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Report for Medway NHS Foundation Trust

Review into the Quality of Care & Treatment provided by14 Hospital Trusts in England

RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT

June 2013

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Contents

1. Introduction 3

2. Background to the Trust 7

3. Key Lines of Enquiry 8

4. Review Findings 9

5. Conclusions and support required 297

Appendices 30

Appendix I: SHMI and HSMR Definitions 31

Appendix II: Interviews Held 33

Appendix III: Observations Undertaken 34

Appendix IV: Focus Groups Held 35

Appendix V: Information Review 36

Appendix VI: Unannounced visit agenda 45

Appendix VII: Theme and evidence base 46

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1. Introduction

This section of the report provides background to the review process and details of the key stages of the review.

Overview of review process

On 6 February 2013 the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided bythose hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on thebasis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio(HSMR). Definitions of SHMI and HSMR are included at Appendix I.

These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care andtreatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of thereview about the actual quality of care being provided to patients at the trusts.

Key principles of the review

The review process applied to all 14 NHS trusts was designed to embed the following principles:

1) Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of thepatients in each of the hospitals, and this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, received

through the Keogh review website. These themes have been reflected in the reports.

2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.

3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.

4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing theinterest of patients first at all times.

Terms of reference of the review

The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapidresponsive reviews and risk summits. The process was designed to:

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Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts. Identify:

i. Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.ii. Any additional external support that should be made available to these Trusts to help them improve.iii. Any areas that may require regulatory action in order to protect patients.

The review follows a three stage process:

Stage 1 – Information gathering and analysis

This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staffviews and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive reviewstage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-data-packs/data-pack-medway.pdf.

Stage 2 – Rapid Responsive Review (RRR)

A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involvedwalking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains the findings from this stage of the review.

Stage 3 – Risk summit.

This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongsideother hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to thehospitals concerned. A report following each Risk summit has been made publically available.

Methods of Investigation

The two day announced RRR visit took place at the Trust’s main site on Thursday 9th and Friday 10th May 2013. A variety of methods were used to investigate the KeyLines of Enquiry (KLoEs) to enable the panel to analyse evidence from multiple sources and follow up any trends present in the Trust’s data.

The visit included the following methods of investigation:

Interviews

Fifteen interviews took place with key members of the executive team, non executive directors and selective members of staff based on the key lines of enquiry during thevisits. See Appendix II for details of the interviews undertaken.

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Observations

Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families whereobservations took placed during visiting hours. They allowed the panel to speak with a range of staff and enabled the panel to analyse any observed handover processeswithin wards, to ensure that the staff that are coming on duty are appropriately briefed on patients.

During the RRR announced visit, observations took place in 16 areas of the Medway Maritime Hospital. See Appendix III for details of the observations undertaken.

Focus Groups

Focus groups provide an opportunity to talk to staff groups individually, and to ask each area of staff what they feel is the contributing factor to the Trust’s high mortalityscores. They enable staff to speak up if they feel there is a barrier that is preventing them from providing quality care to patients.

Focus groups with nine staff groups, including a focus group open to all staff, were held during the announced site visit. See Appendix IV for details of the focus groups held.

The panel would like to thank all those who attended the focus groups and were open and balanced with the sharing of their experiences and their perceptions of the qualityof care and treatment at the Trust.

Listening events

Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needsimproving at the Trust. A listening event for the public and patients was held on the evening of 9

thMay 2013 at the Brook Theatre, Chatham and on the evening of 15

thMay

2013 in Liberty Hall, Isle of Sheppey. This was an open event, publicised locally, and attended by 85 members of the public and patients.

The panel would like to thank all those who attended the listening event and were open with sharing their experiences and balanced in their perceptions of the quality of careand treatment at the Trust.

Review of documentation

A number of documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the site visit. Whilst the documentswere not reviewed in detail, they were available to the panellists to influence/verify findings as considered appropriate by the panellists. See Appendix V for details of thedocuments available to the panel.

Unannounced visit

The unannounced site visit took place on the evening of Friday 17th

May 2013. This focused on observations in identified areas from the announced site visit, see AppendixVI.

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Next steps

This report has been produced by Liz Redfern, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check.This report was issued to attendees at the risk summit, which focussed on supporting Medway NHS Foundation Trust (“the Trust”) in addressing the actions identified toimprove the quality of care and treatment.

Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arisingfrom the 14 investigations will also be published.

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2. Background to the Trust

Context

The Trust is the largest single sited hospital in Kent, with 542 beds, 3670 WTE (whole time equivalent) staff and a £243m budget and has been selected for this review as aresult of its HSMR results for 2011 and 2012. In both years, the HSMR is statistically above the expected level.

Medway has a population of 400,000 with 10% of it belonging to non-White ethnic minorities. Obesity and smoking in pregnancy are significantly more common than in therest of England. Aspects of Medway’s health profile which relate to adults’ health and lifestyle are below the national average, with indicators relating to diabetes, obesity,smoking and physical activity. It is, relative to the rest of England, a medium sized Trust for both inpatient and outpatient. The Trust has a higher level of outpatient activitythan inpatient activity. It has 59% market share of inpatient activity within a 5 mile radius of the Trust. As the radius increases, the market share falls to 39% within 10 milesand 13% within 20 miles.

The Trust became a Foundation Trust in 2008, and provides a range of specialist services, including a cardiac catheter suite, vascular centre, cancer centre for Urology, astroke unit and the Macmillan Cancer Care Unit. Its commissioners for local services are Medway CCG, Swale CCG and for specialist services Kent and Medway Area Team.

Key messages from the Trust data pack

The Trust data pack identified a number of key areas of concern that were used to inform the Key Lines of Enquiry, these are outlined below:

Mortality

The Trust has an overall SHMI of 109 for the last 12 months, meaning that the number of actual deaths is higher than the expected level. Specialty-level analysis of SHMIresults highlight some key diagnostic groups within General Medicine which could potentially be reviewed: urinary tract infections, cancer of bronchus; lung, septicaemia.

Similarly, the Trust has an overall HSMR of 113, which is statistically above the expected range. Specialty-level analysis of HSMR results indicate that the following areasshould be considered: septicaemia, acute cerebrovascular disease, other perinatal conditions, acute myocardial infarction and intestinal obstruction without hernia.

The key lines of enquiry for the RRR targeted the panel’s observations and interviews to review the identified specialities in the Trust with higher mortality indicators.

Patient experience

Three measures of patient experience are rated ‘red”, specifically inpatients, complaints about clinical aspects of care, and patient voice comments. Medway has an inpatientscore lower than the national average. 55% of individual comments from patients and public received through the Keogh Review website as part of the patient voice werenegative, from a sample size of 10.

Data returns to the Health and Social care information centre show that for this Trust, the proportion of complaints relating to clinical treatment was broadly in line with theaverage (52% compared to an average of 47%).

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The Ombudsman rates the Trust as B-rated for satisfactory remedies which indicates intermediate risk of non-compliance with their recommendations. The Ombudsmaninvestigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented therecommendations made at the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates eachTrust’s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance.

Key lines of enquiry were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to thisfeedback.

Workforce and Safety

Medway has a low prevalence rate of new pressure ulcers, compared to national rates and is steadily falling. The Trust is a net contributor to the Clinical Negligence scheme.Their contributions to this ‘risk sharing scheme’ exceeded payouts to litigants. Medway’s response rate to the staff survey rate has fallen since 2011 and is below nationalaverage rate for both years. The Trust’s staff engagement is below average when compared with trusts of a similar type. On all organisational questions, Medway is below thenational average.

Key lines of enquiry were included in the review focusing on workforce measures and what staff say about the quality of care and treatment.

Clinical and operational effectiveness

The Trust records a low percentage of diabetes patients receiving a foot risk assessment during their hospital stay, but is performing within normal range on the other twosafety indicators (severe hypoglycaemic episodes and medication errors). The Trust’s crude readmission rate is 11% and the average length of stay is 3.93 days, shorter thanthe national average. With 95% of A&E patients seen within 4 hours, Medway are in line with the target level although there has been a dip in performance in recent months.The referral to treatment (RTT) is 93.2% which is higher than the target level. Key lines of enquiry were included in the review focusing on management of deterioratingpatients and the effectiveness of clinical care processes.

