Monitoring questions for acute healthcare services

S1: How do systems, processes and practices keep people safe and safeguarded from abuse?

• Are infection risks to people using the service being thoroughly assessed and managed?
• Have you changed the layout/environment of clinical and non-clinical areas to continue to provide services safely in this period?

For example: clean sites, vehicle layout, separate entrances and waiting areas for known/suspected COVID-19 patients, additional signage, spaces between stations, isolation facilities, ensuring compliance with best practice guidance when visiting people in their own homes etc.

• Do you have the resources to obtain, and reliable access to, all the supplies, personal protective equipment and COVID-19 testing it needs, for both staff and, where appropriate, people who use the service?
• Are working arrangements and procedures clear and accessible to staff, people who use the service, their supporters and, where appropriate, visitors to the service?
• Are people using the service being protected from abuse, neglect, discrimination and loss of their human rights?
• Where applicable, have you identified when they may be depriving a person of their liberty, and followed the correct and lawful procedures, for example, DoLS application, Court of Protection?
• Are your safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights?

S1. Additional prompts

Medical care

• Are there there enough supplies, equipment and medicine to treat non-COVID-19 patients while a pandemic may mean that stock is used more quickly? For example, supplies of haemofiltration fluid usually used for renal dialysis patients?
• How are you monitoring the use of sedative drugs for patients living with dementia and experiencing increased stress (for example, due to reduced visiting, staff in masks)?

Surgery

• What processes are in place to maintain a COVID-19 free site for elective activity?

Critical care

• Have wards been converted into facilities for intubated COVID-19 patients?

Maternity

• What specific steps have you taken to support safety of women of Black, Asian and ethnic minority background in consideration of their increased risk of complication from COVID-19?
  • How has this been communicated to women under your care?
  • How have escalation/MDT systems been adapted?
  • How has this been communicated to staff?
• Are systems in place to identify, monitor and protect pregnant women and their babies (antenatally and postnatally) with complex social factors which may be exacerbated during quarantine or lockdown. This includes but are not limited to:
  • Pregnant women who experience domestic abuse
  • Pregnant women at risk of sexual abuse
  • Pregnant women who misuse substances
  • Women with mental health need
• How have changes to the environment/ layout been made clear to women and their partners?
  • Are women and their partners clear on where to go for birth including the appropriate times to come into the service?
  • How have changes been disseminated to staff, women and their partners?

CYP services

• How have safeguarding arrangements changed over the COVID-19 pandemic?
  • How have you followed up on vulnerable/at risk children, young people or family members?
• What arrangements are in place to manage and identify appropriate referrals of children and young people?
  • Are there any additional challenges to the process which could place CYP at additional risk?
  • How are risks mitigated with a reduction in colleagues involved in safeguarding children?
  • What processes are in place to follow up on missed consultations for vulnerable children and young people?
• How has the service managed the cleaning and disinfecting of children’s play areas, family/carer areas and toys?
• Are children still able to access play areas?
• Is the correctly sized PPE available for children and young people when needed?

Outpatients

• How do you meet communication needs and any reasonable adjustments?
• What are the outpatient escalation processes concerning vulnerable patients, for example, safeguarding?
• How are outpatients informed about keeping safe when visiting the hospital for appointments?
• Are there safe routes through the hospital to minimise footfall and enable social distancing?
• What are the patient’s responsibilities? Do they need to bring a mask? What if they are ill?

End of life care

• How are you identifying COVID-19 / non-COVID-19 patients and providing appropriate support, advice and guidance?
• Are you able to access adequate supplies of equipment to support care (for example mattresses, syringe drivers, oxygen therapy, wheelchairs)? What assurances are there that equipment that has been out of use is safe?
• What are the family arrangements for COVID-19/Non COVID-19 patients, for example, visiting and spiritual (viewing arrangements in mortuary, arrangements for additional capacity, resilience plans)? How are these arrangements communicated to families?

S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?

• Are risks to the health and wellbeing of people using the service being properly assessed, monitored and managed?
• Are there enough suitable staff to provide safe care and treatment in a dignified and respectful way? Are escalation plans in place in response to surges in demand, for example second wave, seasonal pressures?
• How is the service identifying and managing risks for patients including any restrictive practices or issues affecting their legal or human rights?

