Transcript Slide 1

Francis Conversations
March 2013
Zoe Packman
Director of Nursing, Midwifery and AHPs
Excellent integrated care for you and your family, when and where you need it.
Background
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Report Commissioned In July 2009 by Rt Hon Andy Burnham, secretary of
State for Health.
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Principle purpose was to give a voice to those who had suffered at Stafford
and to consider what had gone wrong there.
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Francis 1 published February 2010
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Francis felt that there needed to be an investigation of the wider system to
consider why the issues had not been detected earlier and to ensure that
the necessary lessons were learned
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June 2010 Rt Hon Andrew Lansley, Secretary of State decided it should be
a public inquiry under the inquiries act 2005
Terms of reference
1. To examine the operation of the commissioning, supervisory and regulatory
organisations and other agencies including the culture and systems of those
organisations in relation to the monitoring role at Mid Staffordshire NHS
Foundation trust January 2005 – March 2009 and to examine why problems
at the Trust were not identified sooner
2. To build on evidence given to the first inquiry and its conclusions
3. Identify the lessons to be drawn from that examination as to how in the
future the NHS and the bodies that regulate it can ensure that failing and
potentially failing hospitals or their services are identified as soon as
possible
4. In identifying the relevant lessons to have regard to the fact that the
commissioning, supervisory and regulatory systems differ significantly from
those in place previously and the need to consider the situation both then
and now
5. To make recommendations to the Secretary of Sate for Health based on the
lessons learned from the events at Mid Staffordshire and to use best
endeavours to issue a report by March 2011
Some facts
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164 oral evidence witnesses
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87 witness statements
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39 provisional statements
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352 individual witness statements
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290 recommendations
Next steps
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All commissioning service provision regulatory and ancillary organisations in
healthcare should consider the findings and recommendations of the report
and decide how to apply to their own work
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Each organisation should assure at the earliest practicable time its decision
to the extent to which it accepts the recommendations and what it intends to
do to implement those accepted and thereafter on a regular basis publish in
a report information regarding its progress in relation to its planned action
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The Department of Health should collate information about the decisions
and actions generally and publish in a report information regarding its
progress in relation to its planned action
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The House of Commons Select Committee on Health should be invited to
consider incorporating into its review of the performance of organisations
accountable to parliament a review of the decision and actions they have
taken with regards to the recommendations in the report
Warning signs
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Loss of star rating in 2004
Peer reviews e.g. cancer 2005, care of the critically ill child 2006 identified serious
concerns about the Trusts ability to deliver a safe service and manage capacity
Health Care Commission review 2006 – trust did not meet the requirements or the
reasonable expectations of the patients and the public
Auditors report identified and reported serious concerns about deficiencies in the Trusts
risk management and assurance systems and made serious criticisms which called into
question the accuracy and reliability of the Trusts compliance with standards
Worst 20% performing Trust in patient survey
2007 Staff Nurse in Accident and Emergency raised serious concerns about leadership
in the department and was ignored
Royal College of Surgeons post visit report described the department as dysfunctional
Financial recovery plan – staff cuts were identified in an organisation having serious
problems delivering on quality and minimum standards
Foundation Trust application – focussed on financial and governance issues not quality
issues
Health Care Commission had been launched into workings of the Trust but other bodies
didn’t ask questions why or about the findings
Analysis and evidence
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Board and other leaders failed to appreciate the enormity of what was happening, reacted
too slowly and downplayed the significance of others tolerance of poor standards focused
was on finance and targets
Culture of self promotion rather then critical analysis and openness
Consultants were not at the forefront of promoting change
No culture of listening to patients
Inadequate process for dealing with complaints, serious incidents and the results of the staff
and patient surveys
Board failed to get a grip on its accountability and governance structures
Leadership focussed on financial issues and paid insufficient attention in relation to quality
of service
Unacceptable delay in addressing the issues of shortage of skilled nurses
Inadequate staffing levels, poor leadership, recruitment and training, declining
professionalism, tolerance of poor standards
Trust prioritised finance and foundation trust application over quality of care
Patients and relatives excluded from effective participation in the patients care
“Excellent
integrated care for you and your family, when and where you need it.
Analysis and evidence
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Overview & Scrutiny Committee - Lost sight of its duty to scrutinise.
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General Practitioners - did follow up patients concerns.
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The Coroner lacked clarity and consistency with regard to disclosure of information by the Trust.
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Primary Care Trusts. - there was a lack of clarity in regard to whose job it was to ensure safety and
quality standards, limited clinical expertise, failure to investigate HSMR. They received no information on
the substance of complaints, did not engage with clinicians and did not visit or inspect the Trust.
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Local Members of Parliament (MPs) asked the right questions but were too easily reassured.
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Unions were unaware of problems at the Trust, the RCN in particular.
