LQAF: HCLU Guidance on Submitting a Quality Return for Northern LKS

2016

Prepared by Linda Ferguson,

Health Care Libraries Unit North

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Table of Contents 1. Helping you produce a quality LQAF return for 2016 ..................................................................... 3

1.1 Examples of good practice from 2012, 2013 and 2015 NW LQAF submissions ................................ 3

1.2 Other resources to support you...................................................................................................... 4

2. Changes to Criteria 1.3c and 5.3l in the LQAF 2.3a April 2016 ........................................................ 4

3. The LQAF submission process for 2016 .......................................................................................... 5

3.1 The self-assessment process ...................................................................................................... 5

3.1.1 Core criteria ............................................................................................................................ 5

3.1.2 Validated full compliance ....................................................................................................... 5

3.1.3 Variations in compliance ........................................................................................................ 5

3.1.4 New evidence ......................................................................................................................... 6

3.1.5 Personalised requirements ..................................................................................................... 6

4. General observations on submissions ............................................................................................ 6

5. Key points on compliance statements ............................................................................................ 7

6. Key points on evidence ................................................................................................................... 7

6.1 How to name evidence files ............................................................................................................. 7

7. Completing the 2016 Excel Standards Assessment Tool (SAT) ....................................................... 8

7.1 Starting from scratch with the blank SAT ................................................................................... 8

7.1.1 Filling in the blank Domains Criteria worksheet ..................................................................... 8

7.1.2 The Action Plan ....................................................................................................................... 8

8. Copying from your 2015 SAT to the 2016 SAT ................................................................................ 9

8.1 Filling in the Domains Criteria worksheet ................................................................................... 9

9. Providing the evidence for the SAT ................................................................................................ 9

9.1 How to embed evidence in an MS Word document ................................................................. 10

10. Uploading your LQAF self-assessment to the wiki ........................................................................ 10

10.1 Introduction .............................................................................................................................. 10

10.2 Accessing your Trust’s page ...................................................................................................... 11

10.3 How to edit your page and add documents ............................................................................. 12

11. Some Excel hints and tips ............................................................................................................. 13

12. Submitting your LQAF self-assessment to HCLU ........................................................................... 14

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1. Helping you produce a quality LQAF return for 2016 This one document incorporates the main guidance that you will need on completing your Excel Standards Assessment template (SAT) based on the lessons learned which should help you see how we assess submissions. It also includes information on how to upload your SAT and the evidence on the LIHNN wiki. If you have any queries then please contact the HCLU Team member below for your area but anyone of us will be able to help.

North East linda.ferguson@nhs.net 01942 482 583 or 0797 971 1908

North West gil.young@nhs.net 01942 482 584 or 0779 531 0852

Yorkshire & the Humber dominic.gilroy1@nhs.net

07342 059099

Remember this is your opportunity to tell us about your service. Imagine we know nothing!

1.1 Examples of good practice from 2012, 2013 and 2015 NW LQAF

submissions

HCLU have identified services that either provided good compliance statements or good examples of

evidence for criteria where we felt it would be most useful from the 2012, 2013, 2014 and 2015

submissions.

Please go to http://resources.lihnn.nhs.uk/wiki/LQAF.LQAF-Good-Practice.ashx to download

documents relating to the following:

Domain 1 - STRATEGIC MANAGEMENT Strategy 1.1b Implementation Plan 1.2a; 1.2b; 1.2d, 1.2e Operational Management 1.3a; 1.3c Domain 2 - FINANCE AND SERVICE LEVEL AGREEMENTS Finance and Budgets 2.1b; 2.1d

Domain 5 - LIBRARY/KNOWLEDGE SERVICES SERVICE DELIVERY AND DEVELOPMENT Service Promotion and Marketing 5.1a Information Skills/Literacy Training 5.2a - 5.2d Library/Knowledge Services 5.3a; 5.3h; 5.3i; 5.3j Knowledge Management 5.4a*; 5.4b In addition 11 Trusts (3 highest scoring from the North East, 4 from the North West and top 4 from Yorkshire and the Humber) have agreed to share their full submissions, evidence and HCLU verified scores documents. Evidence for Domain 2 has not been shared but the compliance statements have. These can also be found on the http://resources.lihnn.nhs.uk/wiki/LQAF.LQAF-Good-Practice.ashx page.

