CQC has produced guidance for providers about what kind of evidence can be used to demonstrate that the outcomes described in the Essential Standards of Quality and Safety document are being met - Using evidence of outcomes to demonstrate compliance
When CQC monitors your compliance with the essential standards, it will check that you are meeting these outcomes. CQC will focus on evidence which demonstrates that people who use services:
- Have good outcomes and experiences, meaning that their care is effective and that they are safe.
- Are involved in their care and that their views are listened to and acted on.
By focusing on outcomes rather than looking only at a provider’s policies and procedures, CQC states that it can assess health and social care services in a way that is centred on people who use services. This means actually considering the effect that a service has on people.
The evidence a provider uses may be influenced by the factors in the service it provides. For example you could use evidence directly from people who use services and those acting on their behalf, such as:
- Surveys of people who use services, their carers and families.
- Complaints and feedback from people who use services.
- Patient reported outcome measures (PROMs).
- Feedback from other sources eg local groups.
Many dentists are used to collecting feedback from patients. In reality patient feedback is a valuable practice development tool. It collects the views and opinions of patients and service users on the care they have experienced. There are different ways of collecting feedback including the use of anonymous feedback forms, comments books, audits, complaints and compliments. Some practitioners have also used, one-to-one interviews and focus groups.
Once you have collected the feedback you need to review it and decide how to use it to continue to develop your practice. A useful next step is to then inform patients of how their feedback has been used and what changes have been made. This could be done in the practice newsletter or by way of information in the waiting room. In this way patients feel more involved in the practice.
You could also use other evidence which demonstrates outcomes for people directly or indirectly, such as:
- Staff surveys and feedback.
- Quality monitoring including reviews of services, learning from complaints, audits and comparative information.
- Risk assessments.
- Individual treatment planning and records.
- Staff skills and competence.
- Reporting and learning from incidents.
- Equalities monitoring and action plans.
- Information from regulators, inspections or accreditation schemes.
- Action plans and monitoring improvements.
From the broad range of information available, you should focus particularly on evidence that:
- Comes directly from people who use services and those acting on their behalf.
- Relates to the experiences of individual people who use the service.
Your evidence should also demonstrate:
- How you assess people’s needs appropriately and adequately, and how these needs are met.
- How you address and minimise risks to the health, welfare and safety of people.
- How you listen to and act on feedback.
- The results of improvements made following changes in practice.
You can use the Provider Compliance Assessment Tool to help you to demonstrate your compliance with outcomes.
You should remember that simply having policies, procedures and systems in place is not sufficient to demonstrate compliance. Instead, these should demonstrate that you have taken steps to ensure that people’s needs are met and that they experience the required outcomes.
Therefore, when you use evidence of policies, procedures and systems, you should also demonstrate how:
- They impact on the outcomes and experiences of people using the service, and how this is monitored.
- They help to meet people’s needs.
- They help identify and manage risks to the health, welfare or safety of people.
- They are implemented where necessary and their effectiveness monitored.
- They are explained and made available to all relevant staff.
- People who use the service were consulted and involved in their development.
- They are reviewed and updated to ensure that you continue to be compliant.
- You gather feedback about their impact from people who use services.
- Examples of evidence that might particularly be used in this way include policies, procedures and systems that relate to eg:
- Systems for reporting and learning from incidents. You need to have evidence not only that you have appropriate systems, but also that all relevant staff fully understand them and use them correctly. You need to show that these systems are more than just a record. They should enable you to identify and analyse individual incidents and trends for risks to people who use the service and staff. You will also need to demonstrate that, if there is an incident, you make clear action plans and implement them and that this leads to change, reduced risk and improved outcomes.
When you evaluate your own compliance, CQC expects you to focus on evidence that relates to outcomes for people. However, CQC recognises that you may not be collecting direct outcome evidence for all services or all outcomes. Therefore, it anticipates a greater initial emphasis on evidence from policies, procedures and systems. It is therefore appropriate to consider this in relation to the impact that they have on people who use your service.
As the system for ongoing monitoring of compliance is embedded, CQC will increasingly expect you to gather and use evidence that directly demonstrates outcomes or comes directly from people who use your service. This will mean that you can be in a position to demonstrate your compliance.