalisation or a risk to others
d) know who to contact and where to seek advice if there are concerns about an individual who may be being groomed into terrorist activity9
e) be able to recognise potential indicators of risk relating to individuals being radicalised
f) understand what impact direct (bullying, be-friending and influencing) or indirect (internet, media etc.) factors might have on individuals and how it might change their thoughts and behaviours
g) be able to raise concerns and take action when they have concerns
h) understand the importance of sharing information (including the consequences of failing to do so).
Prevent Awareness (Basic Prevent Awareness outcomes plus the following) The learner will:
a) know how to support and redirect vulnerable individuals at risk of being groomed into a terrorist related activities
b) know how to share concerns, get advice, and make referrals into the Channel process and Prevent Case Management
c) understand Prevent in the context of the CONTEST strategy and the concept of pre-criminal space
d) understand that radicalisation uses normal social processes and the “power of influence” on all
e) recognise influence, and understand the concepts of polarisation and the use of narratives and ideology
f) understand the current threat level and that Prevent can be applied to all forms of terrorism, present or emerging
g) understand the term “vulnerable” in the context of Prevent and what vulnerabilities are exploited by terrorist groups
h) understand there is no single checklist or profile of a terrorist, and that health staff are a key group and must use their professional judgement in assessing behaviours and risks
i) understand how to recognise and share concerns, seek support and advice, and make referrals within own organisation and with other agencies where appropriate
j) understand Channel multi-agency arrangements to provide support and redirection to individuals at risk of radicalisation
k) be aware of Building Partnerships, Staying Safe: The health sector contribution to HM Government’s Prevent Strategy: guidance for healthcare workers and their organisations relevant policies, procedures and systems for Prevent.
8 The levels of target audience and associated learning outcomes for are derived from the Prevent Training and Competencies Framework (NHS England 2015). 9 Prevent aims to address all forms of terrorism and violent extremism
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8a.5 Proposed Frequency of Refresher Training or Assessment Basic Prevent awareness: training should be repeated every 3 years as a minimum to ensure that individuals are up to date with current procedures and contacts.
In addition to these programmes, Named Designated Professionals should circulate written update briefings and literature to all staff at least annually which would include, for example, any changes in legislation, changes to local policy and procedure or lessons learnt in respect of Prevent.
The training compliance target for Basic Prevent awareness training should be in line with the local agreed safeguarding key performance indicators.
Prevent Awareness: Workshops to Raise Awareness of Prevent (WRAP) should be completed within 12 months of starting in a role requiring this level of training.
Organisations should ensure that staff are provided with appropriate updating/briefing on Prevent at least yearly; relevant training may also be accessed in a number of ways at local, regional or national level and may be multidisciplinary or inter-agency, all training and development undertaken should be recorded on completion.
Knowledge and skills should be reviewed during the annual appraisal process ensuring that individuals are up to date with current policy and practice, any education and training needs being identified to develop and maintain the required knowledge and skills.
The training compliance target for organisations at this level is 85% over 3 years or as agreed locally by the NHS Standard Contract holder.
8a.6 Suggested Standards for Training Delivery Basic Prevent Awareness training can be incorporated into an organisation’s face to face or e-learning material via:
• Induction sessions; • Level 1 Safeguarding Children training and Level 1 Safeguarding Adults training; • Level 2 Safeguarding Children training and level 2 Safeguarding Adults training; • Safeguarding e-learning package.
Prevent Awareness should be delivered by attendance at a Workshop to Raise Awareness of Prevent (WRAP) or by completing an approved e-learning package.
Only a WRAP Facilitator, registered with NHS England and the Home Office can deliver WRAP. WRAP can be delivered to staff in a single organisation, on a partnership basis between organisations, or on a multi-agency basis. The employing organisation should be assured that all Facilitators have appropriate experience, background and qualifications to deliver this training. If training is delivered via e-learning it should be via a Home Office, Department of Health or NHS England approved product.
8a.7 Relevant National Occupational Standards
Relevant National Occupational Standards • SCDHSC0024: Support the safeguarding of individuals • SCDHSC0035: Promote the safeguarding of individuals • SCDHSC0045: Lead practice that promotes the safeguarding of individuals
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Subject 9: Safeguarding Children (Version 2)
9.1 Context Statement Safeguarding children and young people from harm and providing an environment in which children can flourish is a key societal value. Children and young people have a right to be “protected from all forms of violence, abuse, neglect and bad treatment by their parents or anyone else who looks after them.” (United Nations 198910). Organisations are required to co-operate with other agencies to protect individual children and young people from harm. The importance of this has been powerfully highlighted as part of recent inquiries exploring child and young people safeguarding issues (Children’s Commissioner 201211).
Supportive and trustful relationships between children, their families and healthcare staff will be a key factor in enabling effective safeguarding management. Dependent upon roles, healthcare workers can be in an important position in helping to recognise child maltreatment. Healthcare staff need to be alert to signs and symptoms of maltreatment or neglect. They will have a vital role in ensuring effective recording, communication and sharing of information, to help improve identification and ensure appropriate support is put in place for children and young people in need or at risk of harm. Healthcare staff will need to exercise professional judgement focused on the safety and welfare of children and young people (Munro 201112), and know how to make a referral when appropriate. Accordingly, healthcare organisations need to ensure that all staff that might be in contact with children or involved with their care have a clear awareness and understanding of safeguarding issues.
9.2 Current Legal or Relevant Expert Guidance
UK • United Nations Convention on the Rights of the Child 1989
Legislation – England and Wales • Children and Families Act 2014 • Children Act, 2004 • Children and Young Persons Act 2008 • Female Genital Mutilation Act 2003 • Protection of Freedoms Act 2012
Legislation – Northern Ireland • The Children (Northern Ireland) Order 1995 • The Safeguarding Vulnerable Groups (Northern Ireland) Order 2007 • Safeguarding Board Act (Northern Ireland) 2011
Legislation – Scotland • Children and Young People (Scotland) Act 2014 • Children (Scotland) Act 1995
10 United Nations (1989), United Nations Convention on the Rights of the Child
11 The Office of the Children’s Commissioner (2012) “I thought I was the only one. The only one in the world”, The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups Interim Report, London.
12 Department for Education (2011), The Munro Review of Child Protection: Final Report
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• The Protection of Children (Scotland) Act 2003
Legislation – Wales • Children Act 1989 • The Children Act 2004 (Commencement Orders No1-8) (Wales) • The Children and Young Persons Act 2008 (Commencement Orders No.1- 6) (Wales) Order 2011 • Rights of Children and Young Persons (Wales) Measure 2011 • Social Services and Wellbeing (Wales) Act 2014
Key Guidance – UK Wide • Royal College of Paediatrics and Child Health (2014), Intercollegiate Document, Safeguarding children and young people: roles and competences for health care staff • General Medical Council (2012), Protecting children and young people: The responsibilities of all doctors • Home Office, Protecting the UK against terrorism: The Prevent strategy • Royal College of General Practitioners (2011), Safeguarding Children & Young People: A toolkit for General Practice • Royal College of Nursing (2014), Safeguarding children and young people – every nurse’s responsibility: RCN guidance for nursing staff Key Guidance – England • Department of Education (2011) The Munro Review of Child Protection: final report – a child-centred system • Department of Health (2011), Building partnerships, staying safe: The health sector contribution to HM Government’s Prevent strategy: guidance for healthcare organisations • HM Government (2015) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children • Home Office (2015), Mandatory Reporting of Female Genital Mutilation – procedural information • Lampard K and Marsden E (2015), Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile • NHS England (2017), Prevent Training and Competencies Framework • NHS England (2015), Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework • NHS England (2015), Safeguarding Policy • NHS England (2015), Managing Safeguarding Allegations Against Staff Policy and Procedure • National Institute for Health and Care Excellence (2009) When to suspect child maltreatment, NICE clinical guideline 89 [applies in England and Wales] • Office of the Children’s Commissioner • Report of the Children and Young People’s Health Outcome Forum (2012)
Key Guidance Northern Ireland • Department of Health, Social Services and Public Safety (2009), Choosing to Protect: A Guide to the Protection of Children and Vulnerable Adults (NI) Order 2003 • Department of Health, Social Services and Public Safety (2011), UNOCINI Guidance, Understanding the Needs of Children in Northern Ireland
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Key Guidance – Scotland • Scottish Executive Health Department (2003), Protecting Children. A Shared Responsibility • Scottish Government (2014), National Guidance for Child Protection in Scotland • Scottish Government, Getting it Right for Every Child
Key Guidance – Wales • Children in Wales (2008), All Wales Child Protection Procedures • Welsh Government (2003), Safeguarding Children: Working together for positive outcomes • Welsh Government (2006), Safeguarding Children: Working Together under the Children Act 2004 • Welsh Government (2004), Children and Young People: Rights to Action
9.3 Target Audience The target audience and levels given here are those that have been stated in the Intercollegiate Document, Safeguarding children and young people: roles and competences for health care staff, Royal College of Paediatrics and Child Health (2014). • Level 1: All staff including non-clinical managers and staff working in health care settings. • Level 2: Minimum level required for non-clinical and clinical staff who have some degree of contact with children and young people and/or parents/carers. • Level 3: Clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns. Those healthcare staff who undertake specialist safeguarding roles and responsibilities including named professionals, designated professionals, experts and board members will need to receive higher levels of training and opportunities to promote acquisition of skills to ensure they can develop the desired level of competence for their role and thus contribute to effective safeguarding. The training standards and learning outcomes at Level 4 (Named professionals) and Level 5 (Designated professionals) and requirements for Health Board Executives and non-executive directors/members are set out in the Intercollegiate Document (2014).
The Prevent Training and Competencies Framework (NHS England 2015) was developed in conjunction with the 2014 Intercollegiate document in order to ensure a consistent approach to training and provide parity between the expectations to safeguard both children and adults with care and support needs.
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9.4 Key Learning Outcomes The following section reflects the level and core learning outcomes in accordance with the Intercollegiate Document (2014). However, it needs to be emphasised that dependent upon role/speciality there may be additional learning needs which will need to be addressed. While some of these needs can be addressed through training, some will be achieved through clinical experience and supervision.
Level 1 The learner will:
a) be able to recognise potential indicators of child maltreatment – physical, emotional, sexual abuse, and neglect including radicalisation, child trafficking and female genital mutilation (FGM)
b) understand the impact a parent/carers physical and mental health can have on the well-being of a child or young person, including the impact of domestic violence
c) understand the importance of children’s rights in the safeguarding/child protection context
d) know what action to take if there are concerns, including to whom concerns should be reported and from whom to seek advice
e) understand the risks associated with the internet and online social networking
f) be aware of relevant legislation (i.e. Children Acts 1989, 2004 and the Sexual Offences Act 2003).
Level 2 (Level 1 Outcomes plus the following) The learner will:
a) understand what constitutes child maltreatment and be able to identify any signs of child abuse or neglect
b) be able to act as an effective advocate for a child or young person
c) understand the potential impact of a parent’s/carer’s physical and mental health on the wellbeing of a child or young person in order to be able to identify a child or young person at risk
d) be able to identify their own professional role, responsibilities, and professional boundaries and those of colleagues in a multidisciplinary team and in multi-agency setting
e) know how and when to refer to social care if safeguarding/child protection is identified as a concern
f) be able to document safeguarding/child protection concerns in a format that informs the relevant staff and agencies appropriately
g) know how to maintain appropriate records including being able differentiate between fact and opinion
h) be able to identify the appropriate and relevant information and how to share it with other teams
i) understand key statutory and non-statutory guidance and legislation including the UN Convention on the Rights of the Child and Human Rights Act
j) be aware of the risk of female genital mutilation (FGM) in certain communities, be willing to ask about FGM in the course of taking a routine history, know who to contact if a child makes a disclosure of impending or completed mutilation, be aware of the signs and symptoms and be able to refer appropriately for further care and support
k) be aware of the risk factors for radicalisation and know who to contact regarding preventive action and support for those vulnerable young persons who may be at risk of, or are being drawn into, terrorist related activity
l) be able to identify and refer a child suspected of being a victim of trafficking and/or sexual exploitation.
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Level 3 (Level 1 & 2 Outcomes plus the following) The learner will:
a) be able to identify possible signs of sexual, physical, or emotional abuse or neglect using child and familyfocused approach
b) know what constitutes child maltreatment including the effects of carer/parental behaviour on children and young people
c) understand forensic procedures in child maltreatment, and know how to relate these to practice in order to meet clinical and legal requirements as required
d) to be able to undertake forensic procedures and demonstrate how to present the findings and evidence to legal requirements
e) know how to undertake, where appropriate, a risk and harm assessment
f) know how to communicate effectively with children and young people, and how to ensure that they have the opportunity to participate in decisions affecting them as appropriate to their age and ability
g) know how to contribute to, and make considered judgements about how to act to safeguard/protect a child or young person
h) know how to contribute to/formulate and communicate effective management plans for children and young people who have been maltreated
i) understand the issues surrounding misdiagnosis in safeguarding/child protection and to know how to effectively manage diagnostic uncertainty and risk
j) know how to appropriately contribute to inter-agency assessments by gathering and sharing information
k) be able to document concerns in a manner that is appropriate for safeguarding/child protection and legal processes
l) know how to undertake documented reviews of safeguarding/child protection practice as appropriate to role (e.g. through audit, case discussion, peer review, and supervision and as a component of refresher training)
m) know how to deliver and receive supervision within effective models of supervision and /or peer review, and be able to recognise the potential personal impact of safeguarding/ child protection work on professionals
Level 3: Additional learning outcomes for specialist roles Additional specialist learning outcomes for paediatricians, paediatric intensivists, dentists with a lead role in child protection, forensic physicians, child and adolescent psychiatrists, child psychologists, child psychotherapists, GPs, children’s nurses, forensic nurses, school nurses, child and adolescent mental health nurses, children’s learning disability nurses, specialist nurses for safeguarding and looked after children, midwives and health visitors depending on role.
The learner will:
a) know how to work effectively on an inter-professional and interagency basis when there are safeguarding concerns about children, young people and their families
b) know how to ensure the processes and legal requirements for looked after children, including after-care, are appropriately undertaken
c) know how to advise other agencies about the health management of individual children in child protection cases
d) know how to apply the lessons learnt from audit and serious case reviews/case management reviews/significant case reviews to improve practice
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e) know how to advise others on appropriate information sharing
f) know how to appropriately contribute to serious case reviews/case management reviews/significant case reviews, and child death review processes
g) know how to work with children, young people and families where there are child protection concerns as part of the multidisciplinary team and with other disciplines, such as adult mental health, when assessing a child or young person
h) know how to obtain support and help in situations where there are problems requiring further expertise and experience
i) know how to participate in and chair multi-disciplinary meetings as required.
9.5 Proposed frequency of Refresher Training or Assessment
Proposed Refresher Period It is recommended that refresher training should take place at:
Level 1 – Induction, to ensure awareness of local procedures and no longer than every 3 years.
Level 2 – No longer than every 3 years.
Level 3 – No longer than every 3 years.
Organisational Implications: Each healthcare organisation will need to determine the required refresher training periods, particularly for those staff groups most likely to come into contact with children and young people and/or their parents/carers, ensuring that any agreed training schedule is incorporated into local policy.
Refresher training will be indicated for all staff if there is a change in Safeguarding Children and Young People legislation nationally, or an organisation has amended its policy locally.
Assessment of Competence • Where a staff member* or learner can demonstrate through robust pre-assessment, including where relevant, practical assessment, the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training. • Where a staff member* or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
* Except those staff members who have been working outside of the area of practice or have had a career break
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9.6 Suggested Standards for Training Delivery The employing organisation should be assured that Learning Facilitators who are involved in the delivery of Safeguarding education or training have the appropriate qualifications, experience or background to deliver training to a satisfactory standard. For guidance, this may include the following:
• A thorough knowledge of Safeguarding issues and safeguarding procedures and an understanding of their application and practice within a healthcare setting. • Learning Facilitators should also be familiar/have an awareness of diversity and cultural issues. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities • Preferable to have a relevant qualification in Safeguarding Vulnerable Children such as a Post Graduate Certificate in Safeguarding Children and Young People. Where any training delivery is supported by a person who is not an expert in the subject, then the organisation should ensure that they have put in place a quality assurance mechanism, whereby the accuracy of the content and the effectiveness of its delivery has been quality assured and is subject to periodic review.
Training needs to be flexible, encompassing different learning styles and opportunities.
E-learning is appropriate to impart knowledge at levels 1 and 2 and can also be used at level 3 as preparation for reflective team-based learning.
At level 2 training, education and learning opportunities should include multi-disciplinary and scenario-based discussion e.g. drawing on case studies and lessons from research and audit as appropriate to the speciality and roles of participants.
At level 3 Training, education and learning opportunities should be multi-disciplinary and inter-agency, and delivered internally and externally. It should include personal reflection and scenario-based discussion, drawing on case studies, serious case reviews, lessons from research and audit, as well as communicating with children about what is happening as appropriate to the speciality and roles of participants.
9.7 Relevant National Occupational Standards
Relevant National Occupational Standards • CS16: Improve awareness of the potential abuse of children and young people • CS18: Recognise and respond to possible abuse of children and young people • SCDHSC0325: Contribute to the support of children and young people who have experienced harm or abuse • SCDHSC0034: Promote the safeguarding of children and young people
Subject 10: Resuscitation
10.1 Context Statement It is a common expectation that healthcare staff will have sufficient knowledge and skills to be able to recognise and respond to signs of clinical deterioration. Where healthcare staff can anticipate, identify and respond to patient signs of clinical deterioration they can prevent further decline that might otherwise culminate in cardiorespiratory arrest. Consequently there has been a particular focus in promoting greater awareness and understanding in the needs and care of the deteriorating patient.
While the priority is on preventing clinical deterioration, some patients’ condition will progress to cardiorespiratory arrest and require cardiopulmonary resuscitation (CPR). Early and effective resuscitation can save lives. Research in emergency care of collapsed people has led to significant advances in resuscitation techniques. Healthcare organisations must have a clearly defined resuscitation policy and ensure that they provide an effective resuscitation response and service. As part of their duty to ensure safe and effective care, healthcare organisations must ensure that their workforce receives the appropriate training, including periodic updates, in order to maintain a level of resuscitation competence relevant to their role.
The requirements stated are minimum standards and apply to the majority of the workforce in roles and settings where they might be required to provide initial CPR until the arrival of advanced life support expertise and support.
10.2 Current Policy Guidance
Expert Organisation • Resuscitation Council (UK)
Relevant Expert Guidance • Resuscitation Council (2013-2017), Quality standards for cardiopulmonary resuscitation practice and training • Resuscitation Council (2015), Resuscitation Guidelines • British Medical Association, Resuscitation Council (UK) and the Royal College of Nursing (2015), Decisions relating to cardiopulmonary resuscitation (June 2016) • General Medical Council (2010), Treatment and care towards the end of life: good practice in decision making
Scotland • Scottish Government (2016), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy • Scottish Government (2012), Resuscitation Planning Policy for Children and Young People (under 16 years)
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10.3 Target Audience Learning outcomes are divided into three levels based on knowledge, skills and understanding. The appropriate level of training is dependent upon an individual’s role, work context and a local risk assessment. The learning outcomes are derived from the Resuscitation Council (2015) Resuscitation Guidelines.
The levels given here are for the majority of staff who might need to be involved in delivering CPR. However, there are additional specialist levels of outcomes which need to be achieved for those who are expected to lead a resuscitation team, are resuscitation team members or teach resuscitation. These specialist outcomes for ‘Advanced Life Support’ are not covered in this framework. For further information about specialist outcomes, please see the Resuscitation Council (2015) Resuscitation Guidelines and the Quality Standards for Clinical Practice and Training.
Where staff are exposed to and involved in the care of patients from a range of age groups, they should receive the relevant type of resuscitation training.
Level 1 • Non-clinical staff, dependent upon local risk assessment or work context.
Level 2 – Basic Life Support Staff with direct clinical care responsibilities including all qualified healthcare professionals:
• Staff working with Adult patients should undertake training in adult basic life support. • Staff working with Paediatric patients should undertake training in paediatric basic life support. • Staff working with Newborn patients should undertake training in newborn basic life support.
Level 3 – Immediate Life Support Staff with direct clinical care responsibilities including all qualified healthcare professionals:
• Registered healthcare professionals with a responsibility to participate as part of the adult resuscitation team should undertake adult immediate life support training. • Registered healthcare professionals with a responsibility to participate as part of the paediatric resuscitation team should undertake paediatric immediate life support training. • Registered healthcare professionals with a responsibility to participate as part of the newborn resuscitation team should undertake newborn life support training. • Registered healthcare professionals involved in administering rapid tranquillisation in the care of patients with disturbed mental functioning should undertake adult immediate life support training. • Registered healthcare professionals involved in administering sedation in the care of dental or podiatric patients should undertake adult immediate life support training and, where appropriate to case load, paediatric immediate life support training.
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10.4 Key Learning Outcomes
Level 1 The learner will:
a) be able to recognise cardiorespiratory arrest
b) know how to summon immediate emergency help in accordance with local protocols
c) be able to start CPR using chest compressions.
Level 2 – Adult Basic Life Support (Level 1 outcomes plus the following) The learner will:
a) understand national guidelines and local resuscitation policies and procedures
b) know how to recognise and respond to patients with clinical deterioration or cardiorespiratory arrest, escalating care in accordance with local policy
c) be able to initiate an appropriate emergency response, which may include management of choking, and the use of the recovery position, all in accordance with current Resuscitation Council (UK) guidelines
d) be able to initiate and maintain effective chest compressions in accordance with current Resuscitation Council (UK) guidelines
e) be able to provide basic airway management i.e. ensure an open airway
f) be able to initiate and maintain effective lung ventilations in accordance with current Resuscitation Council (UK) guidelines
g) know how an Automated External Defibrillator (AED) can be operated safely and appropriately
h) understand their individual role and responsibilities in responding to persons in emergency situations
i) understand their individual responsibilities in reporting and recording details of an emergency event accurately
j) understand the importance of undertaking any resuscitation interventions within the limits of their personal capabilities and context of any previous training received
k) know how they should apply the local Do Not Attempt Cardiopulmonary Resuscitation Policy within clinical context.
Level 2 – Paediatric Basic Life Support (Level 1 outcomes plus the following) The learner will:
a) understand national guidelines and local Resuscitation policies and procedures
b) know how to recognise and respond to patients with clinical deterioration or cardiorespiratory arrest, escalating care in accordance with local policy
c) be able to initiate an appropriate emergency response, which may include management of choking and the use of the recovery position, in accordance with current Resuscitation Council (UK) guidelines
d) be able to provide basic airway management i.e. ensure an open airway
e) be able to initiate and maintain effective lung ventilations in accordance with current Resuscitation Council (UK) guidelines
f) be able to initiate and maintain effective chest compressions in accordance with current Resuscitation Council (UK) guidelines
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g) understand their individual role and responsibilities in responding to persons in emergency situations
h) understand their individual responsibilities in reporting and recording details of an emergency event accurately
i) understand the importance of undertaking any resuscitation interventions within the limits of their personal capabilities and context of any previous training received
j) know how they should apply the local Do Not Attempt Cardiopulmonary Resuscitation Policy within clinical context.
Level 2 – Newborn Basic Life Support (Level 1 outcomes plus the following) The learner will:
a) understand national guidelines and local Resuscitation policies and procedures
b) know how to recognise and respond to a newborn child, escalating care in accordance with local policy
c) understand the importance of temperature control in the care of the newborn
d) be able to initiate an appropriate emergency response in accordance with current Resuscitation Council (UK) guidelines
e) be able to provide basic airway management i.e. ensure an open airway
f) be able to initiate and maintain effective lung ventilations in accordance with current Resuscitation Council (UK) guidelines
g) be able to initiate and maintain effective chest compressions in accordance with current Resuscitation Council (UK) guidelines
h) understand their individual role and responsibilities in responding to persons in emergency situations
i) understand their individual responsibilities in reporting and recording details of an emergency event accurately
j) understand the importance of undertaking any resuscitation interventions within the limits of their personal capabilities and context of any previous training received.
Level 3 – Adult Immediate Life Support (Levels 1 & 2 outcomes plus the following) The learner will:
a) be able to recognise the seriously ill adult and initiate appropriate interventions to prevent cardiorespiratory arrest
b) understand and be able to apply the ABCDE approach
c) know how to manage and co-ordinate roles and responsibilities within the team in responding to emergency situations until the arrival of a resuscitation team or more experienced assistance
d) be able to participate as a member of the resuscitation team
e) be able to provide initial post resuscitation care until the arrival of the resuscitation team or more experienced assistance.
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Level 3 – Paediatric Immediate Life Support (Levels1 & 2 outcomes plus the following) The learner will:
a) be able to recognise the seriously ill child and initiate appropriate interventions to prevent cardiorespiratory arrest
b) understand and be able to apply the ABCDE approach
c) know how to manage and co-ordinate roles and responsibilities within the team in responding to emergency situations until the arrival of a resuscitation team or more experienced assistance
d) be able to participate as a member of the resuscitation team
e) be able to provide initial post resuscitation care until the arrival of the resuscitation team or more experienced assistance.
Level 3 – Newborn Immediate Life Support (Levels 1 & 2 outcomes plus the following) The learner will:
a) be able to recognise the seriously ill newborn and initiate appropriate interventions to prevent cardiorespiratory arrest.
b) understand the importance of maintaining newborn temperature control
c) know how to manage and co-ordinate roles and responsibilities within the team in responding to emergency situations until the arrival of a resuscitation team or more experienced assistance
d) be able to participate as a member of the resuscitation team
e) be able to provide initial post resuscitation care until the arrival of the resuscitation team or more experienced assistance.
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10.5 Proposed Frequency of Refresher Training or Assessment
Proposed Refresher Period It is recommended that refresher training should take place at a minimum of:
Level 1 – Initial training (e.g. at induction) followed by local assessment.
Level 2 – Every year.
Level 3 – Every year.
Organisational Implications: Each healthcare organisation should determine the required refresher training periods, ensuring that any agreed training schedule is incorporated into their local policy.
Organisations should have a programme of resuscitation audit in place. The outcomes and implications of audits should be used to ensure that key policies and practices are being implemented appropriately and that they inform training priorities in order to improve practice.
Refresher training is aimed at ensuring maintenance of knowledge and skills and, dependent upon role, clinical responsibilities and context. Some staff groups may need more frequent refresher training.
Additional training will be indicated for all staff if there is a change in Resuscitation guidelines nationally or where the organisation has amended its policy locally. Local action plans developed with the involvement of the lead advisor should determine the best way of achieving any training requirements necessitated by changes in guidelines.
A variety of training methods and approaches may be used to plan and deliver flexibly any required refresher training. Refresher training does not mean that staff have to undertake classroom-based training only. Any training methods used must be relevant for promoting the maintenance of knowledge and skills and their effectiveness must be monitored.
Assessment of Competence • Where a staff member or learner can demonstrate the required level of current knowledge, understanding and practice through robust pre-assessment, including where relevant practical assessment, this can be used as evidence that knowledge and skills have been maintained, and the staff member may not need to undertake refresher training. • Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required. • Those individuals who maintain their instructor status on a life support course should be deemed to have the required knowledge, understanding and skills and do not need to undertake refresher training in the speciality concerned.
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10.6 Suggested Standards for Training Delivery The Resuscitation Council UK has set out recommendations for the planning, organisation and delivery of resuscitation training and these should be used as a key reference point. This includes guidance on suggested training methods:
“For all staff, a variety of methods to acquire, maintain and assess resuscitation skills and knowledge can be used for annual updates (e.g. life support courses, simulation training, in-house training, mock-drills, ‘rolling refreshers’, elearning, video based training/self-instruction). The appropriate methods must be determined locally… ‘Hands-on’ simulation training and assessment is recommended for clinical staff” (Resuscitation Council 2014-15, Quality standards for cardiopulmonary resuscitation practice and training)
In ensuring minimum training standards, the employing organisation should be assured that those learning facilitators that are involved in the delivery of Resuscitation education or training have the appropriate qualifications, experience or background to deliver training to a satisfactory standard. This may include the following:
• A relevant professional and/or healthcare qualification and/or experience, for example, a Resuscitation Officer. • Completion of specific training for cardiopulmonary arrests in special circumstances related to the clinical setting in which they deliver training e.g. paediatrics, newborn, pregnancy and trauma • Demonstration of up to date competences in Resuscitation relevant to the level of practice and teaching. • A thorough knowledge of Resuscitation issues and procedures and an understanding of their application and practice within a healthcare setting. • Experience of teaching and learning, including the ability to meet the competences expected for LSILADD04 Plan and prepare specific learning and development opportunities Learning facilitators must have access to equipment for resuscitation training, including as appropriate adult and paediatric manikins, airway management trainers, ECG monitors, rhythm simulators and defibrillators.
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Subject 11: Information Governance
11.1 Context Statement The effective delivery of healthcare services requires the substantial collection, processing and exchange of personal information and data. Ensuring the appropriate collection, use and security of this information is a significant legal responsibility for healthcare organisations and individual healthcare workers. Recent high profile cases of personal data loss and breaches of confidential information, with a significant number of incidents coming from the health sector, have, however, focused and renewed the requirement for all healthcare staff to have an awareness of their responsibilities in using and safeguarding sensitive information.
11.2 Current Legal or Relevant Expert Guidance
Expert Organisation • Information Commissioner’s Office (ICO) • Information Governance Alliance • NHS Digital
The National Cyber Security Centre
Regulation • General Data Protection Regulation (GDPR) Legislation – England • The common law duty of confidentiality * • The Data Protection Act 1998 • The Freedom of Information Act 2000
Legislation – Northern Ireland • The common law duty of confidentiality *
* Although this does not refer to an Act of Parliament it is a form of law based on previous court cases decided by judges; thus it is also referred to as ‘judge-made’ or case law.
Key Guidance • Guide to the General Data Protection Regulation (GDPR) • Caldicott 1 – Report on the Review of Patient-Identifiable Information. London: Caldicott Committee, 1997 • Caldicott 2 – Information: To Share Or Not To Share? The Information Governance Review. London: Independent Information Governance Oversight Panel, 2013 • Caldicott 3 – Review of Data Security, Consent and Opt-Outs. London: National Data Guardian, 2016 • Care Quality Commission (July 2016), Safe date, safe care • Department of Health (2003), Confidentiality: NHS Code of Practice • Department of Health (2012), The power of information: Putting all of us in control of the health and care information we need • Department of Health (2007), Information Security Management: NHS Code of Practice • Information Government Alliance, Records Management Code of Practice for Health and Social Care 2016 • National Data Guardian for Health and Care (2016), Review of Data Security, Consent and Opt-Outs
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• NHS Digital, Codes of practice for handling information in health and care • NHS Information Governance Toolkit (IGT)
11.3 Target Audience All staff involved in routine access to information.
11.4 Key Learning Outcomes The learner will:
a) understand the principles of Information Governance and how they apply in every day working environments
b) understand within the context of their specific role how to provide a confidential service to patients and service users in line with the duty of confidentiality
c) know how to ensure and maintain good record keeping.
d) understand fundamentals of data protection and the General Data Protection Regulations (GDPR)
e) understand fundamentals of confidentiality and the Caldicott Principles
f) understand the responsibilities of healthcare organisations under the Freedom of Information Act 2000
g) understand individual responsibilities in responding to a Freedom of Information request
h) understand the principles of good record keeping.
i) understand, within the context of their role, how they can apply and maintain information security guidelines.
j) know where they can gain local access to policies, procedures and further information on Information Governance.
11.5 Proposed Frequency of Refresher Training
Proposed Refresher Period In England, NHS staff (or staff in organisations with access to NHS patient information) should receive refresher training or assessment annually.
Assessment of Competence • Where a staff member or learner can demonstrate through robust pre-assessment the required level of current knowledge, understanding and practice, then this can be used as evidence that knowledge and skills have been maintained and the staff member may not need to repeat refresher training.
• Where a staff member or learner does not meet the required level of current knowledge, understanding and practice through pre-assessment they should complete the refresher training and any associated assessments required.
1. Development of the Framework Healthcare organisations have legal responsibilities to ensure that their staff receives training to develop the knowledge and skills to ensure a safe and healthy workplace (Garcaz & Wilcock 2005)13. Furthermore, in the effort to improve healthcare services, organisations are required to meet quality standards required by government and other agencies, many of which need to be evidenced through compliance training of the workforce.
Given the imperative for organisations to ensure their compliance, ensure focus on key training priorities and making effective use of resources many healthcare organisations have defined their approaches for the provision of statutory and mandatory training. Frequently, these approaches will be formally reflected in local policies and procedures.
The provision of statutory and mandatory training represents a significant organisational investment. While many employers recognise and are certain of their commitment in ensuring their workforce receives this training, the focus and delivery of such training can be challenging
These challenges include:
• ensuring that the purpose of the training is understood and appreciated by employees
• ensuring that any training delivered is educationally sound
• that the impact of training results in required performance and risk management behaviours
• is delivered in a cost effective way.
There is evidence that healthcare organisations are interested in a more consistent approach in which this type of training can be prioritised, flexibly delivered, resourced and evaluated. For example, several healthcare regions have previously been working with local employers and Subject Matter Experts to define and help standardise approaches (London, North West, South Central and West Midlands Strategic Health Authorities). In part, the activity in these areas was triggered by a report conducted by PASA (2009)14 which found substantial opportunity to standardise and consolidate guidance around statutory and mandatory training and particularly prevent duplication of learning. PASA concluded that should consolidation and unnecessary duplication of statutory and mandatory training be achieved, there are opportunities for exploiting cost efficiencies. For example, in the London region, a programme of activity has been established to streamline statutory and mandatory training and healthcare organisations and in doing so potentially lead to cost efficiencies of £40 million per year. While the fiscal benefit will not necessarily mean cashreleasing efficiency savings, if the recognition and prevention of unnecessary duplication can be achieved at scale across the health sector, it should result in better compliance rates and more direct service contact time given that the workforce will require less time away from the work environment to undertake this type of training. Furthermore, it will allow organisations sufficient head room to focus on other training priorities that would have benefit for patient and service activity.
The interest in a UK wide Core Skills Framework was strongly supported with the responses to a consultation conducted by Skills for Health exploring the support for a UK Core Skills Framework. Skills for Health was subsequently commissioned as part of a programme of work funded by The UK Commission for Employment and Skills to develop a UK wide Core Skills Framework. Skills for Health has since been working with the UK countries and regions and key national stakeholders to develop and maintain a national framework for statutory and mandatory training. This is with the aim of consolidating and adding value to the activities already evident. The current UK wide Core Skills Framework is the outcome of this participation.
13 Garcaz W & Wilcock E (2005) Statutory and Mandatory Training in Health and Social Care. Radcliffe Publishing, Oxon.UK.
14 The ‘Statutory and Mandatory Skills Training in the NHS Report’ (NHS PASA, 2009)
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2. Defining Statutory and Mandatory Training One of the challenges related to the issue of statutory and mandatory training is the interchangeable use of terms of Statutory and Mandatory training. For the purpose of this framework the following definitions have been used:
Statutory Training: this is training that employers are either legally required to provide as defined by law and for which there is a stated legal reference and/or where a government or regulatory body have instructed employers to provide training on the basis of legislation. These examples would include:
• Health and Safety training (required by legal statute).
• Equality Act 2010 specifies that all employees receive training in order to ensure that employees appreciate their legal obligations in promoting equality.
• Fire safety training is required by statute as determined by the Regulatory Reform (Fire Safety) Order 2005.
Mandatory Training: is a training requirement that has been determined by organisations themselves. This can include:
Policy Required Mandatory Training: these are requirements for mandatory training which have been determined by a government department, or regulatory body, as part of the implementation of an agreed national policy. For example, in England all staff are required to undertake Information Governance training on an annual basis.
Organisationally Required Mandatory Training: these are those training requirements that organisations set themselves. These requirements are usually introduced to ensure that the organisation is compliant with key risk areas that might have an impact upon safety. Or alternatively, are being delivered to achieve a corporate priority/service improvement which the organisation has set itself. Typically, this type of training is undertaken to provide assurance that local policies governing key corporate and risk activities are understood and are being followed by employees.
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3. Importance of Learning Outcomes Often the delivery of statutory mandatory training is just focused on providing staff with information about a particular subject. This approach can be limited in its impact in terms of what staff are expected to understand and demonstrate in their work roles.
Given both the volume of core skills training needed and the investment level required, an approach which seeks to promote clearer expectations about the purpose of core skills training is required. Moreover, an approach which enables a better understanding of the processes by which effective learning in relation to these common areas of learning activity can be supported and then demonstrated by the learners is essential. One of the key processes to encourage this is the effective use of learning outcomes to drive and underpin any learning activity.
Therefore one of the key aspects covered in each training skill subject is the identification of the key learning outcomes to be achieved. Although there is some debate about the limitations of using learning outcomes, there is common agreement that the effective use of learning outcomes can provide a clearer focus for determining what a learner should know, understand or be able to do following completion of any learning activity (Kennedy et al. 2006)15.
Using learning outcomes can:
• Set out clear expectations for learners in terms of what they should be able to demonstrate.
• Help those who design education and training opportunities to focus on key knowledge and skills areas that the learner needs to achieve which in turn will guide the content to be included.
• Be used to promote learner progress.
• Be observed and assessed.
• The use of learning outcomes can guide learning facilitators in the use of appropriate teaching strategies and assessment methods.
• Can be used by those who design healthcare education and training curricula to consider how the required Core Skills learning outcomes can be integrated appropriately and/or demonstrate how they map to overall achievement of curriculum aims. In this way, it will help ensure that those learners undertaking healthcare programmes are being given opportunity to acquire core knowledge and skills that employing organisations will need to be assured are being addressed.
15 Kennedy, D. Hyland, A. Ryan, N. 2006: “Writing and Using Learning Outcomes: a Practical Guide”. In: Froment, Eric (Ed.): EUA Bologna handbook. Making Bologna work. Berlin: Raabe
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4. Why Should Organisations Use the Framework? The key benefits of the framework are:
• That it provides a consolidation and integration of available guidance which organisations can use to inform and, where appropriate, rationalise the delivery of statutory and mandatory training activity.
• It provides a guide for those who have accountability for corporate governance, those with responsibility for delivery of training activity and those internal advisors who guide the content of any training delivery to have a common statement which they can use to audit, and collectively agree, plan and determine how the organisation can best meet or exceed the guidance offered here.
• It provides a focus for the delivery of specific training content/interventions which organisations can use to meet required standards for some workforce developments being implemented in some countries.
• It will help organisations to more explicitly guide training delivery quality and consistency for the identified Subjects.
• It should be valuable in helping to set more explicit expected levels of staff performance following delivery of any core skills training.
• It can be used to guide some of the measures that might be used to assess the effectiveness and impact of training activity supported.
• It should enable organisations to focus on how improvements in this risk area of training can be directed.
• It should be useful as a source of guidance in the development of a specification for those organisations who might need/or wish to commission external training provision to deliver any core skills training.
5. Who Needs to Receive Training? The framework broadly identifies for each subject the key target audience who will need to receive the indicated training. Some of the Subjects are aimed at all the workforce within an organisation, while other Subjects and expected levels of knowledge and skill will be more role dependent and only apply for those in a more direct patient/service roles.
It should be noted that workforce relates to all members of the workforce that the organisation has responsibility for in the conduct of its business and delivery of activities. This will include those learners on work placements, unpaid staff and volunteers. Local factors such as role and responsibility, work context and setting and levels of expected supervision will also be important aspects which will have an impact on the relevance and application of the
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guidance given in each topic. Some discretion in application of the framework guidance might be warranted in some situations, for example, such as the healthcare student who is on a fully supervised short study placement, or the volunteer who makes a contribution to an organisation on a short but infrequent basis.
Accordingly, each organisation will need to use the framework to help it inform and map to their local learning/training needs matrix, risk management analysis controls and to refine more specifically the staff groups/roles that will need to receive the suggested level of training indicated.
It is envisaged that education providers will contribute to the preparation of learners by embedding, as appropriate, the use of the Core Skills Framework as part of curriculum delivery. Where such delivery is clearly evidenced, it should then be recognised by healthcare organisations which then prevents any unnecessary duplication of training.
6. Promoting Workforce Values The core skills statutory and mandatory training Subjects identified in the framework are deemed a priority for an organisation to deliver given that they focus on areas that contribute towards patient and workforce safety. However, the value of the training on these Subjects has been eroded given concerns about educational impact, frequency and format of learning and that they frequently focus on policy and procedural aspects. While such concerns will be relevant from an organisational perspective, they might seem remote to those receiving the training. In addition, given that those being trained might have other significant learning priorities, the participation in statutory and mandatory training activity can seem a distraction and thus is undervalued. If this is evident, this will have potentially adverse implications for organisations given that the impact of their investment in providing the training is lost, whilst also creating pressures on service delivery contact time.
There is an opportunity to view and represent this framework as a Curriculum for Patient and Organisational Safety. In doing so, this highlights more specifically how attention to the knowledge and skills gained through participation in this type of training gives an opportunity for the learner to demonstrate on a daily basis, how they express the values being promoted by the organisation. Presenting the Subjects as a themed and joined up curriculum can be used to promote the following key values:
• Commitment to quality of care: recognising the need to get the essentials of care right, willingness to learn and build upon success.
• Professionalism: to ensure high personal standards of behaviour and response and the commitment to adhere to established policies and procedures.
• Personal accountability: the willingness to take responsibility for own actions, recognise limitations and avoid taking inappropriate actions which might have an adverse impact for self and others.
• Team work and cooperation: the willingness for working with others for common benefit, to overcome shared challenges and the commitment for improving the performance of all.
• Dignity and Respect: recognising and committed to the imperative of responding with concern, sensitivity and compassion, having positive regard for others, appreciating and acknowledging diversity.
7. Delivery and Formats of Core Skills Training This framework does not prescribe how the educational and training activity required to implement the framework should be delivered. Similarly, it is not the intention to indicate that only specific training suppliers are endorsed to deliver training in relation to the indicated Subjects. The approach used for delivery of any training is a shared local decision, which needs to involve the relevant staff with responsibilities for either leading, managing or delivering training and should be based upon:
• meeting any legal requirements which state which delivery formats must be supported
• requirements of local education governance and quality assurance arrangements
• availability of learning infrastructure
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• and the flexibility that best ensures the workforce is able to access and benefit from the training in a timely manner.
The health sector needs to recognise and appreciate that provided there is purposeful and careful consideration of key learning and training principles that a variety of training methods can be effectively used to achieve the desired learning outcomes indicated in the Core Skills Training Framework. The challenge is for organisations to best consider and evaluate potential options. As with other activities that require substantial investment and effort, organisations will need to increasingly evidence that any training interventions put in place are designed and monitored for their effectiveness.
Based upon the findings of the NHS PASA Statutory and Mandatory Training report and the recent SfH consultation, there is particular interest by organisations in using e-learning as a method to help support delivery of core skills training. Given that research has demonstrated that in the right conditions, e-learning is at least as effective as face to face training then the validity of using e-learning to help support delivery, particularly for knowledge elements of any topic should be considered seriously
The health sector to date, has at national, regional and local level made some significant investments in developing e-learning programmes to support the delivery of statutory and mandatory training. The key priority is for organisations to review the available programmes and assure themselves that they address any legal requirements for the format of delivery, meet the learning outcomes of the Core Skills Framework, or if there is a need to develop further content that it is informed by the Core Skills Training Framework.
8. The Value of Assessment Currently much of the reporting of statutory and mandatory training is recorded on an attendance based process. While recording attendance is a key metric for organisations in being able to demonstrate their compliance with key standards the health sector needs to consider much more the value of assessment as a component for the delivery of core skills training.
Educational research has demonstrated that the use of assessment which enables the learner to self monitor and regulate their progress leads to a deeper level of learning. Where this occurs there is a greater likelihood that learners will have the confidence to apply what they have learnt in practice.
Assessment is a key feature of effective learning as:
• it helps to indicate whether learning has taken place
• it can influence the engagement and behaviours of the learner and can direct and support progress
• the use of feedback related with assessment outcomes enriches learner understanding.
The results of learner assessment can provide valuable information for organisations in evaluating the effectiveness of teaching and learning approaches and inform further learning needs analysis.
There has to be a greater expectation by organisations that given the purpose and investment of providing statutory mandatory core skills training that staff will act upon the training provided. The use of assessment will be a tangible way in which a greater value and expectation on the implications of statutory mandatory training can be recognised and so should be utilised much more.
The effective use of assessment will increase learner motivation and participation and will provide the organisation with a more credible indicator of the workforce’s knowledge and skills in these key risk areas and identify potential gaps which should then be addressed. This approach would be more consistent with responsive risk management assurance.
In addition to this, if the effective use of assessment is established, the validity of using pre-assessment must be a significant way in which the management of refresher training could be more efficiently managed. That is where a learner undertakes and demonstrates through a well-planned assessment an acceptable level of knowledge and/or skill application against the specific learning outcomes for a subject, then this can be used as a valid indicator for currency of their knowledge in relation to the topic assessed. This should mean that learners do not duplicate or
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repeat what they already know. This approach would be consistent with principles of effective adult learning which places value on autonomous, self-directed and goal orientated learning.
It is recognised that the health sector has to gain greater confidence and practical use in the use of assessment. Encouragingly, there is now some concerted efforts to develop resources and approaches to achieve this. Organisations are strongly encouraged to consider the use of assessment, including pre-assessment approaches, and work to integrate their use and recognise their value as part of delivery of training activity.
9. Refresher Periods It is anticipated that given the purpose and focus of the Subjects included in this framework, potential changes in legislation and healthcare policy that the workforce will need periodic training updates. The suggested time period is indicated within each of the Subjects.
While refresher training provides an opportunity to practise and update knowledge and skills it should not be just about repeating information that the learners may have already received and know. Rather, it provides an opportunity to also extend knowledge by ensuring that any training update reflects:
• any new policy/organisational changes
• draws upon learning needs analysis and the findings of audits and evaluation. These should be used to prioritise knowledge and understanding on problematic areas or gaps which the organisation has identified which need to be addressed, if currency of knowledge and skills in relation to the identified areas are to be effective.
Where there have not been any substantial programme content changes, then organisations should consider how they use pre-assessment as a mechanism for checking the currency of knowledge and understanding.
Likewise, the methods for delivery of any refresher training should be considered for ways in which it can be delivered flexibly. There may not always be a requirement for formal classroom based attendance.
The use of a variety of learning formats could provide useful ways in which updating of knowledge can and should be supported e.g.
• readers
• case study briefings
• structured professional team based discussions
• peer learning and assessment
• practical assessments and simulations.
There are also opportunities for more use of flexible, randomly assigned, electronic scenario based assessments, which if well designed and their use monitored can be a valid means of ascertaining the knowledge and understanding of the workforce.
To maximise flexibility and impact there are opportunities for organisations to develop approaches, quality assurance processes and monitoring which enables refresher update review by and within team structures. Utilising such an approach will promote further accountability at individual and team level for ensuring these updates occurs. They should also enhance better application of knowledge and understanding when individuals/teams are triggered to consider risk issues reflected in core skill learning and examples of application within the context of their own roles and working environment.
Before the end of the refresher period, or potentially when there is a major change in legislation or policy, staff need to be assessed to ensure that they have retained the knowledge and/or can demonstrate the skill or capability required. Refresher training should be focused on updating knowledge or facilitate where applicable the acquisition of new and improved skills, techniques and best practice. Each organisation needs to consider how best to deliver any required refresher training but the focus should be not on repeating training and content previously delivered but
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instead to assess whether the staff member has retained knowledge and understanding and if appropriate, that their knowledge and skills are extended beyond the minimum levels.

