EMERGENCY SERVICES INDEPENDENT REPORT

FINDINGS AND RECOMMENDATIONS

1ST JULY 2015

Context Four lines of enquiry were agreed due to issues raised through RCN Frontline First regarding the Emergency Services

1 Provision of care compromised due to culture

2 Potential harm to patient care

3 Potential harm to employees due to culture

4 Appropriateness of care, staffing and practices

Emergency Services (ES) are provided on three UHB sites:

1. Medical Emergency Assessment Unit at Llandough Hospital

2. Minor Injuries Unit at Barry Hospital

3. Emergency Unit and Assessment Unit at University Hospital Wales

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Royal College of

Nursing (Wales)

Approach An independent panel undertook the process of review and reporting within five months

Jan Feb Mar Apr May

18th MAY 2015 Final report was submitted

1st JANUARY 2015: An independent panel was secured

7th JANUARY 2015: Review began using a mixed method approach to gather evidence

1st APRIL 2015 A first draft report was submitted to Health Board

Considering: • One-to-one meetings • Focus groups • Staff survey • Observational visits • Documentary evidence

• Quality assured by an Organisational Psychologist

• 120+ staff

interviewed

• 250+ documents

reviewed

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The UHB agreed to progress this review during a very high winter pressure period for ES

Findings and recommendations A comprehensive set of findings and recommendations were defined in the report

4 key lines of enquiry

59 findings

46 recommendations

This presentation aims to highlight the overall findings and recommendations made

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Positive feedback The independent panel highlighted a very important message:

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‘The general ES staff

expressed a deep

commitment to the hospital

and their roles. Many staff

told us “I love my job” ’

Key findings There were 11 overall findings from the review

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1. Provision of care is being compromised due to the prevailing organisational culture within the EU and/or AU

2. No direct evidence that a patient has yet been harmed due to the patient care arrangements

3. Current patient care arrangements lead to patients regularly receiving less than optimum levels of care and experience

4. There is ongoing significant risk of harm to patients based on the current arrangement of care

5. The prevailing organisational culture has resulted in harm to employees

6. Care of patients is not always delivered in the most appropriate way or in the most appropriate location based on a patient’s clinical need

7. There is a high probability that at times of surge in activity; targets are prioritised instead of patient-focused care

8. All areas of the Emergency Services at UHW are significantly understaffed for medical and nursing staff, in terms of budgeted whole time equivalents, staff in post and consequently staff on shift.

9. Skill mix, especially in relation to paediatrics, was insufficient to meet the need of this population.

10. There is clear evidence of a culture of bullying, harassment and inappropriate behaviour and treatment which pervades all levels of staff in the ES at UHW

11. The behaviours are endemic and involve many individuals and this makes it difficult to identify individual perpetrators. However based on the depth of evidence it was found that the inappropriate behaviours of [witheld] are mentioned most commonly. This list is not exhaustive.

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Key recommendations The 46 recommendations fall in to eight themes

Leadership &

Ways of

Working

Health &

Wellbeing

Risk Mngt

& Governance

Roles &

Responsibilities

Caring for

people, keeping

people well

Performance

Management

Comms &

Engagement

Resources &

Skills Devt

Processes

Key recommendations (1) The 46 recommendations fall in to eight themes

Recommendation

theme

E.g.

1 Leadership & ways of working

• Individual & team coaching for managers • Develop medium term strategy & plan for ES • OD programme for sustained culture change

2 Performance management

• Wider accountability across UHB for ES • 2-hourly shop-floor situational stock take meetings • Regular system of 1:1 meetings with staff

3 Roles & responsibilities

• Medicine CB to actively manage & support ES • Introduce clinical governance facilitator role • Nurse in charge is ultimate decision-maker when department

under significant pressure

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Key recommendations (2) The 46 recommendations fall in to eight themes

Recommendation

theme

E.g.

4 Processes

• Review management of rotas and shift swaps • Review use and application of Rosterpro • Ensure local HR processes are aligned to UHB HR policies • Introduce ‘intentional rounding’ i.e. regular checks at set intervals

to ensure patient needs are met • Develop clearly defined escalation & de-escalation route

5 Risk management & governance

• Immediate review of risk register • Standing agenda items on ES Q&S Committee to include:

progress with staff recruitment, review of quality dashboard, analysis of trends in incident reporting etc.