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1.2 Other resources to support you On the LQAF Documents page http://resources.lihnn.nhs.uk/wiki/LQAF.LQAF-Documents.ashx

this guidance

a blank HCLU feedback form

staffing calculation in support of 3.1c – please complete worksheet and provide a copy of the

“calculations sheet”.

You can search for examples of innovation by entering the criterion number in to the innovations

database at http://lks.kss.hee.nhs.uk/data/web/innovations.htm

For updates (April 2015) to URLs and additional references included in the “Additional tips, tools, templates or references” section of each criterion see the national “LQAF wiki “ at http://www.libraryservices.nhs.uk/wiki/LQAF.MainPage.ashx

2. Changes to Criteria 1.3c and 5.3l in the LQAF 2.3a April 2016

Following publication of Health Education England’s Knowledge for Healthcare Working Groups

supported by Task and Finish Groups were established to implement the work programmes. A

major review of LQAF will be carried out in 2016/17 but in the interim changes have been

made to two criteria to align them with this work.

Criterion 1.3c Impact has been edited to bring it in line with the revised “Impact Toolkit” by

the Value and Impact Task and Finish Group.

Criterion 5.3l Patient and Public information guidance has been revised by the Patient and

Public Information Task and Finish Group.

TO NOTE: 5.3l Patient and Public information

At present library/knowledge services which are not required by the organisation[s] to provide

services to patients and/or the public may opt to regard this criterion as “not applicable”.

From 2017, all NHS-funded library/knowledge services will be expected to evidence some

level of direct or indirect contribution to patient and public information.

5.3l for 2016

If you are not required to do this by your Trust then score 5.3l as “Not applicable” but in

preparation for 2017 please see:

http://kfh.libraryservices.nhs.uk/patient-and-public-information/ and in your compliance

statement please tell us which of the services listed you currently provide or could provide in

time for LQAF in 2017.

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3. The LQAF submission process for 2016

All NHS library and knowledge services in England are required to complete an LQAF return. This is

specified in Learning and Development Agreements held between each NHS Trust and Health Education

England. There is a schedule in the LDAs that covers library and knowledge services.

3.1 The self-assessment process The new process of self-assessment is based on the principles of core criteria, validated full compliance

without reservations and variance in compliance.

3.1.1 Core criteria

There are certain criteria which by their very nature require current evidence to demonstrate full

compliance with the standard. We have identified 10 core criteria namely:

Domain 1 Domain 2 Domain 3 Domain 4 Domain 5

1.2a 1.2d 1.3c

N/A 3.1c (including the staffing calculation for 2016/17)

N/A 5.1a 5.3a 5.3h 5.3j 5.3l 5.4a

Plus we would like to see a copy of the generic library leaflet and the url if you have a library website on the Internet.

3.1.2 Validated full compliance

If HCLU has verified that you have met the requirements for full compliance for the other applicable criteria without reservations (i.e. no “Things to be changed…” comments) then unless your self-assessment differs from the previous year or you have new evidence you wish to share with us, you do not need to provide evidence again. You will score the criterion as Full compliance and in you compliance statement say: “No change from 2015”.

3.1.3 Variations in compliance

3.1.3.1 Non-compliance and partial compliance – no change to compliance level

For criteria where HCLU has verified your compliance as non-compliance or partial compliance and the compliance level for 2016 has not changed then you need to:

score the criterion,

complete the compliance statement with “No change from 2015” – remember you also need to do this for any scored as “Not applicable” explaining why.

No evidence is required.

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3.1.3.2 Non-compliance and partial compliance – change in compliance level

For criteria where HCLU has verified your compliance as non-compliance or partial compliance and the compliance level has changed then you need to:

score the criterion,

complete a full compliance statement that explains why the score has increased and

provide any appropriate evidence.