Code of Conduct for healthcare support workers and adult social care workers the following information is taken from a skills for health website. Please see the following link http://www.skillsforhealth.org.uk/standards/item/217-code-of-conduct

 

The Code of Conduct sets the standard of conduct expected of healthcare support workers and adult social care workers. It outlines the behaviour and attitudes that you should expect to experience from those workers signed up to the code. It helps them to provide safe, guaranteed care and support. The Code of Conduct is voluntary but it is seen as a sign of best practice. Guidance documents to help you understand or implement the Code of Conduct are also available:

Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England As a Healthcare Support Worker or an Adult Social Care Worker, you make a valuable and important contribution to the delivery of high quality healthcare, care and support.
Following the guidance set out in this Code of Conduct will give you the reassurance that you are providing safe and compassionate care of a high standard, and the confidence to challenge others who are not. This Code will also tell the public and people who use health and care services exactly what they should expect from Healthcare Support Workers and Adult Social Care Workers in England.

As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. Be accountable by making sure you can answer for your actions or omissions.
2. Promote and uphold the privacy, dignity, rights, health and wellbeing of people who use health and care services and their carers at all times.
3. Work in collaboration with your colleagues to ensure the delivery of high quality, safe and compassionate healthcare, care and support.
4. Communicate in an open, and effective way to promote the health, safety and wellbeing of people who use health and care services and their carers.
5. Respect a person’s right to confidentiality.
6. Strive to improve the quality of healthcare, care and support through continuing professional development.
7. Uphold and promote equality, diversity and inclusion.

