Transcript Dr Elizabeth Hughes

Education Quality Standards
and Standards for Quality
Patient Care-are they
synonymous?
Dr E A Hughes
Regional Postgraduate Dean
West Midlands
NHS Trusts with the West
Midlands
Quality of Education
 Assurance
of quality in higher education is
the collections of policies, procedures,
systems and practices internal or external
to the organisation designed to achieve,
maintain and enhance quality
Quality in healthcare
Effective
Good
Experience
Safe
Making quality the organising principle of the
NHS
Bring clarity
to quality
Measure quality
Publish quality
performance
Recognise & reward
quality
Raise standards
Safeguard quality
Stay ahead
QUALITY OF
EDUCATION
Royal Colleges
Deanery visits
Regulators
Quality Assurance

Royal Colleges
 Deanery
 PMETB
 GMC





QAA
EQUIP
EQC
NMC
QABME
Maintaining Quality of Care
Standards
Maintaining Quality of Care Standards
 Healthcare
 CQC
 NHSLA
 SHA
 Monitor
Commission
Impact model applied to Healthcare
(adapted from Mackinnon Partnership 2000, SfH 2007)
Inputs: Money, staff time, etc
Education & Training Programmes
Better trained staff (competent & capable)
Better treatment & patient care
Better outcomes for patients
13
How can we ensure such systems work together to
achieve high quality care?
Educational change
PMETB established –substantial
change to roles of Colleges and Deaneries
 PMETB –risk based approach
 2007 MMC commenced.
 2005
PMETB
Quality Framework Autumn 2007
 QM



Visits -Deanery
‘All such visits will be targeted and proportionate to
the concerns identified prior to the visit
Wherever possible, autonomy should be given to
the Trusts, Health Boards and other LEPs to monitor
their own performance against PMETB standrards
and requirements.
Visits should have a very clear and articulated
purpose and should be kept to the minumum needed
to ensure that PMETB’s standards are met
Stafford Hospital

Visited by Deanery for Foundation training 2005
–some issues found around induction. Visited by
Head of Foundation and revisited 2006 –
satisfactory
 RCP reviewed medical training 2006 on behalf
of PMETB –satisfactory
 PMETB survey 2006 –all green triangles
 PMETB survey 2007-5 green triangles and 2 red
triangles –clinical supervision noted to be high
satisfaction
Stafford Hospital

Foundation visit in May 2008 with intervening
informal visit from Associate Dean for
Foundation School
 Foundation visitors highly experienced –
Associate Dean, Senior Clinical tutor (A and E
consultant) and Dean of Keele Medical School
 Report notes ‘review well attended by trainees
with strong engagement and people prepared to
speak out’
Stafford Hospital





A and E noted to have high level of work although it is a
very challenging and a good learning environment.
Hours in A and E noted to be good
One consultant only but good use made of Associate
specialists and practitioners in supervising FY2 doctors
Well prepared for appraisal in A and E
All consultants considered approachable
PMETB survey results indicated that some very good
training was occurring with no evidence of an endemic
problem with all training
Stafford Hospital




SpR in A and E raised concerns regarding training with
regard to lack of supervision, training and lack of cover
out of hours
Would not discuss this with the Dean so completed
JEST survey – suggested that patient safety was low in
Trust’s priority
Disparity between his views and those of FY2 doctors –
why?
HCC had identified concerns with high HSMR and care
issues and were undertaking an Inquiry
Stafford Hospital
 Intensive
action plan with weekly
monitoring, SHA involvement, A and E
task force , recruitment of middle grades
and 4 new consultants with immediate
locum input at both levels
 External visits confirmed improvement
 Multiple visits by Deanery, CQC and SHA
over last 3 years
 Can
poor educational quality be
used in isolation as evidence of a
poor standard of clinical care?
 Is good educational quality an
indicator of high quality care?
GMC Survey 2010 Total Red Outliers by LEP – Mid Staffs is 6th in league table
(Taken from GMC survey online tool – total outlier summary matrix)
GMC Survey 2008-09 Total Red Outliers by LEP – Mid Staffs 10th in league table
(Taken from GMC survey online tool – total outlier summary matrix)
Surviving the Storm
 ‘How
did we let it happen?’
 ‘It is sobering to realise how one can get
used to such poor standards
 In retrospect more of us should have
made it clear that there were unacceptable
staffing levels and practices in emergency
care’

