December 2022 (or as required)
Contents 1.0 Introduction 3 2.0 Purpose 3 3.0 Scope 3 4.0 Definitions 3 5.0 The roles and responsibilities for Quality & Equality Impact Assessments 4 6.0 When and how often a combined quality and equality impact assessment should be undertaken? 5 7.0 What should be considered as part of the impact assessment? 5 8.0 Process for assessing potential risks to quality and equality 5 9.0 Process for raising concerns 7 10.0 Monitoring 7 Appendix 1: Integrated Impact Assessment Guidance 8 Appendix 2 - Integrated Impact Assessment Tool - Stage 1 Pro forma 9 Appendix 3 – Guidance for calculating the scores 10 Appendix 4 - Integrated Impact Assessment Tool - Stage 2 – Escalation pro forma 13
1.0 Introduction
NHS Berkshire West Clinical Commissioning Group (now referred to as ‘the CCG’) is committed to ensuring that commissioning decisions, Project Plans, business cases and any other business plans are evaluated for their impact on both quality and equality.
This policy details the process to be undertaken in order to assess the impact of commissioning decisions, QIPP (Quality, Innovation, Productivity and Prevention) plans, Business Cases and any other plans for change.
The Quality & Equality Impact Assessment (QEIA) process provides a focus on quality, in line with the ambitions from the Five Year Forward View and the Long Term Plan. It is to be used alongside the plans for any change. It is not designed to replicate these and should be considered a balance to any financial business case.
2.0 Purpose
The purpose of this policy is to set out the responsibilities; process and format to be followed when undertaking a combined quality and equality impact assessment.
3.0 Scope
The policy relates only to impact assessments that are to be undertaken when developing PIDs (Project Initiation Document,) business cases, commission projects and other business plans. It applies to staff that undertake, scrutinise and challenge impact assessments.
4.0 Definitions
4.1 Definitions of Quality and the different types of impact assessment are:
Quality
Quality can be defined as embracing three key components:
· Patient Safety – there will be no avoidable harm to patients from the healthcare they receive. This means ensuring that the environment is clean and safe at all times and that harmful events never happen.
· Effectiveness of care – the most appropriate treatments, interventions, support and services will be provided at the right time to those patients who will benefit.
· Patient Experience – the patient’s experience will be at the centre of the organisation’s approach to quality.
Quality Impact Assessment
An impact assessment is a continuous process to ensure that possible or actual business plans are assessed and the potential consequences on quality are considered and any necessary mitigating actions are outlined in a uniformed way.
Equality Impact Assessment
Defined in the Equality Act 2010, we are required to consider the impact on those people in possession of any one of the nine protected characteristics of the Act. These nine protected characteristics are as follows:
· Disability - including cancer, HIV, multiple sclerosis, and physical or mental impairment where the impairment has a substantial and long-term adverse effect on the ability to carry out day-to-day activities
· Race - including colour, nationality and ethnic or national origins
· Religion or belief - including a lack of religion or belief, and where belief includes any religious or philosophical belief
· Sex
· Sexual orientation - meaning a person’s sexual orientation towards persons of the same sex, persons of the opposite sex and persons of either sex
· Gender re-assignment - where people are proposing to undergo, are undergoing or have undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex
· Pregnancy and maternity
5.0 The roles and responsibilities for Quality & Equality Impact Assessments
Accountable Officer
The Accountable Officer has ultimate responsibility for quality and equality across the organisation.
Nurse Director – Executive Lead for Quality
Responsible for ensuring that QEIAs are effectively considered as part of discussions and decisions about QIPPs, business cases and other business plans.
Responsible for reviewing all assessments over a threshold score of 8 and escalating relevant risks to Finance Committee for decision.
Governing Body member including Lay Members
Each Governing Body member is responsible for ensuring that financial and operational initiatives (e.g. QIPPs, business cases and other business plans) have been evaluated for their impact on quality and equality and have assured themselves that minimum standards will not be compromised. They will also assure themselves that the impact on quality and equality on an on-going basis is monitored appropriately.
Head of Planning and Transformation
Responsible for ensuring that all QIPP Project Plans and Business Cases include a completed QEIA.
Responsible for forwarding any assessments that reach a threshold score of 8 or more to the Quality Team / Nurse Director.
Project Leads
Responsible for undertaking quality impact assessments, identifying risks and mitigating actions and submitting quality impact assessments to the Head of Planning and Transformation for review and sign off / escalation
6.0 When and how often a combined quality and equality impact assessment should be undertaken?
Impact assessment is a continuous process to help decision makers fully think through and understand the consequences of possible and actual financial and operational initiatives (e.g. Commissioning decisions, business cases, projects and other business plans).