• Top 3 learning priorities to be identified from quarterly review of incidents, complaints and claims

• Immediate steps to implement ‘Freedom to Speak Up’

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Key recommendations (3) The 46 recommendations fall in to eight themes

Recommendation

theme

E.g.

6 Resources & skills development

• Consultant led training & development of ENPs & ANPs • Training to staff on how to report harm/errors • Immediate priority to recruit more nurses (NICE) • Substantively recruit to all consultant posts • Support to managers in applying policies consistently

7 Health & wellbeing • More supportive approach of Sickness Absence Team • OH and support in place to address stress-related absence • More robust process to understand why people leave

8 Communications & engagement

• UHB to review cascade system / communications strategy • Urgent: All ES staff to have an email account • Develop two-way lines of communication within ES • Develop robust mechanism for engaging with unions

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Key recommendations Five recommendations have been classed as ‘urgent’ or ‘immediate’ and actions on these are already in progress

ALL ES STAFF GIVEN A HEALTH BOARD EMAIL

IMPROVE THE RISK REGISTER

RECRUIT NURSES INTO ES USING NICE GUIDELINES

ES MGNT TEAM TO CONDUCT REGULAR SHOP FLOOR MEETINGS

IMPLEMENT ‘FREEDOM TO SPEAK UP’

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Implementation We have set up strong governance to ensure recommendations are implemented efficiently and effectively

Steering Committee

(Chair: COO)

Robust Leadership & Performance Management

Effective Processes

Engaged People

Quality Governance &

Risk Management

Implementation managed by:

• Board level ownership and line-of-

sight via the Quality & Safety

Committee and LPF

• Steering Committee consisting of

Executives and Clinical Board

management

• Multi-disciplinary project team to

implement the plan

Quality & Safety

Committee

(Chair: Independent

Member)

Local Partnership

Forum (LPF)

ES Improvement

Project Team

(Chair: Medical

Director)

Board

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Communications and engagement plan The following plan is currently being progressed

1 JULY

Presentations to Medicine CB, ES Managers & Consultants, Unions

1-3 JULY

ES Staff Roadshowse

7 JULY

Formal presentation to the Board

20 JULY

ToR for Steering Committee and Project Team in place

W/C 27 JULY

First meeting of the ES Improvement Project Team

13 JULY

Deadline for nominations for the ES Improvement Project Team

W/C 20 JULY First meeting of the Steering Committee

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Q&A We anticipate more questions may follow and have set up an email account to receive these. Here are some possible questions:

Question Answer

1 If the UHB was informed about these issues a year ago, why did the review take so long to get started?

There were a number of interactions between the UHB and the RCN (who raised issues) that required specifics and clarity to properly understand the issues. Where specifics were provided, an action plan was formed within the Medicine Clinical Board in August 2014 and implemented. Issues were also raised through the UHB Safety Valve in November 2014.

2 Why was there a ‘first draft’ report? Was anything changed to the findings for the final report?

It is common practice in such matters to have a first draft report to check for factual accuracy. A clear audit trail is in place to show that no changes were made to findings between draft and final versions of the report. Terminology, numbering and structure were improved for the final version, which was also quality assured by an organisational psychologist.

3 What will happen to the ES managers now? What will happen to union members now?

Specific concerns regarding individuals will be addressed through the normal UHB HR policies.

4 What was the outcome of the HIW investigation into patient care from earlier this year?

HIW wrote to the UHB requesting evidence of assurance on the handling of three specific incidents with named patients and four incidents noted on incident forms. This evidence has been provided. The UHB will also be sharing the findings of this independent report with HIW.

5 I heard that the DU paid a visit to the department in June 2015. What was the outcome of this?

The DU visited the UHB in June as a follow up to a previous visit to understand the patient pathway in EU. A final DU visit is scheduled in July after which a report will follow.

Email questions to: cav.es.queries@wales.nhs.uk 14

So what is important now? You are the face of the UHB, at the heart of our community, be proud to be a part of it!

Caring for People: Keeping People Well