3.1.3.3 Full compliance with a “Things to be changed in next submission” comment

For criteria where HCLU has verified your compliance as Full compliance with a “Things to be changed in next submission” comment then you need to:

score the criterion,

complete the compliance statement and

provide any appropriate evidence.

3.1.3.4 Self-assessed reduced score

If your self-assessed compliance level has gone down from the previous year then you will need to:

score the criterion,

complete a full compliance statement that explains why the score has dropped and

provide any appropriate evidence

3.1.4 New evidence

If you have new evidence you wish to share with us then you will need to:

score the criterion,

complete a compliance statement that explains why you have provided new evidence and

provide the new evidence.

3.1.5 Personalised requirements

Each service is therefore likely to have a different number of criteria to complete. HCLU has Identified your requirements for 2016 using your 2015 LQAF results as the basis and produced a personalised LQAF requirement for each service.

4. General observations on submissions When we validate returns we base our assessment solely on the evidence you have submitted and treat each one as if it is the first time we have seen anything about the service. Assume we know nothing! Remember:

to read the LQAF guidance so you do not miss key requirements. This is what we use when we are assessing your returns – if it says you need w, x, y and z for full compliance and you only supply evidence for w and z then it is not full compliance.

to review our comments from 2015 and make sure that if we said “Things to be changed in next submission” that you provide evidence relating to the changes requested otherwise your score will be affected.

allow enough time to complete the submission by the deadline and inform HCLU as early as possible if you think you will encounter difficulties in doing so.

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involve other members of your team in gathering the evidence and completing the compliance statements in the SAT.

ask another member of your team or a colleague from another Trust to read your submission before sending it to HCLU, checking that all attachments will open.

visit the national LQAF wiki at http://www.libraryservices.nhs.uk/wiki/ for updates to urls and additional resources.

But most importantly you can ask us for help or to check your understanding of what is required. We are happy to answer any questions and provide advice on evidence - you just need to ask us.

5. Key points on compliance statements

Compliance statements should:

all be completed even if the criterion is not applicable you should tell us why otherwise we will be unable to score the criterion and have to award non-compliance.

all be scored otherwise we will only be able to award non-compliance

be concise but not too concise i.e. not just a list of bullet points

refer to the evidence that you have either provided or would have provided if you had been

asked to do so

explain why the evidence has been included – if we cannot make the connection then your

compliance level will be lower than you expect.

be easy to read – please check spelling and make sure that words are not missing from your statements otherwise the sense may be changed and the reviewers will have to spend far longer on some submissions than others.

6. Key points on evidence

Think quality, not quantity.

An excessive amount of evidence will not guarantee a verified Full Compliance score. For example, if

you provide a tailored current awareness service to say 30 staff groups then you need only provide a

couple of examples with a note in the SAT compliance statement saying “… similar CAS is provided to

OTs, Physiotherapists etc.”

Try to limit your evidence to a maximum of 5 pieces of evidence for a criterion.

Remember you can refer to other evidence you have provided by with see references e.g. in 5.3g you

could say see evidence number 3 in 5.3a.

6.1 How to name evidence files Best practice is to name the MS Word document (either Word 97-3003 or Word 2010) so that you and

HCLU can see at a glance what is included like this: 5.2abcd.doc OR 5.2a–5.3b.doc OR 5.3cto5.3h.doc

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7. Completing the 2016 Excel Standards Assessment Tool (SAT) We will be using the new Standards Assessment Tool (SAT) issued in April 2016. There are two versions

available: one with the guidance from the 2016 NHS Library Quality Assurance Framework (LQAF) 2.3a

embedded within it and one without the embedded guidance. You choose which version to use but you

should note that the guidance does make the Excel file a much larger file size and this may cause

problems when you come to upload it.

