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Assessment of my personal and professional development through MSc using…

- - - - identifying areas through audit and assurance which demonstrates a theory to practice gap - implemented PDNs to work clinically promoting experiential learning
        
        impact of audit showed that current approach to WARRN training was ineffective, identfying a theory to practcice (RWF XXX) gap.
        
        Required use of experiencial learning to enhance team based staff knowledge and skills impacing on patient care and clinical practice
        
        Identified the need for additional support for all new registrants with the NMC, this included the Streamliners and the IENs.
      - Service Group wide Training needs analysis conducted
        
        to inform the annual training plan
      - Adapting training contemporaneously in line with new National policy and legislation
        
        2023 - training to meet the requirements of Duty of Quality and Candour
        
        2025/26 - training to meet the requirements of Listening to People Regulations (REF, XXXX)
      - Adopting the Train the Trainer model (REF, XXXX) as most effective in practice (REF, XXXX)
    - - example
    - - This supports my role as chair of the Policy Review Group
        
        Combatting imposter syndrome (REF, XXXX)
        
        Improved Terms of Reference for the Group
        
        Improved governance and assurance for the Organisation
        
        Impact on patients and Staff
        
        Consistent up to date and evidence based care
        
        Links to Complaints handling
- - - - Statutory and Regulatory requirements
        
        Implementation of the Welsh Government Quality and Safety Framework to ensure statutory duty across HB
        
        Annual Quality Reporting
        
        Publication of an Annual report on how the duty has been applied within the Health Board
        
        "Always on" Reporting
        
        Regularly updating on quality aspects including providing data on key metrics, feedback, clinical outcomes, through quality and performance reports
      - STEEEP framework (REF, XXXX)
        
        Safe Care
        
        Prioritising safety by management of risk, preventing harm and safeguarding from abuse
        
        As a Quality Lead within the Senior Management Team, ensuring that Quality impact assessments are carried out at every opportunity
        
        Ensures that all decisions relating to changes in process, service provision and opportunities for improvement have a quality lens at the forefront, positively impacting on patient experience and safe and effective care
        
        Timely
        
        care is offered throughout unnecessary delay to streamline processed and reduce waiting times
        
        Effective Care
        
        care informed by robust evidence to enhance patient outcomes
        
        Efficient
        
        Making the most of available resources to enhance value and reduce waste
        
        Equitable Care
        
        Quality care that minimises inequalities and meets the persons individual needs
        
        Person centred
        
        Care is provided with dignity and compassion, tailored to the individual
    - - Accurate and relevant records - robust and thorough investigations using a just culture approach
      - Open, truthful and transparent conversations about the event
      - It is ok to apologise even if there have been no failures
      - Understanding the need to support those involved and mechanism for doing so
      - Service User and family involvement
      - Learning and improvement needs to be the key focus
    - - A proactive approach which is transparent and consistent. Covers complaints, incidents, and potential redress claims
        
        Claims and Redress
        
        Welsh Risk Pool
        
        Identify Learning, Improvement and evidence of sustainable practice
        
        Established Serious Incident Review of Learning (SIRL) process
        
        Part A: New learning
        
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        Part B: improvements and action planning
        
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        Part C: Sustained improvements and assurance
        
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        Revised workforce structure to enhance Quality Improvement capability and oversight within the Service Group
        
        Undertaking a gap analysis to establishing the need, gaining approval and the successful recruitment to the Quality Improvement Nurse Manager post
        
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        Identify and implement the necessary actions
        
        Provide evidence of incremental improvement in practice and sustainability of the changes
        
        Established Quality and Safety Networks
        
        Attending the National Patient Safety Programme
        
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        Action: Organised the Health Board Quality Leads Forum with other peers as a way to collaborate and share learning, experiences and improvements
        
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        Action: Initiated the Research, Development, Innovation, Improvement, Audit and Learning (RDIIAL) Hub within the Service Group of which I am a co- director
        
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        Complaints
        
        New Listening to People Regulations to be implemented from April 1st 2026 (REF, XXXX)
        
        Aim: Ensuring that all complaints, incidents and claims raised are addressed timely, with transparency, compassion, and in a just restorative (REF, XXXX) approach
        
        Breach of Duty - continually asking if there is a breach?
        
        Required at every juncture in the process and not just at incident reporting stage i.e. post investigation, post Coroners, and when new learning is identified.
        
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        Required extensive input in order to clear backlog of overdue complaints ahead of implementation of LtP
        
        Review of Q&S workforce and analysis of capacity to complete
        
        This has provided me with an increased awareness of team capacity to address complaints using the new process, which stipulates a 15 day response time for the complainant
        
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        Proposals for completion and clear trajectories mapping out progress for assurance
        
        Carried out Training needs analysis ahead of the implementation
        
        All Incidents of all levels (No harm through to catastrophic)
        
        Review of structure to post incident strategy meetings to inform the scope and terms of reference for each investigation using a just restorative approach with all involved, family, staff members and contributors
        
        When this Just restorative approach is not used the impact on others psychological safety (REF, XXXX) is negatively impacted and is a retributive approach (REF, XXXX) to investigations, which impacts not only on the person but also the investigation outcomes with elements of blame rather that identifying learning and learning Critical Reflection
        
        Learning: Led to my critical reflection and the impact this had on my wellbeing
        
        Reinforced just cultural (REF, XXXX) approaches within my teams, through use of reflective learning events rather than statement gathering
        
        Led to my proposal using the SBAR (REF, XXXX) around the impact of a team member with lived/living experience would have on helping a just and restorative approach to all investigations
        
        Allow for early identification of learning and immediate actions to protect others and prioritise safety - identifying triggers for Duty of Candour
        
        influencing HB and National changes in incident reporting processes to ensure robust and consistent approach and outcomes - closing the loop
        
