Transcript Slide 1
FRANCIS REPORT
UPDATE
Gary O’Hare, Executive Director of Nursing and
Operations
Dr Douglas Gee, Executive Medical Director
10th December 2013
Purpose of this presentation:
1.
To summarise the key findings and recommendations from the following
reports:•
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2.
What else is on the horizon?
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3.
Francis
Compassion in Practice
Keogh
Berwick
National Quality Board – Staffing
Cavendish Review
Review of complaints
Hard Truth’s
NMC revalidation for Nurses and Midwives
NHS Working Longer Review
NHS Mandate Refresh
Parity of Esteem
To identify any further actions for the Trust – group work
Over-arching messages
Culture
Leadership
Compassion
Carers
Quality
Patient
Staffing
Performance
Clinicians
Listening
Accountability
REPORTS
Francis Report
What went wrong: a culture ….
• Focus on system, not patients
• Positive reports preferred over negative
• Process measures, not patient benefit
• Tolerance of poor performance and risk
• Failure of communication between agencies
• Lack of clear accountability/responsibility
• Failure to build a positive culture
• Loss of corporate memory through reorganisation
Trust Board and other leaders
• failed to appreciate the enormity of what was happening,
reacted too slowly, downplayed significance of reports.
• ..engrained culture of tolerance of poor standards, focus
on finance and targets, denial of concerns, isolation from
practice elsewhere
Why not discovered sooner
• Trust lacked insight and
awareness
• Constant reorganisation
of NHS structures
• Responsibilities of
external agencies not
well defined
• Inappropriate
reassurance leading to
lack of scrutiny
• Regulatory gaps
• Process and target focus
• Communication failures
across system- waiting to
be told, not seeking
information
• Lack of engagement with
patients and public
• Failure to place clinicians
at heart of decisions
Broad recommendations
• A shared culture which puts • Accountability of senior
the patient first
managers and leaders
• A shared set of standards
• Enhance recruitment,
training and support,
• Endorsed by professionals,
especially nursing and
measurable
leadership positions
• Openness, transparency
• Improved measures of
and candour
performance: of individuals,
• Regulator focussed on
teams, units and
these standards
organisations
• Accountability of individuals
and organisations
Jane Cummings – Chief
Nursing Officer (CNO)
Compassion in Practice
“Our Vision and Strategy for Nursing,
Midwifery and Care Givers”
What do organisations
need to consider?
• Values and attitudes training
• Skills and competencies
• Leadership
• Nursing Strategy implementation
Plan
• Professional Fora
• Continuous Professional
Development
• Research and Development
Francis Report Update
Overview of ongoing actions across the Trust in response to the Francis
Report
The Francis report was published in February 2013. Since then a number of
activities and actions have been underway. These can be considered under the
following headings:
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Our values as an organisation.
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The release of the Francis report gave an opportunity to refresh and reconsider our
values and to achieve a high level of staff engagements so that these are owned and
acted upon by all. This work is being led by the Chief Executive, through a number of
avenues.
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Chief Executive’s 150 event
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250 event focussing on values was held on the 3rd May and this was extremely well
attended and received very positive feedback.
Francis Report Update
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Review of Governance Arrangements
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Board Confirm and Challenge
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Regular Board Reporting
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Board and Senior Management Team Awareness of Service Issues
The Board and Senior Management Team have undertaken an ongoing programme of
senior staff spending full shifts on our wards. To date 60+ such shifts have been
completed, with detailed feedback on each. These have been collated and an action
plan drawn up. The findings from these shifts are been correlated with other sources of
information, such as, serious incidents, complaints etc. and linked into the overall Trust
learning lessons
process (see below).
This programme of shifts is in addition to the ongoing programme of SMT / Board visits.
The shift programme will continue and will be extended to other areas of Trust services
including community services in due course.