Purpose This Code is based on the principles of protecting the public by promoting best practice. It will ensure that you are ‘working to standard’, providing high quality, compassionate healthcare, care and support.
The Code describes the standards of conduct, behaviour and attitude that the public and people who use health and care services should expect. You are responsible for, and have a duty of care to ensure that your conduct does not fall below the standards detailed in the Code. Nothing that you do, or omit to do, should harm the safety and wellbeing of people who use health and care services, and the public.
Scope These standards apply to you if you are a:
• Healthcare Support Worker (including an Assistant Practitioner) in England who has a patient-facing role (where they don’t already have a Code that applies to them). The intention is not to prescribe the roles that this Code of Conduct applies to but to have a Code that can apply to as many roles as possible where the Healthcare Support Worker is having contact with patients.
• Adult Social Care Worker in England. This could either be in an independent capacity (for example, as a Personal Assistant); for a residential care provider; or as a supported living, day support or domiciliary care worker. The Code does not apply to Social Work Assistants.
How does the Code help me as a Healthcare Support Worker or an Adult Social Care Worker? It provides a set of clear standards, so you:
• can be sure of the standards you are expected to meet.
• can know whether you are working to these standards, or if you need to change the way you are working.
• can identify areas for continuing professional development.
• can fulfil the requirements of your role, behave correctly and do the right thing at all times. This is essential to protect people who use health and care services, the public and others from harm.
How does this Code help people who use health and care services and members of the public? The Code helps the public and those who use health and care services to understand what standards they can expect of Healthcare Support Workers and Adult Social Care Workers. The Code aims to give people who use health and care services the confidence that they will be treated with dignity, respect and compassion at all times.
How does this Code help my employer? The Code helps employers to understand what standards they should expect of Healthcare Support Workers and Adult Social Care Workers. If there are people who do not meet these standards, it will help to identify them and their support and training needs.
Glossary You can find a glossary of terms and key words (shown in bold throughout the Code) at the end of the document.
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England, you must:
1. be honest with yourself and others about what you can do, recognise your abilities and the limitations of your competence and only carry out or delegate those tasks agreed in your job description and for which you are competent.
2. always behave and present yourself in a way that does not call into question your suitability to work in a health and social care environment.
3. be able to justify and be accountable for your actions or your omissions – what you fail to do.
4. always ask your supervisor or employer for guidance if you do not feel able or adequately prepared to carry out any aspect of your work, or if you are unsure how to effectively deliver a task.
5. tell your supervisor or employer about any issues that might affect your ability to do your job competently and safely. If you do not feel competent to carry out an activity, you must report this.
6. establish and maintain clear and appropriate professional boundaries in your relationships with people who use health and care services, carers and colleagues at all times.
7. never accept any offers of loans, gifts, benefits or hospitality from anyone you are supporting or anyone close to them which may be seen to compromise your position.
8. comply with your employers’ agreed ways of working.
9. report any actions or omissions by yourself or colleagues that you feel may compromise the safety or care of people who use health and care services and, if necessary use whistleblowing procedures to report any suspected wrongdoing.
1. Be accountable by making sure you can answer for your actions or omissions
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. always act in the best interests of people who use health and care services.
2. always treat people with respect and compassion.
3. put the needs, goals and aspirations of people who use health and care services first, helping them to be in control and to choose the healthcare, care and support they receive.
4. promote people’s independence and ability to self-care, assisting those who use health and care services to exercise their rights and make informed choices.
5. always gain valid consent before providing healthcare, care and support. You must also respect a person’s right to refuse to receive healthcare, care and support if they are capable of doing so.
6. always maintain the privacy and dignity of people who use health and care services, their carers and others.
7. be alert to any changes that could affect a person’s needs or progress and report your observations in line with your employer’s agreed ways of working.
8. always make sure that your actions or omissions do not harm an individual’s health or wellbeing. You must never abuse, neglect, harm or exploit those who use health and care services, their carers or your colleagues.
9. challenge and report dangerous, abusive, discriminatory or exploitative behaviour or practice.
10. always take comments and complaints seriously, respond to them in line with agreed ways of working and inform a senior member of staff.
2. Promote and uphold the privacy, dignity, rights, health and wellbeing of people who use health and care services and their carers at all times
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. understand and value your contribution and the vital part you play in your team.
2. recognise and respect the roles and expertise of your colleagues both in the team and from other agencies and disciplines, and work in partnership with them.
3. work openly and co-operatively with colleagues including those from other disciplines and agencies, and treat them with respect.
4. work openly and co-operatively with people who use health and care services and their families or carers and treat them with respect.
5. honour your work commitments, agreements and arrangements and be reliable, dependable and trustworthy.
6. actively encourage the delivery of high quality healthcare, care and support.
3. Work in collaboration with your colleagues to ensure the delivery of high quality, safe and compassionate healthcare, care and support
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. communicate respectfully with people who use health and care services and their carers in an open, accurate, effective, straightforward and confidential way.
2. communicate effectively and consult with your colleagues as appropriate.
3. always explain and discuss the care, support or procedure you intend to carry out with the person and only continue if they give valid consent.
4. maintain clear and accurate records of the healthcare, care and support you provide. Immediately report to a senior member of staff any changes or concerns you have about a person’s condition.
5. recognise both the extent and the limits of your role, knowledge and competence when communicating with people who use health and care services, carers and colleagues.
4. Communicate in an open and effective way to promote the health, safety and wellbeing of people who use health and care services and their carers
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. treat all information about people who use health and care services and their carers as confidential.
2. only discuss or disclose information about people who use health and care services and their carers in accordance with legislation and agreed ways of working.
3. always seek guidance from a senior member of staff regarding any information or issues that you are concerned about.
4. always discuss issues of disclosure with a senior member of staff.
5. Respect people’s right to confidentiality
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. ensure up to date compliance with all statutory and mandatory training, in agreement with your supervisor.
2. participate in continuing professional development to achieve the competence required for your role.
3. carry out competence-based training and education in line with your agreed ways of working.
4. improve the quality and safety of the care you provide with the help of your supervisor (and a mentor if available), and in line with your agreed ways of working.
5. maintain an up-to-date record of your training and development.
6. contribute to the learning and development of others as appropriate.
6. Strive to improve the quality of healthcare, care and support through continuing professional development
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Guidance statements
As a Healthcare Support Worker or Adult Social Care Worker in England you must:
1. respect the individuality and diversity of the people who use health and care services, their carers and your colleagues.
2. not discriminate or condone discrimination against people who use health and care services, their carers or your colleagues.
3. promote equal opportunities and inclusion for the people who use health and care services and their carers.
4. report any concerns regarding equality, diversity and inclusion to a senior member of staff as soon as possible.
7. Uphold and promote equality, diversity and inclusion
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Glossary of terms
ACCOUNTABLE: accountability is to be responsible for the decisions you make and answerable for your actions.
AGREED WAYS OF WORKING: includes policies and procedures where these exist; they may be less formally documented among individual employers and the self-employed.
BEST INTERESTS: the Mental Capacity Act (2005) sets out a checklist of things to consider when deciding what’s in a person’s ‘best interests’.
CARE AND SUPPORT: care and support enables people to do the everyday things like getting out of bed, dressed and into work; cooking meals; seeing friends; caring for our families; and being part of our communities. It might include emotional support at a time of difficulty or stress, or helping people who are caring for a family member or friend. It can mean support from community groups or networks: for example, giving others a lift to a social event. It might also include state-funded support, such as information and advice, support for carers, housing support, disability benefits and adult social care.
COLLABORATION: the action of working with someone to achieve a common goal.
COMPASSION: descriptions of compassionate care include:, dignity and comfort: taking time and patience to listen, explain and communicate; demonstrating empathy, kindness and warmth; care centred around an individual person’s needs, involving people in the decisions about their healthcare, care and support.
COMPETENCE: the knowledge, skills, attitudes and ability to practise safely and effectively without the need for direct supervision.
COMPETENT: having the necessary ability, knowledge, or skill to do something successfully.
CONTINUING PROFESSIONAL DEVELOPMENT: this is the way in which a worker continues to learn and develop throughout their careers, keeping their skills and knowledge up to date and ensuring they can work safely and effectively.
DIGNITY: covers all aspects of daily life, including respect, privacy, autonomy and self-worth. While dignity may be difficult to define, what is clear is that people know when they have not been treated with dignity and respect. Dignity is about interpersonal behaviours as well as systems and processes.
DISCRIMINATE: discrimination can be the result of prejudice, misconception and stereotyping. Whether this behaviour is intentional or unintentional does not excuse it. It is the perception of the person discriminated against that is important.
DIVERSITY: celebrating differences and valuing everyone. Diversity encompasses visible and non-visible individual differences and is about respecting those differences.
EFFECTIVE: to be successful in producing a desired or intended result.
EQUALITY: being equal in status, rights, and opportunities.
INCLUSION: ensuring that people are treated equally and fairly and are included as part of society.
MENTOR: mentoring is a work-based method of training using existing experienced staff to transfer their skills informally or semi-formally to learners.
OMISSION: to leave out or exclude.
PROMOTE: to support or actively encourage.
RESPECT: to have due regard for someone’s feelings, wishes, or rights.
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SELF-CARE: this refers to the practices undertaken by people towards maintaining health and wellbeing and managing their own care needs. It has been defined as: “the actions people take for themselves, their children and their families to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long-term conditions; and maintain health and wellbeing after an acute illness or discharge from hospital.” (Self care – A real choice: Self care support – A practical option, published by Department of Health, 2005).
UPHOLD: to maintain a custom or practice.
VALID CONSENT: for consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. This will be the patient, the person who uses health and care services or someone with parental responsibility for a person under the age of 18, someone authorised to do so under a Lasting Power of Attorney (LPA) or someone who has the authority to make treatment decisions as a court appointed deputy). Agreement where the person does not know what the intervention entails is not ‘consent’.
WELLBEING: a person’s wellbeing may include their sense of hope, confidence, self-esteem, ability to communicate their wants and needs, ability to make contact with other people, ability to show warmth and affection, experience and showing of pleasure or enjoyment.
WHISTLEBLOWING: whistleblowing is when a worker reports suspected wrongdoing at work. Officially this is called ‘making a disclosure in the public interest’ and may sometimes be referred to as ‘escalating concerns.’ You must report things that you feel are not right, are illegal or if anyone at work is neglecting their duties. This includes when someone’s health and safety is in danger; damage to the environment; a criminal offence; that the company is not obeying the law (like not having the right insurance); or covering up wrongdoing.
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Acknowledgements
The Code was adapted from original work developed in partnership by NHS Wales, the National Leadership and Innovation Agency for Healthcare (NLIAH) and the Welsh Government and published online at:
http://www.wales.nhs.uk/sitesplus/829/page/49729
This Code was adapted from original work developed in partnership by NHS Education Scotland, NHS Scotland and the Scottish Government and published online at:
http://www.healthworkerstandards.scot.nhs.uk/pages/profCurrUnreg.htm
Published by Skills for Care and Skills for Health Skills for Care, West Gate, 6 Grace Street, Leeds LS1 2RP http://www.skillsforcare.org.uk Skills for Health, 1st Floor, Goldsmiths House, Broad Plain, Bristol BS2 0JP http://www.skillsforhealth.org.uk © Skills for Care & Skills for Health 2013

Copies of this work may be made for non-commercial distribution. Any other copying requires the permission of the publishers.

Skills for Care is the employer-led strategic body for workforce development in social care for adults in England. It is part of the sector skills council, Skills for Care and Development. Skills for Health is the employer-led authority on workforce development and skills for the health sector. It is the licensed Sector Skills Council for health.

Bibliographic reference data for Harvard-style author/date referencing system: Short reference: Skills for Care/Skills for Health [or SfC/SfH] 2013 Long reference: Skills for Care & Skills for Health, Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England http://www.skillsforcare.org.uk & http://www.skillsforhealth.org.uk

The Code of Conduct Employer Guide

A guide for employers and managers of Healthcare Support Workers and Adult Social Care Workers in England

This employer guide relates to the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England. A separate guide, ‘The Code of Conduct in Action’, is available for Healthcare Support Workers and Adult Social Care Workers.

The Code of Conduct can be found here on the Skills for Health website and on the Skills for Care website.

The Code of Conduct is for:  Healthcare Support Workers (including Assistant Practitioners) in England who have patientfacing roles (where they do not already have a Code that applies to them).
 Adult Social Care Workers in England. This could be in an independent capacity (for example as Personal Assistant), for a residential care provider, or as a supported living, day support or domiciliary care worker. Social Work Assistants are not included.

The purpose of this guide is to:

1. outline what the Code of Conduct is and why it has been developed 2. outline the benefits of adopting the Code of Conduct for you, your worker and people who use services 3. outline how it relates to other initiatives 4. explain what actions you need to take to adopt the code.

What is the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers?

The Code of Conduct provides a clear set of standards. It is essential to protect people who use health and care services, the public and others from harm. The code ensures you can: 1. be sure of the standards your worker is expected to meet 2. check that your worker can fulfil the requirements of their role, behave correctly and do the right thing at all times 3. identify areas for continuing professional development.

Why do we have a Code of Conduct for Healthcare Support Workers and Adult Social Care Workers?
Organisations including employers, unions and professional bodies have been writing and using different Codes of Conduct in different ways for many years. Some employers require Healthcare Support Workers and Adult Social Care Workers to adhere to a Code of Conduct, whilst for others this has never been a
Code of Conduct for HCSW and ASCW Guidance for Employers 2

requirement. This inconsistency has meant that standards for Healthcare Support Workers and Adult Social Care Workers could vary greatly from organisation to organisation.

Providing a safe, efficient and effective health and social care system is complex. One way employers can reduce risks is by ensuring that Healthcare Support Workers and Adult Social Care workers are clear about how they should behave at work and what they should and should not do.

The Department of Health asked to develop a Code of Conduct that could be used consistently by Healthcare Support Workers and Adult Social Care Workers in England. The Code of Conduct was written in consultation with Support Workers, registered health and social care professionals, people who use health and care services and their carers, employers and unions.

The code covers the key behaviours needed to deliver safe and high-quality care. It is also a useful tool to help support and develop staff.

Does the code have to be used?

There is no legal requirement for employers to use this Code of Conduct. However, the Code of Conduct outlines ‘best practice’ and could be used to inform objective setting, personal development reviews, investigation and complaints procedures. Organisations and employers are encouraged to use it for all non-registered staff in roles covered by the code. Organisations may wish to refer to their adoption of the Code of Conduct as evidence of their good practice in Care Quality Commission (CQC) or other quality inspections.

How does the Code of Conduct ‘fit’ with the Care Certificate?

The Code of Conduct describes how a support worker should behave. The Care Certificate describes the minimum things support workers must know and be able to do.

Using the Code of Conduct with the Care Certificate is a measurable way for you to check that your worker is sticking to the same standard as other Healthcare Support Workers and Adult Social Care Workers across health and social care. Together the Code of Conduct and Care Certificate are designed to help you, as the employer, and your worker, to provide safe, effective and compassionate healthcare, care and support.

Employer responsibilities:
Support workers will only be able to meet their obligations under the Code of Conduct if you, as an employer, provide the right support, training and development and work environment for them.
For employers in the NHS: Section 4a of the NHS Constitution, ‘Staff – your rights and NHS Pledges to you’, sets out your responsibilities to your staff. These include encouraging and supporting staff to raise concerns about service quality and safety, and ensuring they have access to personal development, education and training. The rights and pledges in the Constitution provide you with the overarching standards you should meet as an employer – applying these will help enable your support workers to abide by the Code of Conduct.
For employers in social care:
The Social Care Commitment sets out the seven commitments you should make to meet the minimum standards required in care work. The standards include providing education and learning opportunities for staff and ensuring a positive culture and working environment. Your commitment to these overarching standards for employers will help enable your social care workers to abide by the Code of Conduct, and to put the Social Care Commitment into practice.

Code of Conduct for HCSW and ASCW Guidance for Employers 3

ACTIONS YOU NEED TO TAKE

If you are using the Code of Conduct with your Healthcare Support Workers and Adult Social Care Workers:

As an organisation:

1. each worker should have a named workplace supervisor to monitor their progress towards achieving and maintaining all the standards in the Code of Conduct. It is up to your organisation to specify who this should be

2. you should incorporate the Code of Conduct into your organisation’s agreed ways of working. The code is a living document which Healthcare Support Workers and Adult Social Care Workers should apply throughout their working lives. If your organisation already has robust mechanisms for identifying and checking competence you may wish to map the Code to those

3. it is up to your organisation to decide when Healthcare Support Workers and Adult Social Care Workers are asked to sign up to the Code of Conduct. It is recommended that this happens early on in their working life and before they work without direct supervision

4. there is no prescribed way of gaining evidence that your worker is working to the Code of Conduct. You could reference it in a job description and/or design a more formal mechanism to allow /workers to sign up

5. it is important that sign up to the Code of Conduct is directly linked into your appraisal process so that managers and workers have a mechanism for identifying and measuring an individual’s performance against the Code of Conduct

6. you may wish to give additional guidance to managers about the HR processes that should be followed within your organisation, should a worker not meet the standards set out in the code

7. you may wish to advise the patients/people who use services that workers in your organisation have signed up to the Code of Conduct and explain what that means for them. A separate document, ‘What the Code of Conduct means for you,’ is available for you to use.

As a named workplace supervisor:

1. you must give your worker a copy of the Code of Conduct and the Code of Conduct in Action user guide for Healthcare Support Workers and Adult Social Care Workers

2. it is your responsibility to check that your worker recognises the purpose of the code and understands the depth of detail contained within each point. You may have to provide additional supervision or support to your worker whilst they are developing this understanding

3. you should regularly check that your worker is meeting the code and if not, identify how you can work together with them so that they can.

The Code of Conduct in Action

A user guide for Healthcare Support Workers and Adult Social Care Workers in England

This user guide relates to the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England. A separate guide ‘Code of Conduct Employer Guide’ is available for use by your employer.

The Code of Conduct may have been given to you by your employer. The Code of Conduct can be found here on the Skills for Health website and on the Skills for Care website.

The Code of Conduct applies to you if you are a:

 Healthcare Support Worker (including an Assistant Practitioner) in England who have patientfacing roles (where they don’t already have a Code that applies to them)

 Adult social care worker in England. This could be in an independent capacity (for example as Personal Assistant), for a residential care provider, or as a supported living, day support or domiciliary care worker. Social Work Assistants are not included.

The purpose of this guide is to:

 outline what the Code of Conduct is and why it has been developed  outline how it relates to other initiatives  outline the benefits of adopting the Code of Conduct for you, your employer and people who use services  explain what actions you need to take to adopt the code.

What is the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers?

The Code of Conduct provides a clear set of standards. It is essential to protect people who use health and care services from harm. The code ensures you can: 1. be sure of the standards you are expected to meet 2. check that you are fulfilling the requirements of your role, behaving correctly and doing the right thing at all times 3. identify areas for your continuing professional development.

Code of Conduct for HCSW and ASCW Guidance for support workers 2

Why do we have a Code of Conduct for Healthcare Support Workers and Adult Social Care Workers?

Organisations including employers, unions and professional bodies have been writing and using different Codes of Conduct for many years. Some organisations require Healthcare Support Workers and Adult Social Care Workers to adhere to a Code of Conduct, whilst for others this has never been a requirement. This has meant that standards for Healthcare Support Workers and Adult Social Care Workers could vary greatly from organisation to organisation.

Providing a safe, efficient and effective health and social care system is complex. One way we can reduce risks is by ensuring that you and your fellow workers are clear about how you should behave at work and what you should and should not do.

The Department of Health asked to develop a Code of Conduct that could be used consistently by Healthcare Support Workers and Adult Social Care Workers in England. The Code of Conduct was written with lots of help and advice from Support Workers, registered health and social care professionals, people who use health /care services and their carers, employers and unions.

The Code of Conduct covers the key behaviours needed to deliver safe and high quality care. It empowers you to raise any concerns you have about the quality of care and support being provided. It is also a useful tool for you and your employer to use to identify if you need help and to support you to develop in your role.

Does the code have to be used

There is no legal requirement for employers to use this Code of Conduct. However, the Code of Conduct outlines ‘best practice’ and may be a condition of employment. It may also be used to inform objective setting, personal development reviews, investigation and complaints procedures or quality inspections.

How does the Code of Conduct ‘fit’ with the Care Certificate?

The Code of Conduct describes how you should behave. The Care Certificate describes the minimum things you must know and be able to do.

Using the Code of Conduct with the Care Certificate is a measurable way for you and your employer to check that you are working to the same standard as other people in similar roles across health and social care. They are designed to help you, to provide safe, effective and compassionate healthcare, care and support

If you work in health (NHS):
The Code of Conduct relates to section 4b of the NHS Constitution, ‘Staff, your responsibilities.’ It gives you more detailed standards, which work to the overall statements contained within the NHS Constitution.
If you work in social care:
The seven statements and supporting tasks that make up the Social Care Commitment, are based directly on the standards contained within the Code of Conduct.

Code of Conduct for HCSW and ASCW Guidance for support workers 3

Image result for mandatory health training

 

ACTIONS YOU NEED TO TAKE

If you have been given the Code of Conduct by your employer you will be expected to work to the standards described in the Code.

You must therefore: 1. check that you have a copy of the Code of Conduct document as well as this guide

2. you should have a named workplace supervisor to monitor your progress towards achieving and maintaining all the standards in the Code of Conduct. Check that you know who that person is

3. read both this document and the Code of Conduct

4. check that you understand it fully. Ask your named workplace supervisor for help if there is something you do not understand

5. apply the Code of Conduct every day, to all aspects of your working life

6. record evidence to show that you are working to the Code of Conduct in accordance with your local procedure or agreed ways of working. You may wish to refer back to this evidence when you are taking part in your appraisal process

7. discuss with your named workplace supervisor anything in the Code of Conduct that you find difficult to achieve and act on the advice they give you

8. your employer may ask you to formally sign up to the Code of Conduct and you should follow your workplace procedures on how to do this.

What the Code of Conduct means for you

A guide for users of services, patients, carers, families and the general public about the Code of Conduct Healthcare Support Workers and Adult Social Care Workers in England

A code of conduct is in place for Healthcare Support Workers and Adult Social Care Workers in England. It can be found here on the Skills for Health website and on the Skills for Care website.

What does it do?

The code of conduct sets out the minimum requirements of how Healthcare Support Workers and Adult Social Care workers should behave at work.

It is in place to help them to provide safe, effective and compassionate healthcare, care and support to you and your family. Every healthcare support worker and adult social care worker should treat you with dignity and respect.

What are the standards?

The Code of Conduct contains seven standards:

As a Healthcare Support Worker or Adult Social Care Worker in England you must:

1. be accountable by making sure you can answer for your actions or omissions

2. promote and uphold the privacy, dignity, rights, health and wellbeing of people who use health and care services and their carers at all times

3. work in collaboration with your colleagues to ensure the delivery of high quality, safe and compassionate healthcare, care and support

4. communicate in an open, and effective way to promote the health, safety and wellbeing of people who use health and care services and their carers

5. respect a person’s right to confidentiality

6. strive to improve the quality of healthcare, care and support through continuing professional development

7. uphold and promote equality, diversity and inclusion.

Each standard within the Code of Conduct is further explained by a series of guidance statements. If you want to see these please use the link at the top of the page to view the full document.
Code of Conduct for HCSW and ASCW guidance for users of services, patients, carers, families and general public 2

Who is it for?

Healthcare Support Workers in patient-facing roles and Adult Social Care Workers (not Social Work Assistants) in England.

Other registered health and social care staff (eg Social Workers, Nurses, Doctors, Occupational Therapists, Physiotherapists) have regulatory codes of conduct that they already work to so the Code of Conduct for Healthcare Support Workers and Adults Social Care Workers does not apply to them,

Why do we have a Code of Conduct for Healthcare Support Workers and Adults Social Care Workers?

Introducing a single Code of Conduct means that all Healthcare Support Workers and Adult Social Care Workers, who sign up to the code, are working to the same standards. The aim is that wherever you are accessing services, you should receive safe and high quality care and support, whether this is at home, in the community or at the hospital. You should be clear about how Healthcare Support Workers and Adult Social Care Workers should behave and what they should and should not do.

Does the code have to be used?

There is no legal requirement for employers to use this Code of Conduct. However, the Code of Conduct outlines ‘best practice.’ It is likely to be used by employers to measure the performance of Healthcare Support Workers and Adult Social Care Workers. It can also be used to inform investigation and complaints procedures.

How does the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers ‘fit’ with the Care Certificate?

The Code of Conduct describes how workers should behave. The Care Certificate describes the minimum things workers must know and be able to do.

You can get copies of the Care Certificate documents on the Skills for Health website and Skills for Care website.

Using the Code of Conduct with the Care Certificate is a measurable way to check that workers are working to the same standard as other people in similar roles across health and social care. They are designed to help them to provide safe, effective and compassionate healthcare, care and support

Although the Code of Conduct does not have to be used it does provide a model for best practice and supports the NHS Constitution and the Social Care Commitment.

What if you don’t think someone is working to the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers?

If you feel that the care or support you are receiving is not right, you need to ask to see the organisation’s complaints procedure and express your concerns. The complaints procedure will explain how the organisation will address your concerns and outline what you need to do next.

Health care or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairments in human beings. Healthcare is delivered by health professionals (providers or practitioners) in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, midwifery, nursing, medicine, optometry, audiology, pharmacy, psychology, occupational therapy, physical therapy and other health professions are all part of healthcare. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Access to health care may vary across countries, communities, and individuals, largely influenced by social and economic conditions as well as the health policies in place. Countries and jurisdictions have different policies and plans in relation to the personal and population-based health care goals within their societies. Healthcare systems are organizations established to meet the health needs of targeted populations. Their exact configuration varies between national and subnational entities. In some countries and jurisdictions, health care planning is distributed among market participants, whereas in others, planning occurs more centrally among governments or other coordinating bodies. In all cases, according to the World Health Organization (WHO), a well-functioning healthcare system requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; and well maintained health facilities and logistics to deliver quality medicines and technologies.[1]

Image result for mandatory health training

 

 

Healthcare can contribute to a significant part of a country’s economy. In 2011, the healthcare industry consumed an average of 9.3 percent of the GDP or US$ 3,322 (PPP-adjusted) per capita across the 34 members of OECD countries. The US (17.7%, or US$ PPP 8,508), the Netherlands (11.9%, 5,099), France (11.6%, 4,118), Germany (11.3%, 4,495), Canada (11.2%, 5669), and Switzerland (11%, 5,634) were the top spenders, however life expectancy in total population at birth was highest in Switzerland (82.8 years), Japan and Italy (82.7), Spain and Iceland (82.4), France (82.2) and Australia (82.0), while OECD’s average exceeds 80 years for the first time ever in 2011: 80.1 years, a gain of 10 years since 1970. The US (78.7 years) ranges only on place 26 among the 34 OECD member countries, but has the highest costs by far. All OECD countries have achieved universal (or almost universal) health coverage, except the US and Mexico.[2][3] (see also international comparisons.)