7.1 Starting from scratch with the blank SAT

7.1.1 Filling in the blank Domains Criteria worksheet

a. Open the Excel Standards Assessment Tool (SAT) and select the first worksheet called

“DomainsCriteria”. This is where you will enter your self-assessment and compliance statement.

b. Add the name of your library service in the blue box in Cell C2. c. Read the guidance in the LQAF and score your service for each criterion as:

“Full Compliance”, “Partial Compliance”, “Non-compliance” or “Not Applicable” by selecting the appropriate phrase from the drop down list in Column F and

a score of 0, 1 or 2 will automatically appear in Column H. d. Remember to save the SAT regularly as it does not auto save like MS Word does! e. Complete Column D “Evidence Supporting Compliance” by providing a compliance statement

that explains why you have scored the criterion the way you have.

All cells in Column D should be completed regardless of how you have scored the criterion.

If you decide the criterion is “Not Applicable” then you will still need to explain why. If you leave this blank then HCLU will validate this as “Non-compliance”.

f. Use Column E “Online Evidence Supporting Compliance” for hyperlinks to Internet and Intranet sites but remember if you want to include hyperlinks to your Intranet site please make sure it can be accessed outside your Trust.

g. Please DO NOT embed any evidence in the SAT See section 8 Providing the Evidence below. h. Work your way through all 48 criteria completing the compliance statements. Remember if you

leave any of them blank HCLU will only be able to score it as “Non-compliance”.

7.1.2 The Action Plan

If you wish you can go to the “ActionPlan” worksheet and you will see that it has automatically filled in the columns below for you:

o C (Evidence Supporting Compliance), o D (Online Evidence Supporting Compliance) o E (Compliance) and o F (Score).

You may if you wish fill in columns:

o G (Local Actions to be taken to meet criterion) o H (Deliverables (with dates)) o I (Lead person)

We may ask you to complete the Action Plan at a later date if your validated compliance score is

significantly below you “region’s” average score.

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8. Copying from your 2015 SAT to the 2016 SAT

8.1 Filling in the Domains Criteria worksheet It is very likely that the compliance statement and scoring in your 2015 LQAF SAT will still be applicable

as some things do not change. It is therefore appropriate for you to copy the compliance statement to

the 2016 SAT.

Remember to check the evidence or references to the evidence are still up-to-date e.g. ensure minutes

from team meetings are dated between 1 October 2015 and 30 September 2016 (NW) and not from

the previous year!

a. Open the 2015 Standards Assessment Tool and then the 2016 SAT and select the first worksheet called “DomainsCriteria”.

b. In the 2015 SAT select the text from Column D “Evidence Supporting Compliance” (and if it has not changed Column F “Compliance”) and copy it.

c. Switch to your 2016 SAT and paste the text in to Column D for the relevant criterion. d. The compliance should automatically show but if you need to change it for 2016 you will need

to select whether it is: i. “Full Compliance”, “Partial Compliance”, “Non-compliance” or “Not Applicable” by

selecting the appropriate phrase from the drop down list ii. A score of 0, 1 or 2 will automatically appear in Column H.

e. Continue to cut and paste where relevant. f. Do not embed any evidence in the SAT See section 9 Providing the evidence for the SAT. g. Remember to save the SAT regularly as an Excel 97-2003 workbook (*.xls) as it doesn’t auto

save like MS Word does! h. See also 8.1 Starting from scratch with the blank SAT for criteria where you want to start from

scratch.

9. Providing the evidence for the SAT You will be embedding your evidence in to MS Word documents (*.doc or *.docx) and uploading each document on to the wiki. We suggest you provide one Word document per section e.g. 1.1 but this will depend on the amount of evidence you are supplying so you may want to split them in to more than one document per domain.

For Domain 5 it is best to provide at least one document per section (i.e. 5.1, 5.2) but 5.3 is best split in to two or more documents as it contains the most criteria.

Be aware of issues caused by different versions of MS Office

Only embed .docx in Word 2010 files and .xlsx in Excel 2010 files. If you try to embed a 97-2003 version (.doc or .xls) in an Office 2010 file it may corrupt the whole document and HCLU may not be able to open it.

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9.1 How to embed evidence in an MS Word document

a. Open a Word document and save it as a “Word document (*.doc or *.docx)” with the short name/accepted abbreviation of your Trust’s name plus the name of the number of the Domain e.g. AIR1.1.doc

b. You may find it helpful to create a table with say a row for the heading and one row for each criterion number for which you have to provide evidence.

c. “Embed” your evidence in the appropriate column by “inserting” an object that you “Create from a file”. (see screen shot on next page) Do not use the “Create New” option for PDF files.