Francis Report Update
• Development of a Safety Culture
• Staff Engagement and Awareness of the Francis Report
• Safety Reporting and learning lessons
• Working collaboratively with service users and carers
• Strengthening the role of the Council of Governors
• Developing a strong and positive medical culture
Francis Report Update
• Strengthening the nursing culture
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Nursing strategy
Focus on Compassionate Care aspect of 6C’s initiative
Roll out revised job descriptions as per Q1
Implement 15 steps initiative within ward visit programme
Values training
• Openness, Transparency and Candour
Francis Report Update
• Review of Complaints Procedures
• Using information effectively
• Developing leadership in the workplace
• Trust action plan and action log presented to the Trust
Board
Berwick Report
“A promise to learn”
Executive summary
• Place the quality of patient care, especially patient
safety, above all other aims
• Engage, empower, and hear patients and carers at all
times
• Foster whole-heartedly the growth and development
of all staff, including their ability and support to
improve the processes in which they work
• Embrace transparency unequivocally and everywhere, in
the service of accountability, trust, and the growth of
knowledge
Ten recommendations are as follows:
1. The NHS should continually and forever reduce patient
harm by embracing wholeheartedly an ethic of
learning.
2. All leaders concerned with NHS healthcare – political,
regulatory, governance, executive, clinical and
advocacy – should place quality of care in general, and
patient safety in particular, at the top of their priorities
for investment, inquiry, improvement, regular reporting,
encouragement and support.
3. Patients and their carers should be present, powerful
and involved at all levels of healthcare organisations
from wards to the boards of Trusts.
4. Government, Health Education England and NHS
England should assure that sufficient staff are
available to meet the NHS’s needs now and in the
future. Healthcare organisations should ensure that
staff are present in appropriate numbers to provide
safe care at all times and are well-supported.
5. Mastery of quality and patient safety sciences and
practices should be part of initial preparation and
lifelong education of all health care professionals,
including managers and executives.
6. The NHS should become a learning organisation.
Its leaders should create and support the
capability for learning, and therefore change, at
scale, within the NHS.
7. Transparency should be complete, timely and
unequivocal. All data on quality and safety, whether
assembled by government, organisations, or
professional societies, should be shared in a timely
fashion with all parties who want it, including, in
accessible form, with the public.
8. All organisations should seek out the patient and carer
voice as an essential asset in monitoring the safety
and quality of care.
9. Supervisory and regulatory systems should be simple
and clear. They should avoid diffusion of responsibility.
They should be respectful of the goodwill and sound
intention of the vast majority of staff. All incentives
should point in the same direction.
10. We support responsive regulation of organisations,
with a hierarchy of responses. Recourse to criminal
sanctions should be extremely rare, and should
function primarily as a deterrent to wilful or reckless
neglect or mistreatment.
National Quality Board
(Sponsored by CNO)
How to ensure the right people, with the
right skills, are in the right place at the
right time
A guide to nursing, midwifery, and care
staffing capacity and capability
Five key points
• New staffing guidance has set 10 staffing expectations for
NHS commissioners and providers
• Boards must ensure they are operating with safe, highquality staffing levels
• Staffing levels should be monitored on a shift-by-shift
basis
• A multi-professional approach should be taken when
setting staffing establishments for nurses, midwives and
care staff
• Staffing levels should be displayed on wards
Ten expectations
1. Accountability
2. Shift to shift staffing
3. Use of evidence based tools
4. Support staff to raise concerns
5. Using a professional approach
6. Time for additional duties
7. Board report
8. Display staffing information
9. Recruitment and retention
10. Role of Commissioners
Cavendish Review
An Independent Review into Healthcare
Assistants and Support Workers in the
NHS and Social Care Settings
Purpose
In the wake of the Francis Inquiry the Secretary of State
commissioned the independent Cavendish Review to:
– Consider whether there were better ways to recruit, train, support
and supervise Healthcare Assistants (HCA’s) to make patients and
service users more confident
– Ensure that the care they receive is compassionate and competent
outside of mandatory registration for the workforce
Key recommendations
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Certificate in Fundamental Care : to be completed by all care staff prior to
working unsupervised
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Higher Certificate in Fundamental Care linked to more advanced
competencies
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Established linkage between nursing curriculum and joint training with first
year student nurses
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Implementation of national values based recruitment tool