Health care is conventionally regarded as an important determinant in promoting the general physical and mental health and well-being of people around the world. An example of this was the worldwide eradication of smallpox in 1980, declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions.

Delivery[edit]
See also: Health professionals

Primary care may be provided in community health centres.
The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams.[5] This includes professionals in medicine, psychology, physiotherapy, nursing, dentistry, midwifery and allied health, along with many others such as public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based preventive, curative and rehabilitative care services.
While the definitions of the various types of health care vary depending on the different cultural, political, organizational and disciplinary perspectives, there appears to be some consensus that primary care constitutes the first element of a continuing health care process and may also include the provision of secondary and tertiary levels of care.[6] Healthcare can be defined as either public or private.

The emergency room is often a frontline venue for the delivery of primary medical care.
Primary care[edit]
Main article: Primary care
See also: Primary health care, Ambulatory care, and Urgent care

Medical train “Therapist Matvei Mudrov” in Khabarovsk, Russia[7]
Primary care refers to the work of health professionals who act as a first point of consultation for all patients within the health care system.[6][8] Such a professional would usually be a primary care physician, such as a general practitioner or family physician. Another professional would be a licensed independent practitioner such as a physiotherapist, or a non-physician primary care provider such as a physician assistant or nurse practitioner. Depending on the locality, health system organization the patient may see another health care professional first, such as a pharmacist or nurse. Depending on the nature of the health condition, patients may be referred for secondary or tertiary care.
Primary care is often used as the term for the health care services that play a role in the local community. It can be provided in different settings, such as Urgent care centers which provide same day appointments or services on a walk-in basis.
Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all types of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care based on the reason for the patient’s visit.[9]
Common chronic illnesses usually treated in primary care may include, for example: hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations. In the United States, the 2013 National Health Interview Survey found that skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most common reasons for accessing a physician.[10]
In the United States, primary care physicians have begun to deliver primary care outside of the managed care (insurance-billing) system through direct primary care which is a subset of the more familiar concierge medicine. Physicians in this model bill patients directly for services, either on a pre-paid monthly, quarterly, or annual basis, or bill for each service in the office. Examples of direct primary care practices include Foundation Health in Colorado and Qliance in Washington.
In context of global population aging, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected in both developed and developing countries.[11][12] The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy.[6]
Secondary care[edit]
Secondary care includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury, or other health condition. This care is often found in a hospital emergency department. Secondary care also includes skilled attendance during childbirth, intensive care, and medical imaging services.
The term “secondary care” is sometimes used synonymously with “hospital care.” However, many secondary care providers, such as psychiatrists, clinical psychologists, occupational therapists, most dental specialties or physiotherapists do not necessarily work in hospitals. Some primary care services are delivered within hospitals. Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care. Physiotherapists are both primary and secondary care providers that do not require a referral.
In the United States, which operates under a mixed market health care system, some physicians might voluntarily limit their practice to secondary care by requiring patients to see a primary care provider first. This restriction may be imposed under the terms of the payment agreements in private or group health insurance plans. In other cases, medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred.
In the United Kingdom and Canada, patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician (either a primary care physician or another specialist) is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance.
Allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, speech therapists, and dietitians, also generally work in secondary care, accessed through either patient self-referral or through physician referral.

Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.[13]
Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions.[14]
Quaternary care[edit]
The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centers.[14][15] Quaternary care is more prevalent in the United Kingdom.
Home and community care[edit]
See also: Public health
Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases.
They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, treatment for substance use disorders among other types of health and social care services.
Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prosthesis, orthotics or wheelchairs.
Many countries, especially in the west are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes. There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor’s appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge for the design of ICT (information and communication technology) for home care.[16]
Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one,[17] many countries have begun offering programs such as Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income.[citation needed]
With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have positive self-image.
Ratings[edit]
Main article: Health care ratings
Health care ratings are ratings or evaluations of health care used to evaluate the process of care and healthcare structures and/or outcomes of health care services. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media. This evaluation of quality is based on measures of:
hospital quality
health plan quality
physician quality
quality for other health professionals
of patient experience

more prevalent in the United Kingdom.

Home and community care[edit]

Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases.

They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, treatment for substance use disorders among other types of health and social care services.

Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prosthesis, orthotics or wheelchairs.

Many countries, especially in the west are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes. There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor’s appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge for the design of ICT (information and communication technology) for home care.[16]

Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one,[17] many countries have begun offering programs such as Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income.[citation needed]

With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have positive self-image.

Ratings[edit]

Health care ratings are ratings or evaluations of health care used to evaluate the process of care and healthcare structures and/or outcomes of health care services. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media. This evaluation of quality is based on measures of:

Related sectors[edit]

Health care extends beyond the delivery of services to patients, encompassing many related sectors, and is set within a bigger picture of financing and governance structures.

Health system[edit]

A health system, also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources that deliver health care services to populations in need.

Health care industry[edit]

A group of Chilean ‘Damas de Rojo’ volunteering at their local hospital

The health care industry incorporates several sectors that are dedicated to providing health care services and products. As a basic framework for defining the sector, the United Nations’ International Standard Industrial Classification categorizes health care as generally consisting of hospital activities, medical and dental practice activities, and “other human health activities.” The last class involves activities of, or under the supervision of, nurses, midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health facilities, patient advocates[18] or other allied health professions.

In addition, according to industry and market classifications, such as the Global Industry Classification Standard and the Industry Classification Benchmark, health care includes many categories of medical equipment, instruments and services including biotechnology, diagnostic laboratories and substances, drug manufacturing and delivery.

For example, pharmaceuticals and other medical devices are the leading high technology exports of Europe and the United States.[19][20] The United States dominates the biopharmaceutical field, accounting for three-quarters of the world’s biotechnology revenues.[19][21]

Health care research[edit]

The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment. Many important advances have been made through health research, biomedical research and pharmaceutical research, which form the basis for evidence-based medicine and evidence-based practice in health care delivery.

For example, in terms of pharmaceutical research and development spending, Europe spends a little less than the United States (€22.50bn compared to €27.05bn in 2006). The United States accounts for 80% of the world’s research and development spending in biotechnology.[19][21]

In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make populations healthier.[22] Results from health services research often form the basis of evidence-based policy in health care systems. Health services research is also aided by initiatives in the field of artificial intelligence for the development of systems of health assessment that are clinically useful, timely, sensitive to change, culturally sensitive, low burden, low cost, built into standard procedures, and involve the patient.[23]

Health care financing[edit]

There are generally five primary methods of funding health care systems:[24]

  1. general taxation to the state, county or municipality
  2. social health insurance
  3. voluntary or private health insurance
  4. out-of-pocket payments
  5. donations to health charities

In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries.[citation needed] In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other groups to adopt a specific health policy regarding the financing structure.

For example, social health insurance is where a nation’s entire population is eligible for health care coverage. This coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, the system is allowed to operate.[citation needed] This is sometimes referred to as two-tier health care or universal health care.

For example, in Poland, the costs of health services borne by the National Health Fund (financed by all citizens that pay health insurance contributions) in 2012 amounted to 60.8 billion PLN (approximately 20 billion USD). The right to health services in Poland is granted to 99.9% of the population, including registered unemployed persons their spouses).[25]

Health care administration and regulation[edit]

The management and administration of health care is another sector vital to the delivery of health care services. In particular, the practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance.[26] Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history.[27]

Health information technology[edit]

Health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.”[28] Technology is a broad concept that deals with a species’ usage and knowledge of tools and crafts, and how it affects a species’ ability to control and adapt to its environment. However, a strict definition is elusive; “technology” can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques.[citation needed] For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT.

Health information technology can be divided into further components like Electronic Health Record (EHR), Electronic Medical Record (EMR), Personal Health Record (PHR), Medical Practice Management software (MPM), Health Information Exchange (HIE) and many more. There are multiple purposes for the use of HIT within the health care industry. Further, the use of HIT is expected to improve the quality of health care, reduce medical errors and health care costs to improve health care service efficiency.

Health information technology components:

  • Electronic Health Record (EHR) – An EHR contains a patient’s comprehensive medical history, and may include records from multiple providers.[29]
  • Electronic Medical Record (EMR) – An EMR contains the standard medical and clinical data gathered in one’s provider’s office.[29]
  • Personal Health Record (PHR) – A PHR is a patient’s medical history that is maintained privately, for personal use.[30]
  • Medical Practice Management software (MPM) – is designed to streamline the day-to-day tasks of operating a medical facility. Also known as practice management software or practice management system (PMS).
  • Health Information Exchange (HIE) – Health Information Exchange allows health care professionals and patients to appropriately access and securely share a patient’s vital medical information electronicallymore prevalent in the United Kingdom.

    Home and community care[edit]

    Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases.

    They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, treatment for substance use disorders among other types of health and social care services.

    Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prosthesis, orthotics or wheelchairs.

    Many countries, especially in the west are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes. There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor’s appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge for the design of ICT (information and communication technology) for home care.[16]

    Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one,[17] many countries have begun offering programs such as Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income.[citation needed]

    With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have positive self-image.

    Ratings[edit]

    Health care ratings are ratings or evaluations of health care used to evaluate the process of care and healthcare structures and/or outcomes of health care services. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media. This evaluation of quality is based on measures of:

    Related sectors[edit]

    Health care extends beyond the delivery of services to patients, encompassing many related sectors, and is set within a bigger picture of financing and governance structures.

    Health system[edit]

    A health system, also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources that deliver health care services to populations in need.

    Health care industry[edit]

    A group of Chilean ‘Damas de Rojo’ volunteering at their local hospital

    The health care industry incorporates several sectors that are dedicated to providing health care services and products. As a basic framework for defining the sector, the United Nations’ International Standard Industrial Classification categorizes health care as generally consisting of hospital activities, medical and dental practice activities, and “other human health activities.” The last class involves activities of, or under the supervision of, nurses, midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health facilities, patient advocates[18] or other allied health professions.

    In addition, according to industry and market classifications, such as the Global Industry Classification Standard and the Industry Classification Benchmark, health care includes many categories of medical equipment, instruments and services including biotechnology, diagnostic laboratories and substances, drug manufacturing and delivery.

    For example, pharmaceuticals and other medical devices are the leading high technology exports of Europe and the United States.[19][20] The United States dominates the biopharmaceutical field, accounting for three-quarters of the world’s biotechnology revenues.[19][21]

    Health care research[edit]

    The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment. Many important advances have been made through health research, biomedical research and pharmaceutical research, which form the basis for evidence-based medicine and evidence-based practice in health care delivery.

    For example, in terms of pharmaceutical research and development spending, Europe spends a little less than the United States (€22.50bn compared to €27.05bn in 2006). The United States accounts for 80% of the world’s research and development spending in biotechnology.[19][21]

    In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make populations healthier.[22] Results from health services research often form the basis of evidence-based policy in health care systems. Health services research is also aided by initiatives in the field of artificial intelligence for the development of systems of health assessment that are clinically useful, timely, sensitive to change, culturally sensitive, low burden, low cost, built into standard procedures, and involve the patient.[23]

    Health care financing[edit]

    There are generally five primary methods of funding health care systems:[24]

    1. general taxation to the state, county or municipality
    2. social health insurance
    3. voluntary or private health insurance
    4. out-of-pocket payments
    5. donations to health charities

    In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries.[citation needed] In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other groups to adopt a specific health policy regarding the financing structure.

    For example, social health insurance is where a nation’s entire population is eligible for health care coverage. This coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, the system is allowed to operate.[citation needed] This is sometimes referred to as two-tier health care or universal health care.

    For example, in Poland, the costs of health services borne by the National Health Fund (financed by all citizens that pay health insurance contributions) in 2012 amounted to 60.8 billion PLN (approximately 20 billion USD). The right to health services in Poland is granted to 99.9% of the population, including registered unemployed persons their spouses).[25]

    Health care administration and regulation[edit]

    The management and administration of health care is another sector vital to the delivery of health care services. In particular, the practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance.[26] Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history.[27]

    Health information technology[edit]

    Health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.”[28] Technology is a broad concept that deals with a species’ usage and knowledge of tools and crafts, and how it affects a species’ ability to control and adapt to its environment. However, a strict definition is elusive; “technology” can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques.[citation needed] For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT.

    Health information technology can be divided into further components like Electronic Health Record (EHR), Electronic Medical Record (EMR), Personal Health Record (PHR), Medical Practice Management software (MPM), Health Information Exchange (HIE) and many more. There are multiple purposes for the use of HIT within the health care industry. Further, the use of HIT is expected to improve the quality of health care, reduce medical errors and health care costs to improve health care service efficiency.

    Health information technology components:

    • Electronic Health Record (EHR) – An EHR contains a patient’s comprehensive medical history, and may include records from multiple providers.[29]
    • Electronic Medical Record (EMR) – An EMR contains the standard medical and clinical data gathered in one’s provider’s office.[29]
    • Personal Health Record (PHR) – A PHR is a patient’s medical history that is maintained privately, for personal use.[30]
    • Medical Practice Management software (MPM) – is designed to streamline the day-to-day tasks of operating a medical facility. Also known as practice management software or practice management system (PMS).
    • Health Information Exchange (HIE) – Health Information Exchange allows health care professionals and patients to appropriately access and securely share a patient’s vital medical information electronically

 

 

Improving Mandatory Training How reps can play their part – Compliance Training solutions has taken this information from

file:///C:/Users/Silvana/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/PDF-006689%20(1).pdfContents
Introduction 3 Aims and intended learning outcomes 4 Relevance to your role descriptor 4 1. What is mandatory training? 5 2. Why is mandatory training so important? 8 3. What happens when mandatory training is not completed? 12 4. What about agency and bank staff? 18 5. What are the barriers to engaging with training? 19 6. What would a positive learning culture look like in your organisation? 25 7. How can RCN reps work in partnership to change the culture? 27 8. Resources and case studies 32

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Introduction
Every day, in workplaces around the UK, RCN representatives are making a difference. As well as supporting and representing individual members, reps are often working in partnership with RCN staff, other active members, and employers to question and influence for change. To ensure a safe and healthy workplace, mandatory training is vital. Staff need the knowledge and skills both to deliver safe and effective care and protect themselves. But RCN reps tell us local training has some challenges and barriers, including in its design, its delivery and in engaging staff. RCN reps are uniquely placed to support employers in improving the culture around mandatory training. Developed by the UK Learning and Safety Rep committee, this resource uses the experiences and ideas of both reps and members. By working through it and undertaking its activities, our aim is that you will develop the knowledge, skills and confidence to make a difference to mandatory training for staff where you work.

Karen Sanders Denise McLaughlin Chair, UK Learning Reps’ Committee Chair, UK Safety Reps’ Committee

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Aims and intended learning outcomes
The aim of this resource is to provide RCN reps with the knowledge and resources you need to help create a positive culture around mandatory training. After completing the activities, you should be able to: • articulate its value and importance in creating a positive, safe and healthy workplace culture that delivers high quality care • identify any local challenges and barriers • work in partnership with employers to improve provision and engagement.

Relevance to your role descriptor
You can expect to apply a wide variety of your knowledge and skills, but particularly those relating to the ‘questioning and influencing’ element of your role.