Paul Woodmansey Clinical Medicine 2011
 What
lessons have we learned from Mid
Staffs?
 How are we bringing education and quality
together to identify areas of potential
concern and also of good practice?
Quality Review Visit Framework:
Checking our Evidence Base
Framework
Scheduled LEP
Review
Exceptional LEP
Review
Programme
Review
Deanery
Review
Description
Responsible
Scheduled Review
Head of School and
School Quality Lead
Level 1: Exceptional Paper-Based Review
Head of School and
School Quality Lead
Level 2: Exceptional Review Visit by School
Head of School and
School Quality Lead
Level 3: Exceptional Trigger Visit by Deanery with
Externality
Associate Dean for
Quality
Level 4: Exceptional Regulatory Body Trigger Visit
(i.e. GMC)
Postgraduate Dean
Planned Programme Review
Associate Dean for
Quality / Head of
School
Regulatory Body Deanery Visit (GMC)
Postgraduate Dean
Quality Assurance Visit Reviews:
Reviews 2010/11 – Approx 60-80 reviews per
year
Visit Database:
Monitoring and Closing the Loop

All process
points
documented
 Flags up if
monitoring not
completed
 Allows
performance
management
Questionnaires:
GMC Survey
 Shared with all
levels of
Deanery
(Strategic,
School,
Programme,
LEP)
 Analyse red
outliers similar
to JEST to allow
comparison
Questionnaires:
JEST (Local tool)

 Significant work
undertaken in thematic
analysis
Local survey for
Trainees
 Electronic
 Accessible by
LEPs and
Deanery
 Analysed for
themes and QA
evidence base
Patient Safety Concerns during Postgraduate
Medical
Quality Review Visits
 During
Deanery monitoring visits to Local
Education Providers and their training
units, trainees and consultants are
routinely asked by the visiting team if they
perceive any risk to patient safety in the
clinical service at the Trust.
Patient Safety Concerns during Postgraduate
Medical
Quality Review Visits


Organisational Hazards
1. Inadequate facilities (e.g. A&E units without ready
access to urgent imaging and lab services).
 2. Departmental rules preventing ready access to
required services by junior doctors.
 3. Protocols which impede timely medical care (e.g.
care before patient transfer to suitable wards /
 internal referral systems allow for patients to get ‘lost in
the system’).
Patient Safety Concerns during Postgraduate
Medical
Quality Review Visits







4. Protocols / facilities which regularly lead to patient care
within inadequately / unsuitably staffed areas
(e.g. acute medical patients moved to T/O or rehab wards).
5. Rotas which do not provide enough doctors for the work to
be done (e.g. covering excess numbers of
ward patients over the weekend).
6. Doctors routinely expected to perform tasks for which they
are untrained (e.g. take consent for surgery
/ insert central lines / lead paediatric resuscitation without relevant
training - NLS, PLS)
7. A pattern of poor clinical work by other, non medical,
professional workers.
Patient Safety Concerns during Postgraduate
Medical
Quality Review Visits

Supervision and Senior Cover

1 If any junior doctor cannot access the immediate support (by
phone, followed, if necessary, immediately by personal presence) of
a more senior doctor to deal with a clinically dangerous situation,
then this is a patient safety risk. The senior does not need to be from
the junior’s own firm or subspecialty, but must be of the same “
branch” (medicine, surgery, T/O, paediatrics etc)

