Transcript Quality and safety - South Tyneside Clinical Commissioning Group

Quality and Safety in South
Tyneside NHS CCG
Jeanette Scott-Thomas
Head of Quality & Patient Safety
Aim of the presentation
• To provide an update on the response to the
Francis Inquiry Action Plan and what this
means for South Tyneside NHS CCG
community.
Findings from the first inquiry
(published February 2010)
• Lack of basic care across a number of wards and departments
• Trust culture was not conducive to providing good care or a
supportive environment for staff
• Too high a priority on targets
• Consultant body disassociated itself from management
• Acceptance of poor standards
• Management and Board thinking dominated by financial targets
• Absence of effective governance
• Lack or urgency to Board response to problems
• Statistics and reports preferred to patient experience
• Focus on systems and not outcomes
• Lack of internal and external transparency
Learning from 1st Inquiry
resulted in publication of:
 Review of Early Warning Systems in the NHS
 Assuring the Quality of Senior NHS Managers
 The Healthy NHS Board
 NQB – Managing Safety and Quality during in
the transition
Findings from
Inquiry
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A lack of openness to criticism
A lack of consideration for patients
Defensiveness
Looking inwards and not outwards
Secrecy
Misplaced assumptions about the judgements and
actions of others
• An acceptance of poor standards
• A failure to put the patient first in everything that is done
Key Recommendations
•Governance and trust boards
•Monitor and authorisation of Foundation Trusts
•New fundamental and enhanced standards of quality
•Duty of candour, complaints and clinical risk
•Enhancements to provision of information, inspection and
monitoring
•Workforce issues
•Commissioning for quality
•Role for regulators
Expectations from Francis 2
• How lessons learned might be applied to other parts of the
health economy
• All healthcare organisations should consider the findings
and recommendations and decide how to apply them to
their own areas of work.
• Each organisation should announce its progress against
planned actions ( no less than once a year).
• DoH should publish collective progress
• House of Commons select committee on Health should
consider incorporating update on actions from those
organisations responsible to parliament.
The whole enquiry has been focussed relentlessly on the need
to protect patients from unacceptable and unsafe care.
“The extent of the failure of the system shown in this
report suggests that a fundamental culture change is
needed. This does not require a root and branch
reorganisation – the system has had many of those –
but it requires changes which can largely be
implemented within the system that has now been
created by the new reforms.
I hope that the recommendations in this report can
contribute to that end and put patients where they are
entitled to be – the first and foremost consideration of
the system and everyone who works in it.”
• Sir Robert Francis QC (February 2013)
Initial Government Response
to Mid Staffs Inquiry
Statement of Common Purpose:
• Renew and reaffirm NHS Constitution
• Putting patients first- listening carefully and
responding quickly to patients, especially the
most vulnerable.
• Collaborating on behalf of patients – rooting
out poor care and promoting excellent care.
• Outward facing – do the business of the
patient, not the system or organisation.
Continued
• Reduced bureaucracy- freeing up time to care
and to lead. Rewarding staff for their care as well
as for skills.
• Single set of measures of success – focussing on
what matters to patients.
• Duty of candour- challenge ourselves and each
other on behalf of patients. Culture of humility,
openness and honesty.
• Commitment to change – set out plans to make
this a reality
Five Point Plan – Putting
Patients First
A. Preventing problems
B. Detecting problems quickly
C. Taking action promptly
D. Ensuring robust accountability
E. Ensuring staff are trained and motivated
Learning from Mid Staffs
Inquiry
• Francis is an opportunity to reassess what we
(commissioners) are doing and why!
• Quality and the Patient First
• Getting the basics right
• An open culture
• Contracts that work for patients and clinicians
Headline considerations for
South Tyneside CCG
Issues to consider:
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Performance and standards
Information
Professional regulation
Values and accountability
Openness and candour
Leadership
Care and compassion
Organisational culture and staff engagement
Learning from Keogh Review
Next Steps
• Key organisations across health and social care
will continue to take the action needed to
make the document a reality for patients.
• Government will report on progress annually.
• Development NHS ST CCG draft action plan
(September 2013, aligned with findings from
Keogh Reviews) shared with partners and
stakeholders for comment
• Build on assurance from Providers
123 Responsibility for monitoring
delivery of standards and quality
• Recommendation
• GPs are ideally placed to undertake a monitoring role
on behalf of their patients who receive acute hospital
and other specialist services. They offer an
independent, professionally qualified check on the
quality of service, in particular in relation to an
assessment of outcomes. They require robust
internal systems enabling the identification of
patterns of concern, so that cases are not considered
in isolation.
CCG Initial position May 2013
• Datix is rolled out to all practices but use is
variable.
• There is not a standard for communication to
patients and other clinicians re issues.
• Often a GPs duty does end when a patient is
admitted. This is variable.
• Choice is not always informed.
• No standard process from CCG perspective to
cascade info down to practices.
CCG Actions
• Explore strengthening use of Datix to capture concerns and
other soft intelligence to feed into QRGs.
• Use information from Datix, identifying themes and feedback
information through QRG and back to practices.
• Use information from Datix, identifying themes and feedback
information through QRG and back to practices.
• Need to make information easily available to GPs on South
Tyneside Portal using GP data and other intelligence. Refresh
STCCG Informatics Strategy.
• Practices to implement systems of communication.
• Create a consistent reporting and monitoring approach to
quality for the major providers for South Tyneside.
Questions/Comments?