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1. What is mandatory training?
Mandatory training is learning deemed essential for safe and efficient service delivery and personal safety. It reduces organisational risks and complies with local policies and/or government guidelines. It varies depending on the needs of the workforce; the type of service and risks encountered; insurers’ standards; and the governance and legal frameworks in place, including country specific requirements. In a health care setting, mandatory training may relate to general workplace practice or be specific to your role. Examples include: • fire safety • moving and handling • data protection • control of substances hazardous to health (COSHH) • equality, diversity and inclusion • complaints handling • child safeguarding • infection control • basic life support • raising concerns and whistleblowing • conflict resolution or de-escalation skills. Although mandatory training needs to be regularly updated, employers are free to set their own protocols and policies on it, with staff contractually obliged to follow.
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This includes ‘statutory’ training, which ensures organisations are meeting their legislative duties. Examples include: • Health and Safety at Work Act 1974 • Management of Health and Safety at Work Regulations 1992 • The Data Protection Act 1998 • Mental Capacity Act 2005 • Mental Capacity Act (Northern Ireland) 2016 • The Adults with Incapacity (Scotland) Act 2000 • Public sector equalities duties. 1.1 Terms you might see in your workplace Mandatory training – learning deemed essential for safe and efficient service delivery and personal safety, which reduces organisational risks and complies with local policies and/or government guidelines. It may also include statutory training. Statutory training – learning that all staff must undertake to ensure an organisation is meeting its legislative duties – see examples above. Essential training – some use this as a ‘catch-all’ term to describe both statutory and mandatory training, on the grounds that it is ‘essential’ for the organisation. Compulsory training – again can be a ‘catch-all’ term to describe both statutory and mandatory training, making it clear that staff must complete it. StatMand training – an informal term, blending statutory and mandatory together. In this resource, we will use the term ‘mandatory’ to cover all these terms.
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Activity 1: Building your knowledge base Think about the training that is delivered in your workplace. Here are some key questions to help you begin to build up a picture. • How is mandatory training referred to in your organisation? • Does everybody understand what it means? • What courses are currently covered by these terms? • Who can help you to gather this information?
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2. Why is mandatory training so important?
2.1 Ensures a safe working environment for staff Health and safety regulations and guidance help to make sure staff have a safe working environment. But safe practice is a shared responsibility, and everyone must be accountable for their own actions. Mandatory training ensures that individuals have the right knowledge and skills to carry out their duties in the safest ways possible, minimising any risk to themselves and others. It may also relate to specific equipment or devices you use as part of your role. Under the Health and Safety at Work Act 1974, employers have an obligation to protect the health, safety and well-being of their employees. Legislation also requires employers to assess the risk of violence towards their employees, putting in place measures to mitigate risks, including relevant training. “Whatever sort of business you are, there is always the possibility of an accident or damage to someone’s health…The reason there are not even more accidents and diseases caused by work is because systems of prevention are in place which have been built up over generations” Royal Society for the Prevention of Accidents http://www.rospa.com Health care workers continue to be at risk of experiencing work-related conflict, aggression and violence while simply doing their job. In 2016, an RCN survey of members found that more than half had experienced physical or verbal abuse from people they were caring for, with a further 63% from relatives or other members of the public. Employers must make every effort to prevent conflicts and violence at work, offering training on issues such as complaints handling and conflict resolution.
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2.2 Ensures safe and effective care Your organisation has processes or guidance that are applicable to your clinical practice and the care you deliver. Some may be relevant to everyone in the organisation, such as infection control and hand hygiene. Others may be specific to your role or the people you care for, such as child protection or moving people safely. As the regulatory body for workplace health and safety in England, Scotland and Wales, the Health and Safety Executive (HSE), investigates instances when organisations fail to meet their legislative duties. One such investigation – into the death of an older patient following a fall, when being moved with a hoist – found that the care home had no manual handling policy, outlining arrangements for moving residents safely. In addition, nurses and care workers had not received proper training. The Francis Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry (2013) recommends that every NHS organisation should provide training on speaking up and raising concerns about safety and clinical care. For many organisations, this has become part of their mandatory training. 2.3 Supports staff to meet professional standards You will find many of the areas covered in mandatory training support staff to meet the professional standards that cover nursing roles. A good example would be training related to confidentiality which appears in the ‘Prioritise people’ domain of the NMC’s Code for Nurses and Midwives and in professional standards for health care support workers in all four countries. 2.4 Creates a positive workplace culture As part of their mandatory training, and to demonstrate good practice, some organisations include courses to develop the skills of their staff in creating good working relationships; equality and diversity; dignity; and ways of working. These help to promote a fair and respectful working environment, where staff feel supported, included and safe to speak up about any concerns.
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During discussions about the value of mandatory training, RCN learning reps and members talked about the sense of job security and satisfaction that comes with having access to high quality training, including feeling confident that skills are up-to-date. Although there is no data on the effects of mandatory training on staff morale, a 2011 study by the National Institute for Health Research (NIHR) saw a clear link between morale and training in general. A survey of 100 inpatient wards and 38 community teams found: “Those in high-morale wards had more positive things to say about training than those in low-morale wards. Ward managers were generally keen to promote training; not just to improve standards, but also to boost morale. Training was seen as a way of maintaining role clarity and imbuing confidence. It also allowed staff to “look forward” and sent a message that they were valued.”
Activity 2: Supporting professional standards Review your list of mandatory training in your workplace. How does mandatory training help staff meet their professional standards?
The NMC Code The standards are set out in four domains of the NMC Code: • Prioritise people • Practise effectively • Preserve safety • Promote professionalism and trust.
Health care support workers You can review the professional standards for health care support workers in your country by visiting the RCN website: http://www.rcn.org.uk/professional-development/professionalinformation-for-hcas-and-aps
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Activity 3: Promoting a positive culture Review your list of mandatory training in your workplace. Pick three topics. Now think about how completing those courses could: • create a safer working environment • improve care • and create a better workplace culture. Think about what you would say to: • a colleague who was complaining about having to do their training • a manager who had stopped a member of staff from undertaking the training.
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3. What happens when mandatory training is not completed?
Clear negative consequences include a workplace that is less safe; accidents becoming more likely; and patients not receiving the highest quality of care. As the workplace culture deteriorates, staff may become less engaged, more dissatisfied at work and eventually more vulnerable to mental health issues. 3.1 Consequences for individuals Pay, progression and development Completing mandatory training is usually a requirement of an employee. Many employers will have their own policies, with staff penalised for failing to comply. According to RCN reps, this can include pay rises being withheld; being prevented from taking part in professional development opportunities; and the risk of being suspended from employment or paid at a lower grade.
Professional registration and indemnity The NMC does not set specific requirements stating how often mandatory training must be undertaken or completed. However, a registered nurse will not be able to meet the four domains of the NMC Code, if they have not completed their mandatory training. Your professional indemnity arrangement – usually covered by your employer – is likely to have conditions, including undertaking appropriate training to ensure competence in your area of practice. In other words, you should be able to show you have the knowledge, skills and judgment to perform your task or role to the appropriate standard of care. Having such an arrangement in place is also part of the conditions for revalidation.
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Claims relating to workplace related injury or ill-health If you are injured at work or struggling with physical or mental health issues that may be directly attributed to your working conditions, not completing your mandatory training may mean you’re unable to claim relief or compensation from your employer, if this could have prevented the injury or onset of ill-health. For example, if you incur a back injury as a result of using a piece of equipment, it may prove difficult to assert the employer’s liability if you haven’t completed moving and handling training, despite being given reasonable opportunities to undertake it during work time. This is known as ‘contributory negligence’. 3.2 Consequences for managers Managers are expected to provide time, opportunities and access to mandatory training for all their staff. Organisations have various systems for monitoring compliance, often devolving responsibility to departments and individual team managers. Managers who fail to meet their targets may be performance managed or face increased scrutiny. RCN reps report instances where managers have had their progression halted or have not received their pay increment, if their team has not met their compliance target. 3.3 Consequences for the organisation Regulatory consequences All UK health regulators include training as part of their regulation standards. Care Quality Commission (England) http://www.cqc.org.uk ‘Persons employed by the service provider in the provision of a regulated activity must receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.’ Staff should be supported to make sure they are can participate in: • statutory training • other mandatory training, as defined by the provider for their role
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• any additional training identified as necessary to carry out regulated activities as part of their job duties and, in particular, to maintain necessary skills to meet the needs of the people they care for and support • other learning and development opportunities required to enable them to fulfil their role. This includes first aid training for people working in the adult social care sector. Taken from Guidance for Providers on Meeting the Regulations, Care Quality Commission (2015), England. The Regulation and Quality Improvement Authority (Northern Ireland) https://rqia.org.uk (The organisation) has sound human resource policies and systems in place to ensure appropriate workforce planning, skill mix, recruitment, induction, training and development opportunities for staff to undertake the roles and responsibilities required by their job, including compliance with: • departmental policy and guidance • professional and other codes of practice • employment legislation. (The organisation) has a training plan and training programmes, appropriately funded, to meet identified training and development needs which enable the organisation to comply with its statutory obligations. The Quality Standards for Health and Social Care, Department of Health, Social Services and Public Safety http://www.health-ni.gov.uk Scotland There are two regulatory bodies in Scotland – Health Improvement Scotland, which regulates the NHS and independent sector providers; and the Care Inspectorate, which regulates social care services, including care homes. On mandatory training, there is no overarching statement within Health Improvement Scotland. But as part of inspections, they will ‘talk to staff to check their knowledge and understanding of what they should be doing’ http://www.healthcareimprovementscotland.org
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The Care Inspectorate has standards for the different type of care providers (care at home, older people etc) and all have specific standards relating to training. http://www.careinspectorate.com In June 2017 the Scottish Government launched the Health and Social Care Standards. From 1 April 2018 the Standards will be taken into account by the Care Inspectorate, Healthcare Improvement Scotland and other scrutiny bodies in relation to inspections, and registration, of health and care services Written from the perspective of the person receiving care, in relation to mandatory training, it states “I have confidence in the people who support and care for me.” And “I have confidence in people because they are trained, competent and skilled, are able to reflect on their practice and follow their professional and organisational codes.” Health Inspectorate Wales http://www.hiw.org.uk ‘Staff are enabled to learn and develop to their full potential. The leaders of any NHS organisation have a duty to set the appropriate tone and promote the right culture, and ensure that individual members of staff can fulfil their responsibility to deliver high quality and safe services.’ ‘The workforce attends induction and mandatory training programmes’ Taken from NHS Wales Health and Care Standards. ‘Organisations and services ensure that: They have an appropriately constituted and sustainable workforce, who are provided with appropriate support to enable them to: a) have effective workforce plans b) maintain and develop competencies in order to be developed to their full potential c) participate in induction and mandatory training programmes Taken from National Minimum Standards for Independent Health Care Services in Wales.
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When an organisation is not meeting the standards set by each regulating body, there will usually be a notice detailing the areas needing improvement, with a date when this should be achieved. If a regulatory body has more serious concerns, a period of close monitoring and supervision may be needed. They can also issue fines, prosecute or cancel the service’s registration.
Legal consequences Under the Health and Safety Act 1974, an employer has a duty to protect the health, safety and welfare of their employees and other people who might be affected by their business. They must give employees information about the risks in the workplace and how they are protected. They must also instruct and train employees in how to deal with the risks. (www.hse.gov.uk) The HSE and its counterpart, the Health and Safety Executive for Northern Ireland, may investigate reports of injury or harm to a member of staff or patients. If a lack of training is identified as a contributory factor, they have the power to issue an improvement notice, prosecute or fine an organisation. In one instance, a care home group was found to have failed to manage the risk of bedrails. Alongside a lack of proper assessment and review, staff were not trained in safe use. The organisation admitted breaching the Health & Safety at Work Act 1974 and was fined £400,000, plus £15,206 costs. In another, a local authority was fined after two of its social workers were assaulted on a home visit by the mother of a vulnerable child. HSE found that the local authority failed to follow its corporate lone working policy or violence and aggression guidance. No risk assessment was completed and staff were not trained accordingly. The authority was fined £100,000, with costs of £10,918.88. Any organisation failing to meet the expectations of health regulators, or the appropriate HSE, faces a risk to their reputation. Health regulatory bodies are required to publish inspection reports, while information about HSE inspections can be gained via Freedom of Information requests.
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Activity 4: The consequences of not completing mandatory training Go back to your local policy relating to mandatory training. Are there any direct consequences for the individual staff member? Revisit Activity 2 where you thought about influencing staff and managers to positively engage with mandatory training. Reflect on the consequences outlined above and think about how you might talk about them, while maintaining a positive position.
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4. What about agency and bank staff?
Usually agency and bank nurses receive mandatory training provided by their employing agency, which should outline the rights of staff to its access. While they should not have to fund this training themselves, staff do not have the statutory right to request paid time to complete it. Agency staff should bear in mind the consequences of not keeping up-to-date with mandatory training, both as professionals and its impact on their ability to gain work placements. Organisations using agency staff should ensure individuals have undertaken statutory and mandatory training on delivering safe care, and maintaining a safe working environment. This may be a contractual obligation in the agency contract, or take the form of a shared arrangement. Even if they only work one shift, improperly trained agency staff, who have not had an induction into the organisation, pose great risks. The RCN’s Healthy Workplace Toolkit for an Agency Workforce provides a clear framework for employment agencies and host organisations, both in the NHS and the independent sector. It addresses issues identified by the agency nursing workforce, providing guidance on a healthy and safe working environment for staff and patients.
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5. What are the barriers to engaging with training?
Despite the clear benefits of mandatory training, and the serious impact non-compliance may have, some organisations still fail to meet their targets.
5.1 Time and cost Health care organisations are highly pressurised workplaces, where staff resources may be stretched to the limit. This can mean that sometimes managers find it difficult to release staff to complete training. RCN reps report many examples where staff are either denied access to training, or called back to work at short notice, due to staff shortages. Individuals can also feel a sense
Negative culture
Time and cost
Quality and relevance
Access and inclusion
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of obligation to their colleagues and patients, struggling to take the time, even when they are released from their duties. As new guidance and policies for clinical and workplace practices are developed, the list of ‘mandatory’ training can mushroom. It may reach a point where there are more than 20 courses a clinical staff member must complete, to comply with an organisation’s training policy. Coupled with understanding the benefits of training – and the potential consequences of not doing it – many staff report doing mandatory training in their own time. And while some organisations offer staff ‘time off in lieu’ or pay, many don’t. The Working Time Regulation Act 1998 specifically notes that ‘working time’ includes any period during which a worker is receiving relevant training. http://www.legislation.gov.uk At a time when cost savings and financial efficiency are paramount, the money spent on all learning and development is at risk. Costs include releasing staff and providing back-fill, and the training itself. Challenges in finding time can create an increased emphasis on online learning as the main means of delivery, which may have drawbacks for quality and relevance. In the most recent RCN Nursing Employment Survey (2017), four-fifths (83%) of all nursing staff said they had completed all their mandatory training, with half (54%) saying they had completed their last mandatory training in normal working time. One in five (20%) said it was done in their own time and one in four (26%) said it was done in both their own and work time. Staff working in agency/bank settings (83%) and independent care homes (43%) were much more likely than most other staff to have to complete training in their own time.
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5.2 Quality and relevance Online learning Over the last five years, there has been a dramatic shift towards providing learning online, with schools, colleges, universities and businesses all using technology to transform the way that learning is delivered. Online training can be delivered far more cheaply than in a classroom – which requires rooms, tutors and staff attendance. Most online learning offers also provide some form of learner assessment, tracking of staff, and automated reminders for recurrent training. This greatly reduces the administration and monitoring of staff compliance, creating a robust audit trail. Online learning supports greater access and engagement, with staff choosing when they can complete it. It can also provide a high-quality learning experience, ideally suited to some topics and areas of practice, including compliance-led training. The imaginative use of video and audio, ‘bite-size’ learning and ‘in-the-moment’ refreshers may all provide engaging options for learners. But the suitability and quality of some online learning can also be one of the biggest barriers to a meaningful experience. Too often, online learning takes guidance or policy and breaks it down into readable chunks, with a quiz at the end as assessment. At its worst, this can simply be a way of proving the learner has read the guidance. RCN reps report that staff can quickly identify ‘short cuts’ to completing this kind of training, either by circulating the answers or competing it as a group. There has also been much discussion about the value of online learning for areas related to physical movement, such as manual handling or display and screen equipment. In some organisations, RCN reps have successfully challenged the move towards delivering basic life support training online, in favour of a blended approach.
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The content and frequency of mandatory training To ensure they have the most up-to-date knowledge and skills, mandatory training needs to be completed by all staff at intervals determined by the organisation, using a training needs analysis. But RCN reps report that organisations can often take an easier ‘blanket’ approach, asking staff to repeat the same learning package again, regardless of how many times they have done it before. In most organisations, new staff must complete all training, regardless of prior learning and experience in their recent employment. Meanwhile, organisations using external providers, particularly in the case of online learning, often buy a suite of ‘core modules’. These are automatically assigned as mandatory for all staff, regardless of the role they have, or the duties that they perform. As a result, staff may have to complete a large number of courses, repeating them annually, despite feeling that they are already competent and confident in the area, or that the topic has no relevance to their practice. 5.3 Access and inclusion The time and location of training The broad range of services that nursing staff deliver, around the clock, means that work is often not 9 to 5 or based in one location. Many organisations fail to consider all their staff, when planning and delivering mandatory training. RCN reps tell us that night shift, part-time and community workers in particular find it difficult to access training, often having to complete it outside their working hours.
Training must be inclusive and accessible for all When learning is provided face-to-face, accessibility needs to be considered, including training rooms, refreshment areas and toilets. Delegates may need adjustments for hearing and vision, for reading, or cognitive differences, for example, dyslexia. Where possible, it should be designed inclusivity in mind. Being open to accommodating reasonable adjustments is good practice, but providing something that automatically includes all attendees – such as talk
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to text transcribing of speakers, or always choosing accessible venues – means that everyone feels included. Accessibility and an inclusive approach applies in the same way for e-learning. Being open to providing reasonable adjustments, such as a different mouse, headset or keyboard for those with different physical needs, may be required. To be inclusive, try to ensure that software is appropriate for all learning styles, and can be used with voice recognition and dyslexia support software. Text should comply with Plain English requirements and basic inclusion standards, such as Arial font 12 and dark writing on a white background.
Access to IT equipment Although seen as a way of improving access to training, online learning is only successful if staff have equipment that is easily accessible during working hours, and has the capability to run the packages. If equipment is not accessible, staff feel obliged to undertake training in their own time, using their own equipment.
Support with IT skills As organisations move towards online learning, staff who lack confidence in using computers may feel anxious and unsupported. Having IT skills is an expectation of staff, regardless of how much they use them in their role. As with literacy and numeracy skills, some may be reluctant or embarrassed to ask for help. “I had a case where part of the case involved a member who was not completing mandatory e-learning training due to lack of access to computers when on shift. The member was not very computer literate, so needed more time to complete the modules. This led to them having lots of ‘‘red audits’ on their mandatory training file.” RCN Officer
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5.4 Negative culture Learning and development professionals attest to the fact that delivering mandatory training is very different to other forms of learning, and this needs to be taken into account, working harder to engage reluctant attendees. For some staff, the words ‘statutory’ and ‘mandatory’ signal a lack of control over whether or not they want to complete the training. Being forced to do it may be received in the same way as a new rule or task, creating a negative outlook that impacts on its benefits and importance.
Activity 5: Barriers in your organisation Think about your organisation. What is the culture around mandatory training in your organisation? How would you rate your local training for its quality, relevance, access and inclusion?
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6. What would a positive learning culture look like in your organisation?
We asked RCN members what they thought a good culture around mandatory training might look like. Here’s what they said. Time and cost • All staff are able to complete training in work time or are given time off in lieu if completed outside working hours. • The training programme is cost efficient and provides the best value for money – but cost is not the primary driver. Quality and relevance • Learning has defined objectives and outcomes. • The method of delivery is appropriate to the subject matter. • Courses include a range of activities to suit different learning styles. • Learning is meaningfully assessed, demonstrating the learner has understood and can apply it to their practice. • Training is evaluated by learners, with feedback used to review and enhance provision. • Requirements are based on an individual’s knowledge and experience. • Top-up or refresher courses are available to those who have already completed the training, instead of ‘resitting’. • Recent training at a previous employer is transferable. • Mandatory training is relevant and supports the individual’s role. • Organisations map training to relevant nursing themes, such as the 6Cs of nursing or the NMC Code.
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Access and inclusion • Training is delivered to suit the work patterns and locations of all staff members. • All staff are able to access IT equipment that supports the online learning packages. • Staff who lack confidence in IT are offered support during work time to improve their skills. Culture • Staff understand the importance of mandatory training and value the organisation’s learning provision.
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7. How can RCN reps work in partnership to change the culture?
7.1 Questioning and influencing for improvement As an RCN rep, you can apply your questioning and influencing skills to work in partnership with your employer to deliver a high-quality programme of mandatory training, creating a positive culture that engages staff. ‘Questioning and influencing’ involves accessing and analysing information to identify any workplace issues as quickly as possible, supporting proactive interventions. It includes picking up issues before they become major problems, and working with other trade union colleagues, and your employer, to address issues promptly and positively. You may also identify areas of excellence that can be shared more widely across the organisation. 7.2 Staff side/management meetings Your organisation may already have a committee or forum where staff can engage with employers on decisions that affect them, and the services they provide. These committees are very effective in raising and addressing issues or concerns. They also provide useful structures to gain support for ideas on improvement and sharing good practice. All recognised trade union representatives have a place on a staff/employer committee, and it is good practice for union representatives to take on the role of chair and secretary. Organisations may also have specific health and safety and learning/training committees. Health and safety committees provide a forum for safety reps to raise concerns around issues relating to health and safety related mandatory training. Under regulations, an employer is obliged to establish a health and safety committee if two or more safety reps request it.
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If your organisation does not have this type of formal committee or forum, reps can get together with colleagues to consider who the key decision-makers and enablers might be on training, and health and safety. They can then suggest a partnership approach to improving mandatory training.
7.3 Key questions to facilitate action and a change of culture Below are some key questions that may help to provide insight into current provision, compliance and culture on mandatory training in your organisation. The answers should provide a starting point to develop an action plan for partnership working. To get the discussion going and gain support for further work, you may want to pick one or two priority questions to ask at your first partnership meeting. Others can form the basis of your next steps.
Activity 6: Engaging with key influencers First establish whether your organisation has a partnership forum or committee. If yes • Who is the chair and secretary? • Who has a place on that committee from the RCN? • What is the process for raising an agenda item? If no • Who are the key influencers and enablers on training, and health and safety? • Can you meet them to discuss partnership working?
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Information Evidence Action required
Time and cost How is mandatory training delivered? (internal/external providers, costs etc.) Are staff released from work to complete training? Quality and relevance Does the training programme reflect the experience and role of individual staff? Do new staff have to repeat recent training undertaken with another employer? Are ‘refresher’ courses offered? Or are all courses repeated? Has any mandatory training been recently evaluated? And how was it rated? Are we working within any recognised frameworks (such as Skills for Health Core Skills Training Framework)
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What is the current policy on agency workers? How do we assess the quality of training agencies provide? How often is training reviewed? And when is the next opportunity to influence? Access and inclusion Are part-time and night workers able to access training during their working hours? Do all staff have access to IT equipment to complete online training? Culture What are the current attitudes and perceptions around mandatory training? What is the current compliance rate for mandatory training? And how is it measured?
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What reasons are given for noncompliance? Do workers from agencies we use get a fair deal on mandatory training? Does it reflect our own culture?
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8. Resources and case studies
Here are some examples of good practice to help you see what it might look like in your organisation. This is not an exhaustive list and currently feels weighted towards NHS initiatives. As reps start to get active in improving mandatory training, we would welcome examples from organisations outside the NHS. 8.1 The importance of health and safety training The HSE’s Health and Safety Training – A Brief Guide, targeted at owners and managers of businesses, explains the importance of health and safety training and why it is needed. It gives advice on who may need training, what form the training may take and how to organise it. Download at http://www.hse.gov.uk/pubns/indg345.htm 8.2 Partnership working Although developed for the NHS in England, these resources offer guidance for partnership working in all settings and countries. http://www.socialpartnershipforum.org/about-spf/how-we-do-partnership The RCN Ask. Listen. Act. resource is a practical guide that has been designed by RCN representatives and officers to help you to question and influence on behalf of members in your workplace. http://www.rcn.org.uk/professional-development/publications/pub-005357
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8.3 Transferability of training Manual handling passport schemes in Scotland and Wales The NHS in both Scotland and Wales have introduced passport schemes enabling staff members moving to another organisation to transfer their training skills, which minimises duplication and saves time. The scheme also ensures consistency of training throughout participating trusts. Scotland – see The Scottish Manual Handling Forum and download The Scottish Manual Handling Passport Scheme http://smhf.co.uk/application-for-smhp Wales – see All Wales NHS Manual Handling Training Passport and Information Scheme http://www.wales.nhs.uk/documents/NHS_manual_handling_passpor.pdf
Skills for Health ‘Core Skills Training Framework’ This has detailed learning outcomes, standards and guidance for each area of training. Organisations can register, mapping their training to the framework. When moving between registered organisations, staff members’ recent training can be recognised by their new employer, preventing duplication as staff move between roles and organisations. The service is available to NHS and independent sector organisations that provide in-house training, alongside external training providers. http://www.skillsforhealth.org.uk/services/item/146-core-skills-trainingframework
Streamlining London Streamlining London is a collaboration of 36 NHS Trusts and NHS Foundation Trusts who are working together to improve outcomes for patients, by providing NHS leaders, managers and staff with the best possible HR functions. Streamlining statutory and mandatory training was one of four areas of work that began in 2014.
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Their aims and outcomes echo the vision of a positive culture described by our members, and there are some useful ideas, case-studies and outcome reports that your organisation may find interesting. For example, Barnet and Chase Farm Hospitals NHS Trust and the West London Mental Health Trust used the ‘five-point plan’ to review training, with impressive results. http://streamlining.london/statman-training Although a great example of good practice, RCN reps should be mindful that it does not include the many hundreds of nursing staff that are contracted into the NHS from independent sector employers. As we strive for best practice, we should be thinking about those staff who are – and aren’t – included.
The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies April 2018 RCN Online http://www.rcn.org.uk RCN Direct http://www.rcn.org.uk/direct
Published by the Royal College of Nursing 20 Cavendish Square London W1G 0RN http://www.facebook.com/ royalcollegeofnursing http://www.twitter.com/thercn http://www.youtube.com/rcnonline
Publication code: 006 869

 

 

Quality improvement training for healthcare professionals – This information was taken from the following link and publication. Compliance Training Solutions believes that this information is useful for its clients.

https://www.health.org.uk/sites/health/files/QualityImprovementTrainingForHealthcareProfessionals.pdf