Leadership and Governance

The Trust has been in significant breach of two terms of its authorisation since April 2011 due to failure to exercise its functions effectively, efficiently and economically, and itsgovernance duty. The Trust board has undergone significant leadership changes in the last year; The Chair was appointed in April 2012, a new Director of Finance started inSeptember 2012, a new Director of Strategy & Governance started in March 2013 and a new Director of Organisational Development and Communications started in May2013. An Interim Director of Nursing has been in post since April 2013; a new substantive Director of Nursing has been appointed and will start in June 2013. A new MedicalDirector has been appointed and will start in August 2013. A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard key line ofenquiry for the review.

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3. Key Lines of Enquiry

Based on the Trust data pack and background information available, including insights from the Trust’s lead Clinical Commissioning Groups (CCG), Medway CCG, SwaleCCG and review of the patient voice feedback received specific to the Trust prior to the site visit, the KLoEs for the Trust were the following:

Theme Key Line of Enquiry

Governance and leadership Can the trust articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all

levels of the organisation describe the key elements of the quality governance processes?

Are the leadership roles and responsibilities clearly defined for the quality processes?

Clinical and operational effectiveness What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? What

actions is the Trust taking to improve mortality performance, particularly in general medicine and elderly care?

How does the Trust manage deteriorating patients?

What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves duringtheir time in hospital?

Patient Experience How does the Trust seek views from patients about their experience? What are the key themes from patients on their

experiences? What action is the Trust taking to address the key themes emerging?

Workforce and Safety What do staff groups interviewed (including trainee/student groups) say are the main barriers in the Trust to delivering

high quality treatment and care for patients?

How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed

effectively?

Trust specific – Diabetes What specific contribution is the Trust making to improve the health outcomes of the local population with diabetes?

(This KLoE was covered in clinical and operational effectiveness)

Trust Specific – Quality Care Strategy and

Implementation

How have they refreshed their Quality Care Strategy (April 2012)? (This KLoE was covered in Governance and

Leadership)

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4. Review findings

Introduction

The following section provides a detailed analysis of the Panel’s findings and prioritisation based on the evidence received in the Trust data pack, interviews, observationvisits, staff focus groups and patient listening events. It is evident from the data Panel members have gathered that there are six key areas the Trust should focus on toimprove patient safety and these are summarised in the key messages. The findings and supporting evidence to underpin the key messages is contained in more detail in thefollowing tables.

Key Messages

1. Need for greater pace and clarity of focus at Board level for improving the overall safety and experience of patients

The capacity of the Board and Clinical Executive Group has been diminished by changing personnel and the work associated with the possible merger with Darent ValleyHospital in Dartford and Gravesham NHS Trust. This has led to a lack of clear focus and pace at Board and Executive level for improving the overall safety and experience ofpatients. The Trust urgently needs a single visible strategy and action plan based on a recognised patient safety improvement model and underpinned by systematic stafftraining and roll out.

Accountability needs to be threaded through the organisation, via the clinical directorates, to embed responsibility for patient safety and experience at every level of the Trust.In order to achieve the required pace and focus the Trust should drive it through a strong programme delivery structure, with accountability for delivery at Board level.Responsibility for developing and delivering a coordinated action plan should be the full-time day job of one individual (Programme Director – Patient Safety) with input fromthe current Head of Audit and Patient Safety Lead accountable via one of the clinical executives to the CEO. The Programme Director should be supported by anappropriately staffed project management office.

The Programme Director will require the full support of the Board and Clinical Executive Group to ensure blocks are removed and improvement measures are implementedconsistently in every Directorate and every Ward in the Trust without exception.

2. Review of staffing and skill mix to ensure safe care and improve the patient experience

The Panel observed that in some areas of the Trust it was clear that staffing levels and skill mix are potentially unsafe. The proposal for additional nursing staff is a good startbut a holistic medical staffing review and recruitment strategy needs immediate attention. Reducing the level of locum usage for consultants indicates a clear starting point forthis work.

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3. Redesign of unscheduled care and critical care pathways and facilities

Poor A&E admission processes and a lack of early senior review means the Trust is failing to take enough opportunity to prevent admission. The impact of this failure toproperly manage admissions in A&E is felt right across the Trust with frequent use of escalation wards, overstretched staff and a failure to predictably and systematicallymanage patients on the correct care pathway, including critical care. The review team recognise the totally unsuitable layout of the A&E department and the constant workarounds staff are using to try and cope with working in an environment unfit for purpose. This is not a new problem and the lack of Board and Executive capacity and thediversion of the merger work appears to have delayed a solution being planned for earlier.