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The Strategic Health Authority did nothing to assess clinical risk, including no assessment of the impact
of cost improvement plans. The inquiry criticised the length of time taken to carry out a workforce review
overseen by the Director of Nursing. There was failure to undertake an adequate handover. The system
was inadequate and there was evidence that the SUI function was under-resourced
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Monitor – there was a failure to appropriately explore quality issues with the Trust during the application
process. The process to become a Foundation Trust was seen as being an indicator of good quality but
was not assessed.
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Where are we - Nursing
1. 40.28/66.02 RNs recruited 66/61.49 HCAs recruited
2. Case for reviewed skill mix presented to EMG, mobilisation plan to be agreed 18
March 2013 Includes supernummary time for ward leaders
3. Safer Nursing care Tool used twice to be repeated, case for change developed
currently shows 3 - 4 RNs per ward to meet patient acuity requirements
4. E rostering policy written
5. Master vendor contract started January 2013
6. Nurse Specialists - baseline activities identified to be re run March 2013
7. Enrolled on Nurse Productivity programme
8. 4 Associate Practitioners on programme at Kingston university
9. 2 additional Practice development nurses in post (10 in total)
10. Productives facilitator post created
11. Specialist areas establishment review to commence March 2013
12. Community establishment reviews being undertaken in line with contract review
13. 20 midwives appointed ratio filling vacancies for 1:30, 6 midwives to be
appointed for ratio 1:29, 5 midwives 1:28 2013/2014
Excellent integrated care for you and your family, when and where you need it.
Where are we - complaints
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Care Quality Commission (CQC) inspection in November 2011 found
moderate concerns with the system for managing and monitoring
complaints. A subsequent CQC inspection in June 2012 acknowledged the
work that had been done and the Trust was found to be compliant.
49% of complaints are responded to within 25 days of receipt.
The Executive Director lead for complaints reverted to the Director of
Nursing, Midwifery & AHP from the Director of Operations in September
2012.
The Trust has a dedicated team to manage complaints / concerns from
patients. The team has been re-structured and strengthened including the
appointment of a Complaints & PALS Manager
The Trust has a complaints policy and procedure which is NHSLA
compliant. The policy was ratified in February 2012.
An internal audit of management of complaints was completed as part of the
Trust’s Internal Audit Plan showed limited assurance
Where are we – governance structures
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Trust Governance structures were reviewed in 2012 by Chairman
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2013 Interim Chairman undertaking a further governance review, including
reviewing training required for Board members and the requirement for a
clinical Non Executive Director
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Directorate Performance & Quality Boards are developing following clinical
service restructure in 2012
Where are we – patient and public involvement
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Patient Issues Committee established
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FT Membership, currently stands at 4600. Bi-monthly engagement meetings
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Members of patient representative organisations in Croydon make up the
membership of the Trust’s Patient Issue Committee.
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A number of patient user group exist within the organisation, which support
service improvements.
Where are we – SIs
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There is a weekly Executive Review of all high grade incidents and trends of
concern which enables Directors to be fully informed and involved
Establishment of a Patient Safety Committee, chaired by the Medical Director
to lead improvement work based on internal and external intelligence
Serious incidents are presented at clinical governance sessions, directorate
and corporate meeting, incorporated into inductions, teaching and simulated
learning programmes
A For Learning & Action Group (FLAG) with membership inclusive of
commissioners established to provide scrutiny to serious incident root cause
analysis (RCA) and to ensure learning and actions for improvement. Action
plans from RCAs are monitored at Patient Safety Committee
Patient Safety & Quality Bulletin, to share learning and best practice
Internal safety alerts are devised, agreed and circulated throughout the
organisation where the seriousness and frequency of an incident indicate their
necessity
Where are we – Staff engagement
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Work has been done to actively encourage staff to report concerns. The
whistleblowing policy was reviewed and title changed to the Speak up Policy to
reflect the desired ethos
Presentations of the 5 Patient Promises and individual staff responsibility for
raising concerns is made clear at Trust and clinical induction
Incident reporting via the Datix system is actively encouraged. Reports are
investigated and there is feedback to the person reporting the incident
HR keep a log of all Whistleblowing incidents and investigate as far as possible
from the information provided
There is a policy for supporting staff involved in incidents which details the
resources available. For example, free professional staff counselling is available
for self-referral
We have embarked on a Listening into Action (LiA) improvement programme of
hearing staff concerns about their work and establishing 10 improvement
programmes which will most impact staff experience and the organisation
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What do you need to do?
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While the inquiry was confined to Mid Staffs, there is evidence there are
other places where unhealthy cultures, poor leadership and an acceptance
of poor standards are too prevalent
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Robert Francis' first recommendation is for everyone in the NHS to urgently
consider and review what happens in their own organisation in light of the
inquiry's findings, and identify any actions they may need to take to ensure
what happened in Stafford does not happen in their organisation
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Sir David Nicolson said in his letter to CEOs February 2013 said:
‘So please, read the report, reflect upon the findings, discuss and debate the
recommendations with your colleagues, friends and families. Most of all, talk
and listen to the patients you serve, and together we can build a momentum
for improvement, and an NHS of which we can all be proud.’