Impact Assessments must be undertaken as part of the development and proposal stage of developing PIDs and business plans and should also be reviewed on a regular basis by the project leads, as part of reviewing the actual impact throughout the implementation stage and during the final review after the proposal has been implemented. Gateways should be identified during which Impact Assessments should be completed or reviewed.
Where a large scale change is proposed, the tool will be used for each individual component of the proposed change. The responsible lead for the assessment will make a judgement as to which components will need to be assessed individually.
7.0 What should be considered as part of the impact assessment?
The impact assessment template can be found in Appendix 2 and outlines the questions to be considered under the domains of quality as well as the protected characteristics relating to equality.
8.0 Process for assessing potential risks to quality and equality
As part of the impact assessment, authors are required to consider any risks which should be added to the corporate risk register. Mitigating actions should be considered and recorded as a part of the Impact Assessment process.
All assessments with a score of 8 or more must be subject to a Stage 2 pro forma and submitted to the Quality Team for further scrutiny.
Flowchart: Assessment Process
Initial Assessment completed by Project lead (using Stage 1 Proforma)
Stage 2 Proforma completed if risk score is 8 or above for any individual line
Proforma (s) sent to Head of Planning and Transformation for sign off along with relevant PID / BC
Assessments not approved by Nurse Director presented to Finance Committee for decision
Assessments not approved by Quality Team forwarded to Nurse Director
Assessments scoring 8 or more forwarded to Quality Team for review
Assessments scoring less than 8 – PID / BC presented to Programme Boards and Clinical Commissioning Committee for sign off
Assessments approved by Quality Team – PID / BC presented to Programme Boards and Clinical Commissioning Committee for sign off
Assessments approved by Nurse Director - PID / BC presented to Programme Boards and Clinical Commissioning Committee for sign off
9.0 Process for raising concerns
Where concerns are identified, either through monitoring of clinical outcomes; through risk assessments; or via another route such as staff or patient feedback they should be reviewed by the Nurse Director and if necessary referred to the Quality Committee.
10.0 Monitoring
Responsibility
Impact assessments are required to have been completed as part of all PIDs, business cases, and proposals when presented at Finance Committee
Papers for meetings should be scrutinised. Those submitted without confirmation that impact assessments have been completed must be returned to project lead before being progressed.
Head of Planning and Transformation
Chair of Finance Committee / Programme Managers
CCG Chair
Annual review of Finance Committee function
Chief Finance Officer
Risk registers contain appropriate risks in relation to the potential impact on PIDs & business plans
CCG risk registers are reviewed monthly at meetings of the Programme Boards, Quality Committee and Finance Committee
All Directors
All assessments judged as having high impact must be referred to Quality Committee for further scrutiny, and to the Nurse Director, as appropriate
Minutes of Quality Committee
Overview
This tool requires all projects to undergo an initial assessment (stage 1 pro forma) to identify any potential impacts, either positive or negative on quality and equality from any proposed changes to the way services are commissioned or delivered.
Quality is described in five areas, each of which must be assessed. Where a potentially negative risk is identified and scores 8 or more, this indicates that a more detailed assessment is required in this area. All areas scoring 8 or more must go on to a detailed assessment (stage 2 pro forma). All impact assessments must be signed and dated by the person carrying out the assessment. All completed impact assessments must be reviewed and signed off by the Head of Planning and Transformation in the first instance (see flow chart on page 5 which details the process).
All PIDs and business cases presented to the Finance Committee must confirm that a QEIA has been completed and signed off at the appropriate level. Those identified as high risk, requiring a more detailed assessment must be reviewed by the Quality Team and escalated to the Nurse Director as appropriate.
Scoring
An overall risk score for each element is achieved by assessing the level of impact and the likelihood of this occurring and assigning a score to each. These scores are multiplied to reach an overall risk score.
The following table defines the impact and likelihood scoring options and the resulting score.
Please take care with this assessment. A carefully completed assessment should safeguard against challenge at a later date.
Risk Assessment Matrix
Extreme Risk
The risk score is identified by multiplying the likelihood score with the impact score to get an overall risk assessment score (e.g. a change which has a serious impact (3) but is unlikely (2) scores 6 overall and therefore a Moderate Risk). Further guidance is provided in Appendix 3.
Quality & Equality Integrated Impact Assessment Policy Page 2 of 13
Appendix 2 - Integrated Impact Assessment Tool - Stage 1 Pro Forma
Title of Project:
Compliance with the NHS Constitution?
Partnerships?
Preventing people from dying prematurely?
Enhancing quality of life?
Helping people recover from episodes of ill health or following injury?
Ensuring people have a positive experience of care?
Treating & caring for people in a safe environment & protecting them from avoidable harm?
Access
Could the proposal impact negatively on access?
Could the proposal impact negatively on integration?
Duty of Equality
Age?
Disability?