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Widening participation into pre registration training; recognising caring
experience as a pre requisite and valuing vocational experience
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Local development of robust career frameworks linked to simplified job
descriptions
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Empowerment of Directors of Nursing to take greater Board level
responsibility for recruitment, training and management of HCA
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Professional Standards Authority to provide advice to improve effectiveness
in managing the dismissal of unsatisfactory staff
A Review of the NHS Hospitals
Complaints System
“Putting Patients Back in the Picture”
Right Honourable Ann Clwyd MP and
Professor Tricia Hart
Terms of reference
This Review was instigated by the Prime Minister to consider the handling
of concerns and complaints in NHS hospital care in England and, in doing
so:
– consider how to align more closely the handling of concerns and complaints about patient
care;
– identify where good practice exists, and how good practice for delivering to those
standards is shared and what helps or hinders its adoption;
– consider what standards might best be applied to the handling of complaints;
– consider how intelligence from concerns and complaints can be used to improve service
delivery, and how this information might best be made more widely available to service
users and commissioners;
– consider the role of the Trust Board and senior managers in developing a culture that
takes the concerns of individuals seriously and acts on them;
– identify the skills and behaviours that staff, including clinical staff, need to ensure that the
concerns of individuals are at the heart of their work;
– consider how complainants might more appropriately be supported during the complaints
process through, for example, advice, mediation and advocacy; and include the handling
of concerns raised by staff, including the support of whistle-blowers.
To make recommendations about
• any aspect of the NHS complaints arrangements and other means
by which patients make concerns known;
• the way that organisations receive and act on concerns and
complaints;
• how Boards and managers carry out their functions; and
• the process by which individual organisations are held to account for
the way that they handle concerns and complaints
Key messages
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Improve quality
Simplify process for patients and carers
Ensure your system captures their views and opinions
Improve professional standards
Complaints are significant performance measure
Board awareness
Hard Truths
“The journey to putting
patients first”
Department of Health
Purpose - Government response to Francis
Key highlights
Supports
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Duty of candour
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Friends and family test
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Values based recruitment
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Patient safety alert system
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Safer staffing
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Professional regulation
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Accountability, patients should know the name of the doctor
and nurse who responsible for their care
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Rt Hon Ann Clwyd and Patricia Hart’s review of complaints
Hard Truths- Chapter One: Preventing problems
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Patient safety: Patient Safety Collaborative Network to spread best practice. Greater
involvement of patients in decisions and patient safety data to be more accessible to the
public. National Quality Board to work with NHS organisations and staff to maximise the
potential of Human Factors practice and principles. New offence of wilful neglect.
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Rights and responsibilities: NHS England, Clinical Commissioning Groups (CCGs) and
Health Education England (HEE) working with NHS staff and patients on embedding the
NHS Constitution
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Staff wellbeing as the foundation of compassionate care: Point of Care Foundation to
work on spreading Schwartz Rounds.
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Complaints: Chief executives and Boards to take greater personal responsibility for
complaints
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Openness and transparency: Statutory duty of candour on organisations; professional
duty of candour on individuals
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Staffing and recruitment: Values based recruitment. Guidance and toolkits on safe
staffing levels, with Care Quality Commission (CQC) to inspect
Hard Truths - Chapter Two: Detecting problems
quickly
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Standards: clear fundamental standards to be developed by Department of Health and
CQC, complemented by discretionary enhanced quality standards and longer term
developmental standards developed by NICE.
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Inspection: expert-led inspection, all acute trusts will have been inspected under the
new system by the end of 2015. Inspection to consider the culture of the organisation
and where it promotes openness and transparency.