Key messages There is an increasing focus on improving healthcare in order to ensure higher quality, greater access and better value for money. In recent years, training programmes have been developed to teach health professionals and students formal quality improvement methods.
This evidence scan explores the following questions: – What types of training about formal quality improvement techniques are available for health professionals? – What evidence is there about the most effective methods for training clinicians in quality improvement?
For the purposes of this scan, quality improvement training was defined as any activity that explicitly aimed to teach professionals about methods that could be used to analyse and improve quality. Courses about techniques, such as evidence-based medicine, statistics and leadership, were included if the stated aim was to improve quality. Courses about improving a specific condition or pathway were included if they incorporated material about improvement techniques that could also be widely applied to other topics. Ten electronic databases were searched for research published between 1980 and November 2011 and 367 studies were summarised. Sixty higher educational institutions and other organisations in the UK and internationally were contacted for course curricula. Unless otherwise specified, the trends reported are evident throughout the Western world. Types of training Training in quality improvement is available for medical, nursing and paraprofessional students in many parts of the world. Continuing professional development (CPD) courses are also available, including short workshops, on-the-job training and training related to specific projects.
The training approaches most commonly researched include: – university courses about formal quality improvement approaches – teaching quality improvement as one component of other modules or interspersed throughout a curriculum – using practical projects to develop skills – online modules, distance learning and printed resources – professional development workshops – simulations and role play – collaboratives and on-the-job training. Training content In much of the Western world, quality improvement modules for medical and nursing students tend to focus on techniques such as audit and plan, do, study, act (PDSA) cycles. Most courses run by academic institutions tend to be unidisciplinary and classroom based or undertaken during clinical placements. However, there is an increasing acknowledgement of the value of multidisciplinary training, especially in practical work-based projects. Many courses now contain a practical component. Simulation is also becoming popular as a training approach. Continuing professional development training about quality improvement appears to be growing at a faster rate than university education. Ongoing education includes workshops, online courses, collaboratives and ad hoc training set up to support specific improvement projects. There is a growing trend for training which supports participants to put what they have learned into practice or to learn key skills ‘on the job’.
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There are some geographic variations in the content of formal courses and CPD programmes. In the US and to a lesser extent Canada, quality improvement is conceived largely as a ‘total quality management’ paradigm and training focuses on collating predominantly quantitative information. In the UK, a patient safety and change management approach is more common. To some extent the US approach is more standardised and rigid and the UK approach is more open and less consistently applied. Courses in the US tend to focus on ‘named’ approaches such as PDSA cycles. Practical projects are increasingly common. In Canada and Australasia, training about quality improvement also emphasises putting theoretical concepts into practice using work-based projects. In the Netherlands and Scandinavia there has been more focus on mentorship and peer review, whereas in the UK training tends to concentrate on specific components of quality improvement, such as leadership and safety. In recent years, UK courses have started to recognise the importance of population health and risk assessment, but relatively few programmes emphasise the needs and perspectives of service users in any real depth. In the US, training in quality improvement is mandatory for medical students. In contrast, in the UK, until recently there was less focus on training students in quality improvement and little integration of quality improvement concepts into pre-qualification courses. This is beginning to change, with more time now spent on concepts such as evidence-based medicine, audit and improving safety. In England, arms length bodies, workforce deaneries and strategic health authorities run quality improvement courses for health professionals. Activity in this area has increased in recent years. There is no consistent content or definition of quality improvement, but there tends to be a common approach which involves using practical, rather than simply didactic, methods.
Training effectiveness Impact of training A great deal has been written about training professionals to improve quality in healthcare. In fact, more than 5,000 articles were identified about this topic. However, the majority merely describe training approaches and content, rather than examining the impacts of training or the most useful content and training methods. There is some evidence that training students and health professionals in quality improvement may improve knowledge, skills and attitudes. Care processes may also be improved in some instances. However, the impact on patient health outcomes, resource use and the overall quality of care remains uncertain. Most evaluations of training focus on perceived changes in knowledge rather than delving deeper into the longer-term outcomes for professionals and patients. Programmes which incorporate practical exercises and work-based activities are increasing in popularity, and evaluations of these approaches are more likely to find positive changes in care processes and patient outcomes. There is not a body of evidence assessing whether training professionals is any more or less effective for improving the quality of healthcare than other initiatives. Effectiveness of different methods Few studies have directly compared different training methods. This means that there is insufficient evidence to conclude whether classroom formats, practical projects, online modules or other methods are more or less effective. However, active learning strategies, where participants put quality improvement into practice, are thought to be more effective than didactic classroom styles alone. It appears important to include quality improvement methods in both pre-qualification training and CPD. It is also important to upskill trainers so that they can teach quality improvement methods robustly.
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In recent years, the concept of quality improvement has become more widely accepted in the UK and training is increasingly available, especially for qualified professionals. However, a great deal remains uncertain about training in quality improvement, including: the most appropriate content; how training can best be delivered to improve processes and patient outcomes; how to measure and ensure quality within training. This is an essential area for further exploration. Training professionals may be important not only to ensure that they have the skills needed to improve the quality of healthcare, but also to enhance their motivation to do so.
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1. Scope For hundreds of years, clinicians have sought to make healthcare more effective and accessible. Recently, health professionals have begun to learn about formal methods to improve quality. This evidence scan summarises research about the types of training available and its impacts.
1.1 Purpose ‘Not all changes are improvements but all improvement involves change. Changing the systems that deliver care has thus become the cornerstone of the movement that is now referred to as medical quality improvement.’1 The focus on improving the quality of healthcare is not new. In 1517 the founding charter of the Royal College of Physicians emphasised the need for members to set and maintain standards of practice ‘for their own honour and the public benefit’.2 However, over the past 20 years improving the quality and safety of healthcare has taken on new importance in the UK. Health services are now facing significant challenges. There are constant medical and technological advances to keep pace with, the population is growing in size, people are living longer but often in poor health and the demand for healthcare outstrips the staffing and financial resources available.3,4 The focus on patient-centred care, holistic practice and providing value for money means that there is a greater need to ensure that health professionals, allied teams and managers have the knowledge and skills to improve and develop healthcare services. A wide range of techniques have been used to improve healthcare including improvement cycles, clinical audit, guidelines, evidence-based medicine, healthcare report cards, patient-held records, targets, national service frameworks, the Quality and Outcomes Framework, performance management approaches, continuous quality improvement, financial incentives, leadership, choice and competition. All of these initiatives require health professionals and managers to
learn and apply new skills. The Health Foundation believes that training can be an effective lever for improving the quality of healthcare. Yet education and training initiatives are not always prioritised by policy makers or practitioners.5,6 ‘While healthcare organisations are initiating a number of strategies to improve care and respond to changing regulatory and policy requirements, many clinicians practicing in them have not received training on quality and safety as a part of their formal education.’7 Research suggests that a lack of knowledge and skills among clinicians and managers is a significant barrier to improving quality in healthcare.8–10 For example, an evaluation of improvement projects in England found that managers and practitioners often lacked basic skills and knowledge in how to assess evidence, plan improvements, manage projects and analyse data.11 Training health professionals in quality improvement has the potential to impact positively on attitudes, knowledge and behaviours.12 In fact, some suggest that training professionals may be just as effective as financial incentives for improving the quality of healthcare.13 Yet little is known about the most effective ways to train health professionals in quality improvement. This evidence scan explores the following questions: – What types of training about formal quality improvement techniques are available for health professionals? – What evidence is there about the most effective methods for training clinicians in quality improvement?
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This section briefly describes the scope and methods of the scan. Section 2 outlines some of the content and teaching methods used in quality improvement training. Section 3 explores the effectiveness of various types of training. 1.2 Defining quality improvement Quality improvement is not solely about ‘making things better’ by doing the same things and ‘trying harder’. Instead, quality improvement requires a different approach to traditional ‘fact-based’ learning and needs a new set of knowledge and skills to put this approach into practice. For the purposes of this scan, training in quality improvement was defined as any activity that explicitly aimed to teach health professionals about methods or skills that could be used to improve quality. Table 1 lists the domains of quality improvement that the Health Foundation is interested in. The scan focused on training to support health professionals to develop knowledge and skills in these key areas. Quality improvement was not defined solely as ‘continuous quality improvement’, ‘total quality management’ or other named models, but rather as a way of approaching change in healthcare that focuses on self-reflection, assessing needs and gaps, and considering how to improve in a multifaceted manner. In this definition, training about quality improvement aims to create an ethos of continuous reflection and a commitment to ongoing improvement. It aims to provide practitioners and managers with the skills and knowledge needed to assess the performance of healthcare and individual and population needs, to understand the gaps between current activities and best practice and to have the tools and confidence to develop activities to reduce these gaps.
Thus, the scan did not focus only on narrowly defined quality improvement models such as ‘plan, do, study, act’ (PDSA) cycles, Six Sigma, LEAN and so on – although it included courses that defined quality improvement in this way too. Courses about techniques such as evidence-based medicine, statistics and leadership were only included if the stated aim was to improve quality. Courses about improving a specific condition or pathway were included if they incorporated material about improvement techniques that could also be widely applied to other topics. Terminology The focus was on accredited education and ongoing training through courses and workshops rather than resources such as books, mentoring, fellowships or other learning methods. The term ‘education’ is often used to describe formal courses run by higher educational institutions whereas the term ‘training’ is broader and encompasses CPD and short courses run by a variety of providers. For simplicity, the scan uses the general term ‘training’ to apply to both formally accredited education and other CPD. Unless otherwise specified, the trends reported are generalised to reflect what is happening throughout the Western world.
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Table 1: Potential components of quality improvement14 Components Examples of topic areas The wider context How the health system is structured and how it works Historical, social and political context within which health systems develop and operate Health policy Accountability Professionalism Human behaviour Psychology of change Learning styles Leadership Teamwork and collaboration Management Multidisciplinary working Reflection and learning from mistakes Needs and preferences of people who use health services Seeing healthcare from the user’s perspective Identifying and targeting the needs and preferences of different subgroups of users Acquiring tools to assess and respond to users Healthcare as a process Systems thinking Complexity theory and interdependencies Spread Sustainability Planning and predicting Understanding risk and risk management The nature of knowledge Different forms of evidence The philosophy of science Variation Measurement Local versus generalisable knowledge Small versus large scale change Collecting, analysing and interpreting data Reporting and displaying information Process mapping1.3 Identifying evidence The review summarises the findings of 367 articles. To collate evidence for the scan, 10 bibliographic databases were searched: Medline, Embase, ERIC, Science Citation Index, Cochrane Database of Systematic Reviews, NHS Evidence, PsychLit, Web of Science, Google Scholar and the Health Management Information Consortium. The focus was on readily available literature published between 1980 and November 2011. Articles from any country and in any language were eligible for inclusion. Articles about training in quality improvement outside healthcare were not included. The search terms included combinations of the following words and other similes: education, training, curriculum, course, competencies, teaching, learning, quality improvement, improving quality, improvement science, science of improvement, quality, continuous quality improvement and PDSA. In addition, the quality improvement domains listed in Table 1 were used. Articles about training in planning, systems thinking, the philosophy of science, needs assessment, health policy, learning styles, leadership, risk management and self-reflection were identified in order to assess whether these courses also included other components of quality improvement training. Furthermore, the scan identified examples of training by searching the websites and course outlines of organisations such as the General Medical Council and all royal colleges, the Association of American Medical Colleges, the Institute for Healthcare Improvement (IHI), the NHS Institute for Innovation and Improvement, the Improvement Foundation and academic institutions. Sixty organisations were contacted for information about their quality improvement curricula.
More than 5,000 pieces of descriptive and empirical evidence were analysed to draw out key themes about the types of training available and the most effective training methods. Of these, 367 of the most relevant and high-quality studies were summarised as examples alongside descriptive and narrative articles to provide context. The chosen articles were selected based on relevance to addressing the topics of interest, methodological quality, novelty of content and accessibility. The scan does not purport to summarise all available studies about training in quality improvement, but rather seeks to provide a flavour of the available research and an overview of key trends and changes. Unless geographic trends are specifically noted, the information reported reflects what is happening throughout the Western world in generalised terms.
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2. Examples of training This section describes some of the content covered in courses about quality improvement and the variety of training methods used.
2.1 Content covered Quality improvement has been defined in a number of ways in training courses. This section outlines some of the broad content covered in training courses. The aim is not to draw conclusions about how quality improvement should be defined, but rather to illustrate the scope of such courses in general terms. PDSA cycles and total quality management One of the most common approaches, especially in formal accredited education, defines quality improvement as a set of principles and methods originally developed in the commercial sector and known as total quality management, continuous quality improvement or PDSA cycles.15 Other descriptors include the IHI Improvement Model, CANDO, Six Sigma and LEAN.16,17 Although these approaches have some differences, they are similar in that they suggest that unintended variation in processes can lead to undesirable outcomes and that continuous small scale tests of change can be used for improvement.18 A systematic review of 41 quality improvement and patient safety curricula for medical students and residents throughout the world found that the most common content included continuous quality improvement, root cause analysis and systems thinking.19 In the US, quality improvement training is now formally mandated for medical students and this is defined largely in terms of PDSA methods. This approach is supported by the Association of American Medical Colleges,20 the Council on Graduate Medical Education,21 the Pew Health Professions Commission22 and the Institute of
Medicine.23,24 This conceptualisation of quality improvement has also been implemented widely throughout the world.25 Adaptations of these continuous improvement models have been used in the UK in both formal accredited training and in CPD.26 Core competencies Another approach is to see quality improvement as one of a set of core competencies that are essential for health professionals.27–33 For instance, in the US, two out of the six Accreditation Council for Graduate Medical Education core competencies, that all residents (registrars) must achieve, relate to quality improvement. The competencies are ‘practice based learning and improvement’ and ‘systems based practice.’34–36 The Quality and Safety Education for Nurses (QSEN) initiative also identifies six competencies essential for nursing practice: patient centred care, teamwork and collaboration, evidence based practice, quality improvement, safety and informatics.37–39 Another example of this competency-based definition is the Institute for Healthcare Improvement’s eight domains of quality improvement knowledge (see Box 1). A number of educational institutions use similar types of competencies to guide teaching about quality improvement.40–49 These competency-based approaches are not mutually exclusive from definitions which focus on PDSA improvement cycles and the two are often used in tandem.
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Box 1: IHI’s eight domains of quality improvement knowledge50 Customer/beneficiary knowledge: Identifying people or groups using healthcare and assessing their needs and preferences. Healthcare as process/system: Acknowledging the interdependence of service users, procedures, activities and technologies that come together to meet the needs of individuals and communities. Variation and measurement: Using measurement to understand variation in performance in order to improve the design of healthcare. Leading and making change in healthcare: Methods and skills for making change in complex organisations, including the strategic management of people and their work. Collaboration: Knowledge and skills needed to work effectively in groups and understand the perspectives and responsibilities of others. Developing new, locally useful knowledge: Recognising and being able to develop new knowledge, including through empirical testing. Social context and accountability: Understanding the social context of healthcare, including financing. Professional subject matter: Having relevant professional knowledge and an ability to apply and connect the other seven domains. This includes core competencies published by professional boards and accrediting organisations. Standards It was only relatively recently that quality improvement techniques began to be implemented formally in healthcare and training has reflected this growing interest.51 This has been accompanied by the standardisation and institutionalisation of quality improvement via standards and guidelines. For instance, the International Standardisation Organisation (ISO) 9000 is a worldwide standard for the implementation of quality management systems. The ISO 9000 standards require organisations to develop, implement, improve and sustain quality improvement processes. While less common than continuous quality improvement cycles or competency-based approaches, some educators have used ISO 9000 standards to help develop educational strategies for quality improvement.52 This is more common in Europe than in North America.53 Other standards have also been used as a basis for training. For instance, evidence-based guidelines have been considered an ‘ideal’ for quality improvement, with training put in place to work towards certain levels of care. Royal colleges have set standards that include quality improvement and audit.54,55 Safety A great deal has been written about methods to improve patient safety and courses have been developed explicitly with this in mind.56 This scan did not focus explicitly upon safety initiatives, but a number of quality improvement curricula or efforts to improve quality in healthcare use safety as a primary focus.57 Some training postulates that most adverse events in healthcare are the result of the cumulative effects of human errors and failures in organisational and administrative processes so steps should be taken to reduce variation.58 This is similar to the approach in formal quality improvement cycles. Other approaches Outside the US, slightly broader models of quality improvement are taught.59 However, there is no standard approach to, or definition of, quality improvement. Whereas PDSA cycles often emphasise quality improvement at the level of service delivery, broader models define quality improvement at a range of intervention levels (see Table 2).
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Table 2: Levels of quality intervention60 Level Example Level 1: Microinterventions to change individual behaviour New education programme for nurses or financing initiatives Level 2: Micro-system interventions Shared record system to improve team communication Level 3: Organisational interventions Programme to train all departments in quality improvement methods Level 4: Healthcare system interventions Information system linking all health and social care groups Level 5: Public health systems or community wide interventions Identifying population needs through multi-agency meetings
In this view, there are specific components of quality improvement initiatives that distinguish them from audit and feedback or other similar methods. First, quality improvement implies a review of practices at the organisational level and a collective effort to change, rather than focusing on the individual. Second, once the problem has been identified, quality improvement initiatives tailor a solution to the problem and focus on addressing root causes. Third, quality improvement often involves training as one of the solutions.61 A description of the underlying tenets of different quality improvement models and associated training is outside the scope of this scan. However it is important to note that most training approaches target individual practitioners or managers as the ‘change agent,’ seeking to improve knowledge, attitudes, skills and behaviours through educating individuals in change management or quality improvement methods. Some approaches target teams, but most do not take a wider systems approach to quality improvement training. Though the training itself may consider the importance of systems thinking and needs assessment, these strategies are rarely applied within training courses.
In the UK a number of courses focus on leadership and examining the social and historical context of health systems. Other approaches use complexity theory and similar paradigms.62 Thus, in the UK a broader conceptualisation of quality improvement is perhaps more common than in the US. 2.2 Training students and registrars This section provides examples of accredited education in quality improvement for health professionals in training. Classroom teaching A systematic review of 26 studies found that relatively little emphasis is given to leadership, management and quality improvement in medical curricula,63 but a number of studies have described the types of formal training available. Accredited education most commonly uses classroom or lecture style teaching alongside printed education materials.64,65 This is increasingly coupled with practical projects.66,67 Formal courses are available for medical students and to a lesser extent nurses, pharmacists and others. These tend to focus on PDSA-style approaches, be more common in US settings and be uniprofessional.68,69 Some courses cover the broad concept of quality improvement, whereas others focus on particular components such as population health or evidence-based practice.70–72 Numerous examples are available (see Box 2). Most of the published articles about accredited education are descriptive. For example, one university in the US developed a two-year curriculum about systems thinking and human factors analysis, root cause analysis, process mapping and other quality improvement techniques. Learning was applied in practical tasks and projects. The curriculum shifted residents’ thinking towards a systems-based approach, improved self-reported quality improvement skills and was associated with changes in practice following root cause analysis.73
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Box 2: Examples of formal education about quality improvement
Newcastle University in England offers a Masters, Postgraduate Diploma and Postgraduate Certificate in health sciences. Modules include health statistics, fundamentals of research, project management, health economics, healthcare quality, applied epidemiology and others. The University of Birmingham in England runs a Masters programme in healthcare management. Modules include health services management, healthcare policy, organisational development, public and user involvement, partnership working, procurement and contracting, quality and service improvement, strategic commissioning and using quality and service improvement tools.74 The University of Sheffield in England offers postgraduate courses in public health. Modules include research methods, health needs assessment and economic evaluation, statistics, systematic reviews and critical appraisal techniques, evidence-based healthcare, economic analysis and health technology assessments. Some modules can be taken as standalone courses.75 The University of Dundee in Scotland offers a six-week course at undergraduate level focused on quality improvement and safety. Medical students reflect on improvement and safety skills as part of their annual portfolios.76 Betanien College of Nursing in Norway offers undergraduate courses in quality improvement. Nursing students follow a patient’s experiences during their clinical placement and then take part in a two-day seminar about quality improvement methods. Students produce flow charts to identify areas of improvement and cause-and-effect diagrams.77 At Dartmouth Medical School in the US, quality improvement concepts have been interspersed throughout medical training. Quality improvement skills form a background for students’ learning, rather than a separate course. In the first two years, students receive an orientation lecture about process analysis and variation in healthcare. Small group problem-based learning sessions cover topics such as clinical processes, medical error and systems improvement. During clinical placements in the third year, each student picks a clinical problem to study and gathers evidence about the problem. In the fourth year, students take part in workshops and are given a real quality improvement problem to study in groups.78 Training in quality improvement occurs in many departments at the University of Michigan Medical School in the US, ranging from informal discussions to more formal lectures or conferences. Quality improvement concepts are introduced to medical students formally during the second and third years. Students are also taught through role modelling by faculty and residents during clinical rotations.79 For medical students in the final two years of their residency, McGill University in Canada offers 20 hours of classroom instruction divided into four-hour blocks over a five-month period. Topics include leading and motivating change, risk management, quality improvement and balanced scorecards.80
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Another US organisation used the metaphors ‘the mirror’ and ‘the village’ to implement quality improvement training which was divided into the core competencies of practice-based learning and improvement and systems-based practice. Practicebased learning was likened to residents’ holding up a mirror to document, assess and improve their practice. Tools such as morning reports, self-audits and learning portfolios became the mirrors. Systems-based practice was introduced through multidisciplinary patient rounds, nursing evaluations and quality assessment exercises using the metaphor ‘it takes a village to raise a child’. Elsewhere in the US, engineers and doctors partnered to provide a three-week elective course about quality improvement in healthcare. The engineering staff taught medical students about stakeholder analysis, root cause analysis, process mapping, failure mode and effects analysis, resource management, negotiation and leadership.81 Examples for nurses and pharmacists are also available. For instance, a nursing course in the US used a ‘spiral’ approach to teach seven activities of increasing complexity that built on previously acquired skills. Working in teams, nursing students learned how to develop an improvement question, search for literature, synthesise current knowledge, identify the significance of the issue using models, examine existing data and compare those data to national benchmarks, investigate a healthcare issue using quality improvement methods, and draft a proposal for a continuous quality improvement initiative.82 Also in the US, a five-module programme was designed to educate pharmacists and pharmacy students about quality improvement.83 An example of multidisciplinary learning comes from New Zealand where one university provided quality improvement modules during undergraduate education for medicine, nursing and pharmacy students. The content included patient safety, equity, access, effectiveness, cultural sensitivity, efficacy and patient centredness.84 One two-day module focused on patient safety and was a requirement for all third year students. The module examined weaknesses and root causes in healthcare systems that may lead to errors.
Students learned how to make and interpret flow charts and cause-and-effect diagrams, develop causal statements and measure the impact of change.85 The second module focused on healthcare for ethnic minorities. Small groups worked on case scenarios and presented their findings and recommendations to panels comprising heads of participating schools, cultural advisors and health professionals.86 An unusual component of this approach was combining students from medicine, nursing and pharmacy to encourage teamwork. The courses were also taught and assessed by a multiprofessional team. Evaluations found that the courses were well received but the impact on behaviour and practice has not been assessed. Descriptive studies about tools and workbooks used within formal courses are available, such as worksheets to support root cause analysis or team assessment and competency tools.87–90 Novel methods have been used to assess learning too. For example, in the US, students used skits, filmed performances, plays and documentaries to demonstrate competency in key skills.91 Simulated patients and actors have been used in courses to assess improvement skills.92,93 Portfolios have also been used to good effect.94,95 In addition to published research about classroom teaching, we reviewed 60 publicly available course curricula from the UK and abroad to gain a more in-depth understanding of the type of content included. We identified courses in Australia, Africa, Belgium, Canada, China, France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, the Americas and the UK and Ireland, among others. This analysis found that most information available about accredited courses relates to medical students at pre-registration or junior doctor level. There are fewer examples of nursing curricula about quality improvement, although the literature suggests that quality improvement principles, such as reflective practice and critical appraisal, may be more likely to be interwoven throughout a nurse’s educational career rather than taught in a specific course.96 There were few examples of formal courses about quality improvement methods for social workers or allied health professionals in the UK.
THE HEALTH FOUNDATION 15 Evidence scan: Quality improvement training for healthcare professionals
Selected multidisciplinary training and courses for managers are available at postgraduate level and as part of CPD. Most of the courses identified described continuous quality improvement cycles and data collection, measurement and audit. Some courses included structured planning approaches and others focused on leadership. There was far less focus on needs assessment and understanding the views and context of service users. Many of the courses were uniprofessional, although some offered opportunities for multiprofessional learning. Most required some practical component, such as taking part in a work-based improvement project. Distance learning Distance learning, such as online modules, dvds, videos and other non-face-to-face education methods, have been tested to supplement or substitute for classroom methods.97–100 For instance, a US study examined the impact of offering an online Masters in Public Health, including content related to quality assessment and improvement. A survey of 49 students one year after completing the course found that most thought it was useful and said that they had applied the techniques in their work.101 The limitation with follow-up surveys of this nature is that they provide little understanding of what value the online method added to the learner’s role or how they used what they learned to improve health services. In Australia, a university used distance learning for postgraduate courses in quality improvement, including graduate certificates, graduate diplomas and Masters degrees. Students used online and postal methods to receive study materials. The courses were popular among quality coordinators and healthcare managers. In Ireland, videoconferences were used to deliver a course for radiology residents in practice-based learning and evidence-based practice. The course included 16 weekly hour-long sessions for 21 second year residents at eight radiology centres. At each site a staff radiologist who had completed an intensive one-day course acted as a coordinator.
Participants were satisfied with the course content and thought that videoconferencing worked well as an interactive teaching method. In total, 71% of residents reported that they would have been unable to participate in the course without videoconferencing.102 Practical projects Experiential learning involves experiencing, observing, conceptualising and retrying activities.103,104 This differs from theory-based learning because it is case based rather than concept based and requires hands-on practice and reflection.105 There is an increasing focus on experiential learning in accredited quality improvement education.106 This often takes the form of practical improvement projects or opportunities for students to apply their learning in day-to-day clinical practice.107–109 For instance, some training programmes place students into multiprofessional improvement teams110–112 or hospital quality improvement committees,113 assign students to make improvements in community settings or rural areas,114–117 or ask students to undertake improvement projects with or without formal training.118–121 Research suggests that the most promising form of experiential learning for quality improvement combines classroom learning with practical projects.122–124 Many educational programmes for medical students, junior doctors and nurses in the US involve implementing quality improvement projects.125–127 In fact, from 2002, the Accreditation Council for Graduate Medical Education introduced a new requirement that residents must demonstrate competency in ‘practice based learning and improvement,’ which requires hands-on improvement experience.128 For example, one study of 44 US registrars found that two sessions of instruction coupled with implementation of a quality improvement project over a month-long period helped to improve registrars’ knowledge and skills. Pre and post tests were used to measure registrars’ knowledge and confidence before and after implementing a project.129 However, the researchers found that
THE HEALTH FOUNDATION 16 Evidence scan: Quality improvement training for healthcare professionals
one month was not long enough for the students to fully develop and implement their projects. A much longer period would be needed if educators wanted to assess the impacts on systems or service users. Similarly, a US study found that a six-week course, whereby a university partnered with local health services to combine classroom teaching with practical projects, improved pre-registration medical students’ knowledge and confidence, but there was a need for more detailed teaching of quality improvement principles and role modelling of quality improvement behaviours by faculty.130 Elsewhere in the US, a curriculum was developed for first and second year medical students that included classroom teaching about systems theory and quality improvement. Students conducted a project at clinical sites to develop a patient care improvement plan. The plan was presented to a panel of experts for assessment but the implementation of any recommended changes was left to the clinical providers.131 In another study, second year medical students undertaking a family medicine clerkship in the US learned about quality improvement principles during six short sessions and then undertook chart review to make improvement recommendations. The students were positive about the experience but wanted more time to discuss and implement changes.132 Practical training projects occur in primary care as well as in hospital. In the US, seven primary care practices incorporated quality improvement into training for junior doctors as part of dayto-day practical work. An evaluation found that practices that did this most successfully were likely to be larger, have previous experience with quality improvement projects, have staff with extensive experience in quality improvement and have an office manager or medical director who advocated the process.133 Another example involved 77 second year medical students working in groups of two to four who conducted continuous quality improvement projects about diabetes at 24 primary care practices. Students collected baseline data, implemented an intervention based on the results, and reassessed
