HSE National PPPG Framework (Policies, Procedures, Protocols

& Guidelines) Workshop

Ms Brid Boyce & Ms Maria Lordan – Dunphy HSE

Thursday December 8th 2016

HSE National Framework for developing Policies, Procedures, Protocols and Guidelines (PPPGs)

Ms. Maria Lordan Dunphy Assistant National Director Quality Improvement Division

Ms. Brid Boyce

HSE National Lead for PPPGs Quality Improvement Division 8th December 2016

Presentation Content

Background and context

Overview of HSE National Framework for developing PPPGs

Framework Scope

Section 1 – Definitions

Section 2 – Stages in the PPPG development cycle

Section 3 – Template for developing PPPGs (2016)

Section 4 – PPPG Checklist for Clinical and Non-Clinical PPPGs

Section 5 – HSE National Central Repository

Section 6 – Implementation of the Framework

Group Exercise

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Background and Context

Benefits of Robust PPPGs in place

National Standards for Safer Better Healthcare (HIQA, 2012)

Quality Framework for Mental Health Services (MHC, 2007)

Regulatory reports, inspections and recommendations from serious incidents have identified gaps (HIQA, MHC, H&SA) etc.

HSE reports and recommendations

NCEC DoH developed Standards for Clinical Practice Guidance (2015)

HSE National Steering Group for PPPGs in 2015.

Develop a HSE National Framework for developing PPPGs that sets out the standards that must be applied when developing clinical and non-clinical PPPGs

Establish a National Central Repository Office (NCRO) where all HSE national approved PPPGs are available and easily accessible to staff and public

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Overview of HSE National Framework for developing PPPGs 5

Following extensive literature review the HSE National Framework was developed.

Aligned the NCEC Standards for Clinical Practice Guidance with the stages in the PPPG development cycle and sets out the following:

Framework Scope

Scope HSE National Framework for developing PPPGs applies to all HSE staff and HSE funded services and covers clinical and non-clinical PPPGs.

This includes: Models of Care Care Bundles Care Pathways Clinical Decision Aids Checklist and algorithms as part of the implementation tool box can be included in the PPPG in so far as they are components rather than practice guidance. Diagrams or flow charts can be utilised to assist in the visual process in the understanding of PPPGs

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Section 1- Definitions 7

Section 2 - Stages in the PPPG Development Cycle

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Section 3 – Template for developing PPPGs (2016)

Part A-Outline PPPG steps

Part B - PPPG Development Cycle

Table of Contents

1.0 Initiation

2.0 Development

3.0 Governance and Approval

4.0 Communication and Dissemination

5.0 Implementation

6.0 Monitoring, Audit and Evaluation

7.0 Revision/Update

8.0 References

9.0 Appendices

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Section 4 – PPPG Checklist for Clinical – Non-Clinical PPPGs

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Section 4 – PPPG Checklist for Clinical – Non-Clinical PPPGs

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Section 5 – HSE National Central Repository

Function

Provide a reference number for all new HSE national PPPGs being developed

Upload the newly approved HSE national PPPGs onto the HSE DMCS and also publish it on the HSE website

Act as a contact focal point for general information on PPPGs

Transition period

A 3 year transition period will be required to update all existing approved HSE national PPPGs

The updated HSE national PPPGs will be migrated onto the new proposed system once they have met the required standards

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Section 6 – Recommendations for implementation of the framework

National Director to lead the implementation of behalf of the HSE Leadership Team

Communication plan

National PPPG Group to advise on the required structures to support divisions/services to comply with the PPPG standards

Services to identify lead person(s) at appropriate level to support their services to develop PPPGs to meet the required standards

All division/services to put in place structures and processes to ensure their PPPGs are consistent with the standard set out in the framework

Develop a National PPPG Network with nominated leads to advise on the implementation and development of PPPGs

Develop and implement an education and training programme

Secure resources to enable the development and ongoing management of NCRO

Identify processes to monitor implementation through the Performance Accountability Framework for Health Services 2016

Work with senior managers CHO, Hospital Groups, NAS etc. to develop synergies across the HSE to avoid duplication and use of staff time and expertise

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Quality Improvement

“We have two Jobs:

Our job and the Job of improving our Job”

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Donald M. Berwick, MD, MPP, FRCP