2 Senior doctors with acute care responsibility should be on the
hospital site, within daytime hours, and without other responsibilities
for the relevant period.
Patient Safety Reporting Process:
Lead Visitor Responsibilities
Quality Governance:
Joining the QA Framework
Together
Organisational
Levels
Governance
Groups
Quality Review
Processes
Regulatory Body
Regulator
(i.e. GMC)
(i.e. GMC, formerly
PMETB)
Royal
Colleges
Deanery quality review,
report and action plan
PMDE Board
Deanery
Annual
Deanery
Report
PMDE Quality
Committee
Programme quality review,
report and action plan
School
School Annual
Report
School Boards (i.e.
PMDE and FPMB)
LEP quality review, report
and action plan
LEP
LEP Annual
Report
LEP Local Education
Meetings
SHA
Governance /
Patient Safety
Group
Patient Safety Oversight Group
 Formal
subcommittee of the SHA Board
 Medical Directors, DoN Postgraduate
Dean and deputy
 Director of Patient Safety, Regional CQC
Director, Performance Director, HCAI
specialists and mental health
 Others as appropriate are co-opted
Performance
PS
Metric
s
Measures
Performance
KPIs
Information
and
involvement
Definition
M
Cancer waits
M
see suplementary document
CQC Risk Profiles
5 - Meeting nutritional needs
6 - Co-operating with other
providers
8 - Cleanliness and infection
control
9 - Management of Medicines
10 - Safety and suitability of
premises
11 - Safety, availability &
suitability of equipment
see suplementary document
12 - Requirement relating to
workers
14 - Supporting workers
Quality and
16 - Assessing & monitoring
Management quality of service provision
17 - Complaints
21 - Records
Training and
Education
Induction to post
Appraisal and Assessment
Service based training
0/0
2/1
0/0
6/2
0/2
0/0
0/0
The figure stated is the percentage of
trainees surveyed who expressed a
concern.
Amber = 5% to 15% expressed a
concern
Red = greater than 15% expressed a
concern
1/1
0/0
9/9 56/25 13/14 56/44 16/8
1/2
3/2 35/19 28/37 19/16 18/11 35/40
0/2
0/2
2/1
3/3
Apr-Jul 11 30.08.11
30.08.11 n/a
n/a
n/a
n/a
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
M
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
M
M
M
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Jul-11
30.08.11 n/a
n/a
n/a
n/a
Q
Q
Q
Q
Rota Compliance
Q
0/2
0/2 0/1
n/a
31/2 26/3 27/2 18/2
20/7
8
2
2
8
n/a
n/a
Jul-11
Q
1/1 2/3
Apr-Jun 11 30.08.11
M
Inapropriate tasks
RAG rating - Green = Compliant
derogated rota/s.
0/1
Apr-Jul 11 30.08.11
Q
Total Number of respondents
Patient Safety -
1/0
ID
-4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
-3
-4
-1
ID
-4
2
-2
1
-4
-4
-4
1.4% 1.7%
15.5
6.3% %
12.1
30.08.11
2.8% %
15.5
30.08.11
3.5% %
30.08.11