quality indicators six months later. The programme was associated with improved skills and knowledge for students and enhanced clinical outcomes for people with diabetes.134 Others in the US developed an asthma project for third and fourth year medical students in primary care clerkships. Each student wrote a case report about a person with asthma who they were caring for, with a particular focus on the cost of care, A&E visits, hospitalisations and the quality of care compared with clinical guidelines. Students were taught quality improvement methods to help them to analyse the care process and outcomes so that they could make improvement recommendations. Service improvements were made in many cases and students felt that the course enhanced their skills and confidence.135 Most US quality improvement training projects with medical students and registrars have similar characteristics. They tend to take place during ambulatory care assignments or electives and combine didactic instruction with participation in quality improvement activities.136 Most are integrated into a short rotation, although some hold weekly or biweekly meetings for a year.137–143 For example, one organisation implemented structured PDSA teaching modules and practical projects for surgical residents over a year-long period. Residents’ self-reported knowledge and skills improved and residents were eager to apply their learning to make service improvements.144 Most published information about education of this type focuses on doctors, but there have been similar successes with nurses. For instance, a year-long US course encouraged nursing students in their senior year to work in small groups with community nurse mentors to assess the healthcare needs of a population, identify potential changes and develop an intervention. Students then implemented and evaluated their interventions and presented their outcomes and suggestions for improvement. The programme improved nurses’ confidence and skills in quality improvement and had tangible impacts on the communities with which they worked. Good relationships with community providers were a key success factor.145
THE HEALTH FOUNDATION 17 Evidence scan: Quality improvement training for healthcare professionals
In Norway, second year nursing students followed a patient during a day’s work, recording processes of care from the patient’s perspective.146 They collected data about waiting times, patient characteristics, people in contact with the patient and care offered. They then identified aspects of practice that could be improved. Students attended a two-day course about quality improvement methods and produced flow charts, cause-and-effect diagrams and quality goals based on their observations. Nursing students said that they had improved skills compared to before the course and felt that this type of training should be included throughout the nursing curricula.147 Another nursing curriculum integrated didactic instruction and quality improvement activities into an existing four-year programme.148 In the US a dedicated education unit was set up at one hospital to teach nurses about quality and safety competencies through a 10-week experiential learning programme. This practical approach improved competencies.149 An example of multidisciplinary learning also comes from the US. The IHI partnered with a federal agency to develop a training programme to support quality improvement in community services. The training was available to preregistration and specialist medical students, nurses and public health students. Teams of faculty and students met every fortnight. Students were taught continuous quality improvement through classroom learning, coaching by faculty members in team meetings and hands-on project experience. This learning style was associated with self-reported improvements in competency and enhanced community services.150 A number of resources such as workbooks and toolkits have been developed to help get the most out of practical projects.151 One US medical school combined the Institute of Medicine’s aims for improvement and the Accreditation Council for Graduate Medical Education’s core competencies into a tool called the ‘healthcare matrix’.152 The core competencies helped junior doctors identify why care was not safe, timely, effective, efficient, equitable or patient centred. Residents used the matrix to analyse the care of an individual patient
and the care of groups of patients, such as those with heart disease. The healthcare matrix was formatted to help identify what was learned and what needed to be improved. Residents were then taught quality improvement approaches to help address the issues raised.153 A key learning point from these studies is that ensuring that participants have practical experience in improving quality is becoming common in formal education courses154,155 – but practice-based learning alone is not enough. Training programmes appear more successful when classroom teaching and practical implementation are combined and when students have a long enough period of time to learn both theory and application. For example, first and second year medical students at one US university took part in a course that combined didactic learning and small group work to improve an aspect of care at a community practice.156 The educators identified four factors that contribute to successful quality improvement training: – teaching about improvement concepts and tools – the availability of baseline data – cohesive team characteristics and a sense of ownership in the process – access to the information and resources needed to carry out an improvement, such as literature, databases and funds. Other studies support these factors as being important for successful practical learning.157 Ongoing training A number of studies have examined CPD or training in quality improvement of already qualified health professionals. These are courses that managers or health professionals might take after their main accredited education is completed. Some courses span the bounds of both accredited education and CPD. For instance, postgraduate university modules may be taken alone as CPD, but may also be part of a Masters degree or diploma programme. This section concentrates on shorter, informal courses and training offered by organisations other than higher educational institutions.
THE HEALTH FOUNDATION 18 Evidence scan: Quality improvement training for healthcare professionals
Continuing professional development for quality improvement can be divided into three main areas: structured group training sessions, more informal group training and practical initiatives, and individualised training. Many studies combine some of these approaches. Box 3 provides some examples.
Box 3: Examples of continuing professional development In the UK the Open University School of Health and Social Welfare offers a number of courses that focus on components of quality improvement. Key concepts from the courses include defining SMART goals, research methods and how to implement standards.163 The NHS Institute for Innovation and Improvement offers the Organising for Quality and Value: Delivering Improvement programme, spanning five days over a three-to-four month-period. Topics include leading improvement, project management, sustainability, engaging, involving and understanding others’ perspectives, process mapping, the role of creativity in improvement, measurement for improvement and demand and capacity management. Participants are required to undertake a service improvement project.164 Brighton Healthcare in England developed a one-day course around the quality improvement cycle. Sessions include why quality matters, organising for quality, identifying and prioritising quality problems, defining and analysing quality problems, quality measurement and data presentation and solutions to quality problems. Practical tools are introduced in group exercises. In England the Institute of Healthcare Management offers modules through accredited NHS trusts and other centres. The training includes online resources, classroom teaching and practical assignments. Each programme typically lasts six weeks.165 In the US, the Institute for Healthcare Improvement offers a range of online modules and ‘webinars’ followed by assignments. Topics include the improvement model, reducing waiting times for appointments and improving office efficiency in primary care, improving systems for high hazard medications, applying reliability science to health, SBAR and other tools for improving communication between caregivers, building skills in data collection, using run and control charts to understand variation and engaging hospital boards in quality and safety.166 The US Veterans Health Administration offers a one-day session covering quality improvement and development of a practical project. The Robert Wood Johnson Foundation in the US offers courses designed to increase learners’ competence in quality, safety and systems improvement. Four modules are taught which include the structure of healthcare and how it affects care delivered, who pays for care and why it matters, improving the care of individuals, populations and practices and improving the practice and health system. Participants put together a quality improvement plan and selected improvement initiatives are implemented in groups. The Columbus and Franklin County Health Departments in the US ran a two-year CPD course for improving performance at the local level. The programme consisted of four modules for its entire workforce. The modules included public health in transition, visionary leadership and employee empowerment, systems thinking and partnerships.
THE HEALTH FOUNDATION 19 Evidence scan: Quality improvement training for healthcare professionals
Seminars and workshops Health professionals suggest that CPD is essential for ensuring that they maintain and learn new skills and competencies.158 ‘Clinical professionals themselves report a lack of expertise and skills as crucial and emphasise continuing medical education (CME), professional development, self instructional learning, learning from problems, and learning together with colleagues as methods for improving performance.’159 A common method for training qualified professionals in quality improvement involves classroom or workshop style teaching, either at participants’ places of work or at other venues. Numerous examples have been studied.160,161 A number of organisations run such sessions. For example, the Practice-based Commissioning Academy in England was targeted towards general practitioners (GPs) and primary care trust (PCT) managers interested in increasing their commissioning and analysis skills. The Academy was run jointly by the NHS Alliance and private industry and offered 11 half-day modules that professionals could combine or participate in as standalone training. Modules covered needs assessment, analysing data, leading and managing change, business planning, improving patient experience, financial modelling and ethics.162 Another example of offsite classroom type approaches is a course set up to train hospital nurses about quality improvement methods for safety in Canada. A trial found that nurses who underwent seminar-based training had improved self-reported skills.167 As well as inviting health professionals to offsite training, there are examples of visiting practices or hospitals to provide onsite training and mentorship or developing in-house training. There are sometimes difficulties providing ‘in service’ training due to attendance problems, perceived relevance and deciding on an appropriate level of education, however in-house training is usually popular.168 For instance, in England a partnership between a hospital trust and a university ran a series of seven
three-hour sessions focused on developing critical appraisal skills. Each session included a seminar discussion and group work to allow staff an opportunity ‘to have a go’ at critical appraisal using simple clinical scenarios. Participants included nurses, doctors, occupational therapists, dieticians, physiotherapists, technicians and managers. The timing and length of sessions were carefully considered to allow the maximum number of people to attend. Short, regularly repeated sessions were used and the location of modules was varied across the trust to give staff more opportunity to attend. The team found that these in-house sessions were well received and attended, but suggested that it would be more appropriate to design seminars that helped teams make a real change in their clinical environment. This hospital also found some barriers to participation. ‘Whilst staff express an interest in attending courses, if they are provided free of charge and not certificated, enthusiasm can wane and people fail to attend at the last minute, particularly when there are competing pressures… There is no quick fix for this and those providing education have to decide whether to use a carrot or stick approach; the carrot being, say education points, or a stick where some imposition is placed for those booking a place but not attending.’169 Seminars to improve quality improvement skills and knowledge have been implemented across a wide range of disciplines including medicine, mental health, nursing, social work and allied professions.170–173 Training has been set up for managers and policy developers too. In total, 107 senior managers from 20 Serbian general hospitals took part in an improvement course. Organisational skills, motivating and guiding others, supervising the work of others, group discussion and situation analysis skills all improved. The least improved skills were applying creative techniques, working well with peers, professional self-development, written communication and operational planning.174
THE HEALTH FOUNDATION 20 Evidence scan: Quality improvement training for healthcare professionals
In the US, all health department and public health staff in one county were invited to attend four half-day small group workshops over a twoyear period. The sessions covered improvement methods, leadership and systems thinking. In total, 600 people took part. Participants said that the training helped to reduce hierarchical barriers, support bottom-up decision making and involve more non-management staff in planning and policy advisory committee roles.175 Some suggest that it is important to train various levels and types of staff simultaneously in quality improvement approaches. One group of five US hospitals and a multispecialty health practice trained leaders and frontline staff. One twoday course known as ‘leadership for healthcare improvement’ was offered to senior managers and a four-month programme entitled ‘practical methods for healthcare improvement’ was offered to frontline staff and middle managers. More than 600 staff completed the programme over a two-year period. There were improvements in knowledge and confidence about quality improvement principles. Participants also initiated quality improvement projects, many of which were sustained up to one year after the training.176 Sometimes workshops or courses are run alongside other training approaches, especially when the aim is to improve a specific care process or pathway. For instance, in Australia, one hospital tested a ward-based training programme for quality improvement in nursing documentation. The programme consisted of two one-hour writing workshops followed by one-to-one coaching of nurses.177 There are many hundreds of articles describing seminars or courses that aim to provide a quick overview of quality improvement methods as part of CPD or as a component of a specific quality improvement initiative. What most of these articles have in common is that they outline the potential merits of courses and participant satisfaction or knowledge, but there is little focus on whether the training resulted in a real change in behaviours among professionals. There are also studies of particular methodologies, such as teaching crew resource management approaches to upskill professionals in team work, communication and
critical thinking skills,178–180 but most of these studies are not comparative so it is not possible to say whether one type of content or training approach is more effective than another. Simulation Simulation techniques such as role play, using case studies, mock equipment, standardised patients and ‘high fidelity’ simulations which involve a full practice of the situation or environment have been used to support healthcare improvements, particularly regarding safety and teamwork.181,182 In the US, simulation has been used extensively within formal nursing curricula and ongoing professional development about quality improvement.183 Role play has been used to good effect in a number of training initiatives. For instance, a hospital in England used actors to help nurses develop critical thinking and safety awareness skills. A study day was developed to help change the culture in the hospital, to allow nurses to challenge one another with a view to improving safety. The training was experiential and aimed to allow participants to explore their thoughts and feelings about potential barriers as well as providing tools and a safe environment in which to practise new skills. Actors performed scenarios to help nurses identify and learn from issues, and nurses then role played alongside actors. Nurses learned new skills and felt more confident in the need for, and methods to achieve, basic hygiene and safety components of quality improvement.184 Other studies have also found that drama can be useful in developing new skills.185,186 One-to-one training One-to-one training can take the form of coaching, academic detailing and informal teaching sessions. Due to costs, this approach is not common for training about quality improvement, but has been found to be motivating in some instances. In the US, outreach workers visited GPs and primary care staff to teach them about quality improvement. It was difficult to schedule time with primary care staff but outreach visits were associated with increased adoption of quality improvement tools.187
THE HEALTH FOUNDATION 21 Evidence scan: Quality improvement training for healthcare professionals
One-to-one training may also be implemented as a component of a broader learning strategy. For example, in England a programme was developed to improve patient care and develop leadership skills in 19 GPs in an area of social deprivation and underperformance on national quality indicators. New and experienced GPs took part in biweekly action learning sets, individual coaching, and placements with national and local health organisations. One-to-one learning was integral for building confidence and motivation. Each GP completed a project to improve the quality of patient care. The programme was associated with increases in leadership competencies and confidence and changes in services, care processes and culture.188 Distance learning Online and distance learning and web conferences are becoming more popular for CPD.189–194 For instance, PCTs in England partnered with a university to implement a variety of accredited work-based learning programmes for nurses. Distance learning, mentorship, reflection and a portfolio were used. Nurses thought that the training helped them to improve the quality of care.195 In total, 195 public health workers and managers from 38 local health departments in one US state took part in a distance learning programme about quality improvement. Sixty-five of the participants completed eight quality improvement projects, supported by experts, over a 10-month period. Participants were highly satisfied with the training sessions and projects and had increased understanding of the relevance of quality improvement and enhanced knowledge and confidence in applying these techniques. Six out of the eight practical projects were associated with moderate to large improvements in quality or efficiency.196 Elsewhere in the US, an online continuing education programme for oncology nurses used a mentoring format. Twenty-five expert nurses from specialist cancer centres partnered with 50 oncology nurses over a seven-month period. Learning methods included webcasts and printed resources. Several nurses implemented practice changes as a result of the programme.197
Researchers in China found that videos and onlinOne-to-one training may also be implemented as a component of a broader learning strategy. For example, in England a programme was developed to improve patient care and develop leadership skills in 19 GPs in an area of social deprivation and underperformance on national quality indicators. New and experienced GPs took part in biweekly action learning sets, individual coaching, and placements with national and local health organisations. One-to-one learning was integral for building confidence and motivation. Each GP completed a project to improve the quality of patient care. The programme was associated with increases in leadership competencies and confidence and changes in services, care processes and culture.188 Distance learning Online and distance learning and web conferences are becoming more popular for CPD.189–194 For instance, PCTs in England partnered with a university to implement a variety of accredited work-based learning programmes for nurses. Distance learning, mentorship, reflection and a portfolio were used. Nurses thought that the training helped them to improve the quality of care.195 In total, 195 public health workers and managers from 38 local health departments in one US state took part in a distance learning programme about quality improvement. Sixty-five of the participants completed eight quality improvement projects, supported by experts, over a 10-month period. Participants were highly satisfied with the training sessions and projects and had increased understanding of the relevance of quality improvement and enhanced knowledge and confidence in applying these techniques. Six out of the eight practical projects were associated with moderate to large improvements in quality or efficiency.196 Elsewhere in the US, an online continuing education programme for oncology nurses used a mentoring format. Twenty-five expert nurses from specialist cancer centres partnered with 50 oncology nurses over a seven-month period. Learning methods included webcasts and printed resources. Several nurses implemented practice changes as a result of the programme.197
Researchers in China found that videos and online learning were popular among nurses, especially those in rural areas. 96% percent of nurses surveyed said that they had changed their clinical practice as a result of this type of CPD.198 But most studies suggest that online learning or distance training should be coupled with interaction of some sort, such as coaching, blended learning or practical projects. In 2005, the NHS Clinical Governance Support Team’s Primary Care Team launched a set of e-modules targeting practice managers to support clinical governance. The modules were based on, and mapped to, the General Medical Services contract and public policy initiatives. The programme targeted people who had little formal training in practice management, but it was also applicable to pharmacy and dental practice managers and PCT managers. There were nine e-modules with core competencies and interactive self-assessment, supported by a series of action learning sets run by a network of local facilitators. Participants also undertook a service improvement project and vocational training schemes. Quality improvement was one component of the programme. This is a good example of blended learning, whereby online modules were coupled with projects and facilitated support. Practical projects As with accredited education, putting quality improvement concepts into practice is becoming increasingly common in CPD. An Australian study of training to build evidence-based practice into mental health services found that without practice and follow-up shortly after classroom sessions, training lost its usefulness.199 One hospital adapted an industrial quality improvement process for use within the NHS by providing training seminars alongside practical implementation of the methodology. The training was largely targeted at managerial staff. Staff said that putting the methods into practice on a dayto-day basis had improved their learning and most thought there had been some improvements in systems.200
THE HEALTH FOUNDATION 22 Evidence scan: Quality improvement training for healthcare professionals
Other examples of practical CPD are abundant. In Sweden, 240 nurses participated in a four-day training course about quality improvement methods. One group received training alone and another took part in a project to develop national guidelines as part of their training. Participating in the practical project enhanced nurses’ ability to implement quality improvement methods but was no more likely to ensure that nurses maintained quality improvement activities over a longer period.201 Other common examples of practical training include collaboratives and courses set up as part of particular work-based improvement initiatives. Collaboratives Collaboratives combine structured education, practical projects and sharing information between providers. For example, in the IHI Breakthrough collaboratives, organisations pay a fee to send teams to a series of seminars designed to aid in making major, rapid changes in the quality of care. Teams from each organisation include a group leader (usually a doctor) and a day-to-day manager (usually a nurse). Teams are taught how to study, test, and implement systematic improvements in care processes. In between collaborative meetings, the teams recruit others from their sites to participate in quality improvement interventions.202 Collaboratives have been applied to improve the quality of care and teach quality improvement methods across a wide range of care areas and disciplines, including cardiovascular disease, neonatal care, asthma, primary care, end-of-life care, rehabilitation, chronic obstructive pulmonary disease (COPD), diabetes and many more.203,204 Many studies have examined the potential benefits of this model.205–215 For instance, in the US, groups worked together for 12 months, sharing information on their successes and challenges by telephone and email between meetings. An evaluation found that, compared to a control group, the collaborative learning approach resulted in enhanced knowledge and implementation of quality improvement methods and better clinical outcomes and quality of care for service users.216,217
The Improving Prevention Through Organisation, Vision and Empowerment (IMPROVE) and Improving Diabetes Care Through Empowerment, Active Collaboration and Leadership (IDEAL) collaboratives taught quality improvement concepts to US primary care teams using didactic instruction and interactive discussions during seven half-day workshops run over a two-year period.218 In between sessions, participants undertook quality improvement initiatives supported by telephone calls and site visits from faculty.219 Eighteen hospitals in the US collected data about breast cancer care and compared outcomes between institutions. Aggregate and blinded data were shared with project directors and institutions at collaborative meetings and trends were analysed over time. Site project directors disseminated the data to their institutions and developed action plans for professional and patient education. This approach helped to improve care processes.220 A systematic review of seven regional quality improvement collaborations in surgical practice found that collaboratives were often set up in response to external demands for performance data. Collaboratives were associated with changes in care processes and improvements in clinical outcomes such as reduced mortality rates and fewer surgical site infections. Success factors included establishing trust among health professionals and institutions, the availability of accurate and complete data, clinical leadership, institutional commitment and infrastructure support.221 Adaptations of this type of collaborative approach have been tested. Most adapted approaches support learners with audit and feedback at an initial seminar followed by teleconferences or site visits to facilitate collaboration during quality improvement projects.222–226 In the US, online learning collaboratives have been tested. One initiative included an online educational toolkit, quality improvement coaching calls led by faculty, and individual feedback reports to motivate doctors to change. The initiative was associated with increased quality of care processes.227
THE HEALTH FOUNDATION 23 Evidence scan: Quality improvement training for healthcare professionals
Another related concept is managed clinical networks, which involve collaboration across organisations. An evaluation of a diabetes managed clinical network in Scotland over a seven-year period found that the initiative involved progressively implementing multiple quality improvement strategies directed at individuals and clinical teams, such as guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working and task redesign. There were some changes in simple processes, but more time was needed for improvement in more complex processes and pathways. It was important to gain widespread clinical engagement by appealing to shared professional values and using clinical leaders and champions.228 Ad hoc training during projects By far the most commonly researched example of quality improvement training involves sessions run as part of a quality improvement initiative.229–232 For example, a GP practice setting up a new telephone helpline might run a training session for staff covering principles of quality improvement or nurses may be trained in research principles or ethics as part of a programme to achieve clinical standards.233 There are many hundreds of articles describing initiatives of this nature spanning the globe, including Asia, Arab nations, Africa, Australasia and Oceania, the Americas and Europe.234–237 A smaller number of articles describe how quality improvement concepts have been taught at the beginning of improvement projects to support staff with implementation, particularly regarding audit and feedback.238–242 In a number of cases the trainers were faculty from medical schools. The scan did not focus on these studies in any detail because the training provided was not usually about methods for general quality improvement, but rather was specific to the particular project being implemented. This type of training was a component of the quality improvement intervention itself and did not necessarily aim to teach participants skills that they may be able to apply outside of that particular initiative. There were usually very few details provided about the
scope of the training or the learning outcomes but such ‘on the job’ training could comprise short hour or half-day sessions or span a few days. While this type of training may help managers and practitioners learn transferable skills, its purpose was not usually to teach about quality improvement methods. An issue with the evaluation of all initiatives of this type is that it is difficult to link work-based learning to specific outcomes. Researchers cannot usually make causal attributions suggesting that any changes in quality of care are a direct result of learning initiatives.243 Train the trainer approaches Train the trainer approaches have been used in some areas, especially to upskill professionals about improvements in patient safety. Train the trainer approaches involve teaching managers and professionals who then ‘roll out’ the material by offering training sessions to those in their own organisations or fields.244–246 For example, the Patient Safety Education Project used practice improvement toolkits, online learning and safety trainers to support improvement in patient safety in the US and Australia. The teaching style was based on a ‘stages of change’ model, matching people’s readiness and willingness to change with attitudinal and behavioural interventions.247 These methods have also been used to upskill medical school faculty in how to teach quality improvement concepts.248 Another example is public health training in Nicaragua. The Centers for Disease Control and Prevention partnered with local government and non-governmental agencies to develop a ‘train the trainers’ programme for public health managers and government employees. This consisted of two workshops, a practical project and a concluding presentation. The first workshop was five days long and covered team building, behavioural styles and total quality management. Following the workshop, trainees disseminate their learning to peers by leading a local team through a learning project over a two-to-three-month period. This is followed by a seminar on presentation skills and a final presentation. Trainers have been taught to roll out the programme widely.249
THE HEALTH FOUNDATION 24 Evidence scan: Quality improvement training for healthcare professionals
Sometimes train the trainer approaches are implemented to supplement to quality improvement training. For example, one trust in England partnered with the King’s Fund to develop in-house training to support quality improvement and audit. The training involved a one-day session plus a follow-up session some months later.250 The project developed a facilitator’s guide (providing instructions about running each session, group work materials and overheads) to enable staff to train as facilitators after attending the course and then run the sessions themselves. The developers suggested that it was beneficial to have staff from different professional backgrounds involved in the training to bring their unique expertise and experiences to course participants. Other examples involve developing ‘learning helpers’ or quality improvement facilitators onsite.251,252 The theory is that having informal learning support readily accessible will improve practice of, and therefore skills in, quality improvement. In Sweden, learning helpers in hospital have helped increase reflective practice, facilitate experiential learning and support quality improvement projects.253 Feedback for improvement Feedback has been used as a training technique in a variety of forms, including audit, videotaping and structured review sessions with teams. For instance, 102 professionals in mental health teams took part in training to support team development and quality improvement. The teams spanned 12 US inpatient units and included the disciplines of psychiatry, psychology, nursing, social work and occupational therapy. The training programme included structured feedback, seminars, consultation and videotaping of sessions. The aim was to review treatment planning sessions as a tool for examining team functioning and care processes. Feedback and videotaping worked well to help raise awareness of quality improvement and team function among multidisciplinary teams. Here the focus was not so much on learning quality improvement techniques, but rather on using these techniques to make a difference to day-to-day working practices.
In England, the Royal College of General Practitioners developed a programme in partnership with other professional bodies such as the Institute of Healthcare Management and the Royal College of Nursing. The programme aimed to support quality improvement through practice team development, education and service planning. Teams set their own development targets, self-assessed, and took part in multidisciplinary peer review.254 Formal audit and feedback has been used as a training method for quality improvement. For example, in Australia, a learning project was set up to improve discharge management of people with acute coronary syndromes. Forty-five hospitals across the country participated in a quality improvement cycle of audit, feedback, intervention and reaudit. In total, 3,034 staff took part in educational meetings and received reminders and feedback about audit results. The training was associated with improved adherence to evidencebased guidelines about prescriptions, advice and referrals.255 The theory behind using audit and feedback is that clinicians who learn that their performance or behaviour is below par compared to colleagues will be prompted to improve and will learn quality improvement techniques more effectively. ‘Audit and feedback can be effective in improving professional practice. The effects are generally small to moderate (median 5% risk difference), greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.’256 A challenge with this approach is that often audit and feedback is undertaken without providing any formal upskilling in quality improvement techniques. Rating clinicians on a scale or providing graphs showing how they compare with others may raise awareness of the potential for quality improvement but does not train clinicians in how to address any gaps.
THE HEALTH FOUNDATION 25 Evidence scan: Quality improvement training for healthcare professionals
Another approach to using feedback involves peer review ‘quality circles’. These have been researched most commonly in Europe.257 In the Netherlands, continuous quality improvement is being prioritised by many professional organisations and educational institutions. In line with this priority, teams of midwives tried a quality circle approach which focused on continuous, systematic and critical reflection on their own and others’ performance. This method was found to improve knowledge but it did not necessarily help midwives learn new skills.258 In Austria, 445 GPs took part in quality circles to improve prescribing. These peer review groups helped to improve prescribing of generic medications, thus reducing costs. Quality circles also helped GPs exchange ideas about the problems they encountered.259 Similarly, in Switzerland quality circles were used to help pharmacists review and provide feedback about GPs’ prescribing. Over a nine-year period, there was a 42% decrease in drug costs in the group taking part in quality circles compared to a control group. This equated to cost savings of US$225,000 per GP per year.260 2.3 Recertification Bridging the gap between CPD and accredited education is recertification. Such revalidation includes methods to ensure that clinicians remain competent and fit to practice. This can be used to promote continuing improvement in the quality of care.261 The World Health Organization (WHO) has outlined the mandatory and voluntary revalidation strategies of many countries.262 Only a small number such as the US, New Zealand and Australia made learning about quality improvement methods an explicit focus for reaccreditation. For example, the American Board of Internal Medicine now requires completion of a ‘practical improvement module’ for recertification. This involves taking part in a quality improvement programme, collecting data and assessing
outcomes.263 Every internal medicine specialist must be recertified every 10 years. Other specialists undergo a similar review cycle every six to 10 years. One study found that the self-assessment and quality improvement training required for recertification in the US can lead to meaningful behavioural change in doctors. A ‘practice improvement module’ used as part of the recertification programme for general internists and endocrinologists consisted of a self-directed medical record audit, practice system survey and patient survey. Coaching and self-assessment helped doctors learn about, and implement, quality improvement techniques during recertification.264 In Belgium, GPs and specialists are legally required to comply with certain standards. For GPs, this includes continued development of skills to enhance performance and practical demonstration of quality improvement.265 In New Zealand, doctors are expected to spend at least 50 hours per annum on recertification activities including external audit, peer reviewing cases, analysis of outcomes and reflective practice. Learning about and participating in quality improvement initiatives is required to obtain an annual practicing certificate.266 In the UK, participation in CPD is a condition of employment in the NHS and for continued membership of the royal colleges. The Department of Health has outlined how doctors will be required to renew a licence to practise every five years, but as yet quality improvement training is not a requirement.267 In England, practice level or organisational accreditation has been tested, which includes broadly defined quality improvement domains. The Primary Medical Care Provider Accreditation (PMCPA) scheme included 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment and medicines management; provider teams; learning organisation; and patient involvement. An evaluation with 36 practices found that most could pass the core criteria, regardless of practice size or location.268