        Reporting mechanism (DATIX) hinders reporting and transparency, as unable to capture key components to inform thematic analysis e.g. subcategories relating to restrictive practices
        
        Identified as a pilot site for the All Wales reducing restrictive practices project
  - - - Identification of Risk in maintaining patient safety and improving patient experience
        
        Review of Risk processes
        
        Development and embedding of processes through use of ratified Risk Flowchart including embedded links to key documents
        
        Cleansed Risk Register for the Service Group and Health Board
        
        Justification and scrutiny of the rationale for ongoing Service Group risks
        
        Working with other Service groups where Risk identified that straddles both i.e. Allied Health Professionals sit within another Service group
        
        Collaboration, engagement, influence and consistency
        
        Development and sustainability of the Risk Scrutiny Meetings at a senior level
        
        Review of Governance structure and meeting memberships
        
        As risk is fluid and dynamic, this impacts on the contemporaneous review of risks and provides real-time learning to support across the HB
        
        links to DoC
      - Internal and External inspections
        
        Nurse Director Quality Unannounced Reviews
        
        Action: revised templates as more areas of learning and improvement identified
        
        Action: progressing to have AMaT as the desired platform for the reviews and action planning
        
        Impact: visible, decreases duplication, easier to compare and contrast with other areas, and identify trends and themes over time (REF, XXXX)
        
        Action: developed a 'speaking up safety' tool via MS Forms for staff to engage anonymously with the review process
        
        Impact: Staff feel listened to and psychologically safe
        
        outcome: promoting the essential elements of Just Culture (Dekker, 2017)
        
        Health Inspectorate Wales Announced / Unannounced Reviews
        
        Aim: ensuring that governance processes are in place for the timely review and updates to improvement plans are signed off and shared
        
        Action: use of digital platforms such as MS Teams Channels and AMaT to capture and monitor progress
        
        Action: Dashboards/Spreadsheet/Database outlining the programme of work and frequency of reviews and target compliance deadlines
        
        Impact: increased collaboration, cohesion and ownership of the plans and assurance
        
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        HB Corporate Assurance review
        
        Identified that the Corporate tool was more relevant to the other service areas of the HB
        
        Action: a review conducted of the Corporate tool, to ensure the efficacy and relevance of the audit criteria appropriate for the speciality
        
        Impact: more relevant to the speciality and the feedback is positively received by staff as is pertinent to service provision
        
        Outcome: meaningful reviews resulting in improved patient care
        
        Identified that the clinical understanding of the speciality was lacking by the reviewing team
        
        Senior clinical member of the specialist team now participates in all reviews to advise and guide on service specific requirements
        
        feedback sessions were being provided to the senior team and clinician at ward level were not present
        
        Action: clinicians now present for the feedback sessions
        
        Impact: receive the feedback on areas for improvement and able to have a voice in influencing appropriate actions for their areas
        
        Outcome: Empowered Ward Managers and Ward Clinicians
        
        Ward and Directorate level Assurance Reviews
        
        Aim: providing assurance by ensuring consistent reporting and closing the learning and improvement cycle
        
        Action: implemented sessions by the Quality Improvement Lead within my team to support the Directorate leads with the digital system, its configuration and the expectations around the rationale and importance of quality assurance
        
        Impact: consistency approach to reviews and the ability for directorate leads to support each other and provide peer reviews across the service group
    - - Quality Assurance
        
        Ensuring systems operate correctly to uphold quality
      - Quality planning
        
        Outlining clear goals and standards
        
        Scoping and benchmarking using the All Wales Maturity Matrix for Quality Management Systems
        
        Enabled a strategic overview of current positions and allowed for assessment, gap analysis and reflection in our QMS journey
        
        Which has provided demonstratable evidence of Quality services
      - Quality Control
        
        Implementing strategies to prevent incidents and clear mechanism to monitor
      - Quality Improvement
        
        Identifying areas of improvement by triangulating data, audit and feedback
      - There is both a national and Health Board requirement to implement a Quality Management System
- - - - Use of constructive and concise feedback (Brown et al., 2016; Geisler, 2023)
        
        knowing that i am supporting my staff also supports my own wellbeing
        
        Staff reported feeling valued, listened to, better job satisfaction and autonomy
      - Use of performance enhancing techniques (REF, XXXX)
      - Improved staff retention as an outcome of improved staff experience (Ref, XXXX)
        
        ensures that I am better prepared for my own PADR
      - Setting mutually agreed clear SMART aims and objectives (REF, XXXX)
        
        'Mastery' of the PADR processes for myself and team members - Novice to Expert (Benner, 1980)
      - Use of diverse self- assessment tools following my personal use of the Johari window (REF, XXXX)
  - - - involvement in and becoming member of the HB Policy reviews - ensuring that there is a voice for the service group and are sited on all HB policies
    - - understanding the different types of policy documents ensuring governance of the processes
        
        safer for the patients, staff and organisation
      - governance processes strengthened through introduction of the front sheet
  - - - creating space to enhance psychological safety
        
        enhancing opportunities for reflective practice (Rolfe et al, XXXX)
        
        supporting the workforce by increasing resilience (XXXX, ????)
        
        setting up restorative clinical supervision (XXX, ????) for all team members that meets the needs of the diverse workforce
        
        WARRN Risk Assessment facilitators link this to green
        
        IENs Support network
        
        Serious incident investigator team
        
        varying needs as some
        
        impact: trying out different reflective models Borton's (1970) framework 'What’ - sensing, ‘So what’ – transforming, and ‘Now what’ – acting.
  - - - Development of the HB LE strategy
- - - - recognising diversity
        
        acknowledging cultural differences in providing care
        
        Enabling a diverse workforce to meet the needs of a diverse patient group
    - - experiential learning and links to WBL