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
-2
-3
ID
-3
-2
-3
-3
-2
-1
-2
-2
-2
-2
ID
ID
ID
n/a
-4
-4
-4
n/a
n/a
n/a
-4
-3
-4
-1
-2
-3
-3
-2
-4
ID
ID
-3
n/a
-2
n/a
-4
n/a
-2
ID
-4
-2
n/a
n/a
-4
-4
-2
ID
-2
-2
3
-2
-2
-2
n/a
-4
-4
n/a
n/a
17
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ID
n/a
47 128 62 283 51
14
30.08.11 114 59
rotations 30.08.11
ending
2.1% 1.7%
3.9%
3.5%
17.2
11.0
16.0
30.08.11
Jul-11
4.2% % 8.7% % 8.2% 8.5% % 7.7%
30.08.11
n/a
ID
-3
-2
ID
ID
ID
ID
-4
n/a
-4
ID
13 - Staffing
JEST PS
issues
identified
0/1
-1
1 - Respecting and involving
people who use services
2 - Consent to care and
treatment
Safeguarding 7- Safeguarding people who use
and safety
services from abuse
Suitability of
staffing
last
Period
updat
covered
ed
M
MRSA - 11/12 year to date
(actual vs tolerance)
First figure = no. of incidents reported
CDiff - 11/12 year to date (actual Second figure = target for the same
vs tolerance)
period
Personalised 4 - Care and welfare of people
care, treatment who use services
and support
Frequenc
y
-2
-2
-3
-2
-4
-2
172
246
140
-2
-2
ID
-2
ID
-1
ID
ID
-2
-3
-3
ND
-2
-2
-3
-3
-4
-4
-2
-2
-2
-1
-4
ND
ID
ID
-2
ID
-3
ND
ID
ID
ID
ID
ID
ID
ID
-2
4
-2
-2
-2
1
2
4
-1
-1
-1
-4
-2
-3
-2
-3
ID
ID
-1
ID
ID
ID
-1
ID
ID
-2
-2
-2
-2
-4
-2
-2
-2
ID
ID
-2
2
ID
ID
-2
-2
-2
-2
-2
-2
-4
-4
-2
-2
ID
-2
-2
-2
-2
-3
-2
-4
-3
ID
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
68
266 265 224
77
163 44 n/a
2.3% 1.6% 5.0% 4.5% 4.2% 4.9%1.3% 1.3% 1.2%2.3% n/a
11.3
4.1% 2.9% 5.8% 4.5% % 6.4%7.2% 1.3% 6.2%4.7% n/a
4.3% 6.3% 3.3% 3.2% 4.0% 7.7%
1.2% 1.6% 1.4% 4.5% 6.4% 4.5%5.4% 3.9% 6.8%2.3% n/a
18.1 14.0
11.9 16.6 15.5
10.5 12.3
4.3% 8.7% 4.9% %
%
12.5% 4.1% 8.6% 9.4% %
%
% 8.1% %
% 2.3% n/a
2.2% 4.7%
4.6% 4.0%
15.0
13.1
6.5% % 9.8% % 6.0%
1.2% 3.7% 1.4% 6.0% 7.5% 4.2%2.2% 1.3% 5.6%2.3% n/a
10.6 16.5 13.4 10.2 16.3 12.1 17.1
11.6
%
%
%
%
% %
% 7.4% % n/a
6.3% 7.6%
Escalating Concerns
NHS West Midlands Postgraduate Medical Trainees are encouraged to raise
concerns when appropriate regarding their training programme via a number of
mechanisms such as the GMC Survey, Job Evaluation Survey Tool (JEST),
Reviews/Visits
to Local Education Providers (LEPs), Annual Review of Competency
Progression (ARCP), Appraisals, and Incident Reporting etc.
When issues arise that are not appropriate or out of sequence
with these processes, Trainees may raise concerns by using the
following pathways as appropriate to their concern. Concerns
may cover any issue including patient safety and quality of
education and training. Trainees should invoke pathways
appropriately and in order of priority.
http://www.westmidlandsdeanery.nhs.uk/Home/EscalatingConcerns.aspx
Lay Advisors