S2. Additional prompts

Urgent and emergency care

• is the ambulance queue being safely managed?

Medical care

• How do you manage VTE risk assessments and allergy status?
• How do you assess and monitor the impact on safety when there may be significant changes to the staffing levels?
• How is a patient’s COVID-19 status determined and how is this managed?
• What changes (if any) have been made to discharge processes to ensure a patient’s positive COVID-19 status is made known to all relevant persons (for example DN, care home, GP etc) What sort of planning is there for discharge? What if the person needs to be accompanied?
• How do you assess the impact of any pathway changes on vulnerable patients?
• Are ‘harm reviews’ carried out for those non-COVID-19 patients where there has been a delay in receiving care and treatment?
• How are you managing full restoration of cancer services? How is it putting in place specific actions to support any groups of patients who might have unequal access to diagnosis and/or treatment?

Surgery

• Is there a designated pool of anaesthetic and surgical consultants, who may need to work outside their employing trust established at clean sites? Are appropriate governance arrangements required to support this, such as honorary contracts in place?

Critical care

• What arrangements are in place to train and use non-critically care trained staff?
• Are staffing structures and ratios being met?

Maternity

• How have you ensured that records of all pregnant women contain the ethnicity and as well as other risk factors on maternity information systems?
• How have antenatal (including scans) and postnatal services been adapted during this period?
  • How have changes been risk assessed?
  • How have risks been mitigated?
• Have you adapted processes for women of Black, Asian and ethnic minority background in consideration of their increased risk of complication from COVID-19?
  • How has this been communicated to women of Black, Asian and ethnic minority backgrounds?
  • How has this been communicated to staff?
• Are women able to attend for emergency reviews where needed? For example, day assessment and triage services.
• What measures are in place to maintain places of birth including support for home births?

CYP services

• What approach has been taken to ensure individualised care plans have been reviewed and amended to consider new and emerging risk in relation to the COVID-19?
  • Are plans in place for regular reviews and amendments as circumstances change?
• How do you ensure families and patients have the correct advice on self-isolation (stay at home)?

Outpatients

• How stable is the Outpatients workforce? Is there use of bank, agency and Locums?
• How are waiting lists (new and follow ups) reviewed to prioritise patient appointments on the basis of clinical risk?
• How do you deal with specific risks to different ethnic groups and other diverse groups
• What information are patients given when they are discharged?

S3: Do staff have all the information they need to deliver safe care and treatment to people?

• Does the service have access to and is following guidelines around Treatment Escalation Plans (TEPs), anticipatory care planning, Do Not Attempt CPR(DNACPR) orders and individualised care plans?
• Are plans in place for rapid transfer to preferred places of care – relationships and planning with PMS, district nursing etc.
• Is the service able to effectively manage referrals and, where relevant, discharges, and ensure safe transfers of care? Where relevant, what testing arrangements are in place, and how does the service handle transfers of known/suspected COVID-19 patients safely? How is the service working with other partners?

S3. Additional prompts

Surgery

• How do you assure yourself that pathways are being followed - i.e. those in working households or unable to drive to a Pod for testing?
• How are patients being consented for surgery and undergoing pre-assessment? Is this being done by video or are patients expected to attend hospital? Are patients being consented so that they understand the risk of contracting COVID-19 whilst in hospital?
• Are surgical hubs being fully utilised? If patients are exceeding waiting time standards, are they being referred appropriately?

CYP services

• What plans are in place to support young people with complex needs in their transition to adult services?
• What network escalation policies are in place for neonates?
• What processes are in place if a CYP requires transfer to a specialist unit/hospital?
• What are the community liaison/discharge arrangements, for example for handover to HV, Paediatric nurse, SHA, GP etc - are there any specific current challenges?
• What arrangements are in place to support safe transfer of suspected or confirmed COVID-19 children to the appropriate levels of paediatric critical care needed? What arrangements are in place for the parent/carer of the child?

Outpatients

• How you assure yourself clinicians have access to all the information they need to deliver virtual consultations safely?

End of life care

• Have you introduced the ResPECT process and have staff been trained in the use of the process? Are the recommendations for personalised care inclusive of the patient, their family and the multidisciplinary team?

S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible?