4. Improved senior clinical assessment and timely investigations

Insufficient senior medical assessment of acute medical and surgical admissions and timely investigations and interventions for them means the Trust is not taking enoughearly opportunity to prevent deterioration. This is particularly so out of hours and at weekends, but not exclusively. As a result of this and pressure on meeting A&E waitingtimes there is also evidence that patients are potentially being admitted unnecessarily.

The Medical and Nursing Director must urgently agree a single model to assess the deteriorating patient and a clear protocol for escalating concerns which is rapidlyimplemented on every ward. Junior Doctors must be trained in the system so when they are called by nursing staff they understand how to respond, including asking forconsultant help, and that the single model is part of the induction process for all staff.

5. Need to galvanise the good work that is already going on in Wards and to adopt and spread good practice

We met a large number of committed and concerned staff who frequently reported that they feel unable to raise patient safety concerns and when they do, little or no action istaken. The Trust needs to create a culture that welcomes improvement, galvanises the good work that is already going on in some Wards and adopts and rapidly spreadsgood practice.

Staff feedback on patient safety must be taken seriously by the Board and Clinical Executive Group. This will require the Executive to engage all staff in suggesting ideas forimprovement, and where good ideas are identified action plans must be developed and implemented to deliver improvements consistently. Staff need to know that they arenot only being listened to but that their concerns are being acted upon. The Big Conversation staff engagement and empowerment methodology adopted by the CEO overthe last year is a good start to this.

6. Improve public reputation

The review team held two public meetings in Gillingham, Kent and in Minster, Isle of Sheppey, Kent. The public meetings identified a number of common themes about theway this Trust is viewed by the public that attended and in many cases supported the key themes emerging from interviews, observations and data review. Many of thepatient stories we heard had common threads of inconsistent and inaccurate communication with patients, poor identification and management of deteriorating patients,inappropriate referrals and medical interventions, delayed discharges and long A & E wait times. Some of the stories were historical in nature, but not all. The Trust needs toimprove the methods and frequency with which it engages with the public and as a starting point extend its staff Big Conversation work to the public.

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The following definitions are used for the rating of recommendations in this review:

Rating Definition

Urgent The Trust should take immediate action to respond to these recommendations andensure improvement in the quality of care

High The Trust should develop a response and action plan for these recommendations toensure improvement in the quality of care

Medium The Trust should implement these recommendations to ensure ongoing improvementin the quality of care

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Governance & Leadership

The review into governance and leadership focussed on understanding the Trust’s ability to identify and respond to issues regarding mortality performance through thefollowing areas:

The quality governance process and the sub-committees and groups through which the Board delivers the patient safety agenda

Who is accountable for patient safety and quality and how do they deliver their responsibilities

How does the Trust embed responsibility for patient safety at every level of the organisation, consistently and without exception

KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all levels describe keyelements of quality governance processes?

Good Practice identified

The Chief Executive recently launched ‘The Big Conversation’ in July 2012 which has received very positive feedback from all staff groups. This was seen as a

significant step towards engaging Trust staff in the improvement journey and closing the gap between the Board and the Ward.

There is evidence of increased clinical engagement in cost improvement programmes which is starting to rebalance the focus between finance and patient safety and

experience.

The Trust has a high level Patient Safety Improvement Plan (April 2013) and has agreed Quality Account Priorities for 2013/14.

The Trust held an away day on Friday 26 April 2013 to progress the patient safety strategy. Attendees included the executive team, clinical directors, heads of nursing

and general managers.

A new patient safety lead has been appointed. The patient safety lead has redesigned the current patient safety committee so it meets on a monthly basis and has

increased the membership and focus on the learning from serious incidents, DATIX and complaints.

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Detailed Findings

Outstanding Concerns based on evidence gathered Planned Improvements Recommended Action Priority(urgent, high,

lower)

Lack of clarity around the governance processes

for assuring the quality of treatment and patient

care is leading to a lack of accountability, pace and

focus

There is insufficient attention on this issue at Board

level, focus has been diverted on the merger and

addressing capability gaps in Board membership as

evidenced through Board agendas and discussion

with Board members.