Currently have pool of 35 Lay Advisors

Activity Organiser / Activity Lead Guidance
has been developed.

April 2010/March 2011 – 71 Activities Attended
which included QA Reviews, Programme
Reviews, ARCP/RITA, Assessment, Recruitment
etc.

Feedback from both Lay Advisors and Activity
Leads has been extremely positive
“Utilisation of Lay Advisors has been valuable due
to their independency and professional knowledge
and skills from business and other non-health
sectors”
Was Mid Staffs an Isolated Case?

An NHS hospital is to face a lawsuit launched by more
than 20 families who claim their loved ones were
subjected to "appalling and humiliating" treatment.
Law firm Leigh Day & Co intends to argue that the
standard of care offered at Redditch's Alexandra
Hospital was so bad that it breached the human rights of
several patients, including a 73-year-old man whose ribs
are alleged to have been "broken open" by the use of a
hoist after heart surgery.
The action includes allegations of neglect such as
dehydrated patients not being given water or not being
fed.
DO GMC SURVEYS GIVE US INDICATORS OF POOR QUALITY OF
CARE?
All trainees by post specialty by local
education provider
Trust
May 2010
May 2011
Green Outliers
Red Outliers
Green Outliers
Red Outliers
HEFT
Heartlands – 25
GHH – 2
Combined = 27
Heartlands – 29
GHH – 22
Combined = 51
19
16
Mid Staffs
4
16
6
11
Walsall
11
12
9
16
Worcs
Alex – 10
Alex – 8
Alex – 10
Alex – 10
UHB - QE
7
20
12
30
Dawn of a New Era
NHS Outcomes Framework
NHS OUTCOMES FRAMEWORK
Domain 2
Domain 3
Domain 4
Domain 5
Enhancing
the quality
of life for
people with
LTCs
Recovery
from
episodes of
ill health /
injury
Ensuring a
positive
patient
experience
Safe
environment
free from
avoidable
harm
Duty of quality
Duty of quality
Domain 1
Preventing
people from
dying
prematurely
NICE
Standards
NICEQuality
Quality
Standards
(Building a library of approx 150 over 5 years)
Commissioning
Outcomes
Framework
Provider payment mechanisms
Commissioning
Guidance
tariff
standard
contract
Commissioning / Contracting
specialist
services
and
primary
care
NHS Commissioning Board
–certain
certain
specialist
services
and
primary
care
GP Consortia
– all
other
services
all other services
Duty of quality
CQUIN
QOF
Educational Outcomes Framework
Architecture ver 3 dated 26 Aug
Plan,
develop
and secure
supply of a
capable
patient –
centered
workforce
Meet standards
set by
independent
regulatory/
statutory bodies
Excellent
quality care in
training
environments
Promote health
and wellbeing
and health
inequalities
Competent and
capable staff
Support the NHS
constitution
Fitness for
purpose &
leadership
Excellence
of education
training &
development
Promote
research and
innovation
Excellent
experience
for students
and trainees
Effectiveness
Promote
effective team
and
interdisciplinary
working
Specific
Indicators
(using
where
possible
already
establishe
d metrics)
Safety
Individuals &
professional
groups aligned
with workforce
demand
Respond
to changing
service demands
Meets strategic
local workforce &
commissioning
plans
SoS/DH
HEE
LETB/HEIs
Healthcare
Org
46
4
6
Outcomes
 Excellent quality care in training
environments
 Competent and capable staff
 Fitness for purpose and leadership
 Excellence of education training and
development
 Individuals and professional groups aligned
with workforce demand
47
Relationship between health care education
and quality of care
Quality healthcare education and training can
directly and substantially benefit care.
The EOF will provide a framework to make
these benefits explicit and enable further
research to directly link education and learning
to improvements in patient care outcomes.
48
Professionalism
Origins of “Professionalism”
 from
Latin by way of Middle English,
 professiō, the taking of vows of a
 religious order
Just what is Professionalism?
“... I know it when I
see it ....”
 Supreme Court
Justice
 Potter Stewart
 1964

Professionalism in Action
 We
are what we repeatedly do. Excellence
then, is not an act, but a habit.”

Aristotle
The future


However well designed the systems for
regulating performance and managing services
might be, the quality and safety of patient care
depend first and foremost on the skills of the
clinical teams delivering that care –
professionalism will return to centre stage –
those with responsibility for high standards of
clinical practice will find themselves under
scrutiny
Chris Ham BMJ 2011
Although your job is not easy…
Making a difference….
“In this moment, in this place, you have a valuable
opportunity. You can make something happen, and you
can make a difference ”
Ralph Marston
“Change will not come it we wait for some other person or
some other time. We are the ones we’ve been waiting for.
We are the change that we seek”
Barak Obama