FRANCIS REPORT UPDATE

Gary O’Hare, Executive Director of Nursing and Operations

Dr Douglas Gee, Executive Medical Director

10th December 2013

1. To summarise the key findings and recommendations from the following reports:-

• Francis • Compassion in Practice• Keogh• Berwick• National Quality Board – Staffing• Cavendish Review• Review of complaints• Hard Truth’s

2. What else is on the horizon?• NMC revalidation for Nurses and Midwives• NHS Working Longer Review• NHS Mandate Refresh• Parity of Esteem

3. To identify any further actions for the Trust – group work

Purpose of this presentation:

Over-arching messages

Compassion

Carers

Staffing

Listening

Account-ability

Clinicians

Performance

Quality

Leadership

Culture

Patient

REPORTSREPORTS

Francis ReportFrancis 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

• Responsibilities of external agencies not well defined

• Regulatory gaps

• Communication failures across system- waiting to be told, not seeking information

• Constant reorganisation of NHS structures

• Inappropriate reassurance leading to lack of scrutiny

• Process and target focus

• Lack of engagement with patients and public

• Failure to place clinicians at heart of decisions

Broad recommendations

• A shared culture which puts the patient first

• A shared set of standards

• Endorsed by professionals, measurable

• Openness, transparency and candour

• Regulator focussed on these standards

• Accountability of senior managers and leaders

• Enhance recruitment, training and support, especially nursing and leadership positions

• Improved measures of performance: of individuals, teams, units and organisations

• Accountability of individuals and organisations

Jane Cummings – Chief Jane Cummings – Chief Nursing Officer (CNO)Nursing Officer (CNO)

Compassion in PracticeCompassion 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 UpdateOverview 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:

•Our values as an organisation.

•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.

•Chief Executive’s 150 event

•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• Review of Governance Arrangements

• Board Confirm and Challenge

• Regular Board Reporting

• Board and Senior Management Team Awareness of Service IssuesThe Board and Senior Management Team have undertaken an ongoing programme ofsenior 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• 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 ReportBerwick 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 BoardNational Quality Board

(Sponsored by CNO)(Sponsored by CNO)

How to ensure the right people, with the How to ensure the right people, with the right skills, are in the right place at the right skills, are in the right place at the

right time right time

A guide to nursing, midwifery, and care A guide to nursing, midwifery, and care staffing capacity and capabilitystaffing 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, high-quality 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 ReviewCavendish ReviewAn 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

• Certificate in Fundamental Care : to be completed by all care staff prior to working unsupervised

• Higher Certificate in Fundamental Care linked to more advanced competencies

• Established linkage between nursing curriculum and joint training with first year student nurses

• Implementation of national values based recruitment tool

• Widening participation into pre registration training; recognising caring experience as a pre requisite and valuing vocational experience

• Local development of robust career frameworks linked to simplified job descriptions

• Empowerment of Directors of Nursing to take greater Board level responsibility for recruitment, training and management of HCA

• Professional Standards Authority to provide advice to improve effectiveness in managing the dismissal of unsatisfactory staff

A Review of the NHS HospitalsA Review of the NHS Hospitals

Complaints SystemComplaints System

“Putting Patients Back in the Picture”

Right Honourable Ann Clwyd MP and Professor Tricia Hart

Terms of referenceThis 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• 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 Hard Truths

“The journey to putting patients first”

Department of Health

Supports

• Duty of candour

• Friends and family test

• Values based recruitment

• Patient safety alert system

• Safer staffing

• Professional regulation

• Accountability, patients should know the name of the doctor and nurse who responsible for their care

• Rt Hon Ann Clwyd and Patricia Hart’s review of complaints

Purpose - Government response to Francis

Key highlights

Hard Truths- Chapter One: Preventing problems

• 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.

• 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

• Staff wellbeing as the foundation of compassionate care: Point of Care Foundation to work on spreading Schwartz Rounds.

• Complaints: Chief executives and Boards to take greater personal responsibility for complaints

• Openness and transparency: Statutory duty of candour on organisations; professional duty of candour on individuals

• 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

• 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.

• 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.

• 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 evidence-based 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

• 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

• Collaboration: CQC, Monitor and Trust Development Authority (TDA) will publish further guidance on how they work together to address quality after April 2014

• Ratings: Ratings will be published for certain individual services, e.g. emergency or maternity, as well as for the hospital overall

• 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.

• 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

• 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.

• Professional regulation: Law Commission working on streamlining professional regulation law, enabling the majority of concerns to be resolved within a year

• Commissioners: NHS England to examine standard NHS contract provisions to facilitate commissioner intervention in case of concerns

• Coroners: regulations to be published strengthening requirement of independence.

Hard Truths - Chapter Five: Ensuring staff are trained and motivated

• 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.

• 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

• 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.

• 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.

• 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 HORIZONON THE HORIZON

Nursing and Midwifery Nursing and Midwifery CouncilCouncil

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

43

Mostly the same, one new objective and some areas of increased emphasis: •Objective 4 supporting people with Long Term Conditions (LTCs) : to include Vulnerable Older People’s Plan

•Objective 7 integrated care: reference to the Integration Transformation Fund

•Objective 8 dementia diagnosis, treatment and care: inclusion 2/3 diagnosis ambition

•Objective 11 parity of esteem for mental health: crisis services and adequate liaison psychiatry services

•Objective 12 response to Francis: new objective to implementing actions from Francis

•Objective 15 improving patient experience: faster implementation of Friends and Family Test

Letter from Chair of Board to be issued alongside Mandate

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 TO IDENTIFY ANY FURTHER ACTIONS FOR THE TRUSTACTIONS FOR THE TRUST

GROUP WORKGROUP 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 Improving the Safety of Patients in EnglandPatients 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 Review into the Quality and Care Provided by 14 Care Provided by 14

Hospital Trusts in EnglandHospital 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