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Quality: Monitor will be publishing an updated Code of Governance for Foundation
Trusts in early 2014. King’s Fund and University of Lancaster to examine evidencebased solutions for evaluating leadership and culture within an organisation. Quality
surveillance groups to ensure that the different organisations with an interest in quality
are aligned at local and regional levels
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Registration and licensing: joint registration and licensing system to be implemented
by Monitor and CQC from April, with clearer delineation of their respective roles and FT
process
Hard Truths - Chapter Three: Taking action
promptly
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Collaboration: CQC, Monitor and Trust Development Authority (TDA) will publish
further guidance on how they work together to address quality after April 2014
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Ratings: Ratings will be published for certain individual services, e.g. emergency or
maternity, as well as for the hospital overall
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Intervention: CQC to have powers to act immediately if patients at immediate risk of
harm. DH intends to enable Monitor to impose additional licence conditions on trusts
issues with a CQC warning notice. Where FTs are placed in special measures, they
will have their autonomy suspended.
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Special administration: Special administration as a last resort, with the majority of
failures resolved through actions taken by trust boards and a minority through service
redesign driven by local commissioners
Hard Truths - Chapter Four: Ensuring robust
accountability
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At board level: A fit and proper persons test, regulated by CQC, will be introduced
for board directors or equivalents across public, private and voluntary sector
providers. Greater performance management at board level., with contracts to be
reworded to make it easier for leaders to be removed when CQC ratings are
unsatisfactory. Guidance on healthy NHS boards.
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Professional regulation: Law Commission working on streamlining professional
regulation law, enabling the majority of concerns to be resolved within a year
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Commissioners: NHS England to examine standard NHS contract provisions to
facilitate commissioner intervention in case of concerns
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Coroners: regulations to be published strengthening requirement of independence.
Hard Truths - Chapter Five: Ensuring staff are
trained and motivated
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Staff engagement: Chief Inspector of Hospitals to cover staff engagement. Social Partnership
Forum to develop a description of what good staff engagement looks like for employers.
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Older people: Older Persons Nurse Fellowship programme. Taskforce led by Age UK to reduce
malnutrition among older people in a range of health and care settings
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Nursing and care assistants: Leadership Academy to support nurse leadership, while NMC will
begin revalidation for nurses. Development of Care Certificate for healthcare assistants and social
care support workers. Better dismissal procedures for healthcare assistants and improved
recognition of good practice.
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Bureaucracy: Health and Social Care Information Centre (HSCIC) to act as ‘gateway’ for
information requests and national bodies to have single transparent process, reducing the burden of
bureaucracy. NHS England Clinical Bureaucracy Index to track how well trusts are using digital
technology in data collection.
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Leadership: NHS Leadership Academy to initiate a new leadership programme to fast-track NHS
clinicians and individuals from outside the NHS to be the next generation of senior leaders; while
NHS Executive fast-track programme to develop leaders from inside the NHS.
Key quotes from the Government response
“If staff are to deliver good, compassionate care, it is critical to care for them so
that they can care properly for others. Good working environments have the right
levels of staff with the right skills, and support from colleagues and managers."
“Systematically creating an environment in which compassionate care is the norm
requires imaginative commissioning, organisational commitment, planning,
education, training, reinforcement through leadership and insightful scrutiny and
challenge. It is the very opposite of the ‘soft’ issue it can too often be characterised
as. Ensuring compassionate care is therefore not an ‘issue’ for organisations
providing care. It is, along with safety, the essence of the business that they are
in."
ON THE HORIZON
Nursing and Midwifery
Council
Revalidation for nurses and
midwives
Proposals
• Revalidation will replace PREP – transition over 3 year period
• Purpose is to provide greater public protection
• Public consultation will commence on 6 January 2014 until 31
March 2014
• Are not proposing similar model to GMC e.g. Responsible
Officer
• They are proposing a system of 3rd party validation, however,
accountability framework is not available at present
• 360 degree feedback will be required
• 60 events planned between Sept-Dec 2013
• NHS has an ageing workforce which is an issue in itself, the
Government proposals around working longer will have further
implications in relation to capability, performance, health and safety,
well-being etc.