Interviews with Board members and the Chair of

the Quality Committee indicated that the Board

does not have a comprehensive and clear strategy

for addressing patient safety and quality of care

backed up by action plans.

The Board does not sufficiently hold individuals to

account for implementing existing improvements

into clinical directorates in a consistent and timely

manner leading to a lack of pace and focus as

reported in staff focus groups.

Multiple groups and sub-committees are involved in

the governance process for patient quality and it is

not clear where responsibilities lie between the

Board, Quality Committee, Clinical Executive Group

and Mortality Working Party.

The Trust Board has focused significant attention

on the merger with Darent Valley, as a result there

is no improvement strategy for the Medway site in

terms of clinical services and estate, evidenced

through a meeting with the Finance Director and

The appointment of new Board

members means that the Board has

the relevant expertise and capacity

to take control of patient safety and

quality of care issues.

The appointment of a Programme

Director – Patient Safety will enable

a focused programme of work to be

delivered for the Board.

The Board (supported by the Programme

Director – Patient Safety) must quickly develop

a single strategy and action plan for

addressing patient safety and quality of care

issues.

Ensure key themes arising from the ‘Big

Conversation’ are communicated to staff and it

is clear what actions are being taken to

respond.

Consider a Board development Programme to

support delivery of improvement plans.

Urgently agree an estate strategy to develop

the Medway site and address the disparity

between demand and capacity, particularly in

unscheduled care. Partnership working with

health and social care providers will be critical

to the success of this.

Urgent

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lower)

Director of Strategy and Governance.

Staff at all levels cannot articulate the quality

governance process

Interviews with individual staff members and Focus

Groups indicated that staff could not describe the

quality governance process or the key procedures

to ensure patient safety and quality of care. This

was particularly apparent amongst Junior Doctors.

Lack of clarity over the governance process meant

that staff were unsure how to raise concerns or

spread good practice this was a consistent

message in the nurses and Junior Doctors Focus

Group.

Training on quality is not currently embedded in the

Junior Doctor training program or Ward inductions

for new permanent staff, locums and agency staff.

None identified Clearly document the quality governance

process and roles and responsibilities of key

individuals and groups, including the Medical

Directorate agenda.

Embed quality training in to the Junior Doctor

training program and Ward inductions.

High

(dependent on

completion of the

strategy and

action plan)

KLOE 2: Are the leadership roles and responsibilities clearly defined for the quality processes?


The Trust has documented its governance and committee structures following a recent review, this has provided greater clarity on the terms of reference of Board sub-

committees and working groups

The Trust has identified a clinician who is keen to lead on patient safety issues and is part of the Clinical Executive Group but they have yet to formalize this

arrangement through an updated job description

The Trust recently appointed a Programme Director – Patient Safety to provide greater focus on this area working closely with the Trust Chief Executive

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Detailed Findings


lower)

Lack of clarity around the leadership roles and

responsibilities for quality and patient safety

There is a lack of clarity around leadership roles

and responsibilities for quality and patient safety at

all levels of the Trust leading to a lack of focus and

pace for delivering improvement evidenced through

meetings with staff who should have responsibility

for quality and patient safety.

The Panel observed that existing improvement

plans are inconsistently implemented and in some

areas are ignored completely. There is no evidence

that this issue is being tackled as a priority by the

Clinical Executive Group, including the Medical

Director and Nursing Director.

A lack of clarity over the leadership roles and

responsibilities for quality and patient safety means

the issue has been given insufficient attention in

Cost Improvement Programmes.

A PMO office is being developed to

support the Programme Director -

Patient Safety.

This team will collaborate with the

executive team to support the

increase in pace that this programme

will require.

Three new clinical patient safety

leads have been appointed to

strengthen the clinical leadership

across the Trust.

The Board should agree a patient safety

improvement methodology.

The Programme Director – Patient Safety

should ensure the action plan is implemented

consistently and quickly in to every Ward with

the full support of the Board and in particular

the Medical Director and Nursing Director.

Individuals should be held to account for

implementation of the plan.

A project management office must be put in

place to support and monitor delivery of the

action plan.