Race?
Date of assessment:
Quality & Equality Integrated Impact Assessment Policy Page 9 of 13
Appendix 3 – Guidance for calculating the scores
Please contact the Quality Team if you require further support in completing this pro forma
Impact scores (I)
Choose the most appropriate domain for the identified risk from the left hand side of the table Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column.
Impact scores (severity levels) and examples of descriptors
Impact
1
2
3
4
5
Domains
Negligible
Minor
Moderate
Major
Catastrophic
Impact on the safety of patients, staff or public (physical/psychological harm)
Minimal injury requiring no/minimal intervention or treatment.
No time off work
Increase in length of hospital stay by 1-3 days
Moderate injury requiring professional intervention
Requiring time off work for 4-14 days
Increase in length of hospital stay by 4-15 days
RIDDOR/agency reportable incident
An event which impacts on a small number of patients
Major injury leading to long-term incapacity/disability
Requiring time off work for >14 days
Increase in length of hospital stay by >15 days
Mismanagement of patient care with long-term effects
Incident leading to death
An event which impacts on a large number of patients
Quality/complaints/audit
Informal complaint/inquiry
Formal complaint (stage 1)
Minor implications for patient safety if unresolved
Reduced performance rating if unresolved
Treatment or service has significantly reduced effectiveness
Formal complaint (stage 2) complaint
Local resolution (with potential to go to independent review)
Repeated failure to meet internal standards
Major patient safety implications if findings are not acted on
Non-compliance with national standards with significant risk to patients if unresolved
Multiple complaints/ independent review
Gross failure of patient safety if findings not acted on
Inquest/ombudsman inquiry
Human resources/ organisational development/staffing/ competence
Short-term low staffing level that temporarily reduces service quality (< 1 day)
Low staffing level that reduces the service quality
Late delivery of key objective/ service due to lack of staff
Unsafe staffing level or competence (>1 day)
Low staff morale
Uncertain delivery of key objective/service due to lack of staff
Unsafe staffing level or competence (>5 days)
Loss of key staff
Very low staff morale
Non-delivery of key objective/service due to lack of staff
Ongoing unsafe staffing levels or competence
Loss of several key staff
No staff attending mandatory training /key training on an ongoing basis
Statutory duty/ inspections
No or minimal impact or breech of guidance/ statutory duty
Breech of statutory legislation
Enforcement action
Improvement notices
Prosecution
Elements of public expectation not being met
Local media coverage –
long-term reduction in public confidence
National media coverage with <3 days service well below reasonable public expectation
National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House)
Total loss of public confidence
Business objectives/ projects
<5 per cent over project budget
Schedule slippage
Schedule slippage
Non-compliance with national 10–25 per cent over project budget
Schedule slippage
Schedule slippage
Loss of 0.1–0.25 per cent of budget
Claim less than £10,000
Claim(s) between £10,000 and £100,000
Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget
Claim(s) between £100,000 and £1 million
Purchasers failing to pay on time
Non-delivery of key objective/ Loss of >1 per cent of budget
Failure to meet specification/ slippage
Loss of contract / payment by results
Claim(s) >£1 million
Loss/interruption of >8 hours
Minor impact on environment
Loss/interruption of >1 day
Moderate impact on environment
Loss/interruption of >1 week
Major impact on environment
Catastrophic impact on environment
Likelihood scores (L)
What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency.
Likelihood score
This will probably never happen/recur
Do not expect it to happen/recur but it is possible it may do so
Might happen or recur occasionally
Will probably happen/recur but it is not a persisting issue
Will undoubtedly happen/recur,possibly frequently
Likelihood
1
2
3
4
5
For grading risk, the scores obtained from the risk matrix are assigned grades as follows
Risk Assessment Scores
Instructions for use
1. Define the risk(s) explicitly in terms of the adverse impact that might arise from the risk.
2. Use table 1 to determine the impact score(s) (I) for the potential adverse outcome(s) relevant to the risk being evaluated.
3. Use table 2 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score.
4. Calculate the risk score the risk multiplying the impact by the likelihood: I (impact) x L (likelihood) = R (risk score)
5. Identify the level at which the risk will be managed in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the CCG’s risk management system. Include the risk in the corporate risk register at the appropriate level.
Appendix 4 - Integrated Impact Assessment Tool - Stage 2 – Escalation Pro Forma
To be completed when the initial impact assessment indicates a high or extreme risk and a more detailed assessment is required
Please contact the Quality Team if you require further support in completing this pro forma
On identification of a high or extreme risk PID, business case, commissioning decision or business plan this pro forma must be submitted along with the proposed change to inform the decision making process and ensure informed choice. A copy of the complete impact assessment must be submitted to the next available Quality Committee to ensure scrutiny from a quality perspective.
Background and context of the proposal