• The Working Longer Review is a tripartite partnership review group
between national recognised NHS Trade Unions, NHS employers and
health department representatives. The Working Longer Review
Steering Group has been established and reports directly to the NHS
Pension Scheme Governance Group and the NHS Staff Council and its
Executive
• The review is considering the implications of a raised retirement age for
staff, patients and employers in the NHS
Refreshed NHS Mandate
Expectations
Mostly the same, one new objective and some areas of increased
emphasis:
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Objective 4 supporting people with Long Term Conditions (LTCs) : to include
Vulnerable Older People’s Plan
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Objective 7 integrated care: reference to the Integration Transformation Fund
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Objective 8 dementia diagnosis, treatment and care: inclusion 2/3 diagnosis
ambition
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Objective 11 parity of esteem for mental health: crisis services and adequate
liaison psychiatry services
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Objective 12 response to Francis: new objective to implementing actions from
Francis
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Objective 15 improving patient experience: faster implementation of Friends and
Family Test
Letter from Chair of Board to be issued alongside Mandate
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Parity of Esteem
Valuing mental health equally with physical health
What Parity will mean:
• People have access to services which enable them to maintain both
their mental and physical wellbeing.
• Services will assess and treat mental health disorders or conditions
on a par with physical health illnesses.
Parity of Esteem - Drivers
TO IDENTIFY ANY FURTHER
ACTIONS FOR THE TRUST
GROUP WORK
Questions to consider
• Are our systems and processes fit for purpose?
• Do we have values based recruitment?
• Is our workforce compassionate?
• Are we gathering and using patient and carer feedback?
• Is our complaints process fleet of foot?
• Do we operate a duty of candour?
• Are our staffing levels appropriate?
• Are we looking at the right performance information?
• Can we validate management reports with clinician feedback?
• Are our clinicians and managers saying the same things? If
not, why not?
• Are we using evidence based approaches?
• Do we know where the gaps are in our evidence?
• How do we access real grassroots clinical opinion? Do our CG
structures reach our clinicians in a meaningful way?
• How do we know what we don’t know?
• Are we taking enough account of and responding enough to
“warning signs”?
• Are we improving quality and reducing harm?
• Is the Board connected to the front-line?
• In April 2013, Monitor published a guide for Boards on
how to ensure organisations are working effectively to
improve patient care. Monitor will also be publishing an
updated Code of Governance for Foundation Trusts in
early 2014 which will make recommendations to
strengthen corporate governance in light of the Inquiry
report.
• There are also plans for regular governance reviews of
foundation trusts which will include quality governance
Improving the Safety of
Patients in England
Prof Don Berwick
Highlights
• The point now is to move on
• The strengths of the NHS
• Report not focussed on a failing organisation but
on safety and the concept of “zero harm”
The Problems
• Patient safety problems exists throughout the NHS.
• NHS staff not to blame.
• Incorrect priorities.
• Warning signals not heeded.
• Diffused responsibility.
• System to support continual improvement.
• Fear is toxic
Solutions
• Wide systemic change.
• Abandon blame.
• Working with patients and service users.
• Caution re: quantative target
• Transparency re information.
• Cooperation.
• Career long help – master and apply quality control,
quality improvement, quality planning.
• Pride and joy infuse work not fear.
The Nature of Quality and Safety
• Definition of quality.
• Lord Darzi three dimensions.
• The never ending struggle against entropy.
• Three types of patient harm – due to neglect or wilful
misconduct, due to system failure, due to error.
Review into the Quality and
Care Provided by 14
Hospital Trusts in England
Prof Sir Bruce Keogh
Methodology
• Analysis of hard and soft data.
• MDT reviews
• Staff and Patients.
• Risk Summit
Common Themes
• Quality Governance
• Isolation
• Learning
• Financial Pressure
Eight Ambitions
1.
Reducing avoidable deaths
2.
Forensic pursuit of quality
3.
Patient and Carer feedback
4.
Patient and carer confidence in CQC assessment
5.
Not “island to itself”
6.
Nursing staff skill mix and level
7.
Junior Doctors and Student Nurses
8.
Happy and engaged staff