Urgent

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Clinical and operational effectiveness

The review into clinical and operational effectiveness focused on how the Trust is implementing actions to monitor mortality performance and identify areas where clinicaleffectiveness is potentially impacting patient quality and safety, this included the following:

How the Trust reviews deaths to understand if trends can be identified and lessons learned

How clinical effectiveness is monitored

How actions to improve mortality performance are implemented in the Trust

KLOE 3: What processes are in place to support monitoring mortality data and clinical effectiveness? What actions are being taken by the Trust to improvemortality performance, especially for General Medicine and Elderly Care?


Safety thermometer and mortality metrics are reported to the Patient Safety Committee and Quality Committee

The Trust requested an Emergency Care Intensive Support Team (ECIST) review which was held on 15 May 2013

Detailed Findings

Outstanding Concerns based on evidencegathered

Planned Improvements Recommended Action Priority(urgent, high,

lower)

Limited evidence of effective processes for

monitoring mortality data and clinical

effectiveness

It is not clear who has responsibility for analysing

the root cause of all deaths to identify trends and

report key messages to the Board as evidenced

during a meeting with the Clinical Executive

Establishing mortality review process –

rapid review at the time of death by

senior nurse team, issues identified and

actions escalated immediately.

Implementation of monthly meetings for

the Medical Director and Director of

Nursing to review deaths.

Reviewing learning from incidents

The Clinical Executive Group should

monitor monthly trends in mortality and

oversee action plans to address areas of

concern.

The Trust needs to understand the high

mortality rate in the medical HDU and

develop an action plan to address it. This

should include implementing an admissions

Urgent

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lower)

Group.

Heads of Nursing reported that the Daily Death

Review Meetings only require review of patient

notes by a nurse; if the death is unexpected then

the notes are reviewed by a consultant. This is not

necessarily a multidisciplinary meeting although it

does work well in some areas.

The medical HDU (High Dependency Unit) activity

analysis (April 2012 – March 2013) has indicated

a high mortality rate (24%). The Panel saw no

evidence this is being reviewed in depth by the

Medical Director to understand the root causes

and develop an action plan to understand if, for

example, the mortality rate is due to poor

implementation of the admissions policy or lack of

out of hours dedicated specialist cover for the

unit.

Patients and staff reported that complaints are not

investigated in a timely manner. There is also

limited evidence of complaints being followed

through to implemented action plans and learning,

this was a consistent message from all staff focus

groups.

The Panel found little evidence of downward

dissemination of lessons from Serious Incidents

or DATIX data. Action plans are not consistently

developed and implemented as a result of

incidents. Junior Doctors and Nurses reported

that they raise incidents but get no response and

nothing changes as a result.

The Nurse and Junior Doctor Focus Group

attendees reported that they are encouraged not

Implementation of findings from the

ECIST team review. The ECIST team

visited the Trust on 15 May and

following this visit the Trust has agreed

to establish an Improving Emergency

Flow Board to:

- Improve patient safety by

reducing delays in assessment

areas;

- Increase patient experience and

satisfaction

- Ensure safe care is delivered in

the right environment

- Achieve better patient flow

- Reduce transfers in the patient

journey

- Implement the Enhanced

Quality Programmes of Care

- Develop a set of metrics to

support and monitor the

implementation and outcomes

of the programme

CHKS are implementing the Qlab

approach in line with Darent Valley

Hospital and to provide external review

of the Trust mortality data and patient

safety metrics. The findings will be fed

back through the current clinical audit

structure for investigation and action.

policy for the medical HDU.

The Trust must ensure learning from

serious incidents and complaints is

disseminated in a timely manner and that

actions to prevent a recurrence are

implemented.

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lower)

to report incidents on DATIX.

Consultants reported that Mortality and Morbidity

meetings are sporadic and were suspended in

medicine until recently.

Limited evidence of actions to improve mortality

performance being implemented consistently

across the Trust

The Clinical Executive Group are not overseeing

mortality implementation plans.

There are examples of good practice such as the

Sepsis Bundle, however the ‘Think Sepsis’

programme has been in place for two years and

has lacked pace. The Sepsis Bundle was only

recently implemented in A&E and has not yet

been implemented in other high dependency

wards.