• Can you give examples of how medicines are being managed safely and effectively? Does COVID-19 continue to impact on your ability to manage medicines?

S4. Additional prompts

Medical care

• How do you manage time-critical medicines on relevant wards? What is the extent of pharmacist support to wards?
• How do you manage dialysis medicines, for example, to ensure there is no confusion over medicines with similar names?

End of life care

• How do you support the safe management of patients’ own medications?

S5: What is the track record on safety?

• Are there any significant trends in non-COVID-19 activity - Never Events, Significant Incidents, themes in incidents, mortality, unexpected deaths? What is being done by the provider to assess and learn, including mortality reviews of non-COVID-19 patients?
• Are there any significant trends where groups of patients are faring worse in terms of safety concerns?

S5. Additional prompts

Maternity

• Is a maternity dashboard available and displayed? Have you been able to continue discussing and disseminating learning from this?
• Is there a safety thermometer available and displayed? Have you been able to continue discussing and disseminating learning from this?

E1: Are people's needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?

• How are you identifying, cascading and keeping up-to-date with changes in clinical guidance?
• Where people are subject to the MHA, how are you ensuring compliance with the MHA?

E2: How are people’s care and treatment outcomes monitored and how do they compare with other similar services?

• How are you collecting information about people's care treatment and outcomes? Where relevant, are you continuing to submit to relevant national clinical audits?
• How are outcomes being monitored for groups of people that may be at higher risk, such as different ethnic groups and older people?

E2. Additional prompts

Medical care

• What information can you share on outcomes for stroke, cancer etc?
• Has there been any evaluation of particular pathways, for example frailty?
• There is an expectation that you will develop digitally-enabled care pathways, in ways which increase inclusion, and review who is using new digitally-enabled pathways by 31 March. What progress have you made with this?
• How do you monitor outcomes from telemedicine to ensure it is being used effectively and appropriately?

End of life care

• Do you monitor preferred place of death outcomes?

E3: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment?

• How do you ensure that all staff, including those being flexibly re-deployed, have the skills and training to carry out their roles effectively?

E3. Additional prompts

Maternity

• What assurances are in place to make sure staff are competent to deliver maternity care:
  • Ongoing training has continued, for example CTG training
  • What support and assurances are in place for newly qualified staff that have been brought into the service early? Doe example newly qualified midwives will have a preceptorship program, how is that program of support continuing?
  • What COVID-19 specific training has been implemented within the service?

CYP services

• What support and training is in place for newly qualified staff?
• How has COVID-19 specific training been deployed to staff?

Outpatients

• How well do you use clinical nurse specialists to tailor service to different conditions and meet demand?

End of life care

• What staff training is available on compassionate care at end of life? How is it delivered, how frequently, and how does the service provide cover arrangements to ensure staff can attend?

E4: How well do staff, teams and services work together within and across organisations to deliver effective care and treatment?

• How are you ensuring that the necessary staff, teams and services are involved in assessing, planning and delivering peoples care and treatment?

E4. Additional prompts

Surgery

• Has a senior level hub triage for essential cancer surgery been established? How does the hub engage with MDTs?

Maternity

• How have you ensured continued MDT working where needed? For example, neonatal team available for advice and at birth.
• What plans are in place for the safe transfer of neonates to the level of NICU needed?
• Have discharge planning with community midwifery teams, health visitors etc changed during COVID-19 pandemic? If so, how have they changed and how have risks been mitigated?

CYP services

• Is there access to paediatric pharmacy advice 24/7?
• Are paediatric MDT meetings still able to take place?
• What arrangements are in place to effectively share information across different services? For example, between adult and children’s services, or on discharge with GPs and community and mental health services.
• What access aids are in place between hospital and community settings?
• How is access to mental health services/learning disability services facilitated?

Outpatients

• How well do clinics work with GPs?
• How do you coordinate appointments for patients with multiple conditions?

End of life care

• Are tests and results communicated to other partners involved in transfer of care?

E6: Is consent to care and treatment always sought in line with legislation and guidance?

• How do you ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
  • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
  • promoting supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
  • ensuring staff apply relevant legislation where people may lack capacity to consent to particular care and treatment, including the Mental Capacity Act 2005 (including DoLS) and the Children’s Acts 1989 and 2004?

