Domain 1: leadership, strategy and management

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Standard 1.1: The ethos, culture and team approach of the service is defined and published.


Evidence Requirements

  • Documentation outlining the ethos, culture and team approach in the service (in the operational plan for the service and displayed on the organisation’s website).

Guidance

  • This might be in a mission, vision and values statement that links to the organisation’s values and objectives.
  • Ethos: This might describe what the team is committed to and the principles they apply. Components that make up this ethos include patient-centredness, commitment to quality and outcomes, culture, safety, safeguarding and working in partnership with patients.
  • Culture: This might describe the commitment of the leadership team to promote a sense of belonging and ownership to every member of staff through expectations and excellence in service delivery. It should be supported by a commitment to a programme of continuous professional development and support.
  • Team approach (professional): The team approach for a service should be established on core values that underpin every aspect of its work: being person-focused, professional, open, caring and respectful.

Standard 1.2: The service has a leadership team that is visible, approachable and communicates regularly with staff members.


Evidence Requirements

  • A document outlining the names of leadership and staff team, including a summary of key clinical and managerial roles and responsibilities.
  • Evidence of relevant qualifications/training certificates of leadership team.
  • Organogram of team structure with clear lines of responsibility/accountability/ line management.
  • Evidence of feedback process for leaders, including feedback data and action plans with timelines.
  • Annual feedback in various forms from referrers of the service with accompanying evidence of discussion of feedback and planned actions to continue to improve.
  • Examples of notices/bulletins or other such communications to staff and stakeholders to share updates and highlight changes to service delivery.

Guidance

  • The roles and responsibilities of individuals in the leadership team should be clearly defined. The service should be delivered by experienced and specialist healthcare professionals – it is expected that the service will have physiotherapist and/or nursing input in collaboration with a broader multidisciplinary team.
  • The named lead clinician should be a registered healthcare professional with appropriate specialist competencies in this role and should undertake regular clinical work within the service. The lead clinician should have overall responsibility and accountability for the service.
  • Leads for the service should have responsibility for staffing, training, guidelines and protocols, service organisation, governance and for liaison with other services.

Standard 1.3: The service has a leadership team that is responsible for operational planning and service development.


Evidence Requirements

  • Operational plan.
  • Evidence of annual review of operational plan (in team meeting minutes and in operational plan).

Guidance

  • The operational planning/service development process must consider:
    • the needs of the local population, including geographical and clinical profiling
    • disease burden
    • national and local requirements
    • value for money
    • promotion of the service
    • review of demand and capacity of the service.
  • The operational plan should include as a minimum:
    • accessibility (including reasonable adjustments for those with specific needs and signage for service), clinical space, facilities and equipment, what is available at the different sites and how appropriateness and suitability of the site was determined
    • safety/adverse event monitoring and reporting in the service
    • measurable objectives, key performance indicators (KPI), service evaluation and metrics for the service, including patient- reported experience and outcome measures (PREMS and PROMS)
    • roles and responsibilities for the staff members involved in the service
    • staff induction and training, mandatory and specialist training requirements and competency sign off process
    • how staff debriefing/handover occurs, including at times of annual leave
    • key relationships with organisations involved in the service
    • organisational chart/organogram for the service
    • statement on improvement, innovation and transformation
    • plans for development, including strategies for the development of the service to meet the needs of the local population across the clinical pathway
    • training and workforce development plan which includes succession planning to meet the needs of the service
    • procedures for collecting, monitoring, reviewing and analysing quantitative and qualitative data and feedback.
  • The operational plan should be developed with multidisciplinary input.

Standard 1.4: There are escalation procedures for staff members.


Evidence Requirements

  • Service standard operating procedure (SOP) that includes a section on raising concerns.
  • Whistleblowing policy and/or harassment and bullying policy (can be organisation’s policy).
  • Evidence of disseminating policy/ies and principles of escalation to staff team.

Guidance

  • This must include:
    • the sharing of information and raising general concerns
    • challenging questionable and/or poor clinical practice
    • breaches of code of conduct and accountability; raising concerns of an ethical nature
    • disrespectful, discriminatory, abusive behaviour or harassment
    • provision of information and support for staff members raising concerns to clarify that there is no blame for adverse consequences
    • staff awareness of service/organisational policy on ‘bullying and harassment’.

Standard 1.5: The service promotes the health and wellbeing of staff members.


Evidence Requirements

  • Examples of how wellbeing is promoted.
  • Process in place for debriefing after a ‘critical incident/event’ within the service.

Standard 1.6: The service leadership team carry out a PR staff survey and provide opportunities for informal feedback.


Evidence Requirements

  • Staff survey template, data, and action plan outlining areas to improve and ways to continue to do well (where feedback is positive), including timescales and named leads.
  • Team meeting minutes within the past year that demonstrate clear staff involvement in the service.
  • Examples of informal ad hoc feedback, where appropriate.

Guidance

  • There are systems in place to ensure that staff are able to feedback in confidence.
  • The staff survey should include:
    • if staff feel wellbeing is supported
    • support from leadership
    • experience of implementing improvements in the service
    • experience of IT systems to support clinical work
    • working environment and safety
    • service delivery and staffing levels.

Standard 1.7: There is promotion of the service to referrers and potential patients.


Evidence Requirements

  • Examples of relevant literature/online material and how this is shared with patients/ carers/referrers.
  • Evidence of review of referral forms with relevant stakeholders (at relevant intervals, as determined by service need).
  • Evidence that PR is available for people with Chronic Obstructive Pulmonary Disease (COPD) with an Medical Research Council (MRC) breathlessness score of 2, as well as those with other respiratory diseases as defined by the BTS quality standards for PR.

Guidance

  • The service promotion must describe:
    • the scope of the service provided (including who the service aims to provide treatment/care to and whether research or training is undertaken)
    • the range of services offered and expected clinical outcomes
    • service organisation including the team members involved in delivering the service, frequency of clinics and opening times, their location(s), including satellite services, how to contact the service for help and advice, including out of hours
    • facilities available, including access for users with specific needs
    • expected timescales for the patient pathway, including initial assessment, start of PR, length of programme and discharge assessment
    • information regarding volunteers participating in the PR programme, if applicable to service
    • any links with other services/stakeholders, including how referral pathways are managed, eg information about other services in patient pack or referral agreements/pathway documents.

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