Clinical Accreditation Tool (CAT)
The CAT was introduced within Newcastle Hospitals as a Trust-wide tool to provide continuing clinical assurance to the Board as an overview of performance for each ward and Directorate. The CAT is one of the Trust’s methods of checking that the highest standards of patient care are met.
Each month, around 180 clinical areas of the Trust complete a self-assessed electronic survey about a sample of their patients and staff – in most cases, completion of the tool is led by nurses (Sisters/Charge Nurses, Matrons, Clinical Leaders and others). Questions relate to subjects ranging from the cleanliness of the ward/environment, to observations of clinical practice, and from the testing of staff knowledge, to the completion of patient care documentation.
The CAT has been divided into four categories: Environmental Cleanliness; Assurance Measures; Clinical Assurance; and Staff Knowledge. It has been tailored to specific areas of the Trust (Adult Inpatients, Outpatients, Theatres, Critical Care, Paediatrics, Dental, Maternity, Day Case, Community Nursing, Community Outpatients, Community Dental, Health Visiting and Occupational Health).
Every month, an email link is sent to each ward or department link-nurse, Matron or senior nurse. Once the staff have completed the CAT, they contact their Matron or senior nurse to inform her that the tool is now ready for completion of the cleanliness spot check section. The Matron is then responsible for the submission of the CAT. The CAT has also incorporated previously separate audits on hand hygiene and the matrons’ cleanliness spot checks.
We ensure that the CAT is a user-friendly, quick and easy tool to complete, releasing staff to perform essential nursing and patient interaction. As part of this pledge, an annual user evaluation survey is carried out to gauge how staff feel about the tool, with changes being made to the CAT on a six-monthly basis.
The scores from the CAT also contribute to a Care Summary, drawing together a number of different quality measures (nurse staffing levels, Friends & Family Test scores, complaints) as well as patient outcomes (healthcare-associated infections, falls, pressure ulcers, drug administration errors). The Care Summary is designed to provide an overall picture of the nursing care issues at a ward, Directorate and Trust level.
To recognise clinical areas which achieve consistently high standards, “The ACE Award” (Acknowledging Continuous Excellence) was introduced. This award recognises achievement in each of the categories identified above and also for ‘patient experience’.
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