E6. Additional prompts

CYP services

• Has there been any challenges for managing informed consent (for example Gillick competencies and Fraser guidelines)? How have these risks been mitigated?

C1: How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed?

• How do you ensure the care delivered is compassionate and upholds people's human rights?

C1. Additional prompts

Critical care

• How are you managing the support of patients’ relatives and loved ones including keeping them informed of their loved one’s condition?
• How are you supporting families who have not been able to visit their loved ones who have passed away? Are you working with partners on this?

Maternity

• Are you still able to offer a bereavement pathway to women and their families?
• How has the COVID-19 pandemic changed bereavement care offered? What support is available?

CYP services

• What arrangements are in place to manage the needs of parents/carers and the family?
  • How are the needs of sibling/s accommodated if no childcare is available?
  • What are the current policies around parents/carers for suspected or confirmed COVID-19 children?
  • Are parents/carers actively involved in the care the child?

End of life care

• Have you introduced the ResPECT process and have staff been trained in the use of the process? Are the recommendations for personalised care inclusive of the patient, their family and the multidisciplinary team?

C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?

• How do you support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
• Where appropriate, how are you managing the impacts of limited visiting on patient's wellbeing?
• Where appropriate, how are you promoting and ensuring patients know how to access advocacy support in the absence of ward visits?

C2. Additional prompts

CYP services

• How are you dealing with calls from concerned parents of children with and without risk?
• How have you communicated changes that have been made for COVID-19 and non-COVID-19 cases to children, young people and their families?
• How have you ensured that the views of children and young people have been sought during this period? For example, CYP panels feeding into service development.

End of life care

• Are people’s choices delivered in a timely way?
• Is there a personalised approach to End of Life Care? Are patients involved in Advanced Care Decisions, how do you approach this?

R1: How do people receive personalised care that is responsive to their needs?

• How do you ensure that they meet the needs of the population served and do they enable flexibility, choice and continuity of care?
• Where relevant, do individual patients have choices about how, when and where they are seen?

R1. Additional prompts

Maternity

• What provisions are made to provide continuity of care for women from Black, Asian and ethnic minority families, and those from the most deprived areas?
• How are you progressing against plans to meet the Better Births requirement for continuity of carer?

CYP services

• Do you have a suite of patient information about the current circumstances, specifically written for parents and children, including information for admitted patients and posters in waiting areas?

Outpatients

• Using technology for patient appointments - how are patients supported and is this risk assessed?
• How do you ensure a holistic, patient centred approach where telemedicine is used? For example, noticing issues such as safeguarding which would not be possible via video link.
• Are patients given a choice of different types of appointment and how is their preference recorded?

R2: Do services take account of the particular needs and choices of different people?

• How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
  • How do you ensure that each patient has their information and communication needs identified, recorded, flagged, shared and met?
  • How do you identify and make other reasonable adjustments for disabled people?
• Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?

R2. Additional prompts

Medical care

• How do you offer treatments inclusively, tailoring them to diverse groups within the community (for example, different ethnic groups)?
• How are you contributing to protecting the most vulnerable from COVID-19 to mitigate the risks associated with relevant protected characteristics and social and economic conditions?
• Have have you improved engagement with those communities who need most support?

Outpatients

• How do you offer treatments inclusively, tailoring them to diverse groups within the community (for example, different ethnic groups)?
• How have you ensured accessibility of, and communication of, new arrangements to diverse groups such as homeless patients; patients with mobility issues; visually impaired and deaf patients; and those who speak languages other than English?
• Have you provided support, for example, interpretation, British Sign Language?
• How do you manage when patients need someone to attend with them?
• How are you adapting your approach, including their Did not Attend/Access Policy to the COVID-19 scenario, when patients are too anxious to attend, are isolating, or are clinically vulnerable?

End of life care

• Do people at end of life and their families have access to differentiated and appropriate spiritual and pastoral and religious support? For example, Muslim, Hindu, Buddhist, Humanist, Jewish, Sikh?

R3: Can people access care and treatment in a timely way?

• How are you managing access to the service to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including reinstating services and handling backlogs of activity?
• Is there a structured approach to patient flow that ensures all components of the system are appreciated and managed appropriately, and flow issues are escalated appropriately? How does the approach take account of the pandemic?

