Airedale NHS Foundation Trust: Quality Impact Assessment Tool

Overview

An impact assessment is a continuous process to ensure that possible or actual business plans, changes to use of clinical areas, new information technology (IT) software for patient management or any other proposed business, change or implementation plans that impact on patient services are assessed and the potential consequences on quality of care for patients and any impact on staff are considered and any necessary mitigating actions are outlined in a uniformed way.

This tool involves an initial assessment (Stage 1) to quantify potential impacts (positive or negative) on quality from any proposal to change the way services are delivered, policies that are reviewed / developed and any new services. Where potential negative impacts are identified they must be risk assessed using the risk scoring matrix to reach a total risk score.

Quality is described in 6 areas, each of which must be assessed at Stage 1. Where a potentially negative risk score is identified and is greater than (>) 9 this indicates that a more detailed assessment is required in this area. All areas of quality risk scoring greater than 9 must go on to a detailed assessment at Stage 2.

Scoring

A total score 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 a total score. The following tables define the impact and likelihood scoring options and the resulting score: -

LIKELIHOOD		IMPACT
1	RARE	1	NEGLIGIBLE
2	UNLIKELY	2	MINOR
3	POSSIBLE	3	MODERATE
4	LIKELY	4	MAJOR
5	ALMOST CERTAIN	5	CATASTROPHIC

Risk score	Category
1 - 8	Low risk (green)
9 - 12	High risk (orange)
15 - 25	Extreme risk (red)

A full description of impact scores can be found at Appendix 1.

Stage 1

The following assessment screening tool will require judgement against areas of risk in relation to quality. Each proposal will need to be assessed whether it will impact adversely on patients / staff / organisations. Where an adverse impact score of greater than (>) 9 is identified in any area this will result in the need to undertake a more detailed Quality Impact Assessment (stage 2).

Title and lead for scheme:  Neonatal Unit Level 1       Mathew Babirecki, Lead Neonatologist, Airedale Hospitals NHS FT

Brief description of scheme: The Neonatal Unit at Airedale NHS Foundation Trust is commissioned to provide Level 2 Neonatal Care.  In 2018/9 the unit reviewed the current activity, acuity and staffing models in response to paediatric workforce challenges and in order to respond to these a joint decision between operational and clinical teams was made to deliver a Level 1 service. 

The cot base was reduced to 10 as the activity infrequently exceeded this number and because the acuity of the babies received on the unit was low, ANHSFT and BTHFT worked in collaboration to agree a joint pathway to ensure that all women presenting under 32 weeks of gestation were assessed at Airedale and then transferred to another unit if appropriate  This could be Bradford or could be another unit across the Yorkshire and Humber network. This is consistent with network practice. 

The unit has continued to function as a Level 1 unit since and there have been no adverse events to date.

Answer positive / negative (P/N) in each area. If ‘N’ score the impact, likelihood and total in the appropriate box. If score > 9 insert ‘Y’ for full assessment

Area of Quality	Impact question	Positive/Negative	Impact	Likelihood	Score	Full Assessment required
Duty of Quality	Could the proposal impact positively or negatively on any of the following - compliance with the NHS Constitution, partnerships, safeguarding children or adults and the duty to promote equality?	N	1	2	2
Patient Experience	Could the proposal impact positively or negatively on any of the following - positive survey results from patients, patient choice, personalised & compassionate care?	N	3	2	6
Patient Safety	Could the proposal impact positively or negatively on any of the following – safety, systems in place to safeguard patients to prevent harm, including infections?	P
Clinical Effectiveness	Could the proposal impact positively or negatively on evidence based practice, clinical leadership, clinical engagement, staff experience and / or high quality standards?	P
Prevention	Could the proposal impact positively or negatively on promotion of self-care and health inequality?	N	3	2	6
Productivity and Innovation	Could the proposal impact positively or negatively on - the best setting to deliver best clinical and cost effective care; eliminating any resource inefficiencies; low carbon pathway; improved care pathway?	P
Resourcing	Could the proposal impact positively or negatively on the number of vacancies or on the need for temporary workforce?	N	1	1	1
Resource Impact	Could this proposal impact positively or negatively with regard to estates, IT resource, community equipment service or other agencies or providers e.g Social care/voluntary sector / District nursing	P
People Experience	Could this proposal impact positively or negatively on the experience of our people? E.g. impact on morale, increase in turnover	N	1	1	1
Equality, Diversity and Inclusion	Could any colleagues or patients with a protected characteristic (Equality Act 2010) suffer detriment as a result of the proposal?	N	1	2	2

Please describe your rationale for any positive impacts here:

Patient safety – Reduces the risk of harm to the baby born in a unit that does not see the number of babies born under 32 weeks to maintain a safe level of competence  

Clinical effectiveness –  Unit already involved with Y+H neonatal network and works closely with Bradford for shared guidance

Productivity and Innovation – Reduces harm to baby born in wrong unit and instead baby born in a unit with specialist available to manage care needs

Resource Impact – No change

Signature:

Designation:

Date:

Stage 2

Area of quality	Indicators		Risk (5 x5 risk matrix)			Mitigation strategy and monitoring arrangements
		Description of impact (Positive or negative)	Impact	Likelihood	Overall Score
DUTY OF QUALITY	What is the impact on the organisation’s duty to secure continuous improvement in the quality of the healthcare that it provides and commissions. In accordance with Health and Social Care Act 2008Section 139?	Positive - Improvement in babies care as they will be born in a unit where there are specialised staff to manage the condition of the baby. The staff on the unit will continue to maintain staff skills and knowledge to ensure any unexpected pre-term deliveries are managed safely whilst awaiting EMBRACE transfer	2	1	2
	Does it impact on the organisation’s commitment to the public to continuously drive quality improvement as reflected in the rights and pledges of the NHS Constitution?	Positive – As above babies will be born in units with specialised teams	2	1	2
	Does it impact on the organisation’s commitment to high quality workplaces, with commissioners and providers aiming to be employers of choice as reflected in the rights and pledges of the NHS Constitution?
	What is the impact on strategic partnerships and shared risk?	Positive – NNU already works closely with Y+H neonatal network	1	1	1
	What is the equality impact on race, gender, age, disability, sexual orientation, religion and belief, gender reassignment, pregnancy and maternity for individual and community health, access to services and experience of using the NHS	No change
	Are core clinical quality indicators and metrics in place to review impact on quality improvements?	Positive – data collected through badgernet and Y+H network. Dashboards shared monthly with clinical leads. Off pathway deliveries reviewed at peri-natal and within network	1	1	1
	Will this impact on the organisation’s duty to protect children, young people and adults?	No change

PATIENT EXPERIENCE	What impact is it likely to have on self reported experience of patients and service users? (Response to national/local surveys/complaints/PALS/incidents)	Negative – risk of increased compliant from parents whose choice of place of delivery cannot be upheld due to needing to transfer to another hospital where the baby can receive the correct care	2	2	4
	How will it impact on choice?	Negative – may reduce choice of delivery location for some woman	2	2	4
	Does it support the compassionate and personalised care agenda?	Negative	2	2	4
PATIENT SAFETY	How will it impact on patient safety?	Positive – babies will be transferred in utero where every possible and baby will be born at a hospital where the neonatal unit has the appropriate skilled staff to manage ongoing cares	2	2	4
	How will it impact on preventable harm?	Positive – babies will receive care from staff with specialised skills	1	1	2
	Will it maximise reliability of safety systems?
	How will it impact on systems and processes for ensuring that the risk of healthcare acquired infections is reduced?	No change
	What is the impact on clinical workforce capability care and skills?	Negative – risk staff will be become deskilled in managing on going care. Additional training has been implemented to support maintaining skills for stabilisation		2 x 2	4
CLINICAL EFFECTIVENESS	How does it impact on implementation of evidence based practice?	No change – will continue to work with Y+H network and tertiary centre to ensure best practice delivered
	How will it impact on clinical leadership?	Negative – additional clinical leadership will be required to support ensuring staff maintain skills required for stabilisation of a pre-term baby	2	2	4
	Does it support the full adoption of Right Care Value metrics?	Positive	1	1	1
	Does it reduce/impact on variations in care?	Positive	1	1	1
	Are systems for monitoring clinical quality supported by good information?
	Does it impact on clinical engagement / staff experience?	Negative – some staff may prefer to provide care for Level 2 and 3 babies rather than level 1 babies	1	1	1
PREVENTION	Does it support people to stay well?	Positive – supports babies getting the best start	1	1	1
	Does it promote self-care for people with long term conditions?
	Does it tackle health inequalities, focusing resources where they are needed most?	Negative – allows resources to be focused on high intensive neonatal unit but can impact upon families having to travel further	2	2	4

PRODUCTIVITY AND INNOVATION	Does it ensure care is delivered in the most clinically and cost effective way?	Positive	2	2	4
	Does it eliminate inefficiency and waste?	Negative – increase in patient transport costs	2	2	4
	Does it support low carbon pathways?	Negative	2	2	4
	Will the service innovation achieve large gains in performance?	Negative – no change
	Does it lead to improvements in care pathway(s)?	Positive
RESOURCE  IMPACT	Will the proposal result in additional/reduced accommodation requirements	No change
	Will the proposal require an increase/purchase of IT products or services.	No change
	What impact will the proposal have on the cost of prescribing community equipment?	No change
	Will this proposal affect any existing partnership/commissioning  arrangements when service is implemented	Negative – change to designation of level of unit from level 2 to level 1
WORKFORCE AND PEOPLE IMPACT	Does the proposal involve increasing or reducing staff posts? If so describe the impact this will have	No change
	Could services be negatively impacted by this workforce change for a short term, medium term or longer term?	No change
	Could this proposal impact positively or negatively on the experience of our people?  E.g. impact on morale, increase in turnover	Neutral.  Although some staff will miss the opportunity to provide ongoing specialist care there has been a shift to focus on providing family centred care to our babies and support them prior to discharge.  We have already appointed several experienced nurses from tertiary units who recognise this.
	Is the loss of posts likely to impact on the number of vacancies or the need for temporary workforce?	No change
	Could any colleagues or patients with a protected characteristic (Equality Act 2010) suffer detriment as a result of the proposal?