Remember to “Display as icon” rather than “Link to file”. Word can accept PDF, Excel,

PowerPoint, Word, JPG, BMP, TIFF

(different types of pictures) as

embedded objects.

d. Continue to supply your evidence in Word documents for each Domain. You may want to “zip” the files to compress the size. The wiki will accept .zip files.

e. Once you have provided evidence for all the “Applicable” criteria i.e. those scored as Full, Partial or Non-compliance then you are ready to add the SAT and the evidence documents to the LQAF namespace in the LKS in the North wiki. See 10 Uploading your LQAF self-assessment to the wiki below.

10. Uploading your LQAF self-assessment to the wiki

10.1 Introduction

Login at http://resources.lihnn.nhs.uk/wiki/LQAF.Login.aspx and select LQAF from the namespace menu:

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If you forget to change the namespace you will see the “root” (LIHNN wiki “Home” page) you can select

the HCLU Namespace - Library Quality Assurance Framework (LQAF) by clicking here

10.2 Accessing your Trust’s page The LQAF “home page” (screen shot below) contains tables listing the names of the NE, NW and Y&H Trusts. Clicking on your Trust’s name you will open your page. Only HCLU and nominated people from your library will be able to see your page.

As an example I have created a “Your Trust” page which is accessible to all.

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When you click “Attachments” you will see a box showing all the documents attached to the page.

10.3 How to edit your page and add documents a. Click on the “Edit” button This gives you access to the page editor. You can add any text you want to this page including messages

to HCLU or even your own staff who have been given access to the page.

You will see the page editor:

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b. If you scroll to the bottom of the page you will see “Page Attachments Management”:

c. You will need to delete the attachments from the previous year before you start. It doesn’t take long to do. HCLU has copies of all your submissions.

d. To upload the completed 2016 SAT and evidence documents “Browse” for each document on your PC etc. and then press the Upload button. Repeat for each document you wish to upload.

e. If at a later stage you want to replace an existing document make sure you give it the same name as

the one you want to replace. Browse and Upload remembering to click the “Overwrite existing attachment” check box.

f. Don’t forget to save the page when you are done otherwise you will have to reload everything again. (I know because I have had to do it more than once.)

11. Some Excel hints and tips Word wrap enabled

The “Evidence Supporting Compliance” cell has been formatted to wrap the text to the next line to

ensure it fits in the cell.

Adding line/paragraph breaks

If you have a lot of text you can add line/paragraph breaks to split it up and make it easier to read.

Press the Alt and Enter key to add a line/paragraph break.

Copy and paste

Excel has two different types of “paste” – normal paste using the standard Paste icon or the command

option of Ctrl V or and “Paste Special” (available by right clicking in any cell).

With paste special you can tell Excel to paste the text and retain its original formatting or tell it to

match the new cell’s formatting.

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Saving Excel work

Excel does not automatically save your work for you. You will need to remember to save often either pressing the Ctrl then S keys or hitting the save button.

12. Submitting your LQAF self-assessment to HCLU When your page is ready please email hclu@lihnn.nhs.uk and let us know. You can return to your LQAF page at any time but please remember that if you make changes after you have submitted your self-assessment then you will need to email hclu@lihnn.nhs.uk again so that we are aware of it. The timetable for submissions, consistency meetings and announcement of results is provided below

Area Submission deadline

Planned consistency meeting*

Expected date for results to be announced*/letters sent to Chief Executives

North West Wednesday 31 August 2016

Thursday 27 October 2016

Mid November 2016

Yorkshire and the Humber

Friday 16 September 2016

Monday 21 November 2016

Early December 2016

North East Friday 14 October 2016

Monday 21 November 2016

Early December 2016

* these dates are subject to change if verification dates have to be moved

Linda Ferguson

Deputy Director NHS Library and Knowledge Services North & LKS Quality Lead North

NW Health Care Libraries Unit

April 2016