R3. Additional prompts

Urgent and emergency care

• How are emergency department managing the patient queue – are they taking responsibility for patients on arrival?

Medical care

• Are you meeting NHS targets for backlog reduction, especially for cancer patients?
• How robust are systems, including IT systems, to manage effective record keeping, referrals and transfers of patients?

Surgery

• How are patients who are classified in the P3 or P4 groups, or whose outpatient appointments are deferred, being safety netted? What processes are in place to ensure that these groups of patients do not deteriorate whilst awaiting surgery or clinic appointments?
• Do you have a system in place of list confirmation to ensure that those patients waiting for treatment still wish to proceed?
• For NHS trusts which contract with IH providers, how are differences in admission policies being managed?
• How is the flow into and out of critical care being approached?

Critical care

• How is the critical care outreach pathway working? How is the post discharge pathway working?
• How are non-COVID-19 patients requiring ICU care being managed?

Outpatients

• How are you measuring waiting list times?
• How are you quantifying, triaging and re-triaging new and follow up patient backlogs to ensure patients are not harmed while waiting for an appointment? What is the clinical oversight for this?
• there daily review of the patient tracking list? What is the clinical oversight? What action plans have resulted?
• How robust, secure and interconnected are IT systems? How do you manage data collection, referrals and waiting list bookings? What information is the service sharing with referrers?
• How are health inequalities proactivity managed?
• Have you been affected by delays in other services (for example diagnostics) and what action have yous been taken as a result?
• How are you planning to meet demand and reduce backlogs caused by:
  • uplift in demand for new appointments because people stayed away and
  • backlog of unfulfilled existing demand.
• What is the availability of clinicians and clinic spaces, by speciality? How available have clinics been? Are there clinics:
  • 7 days a week?
  • Evening clinics?
  • Urgent clinics?
• Are there any new approaches to service delivery (for example telemedicine, community locations for clinics) and how are you managing this? For example:
  • If using telemedicine, how do you monitor outcomes to ensure it is being used effectively and appropriately? How inclusive are the digital pathways? How is the use of telemedicine risk assessed?
  • If new community locations and alternatives for rural patients have been established, how are they helping with preventative programmes for those at greatest risk of poor health outcomes?
• How do patients let the service know about any changes in their condition? How do you ensure that it’s easy to get through on the telephone, for example?

End of life care

• How do you ensure that patient’s wishes about their preferred place of death are acted on quickly?
• How do you manage sudden increases in demand for care?

W1: Is there leadership capacity and capability to deliver high-quality, sustainable care?

• Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place should it be affected?
• Do leaders understand the challenges to quality and sustainability during this period, and can they identify the actions needed to address them?

W1. Additional prompts

Maternity

• Is there a board maternity safety champion? What is their role? How do they link into the service?

CYP services

• What oversight does the board have around plans and mitigations for safeguarding the most vulnerable children and young people?

W3: Is there a culture of high-quality, sustainable care?

• Is the service monitoring and protecting the health, safety and wellbeing of staff?

W3. Additional prompts

Critical care

• How are you supporting bereaved staff - not just from a patient point of view but from potentially losing colleagues and family members themselves?

Maternity

• How do you support staff after significant incidents?
  • debrief?
  • within what time frame?

For example, a junior midwife is involved in an intrapartum stillbirth – what is your process following this?

Outpatients

• How do you audit the effectiveness of its approach to equality in service delivery?
• How much is there a team identity or team spirit in outpatient services?

W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?

• Are you able to work effectively with system partners when care and treatment is being commissioned, shared or transferred?

W4. Additional prompts

Urgent and emergency care

• What collaboration has there been with primary care, 111, ambulance and care sector partners?

Maternity

• How have you worked together as part of local maternity systems (LMS)? How have you worked with the LMS to maintain intrapartum services?

Outpatients

• How do you know your risk stratification, or any digitally enabled work, is effective and safe, and what are the governance arrangements? (for example. for delivering services in independent hospitals)

W5: Are there clear and effective processes for managing risks, issues and performance?

• Do you have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed?

W5. Additional prompts

Maternity

• Can you demonstrate that the trust safety champions (obstetrician and midwife) are meeting bi-monthly with board level champions to escalate locally identified issues?

Outpatients

• How do you measure performance while keeping patients safe and prioritising based on risk?