Signature:	Designation:	Date:
Signatures Medical Director: Chief Nurse: Director of People &OD:	EQIA reviewed by Executive Directors through EQIA panel and signed off on behalf by the Chief Nurse in support of the proposal. No significant risks identified to the change in level of neonatal unit status from Level 2 to Level1.	11 December 2023

Appendix 1

Consequence	1. Negligible	2. Minor	3. Moderate	4. Major	5. Catastrophic
Financial	£0k - £50k	£50k to £250k	£250k to £900k	£900k to £1.8M	Over £1.8M
Harm	No injury or harm	Some minor injuries or ill-health - minor. <3 days absence	Many minor injuries or ill-health – temporarily incapacitating. RIDDOR reportable.	Some major injuries/ ill-health - permanently incapacitating	Multiple injuries/infections Unexpected Death
Disruption	One day Service disruption/1 or 2 staff absent.	One week Service disruption/<5 staff absent.	One month service disruption/5-10 staff absent.	Up to 6 months service disruption/11-20 staff absent.	6 months to 1 year service disruption/21-50 staff absent.
Litigation	Replacement of property.	Replacement of property and finances.	Minor out-of-court settlement.	Civil action – no defence.	Criminal prosecution.
Damage	Minor property damage/ no environmental impacts.	Slight property damage/ impacts on internal environment.	Moderate property damage/impacts on local environment.	Severe property damage/impacts on local environment.	Loss of whole department/impacts on regional environment.
Reputation/ Confidentiality/ Data Loss	Damage to individuals’ reputation. Minor breach of confidentiality. Minor complaint resolved within team.	Damage to team reputation. Temporary loss of information. Minor complaint resolved by local management.	Damage to Service reputation/local media coverage on day. Loss of information/ records. Some complaints resolved by Senior management.	Damage to Trust reputation/local media coverage <3 days. Irrecoverable loss of vital records/information. Complaints resolved by Chief Executive.	Damage to Health Authority reputation / national media coverage <3 days. Prosecution under Data Protection legislation. Complaints resolved by Ombudsman or Healthcare Commission
Clinical care	No significant effect on quality of care provided	Noticeable effect on quality of care provided	Significant effect on quality of care provided	Patient care significantly impaired	Patient care impossible
Consequence	1. Negligible	2. Minor	3. Moderate	4. Major	5. Catastrophic
Performance	No significant effect on internal standards	Internal Standards not achievable	Repeated failure to meet internal standards	National Performance not achievable (Intermittent)	National Performance not achievable (Continuous)
Enforcing action	Audit non-conformance/advice from enforcers.	Breach of procedure/ Directive from enforcers.	Improvement Notice.	Prohibition Notice.	Government Investigation.
Transfer of paper – electronic	No injury or harm	Noticeable effect on quality of care provided Internal standards not achieved	Significant effect on quality of care provided Repeated failure to meet internal standards	Patient care significantly impaired National Performance not achievable (Intermittent)	Patient care impossible National Performance not achievable (Continuous)
Human Resources / Organisational Development / Staffing & Competence	Short term low staffing level temporarily reduces service quality (<1 day) Short term low staff level (<1 day) where there is no disruption to patient care	Ongoing low staffing level reduces service quality Minor error due to ineffective training / implementation of training	Late delivery of key objective / service due to lack of staff. Unsafe staffing level or competence (<1 day) Low staff morale Poor staff attendance for mandatory / key training Ongoing problems with staff levels	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 No staff attending mandatory / key training	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

LIKELIHOOD

LEVEL	DESCRIPTOR	DESCRIPTION	% CHANCE OF        RE-OCCURENCE
1	Rare	Can’t believe this will ever happen (that is to say not in the next 5 years)	1  - 5 %
2	Unlikely	Do not expect it to happen but it is possible (once every 3 – 5 years)	6 – 25%
3	Possible	May occur occasionally (once or twice a year)	26 – 50%
4	Likely	Will probably occur (once or twice a month)	51 – 75%
5	Almost Certain	A persistent issue (more than once a week)	76 – 100%

Likelihood	Consequences
5. Almost Certain	5	10	15	20	25
4. Likely	4	8	12	16	20
3. Possible	3	6	9	12	15
2. Unlikely	2	4	6	8	10
1. Rare	1	2	3	4	5
Impact	1. Negligible	2. Minor	3. Moderate	4. Major	5. Catastrophic

Plans scoring 9 and above will be reviewed by the DoN & MD

Plans scoring 15 and above will be reported through to the Board of Directors in line with ANHSFT processes.

Released : 13 April 2018

Updated :12 July 2022

Acknowledgment : ANHSFT would like to acknowledge the work of Southern Derbyshire Clinical Commissioning Group in the creation of this document