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2.4 Summary Many descriptive and narrative articles outline training in quality improvement for qualified health professionals and health professionals in training. The training approaches most commonly researched include: – university courses about formal quality improvement approaches – teaching quality improvement as one component of other modules or interspersed throughout a curriculum – using practical projects to develop skills – online modules, distance learning and printed resources – professional development workshops – simulations and role play – collaboratives and on-the-job training. The next section examines the impacts of these types of training and whether one approach is more effective than others.
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3. Most effective approaches This section explores evidence about the impacts of training in quality improvement and the relative effectiveness of different training approaches.
3.1 Impacts of training The previous section described some of the impacts of individual training approaches. This section draws this information together to look at the impacts of training more generally on outcomes for learners, patients and the wider healthcare system. It is generally accepted that education and training can have an impact on the attitudes, knowledge, skills and potentially the behaviours of those who take part.269 Thus, it is often assumed that training professionals in quality improvement is beneficial. However, published evidence about the effectiveness of quality improvement training is not clear cut.270,271 In fact, some studies suggest that continuing medical education may have very little impact on compliance with guidelines or improved care.272 For example, a randomised trial with 47 rural and small community hospitals in the US compared quality improvement education to a control group. The educational programme consisted of two two-day didactic sessions about continuous quality improvement techniques, followed by the design, implementation and reporting of a local quality improvement project, with monthly coaching conference calls and annual follow-up meetings. There were no significant differences in processes or clinical outcomes between hospitals that took part and those that did not.273 Other trials comparing professionals who took part in quality improvement training and those who did not have also found no differences in skills and outcomes.274 A synthesis of 36 systematic reviews about training methods found that most techniques have limited effects. Even where ongoing training does have an effect on attitudes or behaviour, the magnitude
tends to be small. This synthesis was about training for healthcare professionals generally, and was not specific to training about quality improvement, but it emphasises that there are not necessarily ‘quick wins’ from CPD.275 Several other studies and reviews about the effectiveness of quality improvement training suggest that the impacts may be mixed and variable.276–279 For instance, a systematic review of 26 studies found that education had variable effects on students’ attitudes to clinical practice guidelines, quality improvement techniques and multidisciplinary teamwork.280 Another systematic review of postgraduate training programmes identified 39 studies with a comparative design. Of the 39 studies, 31 described team-based projects and 37 combined didactic instruction with experiential learning. The review found that most quality improvement curricula were associated with improved knowledge and confidence in the use of quality improvement techniques, but evaluation tools were not always of high quality. There was much less certainty about the impact of quality improvement training on clinical or patient outcomes. Randomised trials were more likely to have mixed or null effects.281 The implication is that we cannot automatically assume that training has positive effects on quality. But not all research is negative, and more and more studies are emerging that suggest that training in quality improvement can be beneficial. A systematic review of quality improvement curricula for medical students and residents found that most formal education of this nature was associated with improved knowledge. One-third of curricula were associated with local changes in care delivery and 17% improved specific processes of care.
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Factors that affected the success of curricula included having sufficient numbers of teachers familiar with quality improvement concepts, addressing competing educational demands and ensuring buy-in and enthusiasm from learners.282 Other individual studies from around the world reinforce these conclusions, suggesting that many types of training improve professionals’ knowledge and skills and may have some impact on care processes.283–290 A small number of studies suggest that training is associated with improvements in clinical outcomes and direct benefits for service users or care systems, though examination of these types of impacts is rare.291,292 An example comes from an evaluation of a programme sponsored by the US Agency for Healthcare Research and Quality to train ‘Patient Safety Improvement Corps’. Health professionals and managers were taught methods for improving quality and safety, with the aim of helping to build a national infrastructure supporting effective patient safety practices. One year after training, about half of state agency representatives reported that they had initiated or modified legislation to strengthen safe practices and modified adverse event oversight procedures. About three quarters of hospital staff said that training contributed to modifying adverse event oversight procedures and enhancing patient safety culture.293 The impact of training professionals on patient outcomes is uncertain. One randomised trial in the US included 20 GP practices in 14 states. All practices received copies of practice guidelines and quarterly performance reports. In addition, one group participated in meetings and received quarterly site visits to help them adopt quality improvement approaches. The practices receiving onsite training did not have significant improvements in patient outcomes compared to the group receiving guidelines and performance reports alone.294 Table 3 illustrates the mix of findings about the effectiveness of training in quality improvement.
Table 3: Effectiveness of training295–297 Technique Effects Printed educational materials, posted information and media298 Limited effects on knowledge CME courses, lectures and conferences299 Limited effects on knowledge Reminders, prompts and computers300–302 Mixed effects on behaviours Audit and feedback on performance303,304 Mixed effects on knowledge and behaviours Opinion leaders305,306 Mixed effects on knowledge Guidelines Mixed effects on behaviours Education outreach visits/ academic detailing307 Often effective for prescribing Interactive seminars and small groups308 More effective for behaviours Including practical components309–312 More effective for changing behaviours and may influence care processes Courses plus other initiatives313–317 Usually effective for changing behaviours and some effects on patient outcomes
There may be a number of reasons for the varying findings about the impact of quality improvement training. Firstly, outcomes do not tend to be measured systematically and widely varying measures may be used.318 The definition of quality improvement and what is encompassed in this term also varies widely. Another issue with reviews of the effectiveness of quality improvement curricula is that they tend to combine many disparate types of training. This means that it is not possible to assess whether one type of training is more effective than others.
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Alternatively, the focus is on a narrowly defined type of training, such as classroom-based methods, but the reviewers generalise to all types of quality improvement training. Most reviews tend to describe educational interventions that improve clinicians’ knowledge of, or adherence to, guidelines rather than providing them with the skills needed to improve the quality of care.319–321 This means that it may be unrealistic to expect changes in clinical outcomes or system issues. Furthermore, in the US training in quality improvement is a component of most professional training curricula. As a result, most of the studies available about the effectiveness of quality improvement training are drawn from the US.322,323 The findings are not always generalisable to other countries and this may influence some of the variations observed. The extent to which training is more or less effective than other ways to improve quality is uncertain. A systematic review found that the most effective strategies for improving quality and safety in healthcare included audit and feedback, clinical decision support systems, specialty outreach programmes, disease management programmes, continuing professional education with small group case discussions and clinician reminders. Pay for performance schemes and organisational process redesign were modestly effective. This suggests that training may be one way to improve quality, but it is not possible to say whether it is more effective than other mechanisms. Furthermore, the training covered in this review was not solely about quality improvement.324 Others suggest that training professionals may be just as effective as financial incentives for improving the quality of healthcare.325 But there is a very limited evidence base comparing quality improvement training with financial or other initiatives to improve healthcare.
3.2 Effective training methods Most research published about quality improvement training in healthcare comes from North America. It is often descriptive or observational, with few rigorous evaluations of impact.326 A review of 27 articles about educational strategies for quality improvement found that 75% were descriptive and that only 7% included an experimental design.327 The quality of available research impacts on the conclusions that can be drawn about the benefits of different training methods. However, some broad statements can be made about content, training methods and other key success factors. Content Research suggests that to be most effective, training should examine the needs of learners, target content appropriately and illustrate how the content applies to the participants’ work environment (see Box 4). However, the most beneficial content regarding quality improvement has not been researched in any depth. Studies have not compared whether it is more effective to teach professionals about PDSA cycles or improvement science philosophies, for example. In the UK there is an increasing focus on combining overviews of the philosophies behind quality improvement with training about specific tools. However, there is no research about whether this is more useful than the more structured focus on PDSA cycles often taken in the US.
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Box 4: Features of effective training328 Needs assessment Include data showing a gap between current and best practice Include data showing how practices or teams have improved Identify evidence-based sources for programme content Content Describe key learning from implementing known best practice Discuss data before and after successful implementation Include as an objective ‘by the end of course, participants will be able to summarise evidence on…’ Allow time for questions about the pros and cons of evidence Application Describe how evidence relates to participants’ work environment Ask participants how they will apply the evidence to their work environment Training approaches Just as the most successful content remains uncertain, so too do the most effective training methods. A consensus from 53 countries in Europe suggested that: ‘Education strategies vary in format and effectiveness. Passive strategies – didactic educational meetings, dissemination of printed or audiovisual educational material – often have no or modest effects. Active strategies – interactive workshops, outreach visits, charismatic opinion leaders – are more often effective. The source of information, format of presentation, frequency and timing of delivery and content affect impact. There is no magic bullet.’329 It is not possible to draw conclusions about which training methods are most useful because there is a lack of rigorous comparative research and little focus on sustainable outcomes for service users and resource use. However, it is possible to suggest components of successful training which may be worth further exploration. Reviews and studies have concluded that there is not one ‘magic blueprint’ for teaching quality improvement, either in formal educational environments or as part of CPD.330 But researchers tend to agree that in order to be effective, quality improvement training should be part of the curricula for students, as well as being available as part of ongoing professional development training.331 A review of 26 systematic reviews and metaanalyses of general continuing medical education (not solely quality improvement), found that interactive techniques such as audit and feedback, academic detailing and outreach and reminders were the most effective at simultaneously improving care and patient outcomes. Clinical practice guidelines and opinion leaders were less effective. Didactic presentations, such as lecture style teaching and distributing printed information, had little or no effect on professionals’ behaviour.332 A significant body of individual studies reinforce these conclusions. But the question is whether these observations also apply to training in quality improvement methods.
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A more specific review of 27 studies about quality improvement training concluded that there was insufficient evidence to suggest which training methods are most effective, but that courses that include a practical focus can be beneficial. ‘Factors that may contribute to successful improvement experiences for students include using health data to set project priorities, having a clear definition of a target community, selecting projects that can be completed in short periods of time that coincide with the structure of an academic year, and emphasising interdisciplinary teamwork. However, there are no data to demonstrate the effectiveness of specific teaching methods or learning outcomes.’333 A number of other studies have concluded that training with a strong practical component, such as work-based learning, improvement projects or collaboratives, is often associated with changes in care processes and sometimes patient outcomes.334–336 In fact, most studies which have found benefits for patients or healthcare resource use relate to training as part of broader quality collaboratives or work-based improvement initiatives.337–339 Including practical examples and projects as part of the training process is important not only due to the benefits for learners, but also because the projects undertaken can have a real benefit for health systems, organisations and service users.340 ‘Adult learners are best educated by involving them in real work that interests them. In those circumstances, a teaching organisation can leverage the power and enthusiasm of learners to create change. Learners are a valuable untapped resource for quality, safety and systems improvement in teaching hospitals. They are not constrained by the usual ways of doing things, and can raise system concerns in a way that others cannot, or will not… In turn, when the learners
feel that they are doing “real work”’ and facilitating important improvements in quality, safety, and system performance, they are stimulated to learn more.’341 However ongoing training opportunities may be needed to maintain effectiveness. It is also important to train new staff given the high turnover of healthcare quality improvement personnel.342 Other training components Some educational strategies suggest that practical implementation is so important that all learning should be based around problem solving rather than divided by discipline.343–345 For example, a medical school in Canada changed from a traditional disciplinary-based curriculum to a problem-based learning curriculum. This included training in quality improvement methods at each stage in students’ learning. A before and after study comparing students who learned through traditional versus problem-based learning found that problem-based learning styles were associated with improved quality improvement learning and implementation.346 Others suggest that such significant changes to curricula are not required, but that experiential learning, didactic activities that support active learning, structured reflective practice that examines the role of teams, and faculty development in, and role modelling of, quality improvement are all essential components of successful quality improvement training.347–352 The importance of ongoing support and coaching from mentors or faculty has also been highlighted.353–355 The importance of multidisciplinary learning remains uncertain. There is growing consensus that multiprofessional collaboration is an essential component for improving quality and safety, but the importance of including a range of disciplines in training about quality improvement methods is an area of debate. Some argue that in order for teams to work collaboratively in practice, they must be taught teamwork skills as part of quality improvement education.
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‘Collaboration and teamwork do not just happen. Health professionals cannot be expected to work together collaboratively if they are not even exposed to one another during the formative educational training years.’356 Some have suggested that to be most effective, interdisciplinary training should begin early, before learners become isolated in disciplinary domains and ensconced in traditional disciplinary hierarchies and boundaries.357 In the US, higher educational institutions partnered with the Robert Wood Johnson Foundation to develop a self-directed, four module web-based and action learning curriculum designed to increase graduate level learners’ competence in quality, safety and systems improvement. Participants completed online modules and then set up quality improvement programmes in their teaching hospital. Students were drawn from internal medicine, emergency medicine, anaesthesia, family medicine, gynaecology, nursing, physical therapy, management and administration, surgery, rehabilitation and psychiatry. Twelve hospitals took part in an initial evaluation, which found that learners’ knowledge of, and self-assessed competence in, quality improvement increased as did their attitude towards, and participation in, multidisciplinary work. This illustrates that relatively low intensity web-based programmes can have an impact on practitioners’ attitudes and behaviour when coupled with a requirement to apply learning in practical projects.358 Some suggest that doctors and medical students may have a less positive attitude to multiprofessional education compared to nursing and pharmacy teams.359 To address this, the Robert Wood Johnson Foundation programme was first piloted with medical learners and was accredited using the US Accreditation Council for Graduate Medical Education requirements. Only then was the programme rolled out as an interprofessional model. Another key success factor in quality improvement training may be the capacity of trainers to provide high-quality education.360 It has been suggested that strong clinical faculty role models are critical in learning about quality improvement
and collaboration. Studies suggest that many professionals and educators feel uncertain about their knowledge of quality improvement competencies, let alone their ability to teach them to others.361–363 There is a gap in the training and development opportunities available for faculty themselves.364 In the US, a number of organisations have set up ‘train the trainer’ initiatives to prepare educators to teach practice-based learning and improvement.365,366 3.3 Summary To summarise: – It is important not to assume without question that training in quality improvement is the best or only method for helping professionals improve the quality of healthcare. There is mixed evidence about the effect of training on outcomes. – Training in quality improvement may increase the knowledge and confidence of health professionals, but didactic sessions alone are unlikely to improve care processes or patient outcomes. – Learning methods that encourage active participation may be more effective than classroom-based learning alone. – Online courses and other distance learning approaches may be useful and popular, especially when ‘blended learning’ approaches are used which also incorporate face-to-face tuition. – Mentorship, supervision and audit and feedback cycles may be useful as components of training, but used alone are unlikely to produce sustained changes in quality improvement skills or behaviour. – There is no evidence about whether it is more effective to train students versus qualified health professionals in quality improvement. Training both students and professionals is likely to have a place.
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4. Important messages
4.1 Key trends More than 5,000 articles have been published about training health professionals and students in quality improvement approaches over the past 30 years. Most are descriptive overviews or small observational studies, predominantly from North America. There is relatively little empirical research about the impact of training in quality improvement or the effectiveness of various training techniques. However, it is possible to draw some conclusions from the current knowledge base. Conceptualising quality improvement Within education for students and CPD for qualified professionals, quality improvement is generally defined as PDSA cycles, total quality management, or as a set of interrelated competencies. However, there are some geographic variations. In the US, and Canada to a lesser extent, quality improvement is conceived largely as a PDSA cycle paradigm and training focuses on collating and interpreting quantitative information. There may be a quantitative bias, whereby quality improvement is largely associated with audit and small tests of change. In the UK, a leadership and change managementorientated approach is more common. However, in CPD the focus is sometimes on making one-off improvements rather than training professionals and students how to think critically about improvement, take a whole systems approach and continuously improve healthcare processes and services.367
Training students in quality improvement Some universities in the UK provide modules or courses about quality improvement for students before they qualify as health professionals, but there appears to be less explicit focus on quality improvement in the UK compared to the US, Canada, Australia and Europe where medical and nursing students often have these concepts interwoven throughout their studies.368–371 This is slowly beginning to change in the UK, and courses or modules are now available focusing on critical appraisal, measurement for improvement and quality assurance. Compared to the US, where quality improvement training is mandatory for doctors and routinely incorporated into the curriculum for nurses, the UK has a more implicit focus on quality improvement within formal education. The outcomes of quality improvement may be talked about, such as patient-centred care or safety, but formal techniques for thinking about and implementing improvement are less pervasive. For instance, a study in England found that although patient safety has been recognised as a key priority nationally, this is implicit in the formal pre-registration nursing curriculum. It is included in teaching, but at a basic level and with limited quality improvement content. Students reported gaining most knowledge and experience about safety improvement from clinical practice. The organisational culture of both education and practice was characterised as being defensive and closed and as having an individual versus a systems approach.372 In the UK, formal education for students does not appear to draw on the full menu of techniques for quality improvement. Courses tend to be either narrowly focused on methods such as audit or
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critical appraisal or to be very time and resource intensive, such as postgraduate degrees or modules. There are few ‘middle ground’ courses providing participants with both theoretical and practical grounding but not taking excessive time or commitment in formal education. However, this gap may be increasingly being filled by CPD. Most training of students in the UK and internationally is unidisciplinary, although in some cases multidisciplinary practical projects have been tested with success. Continuing professional development Over the past few years there have been significant developments in CPD about quality improvement in the UK. Arms length bodies such as the NHS Institute for Innovation and Improvement offer a number of quality improvement courses, as do workforce deaneries, leadership academies, strategic health authorities and private organisations. These tend to cover the basic philosophies underlying continuous quality improvement as well as practical techniques such as measurement and analysis. In addition, training is commonly run as part of specific improvement initiatives. For example, professionals taking part in a safety improvement programme may participate in workshops related to quality improvement as one component of the programme. There is also an increasing focus on offering short courses with practical components and developing communities of practice or learning collaboratives to share learning in a less formal manner. However, there does not appear to be one consistent conceptualisation of quality improvement or a standard foundation of content. Each course varies in approach and content. Impact of training in quality improvement Research suggests that training in quality improvement can improve health professionals’ skills and knowledge and may be associated with short-term improvements in care processes.
However, few studies have examined the impact of training on health outcomes, safety or resource use. It is important not to assume that training will automatically improve outcomes. Types of training The need to provide patient-centred care, and provide value for money, means that health professionals require more than clinical skills alone. They also need to know how to assess, enhance and disseminate good practice.373,374 Surveys of medical, nursing and pharmacy students have identified gaps in formal training about quality improvement, leadership and safety.375,376 Students often say that they do not feel well-prepared and that they would like additional training about quality improvement.377–381 For example, a survey of 436 nurses in the US found that almost four out of 10 new nurses thought that they were ‘poorly’ or ‘very poorly’ prepared for or had ‘never heard of’ quality improvement. New nurses wanted more information about evidence-based practice, assessing gaps in practice, and research skills such as data collection and analysis.382 Research is available about a number of different training techniques, including classroom format, online modules, simulations and practical quality improvement projects. Few studies have compared one type of training with another so it is not possible to say that one type is most effective. There is evidence that blended approaches that combine classroom or online learning with opportunities to apply that learning in practice may be effective. Active learning strategies are thought to be more effective than didactic classroom styles alone but comparative research is rare. No studies have assessed whether formal education for students before they become health professionals is any more or less effective than CPD or on-the-job learning for enhancing skills in quality improvement. It may be important to provide training for students as well as opportunities for CPD rather than relying on one or the other alone. Key to this is ensuring that trainers and faculty have a consistent concept of quality improvement and are skilled at teaching about this topic.383
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Components of successful training Educating health professionals about how to improve quality and safety may be key to the future of healthcare.384 However, training opportunities are currently somewhat limited and fragmented.385,386 This is more the case in the UK than in the US but even in the latter, where training in quality improvement is mandated for some professionals, there are opportunities for development. A systematic review of 18 published quality improvement curricula for medical students and residents in the US found that curricula varied widely in the quality of reporting, teaching strategies, evaluation instruments and funding obtained. Many curricula did not adequately address the topic of quality improvement or educational objectives.387 There may be scope to enhance the undergraduate and specialist curriculum in order to: emphasise team working, communication skills, evidencebased practice and risk management strategies;388–390 develop a systematic approach to entrance requirements to medical school, the curriculum, training environments and student assessment;391 offer ongoing opportunities to develop quality improvement skills; ensure that leaders are committed to quality improvement.392
Research suggests that there are a number of key elements needed for successful and sustainable quality improvement education, including role models and champions, strong partnerships between academia and practice environments, a variety of educational modalities and a supportive learning environment.393 4.2 Geographic trends It is difficult and potentially inappropriate to generalise about the nature of training in different countries based solely on this rapid scan. However, some broad trends are evident. There appears to be greater focus on quality improvement training in North America compared to the UK. US training typically emphasises systematised methods and teaching managers and practitioners how to apply particular techniques, including how to collect and analyse data. Quality improvement is generally taught as a very structured and quantitative method. In contrast, the UK tends to emphasise leadership and theory much more. In the Netherlands and Scandinavia, there is more evidence of peer review and structured feedback as a training method, whereas Canada and Australasia are more likely to describe practical examples and work-based learning. Studies have not investigated whether any one of these approaches is more beneficial than others.
Figure 1: Models of quality improvement
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It has been suggested that there is a ‘quality improvement lifecycle.’ Individuals, organisations or health systems move through the lifecycle as quality improvement conceptualisations become more advanced. In this view, basic quality assurance approaches are contrasted with continuous quality improvement cycles and ‘quality improvement maturity’ (see Figure 1). While it may be inappropriate to see the lifecycle as a hierarchy, this model may be useful for describing some of the variations in approaches to quality improvement training between countries. 394,395 While the US and Canada tend to focus on training for ‘quality improvement’ or ‘continuous quality improvement’, regions such as Australasia and Scandinavia may place more emphasis on ‘quality improvement maturity’. This is not to suggest that any approach is more effective than others and it is acknowledged that such statements are generalisations. It is difficult to categorise UK approaches within this typology because there is not necessarily a strong focus on quality improvement training. The training that does exist tends to be fragmented. There are examples of training in the UK that fit within each of these four conceptualisations, but the majority may be within the ‘quality improvement’ category rather than ‘continuous quality improvement’ or ‘quality improvement maturity’. There may also be differences in the training prevalent in different disciplines. Based on published studies, quality improvement training for nurses appears to be more reflexive and practical, whereas training for doctors and managers is sometimes more process orientated. Based on the number of articles published, it appears that there has been a substantial increase in the awareness and ‘popularity’ of quality improvement training in recent years. It is difficult to judge whether the developing interest in quality improvement is cyclical or marks a linear increase. There seems to be a trend towards increasing interest over the past decade, but this is largely influenced by the US where improvement training
is now seen as mandatory for medical students – and thus more has recently been published about the topic. In the UK, the number of courses in quality improvement is growing, particularly in terms of CPD. However, as yet there does not appear to be a wide appreciation of the full menu of techniques for quality improvement. 4.3 Gaps in knowledge Despite the quantity of published material available, there are gaps in information about quality improvement training. This scan identified the following questions as gaps in knowledge. Does training make a difference? There is an assumption that training in quality improvement makes a difference. While there is evidence that training can influence participants’ knowledge and confidence, most studies have not explored whether training directly results in positive outcomes for service users, care quality or resource use. The literature acknowledges that courses alone are not enough to facilitate skills in quality improvement. Thus formal educational curricula alone are not likely to generate improved quality of care downstream. ‘While most newly qualified physicians are well prepared in the science base of medicine and in the skills that enable them to look after individual patients, few have the skills necessary to improve care and patient safety continuously… medical school education can increase the number of graduates prepared to reflect on and improve professional practice. Doing so requires a systematic approach involving entrance requirements, the curriculum, the organisational culture of training environments, student assessment, and programme evaluation.’396
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Who would benefit most from training? Most published research focuses on doctors and, to a lesser extent, nurses. However, taking a holistic approach to quality improvement may necessitate considering the value of training allied health professionals, support workers such as healthcare assistants, faculty and healthcare managers. There appears to be a significant gap in the market for training that supports management teams to put quality improvement principles into practice. Where managers are taught quality improvement techniques, these tend to focus on monitoring and measurement rather than how to lead and manage change, incorporate the needs of service users and consider the impact on staff. To be effective, it is likely that quality improvement training should begin at pre-registration level, have options for specialist training and be available for regular updates during the careers of managers and clinicians. Are short courses, websites and one-to-one mentoring more or less effective than building quality improvement skills into formal pre-registration education? There has been little comparative research into the most effective training methods and learning styles. Rather than considering the level of education as an either/or question, it may be worthwhile to think about supporting a menu of education to ensure that training is available to a wide range of professionals at different times in their careers. While much quality improvement education is uniprofessional, in order to mirror the ethos of quality improvement such training may be more effective if run on a multiprofessional basis, emphasising reflective practice and providing opportunities for action research or on-thejob learning. It seems unlikely that focusing on classroom-based learning alone will support managers and practitioners to improve and apply their skills.
How important is it to put quality improvement concepts into practice as part of the learning style versus classroom-based or online learning? There is evidence that training that includes a practical focus, such as implementing quality improvement projects or work-based learning, may be more likely to result in tangible change compared to classroom-based or online learning. However, the balance of theoretical and practical learning remains uncertain. The most effective methods for introducing practical experience into quality improvement training are also unknown. How frequently should training be reinforced to ensure continued use? In the US, doctors undergo training in quality improvement as part of their formal preliminary education. But little follow-up work has been done to assess whether the skills and knowledge learned pre-registration or as registrars lasts into longerterm practice. Studies with nurses, though rarer, suggest that quality improvement teaching needs to be reinforced and practised regularly in order for learning to be sustained. There may not be a shortage of quality improvement training, but rather a shortage of training that is simple and practical enough for managers and clinicians to apply in daily practice. A study in Finland surveyed a large sample of doctors about the availability of quality improvement training in 1998 and again five years later in 2003. The authors found that in both years, doctors thought that there was plenty of opportunity to obtain continuing medical education, in-house training, feedback from colleagues and guidelines for quality improvement education.397 No similar study has been conducted in the UK so it is uncertain whether practitioners feel that there is adequate training available and whether the training is accessible and meets people’s needs.
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To conclude, researchers and practitioners are increasingly recognising gaps in training about quality improvement, both in terms of what is known about this topic and in terms of the quality and effectiveness of how the concepts and methods are taught.398,399 There is a move towards seeing quality improvement as a dynamic concept underpinning service planning and provision, but as yet this has not permeated most training courses.400 There is scope for major development in this area. ‘To the extent that quality and safety are addressed at all, they are taught using pedagogies with a narrow focus on content transmission, didactic sessions that are spatially and temporally distant from clinical work, and quality and safety projects segregated from the provision of actual patient care… Transformation will require new pedagogies in which a) quality improvement is an integral part of all clinical encounters, b) health professions students and their clinical teachers become co-learners working together to improve patient outcomes and systems of care, c) improvement work is envisioned as the interdependent collaboration of a set of professionals with different backgrounds and perspectives skilfully optimising their work processes for the benefit of patients, and d) assessment in health professions education focuses on not just individual performance but also how the care team’s patients fared and how the systems of care were improved.’401
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The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK. We want the UK to have a healthcare system of the highest possible quality – safe, effective, person-centred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work. We are here to inspire and create the space for people, teams, organisations and systems to make lasting improvements to health services. Working at every level of the healthcare system, we aim to develop the technical skills, leadership, capacity, knowledge, and the will for change, that are essential for real and lasting improvement.