Consultants and Junior Doctors reported that

there is no GI bleed rota which presents a

significant risk to patients.

The sepsis bundle will be rolled out

across the Trust but this needs to be

accelerated.

The GI bleed rota will be agreed if the

merger goes ahead.

Accelerate roll out of the sepsis bundle

across the Trust.

Agree a GI bleed rota (involving clinicians

from Dartford if necessary) regardless of

the merger.

Urgent

KLOE 4: How does the Trust manage deteriorating patients?


Consultant led multidisciplinary handover on delivery suite every evening

24/7 critical care outreach team

The Trust has a ‘Think Sepsis’ campaign

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Detailed Findings


lower)

No consistent process for managing deteriorating

patients

Consultants and Junior Doctor Focus Groups

reported that there is no single process for

recognising and managing deteriorating patients

that is implemented consistently in every Ward.

The Panel observed that the Sepsis Bundle was not

implemented in every Ward.

The Panel observed that the design of the

observation charts are not user friendly and have

no clear escalation criteria.

Ward staff reported that agency staff are not given

orientation time to understand the process for

managing deteriorating patients .

Junior Doctors reported that their training does not

give sufficient attention to patient safety and the

Early Warning System.

Junior doctors felt they frequently had to make

clinical decisions above their level of competency in

the management of unwell patients (particularly

hematology and orthopedics departments).

Simplify process for managing

deteriorating patients and involve

stakeholders and users in designing a

system for an effective chain of

prevention.

Develop a clear universally known and

understood, mandated, unambiguous,

graded, activation protocol for escalating,

monitoring or summoning a response to a

deteriorating patient. This should be

standardised across the whole hospital.

It must include specific responsibilities of

senior medical and nursing staff, including

consultants and identify the maximum

response times. When patients continue to

deteriorate after non-consultant review there

should be escalation of patient care to a

consultant. If this is not done, the reasons for

non-escalation must be documented clearly

in the case notes.

Urgent

Inconsistent assessment and referral processes

Junior Doctors and nurses reported that there is a

lack of senior staff to assess and refer patients

leading to inconsistency. This was supported by

Panel review of a sample of Ward rotas and

observations during the announced and

The Board asked for Nursing

Establishment to be reviewed in

January 2013. This has resulted in the

Interim Director of Nursing undertaking

a further detailed review of nursing skill

mix in each clinical area.

The Trust Board have recognised that

Complete a holistic medical staffing review

and recruitment strategy.

Ensure appropriate consultant cover for

acute medicine and medical HDU at night

and weekends.

Review care provided in the ADL.

Urgent

21


lower)

unannounced visits.

The Trust has no acute physicians for AMU (Acute

Medical Unit) out of hours and there is insufficient

cover during the day. There are no intensive/ HDU

specialists for out of hours cover on medical HDU.

This was reported by Junior Doctors and evidenced

through a review of staff rotas and Panel

Observations during the visit.

Low nursing staff levels were reported on AMU,

particularly when escalation wards are being used.

A review of staff rotas did not support this finding,

however nurses reported that they are often moved

from AMU at short notice to go and work on

escalation wards resulting in low staff numbers.

The Trust needs to review its measures to ensure

adequate care is provided in an appropriate

environment in the ADL, the Panel noted concerns

in this area during the unannounced visit.

the Medical and A&E physicians are

understaffed. There has been recent

investment in A&E consultants. The

Clinical Executive Group agreed in

March to invest in a further 5

Consultants in medicine and recruitment

is underway. Two substantive

physicians have been appointed and it

is expected that the Trust will shortly

appoint one more.

Poor design and layout of critical care areas

The Panel observed that the design and layout of

critical care areas needs urgent attention.

Concern was raised by Junior Doctors and

Consultants on the practicalities of staffing and

covering several critical care areas d in different

parts of the trust especially overnight and at

weekends.

Junior Doctors reported that they were frequently

left in charge of the medical HDU areas with no

senior oversight and low staff numbers, particularly

when escalation wards are in operation. This was






Flow Board to:



areas


satisfaction



Urgent review of the design and layout of

admission and critical care areas

Urgent

22


lower)

reported as a frequent occurrence. - Achieve better patient flow


journey






of the programme

Poor admission processes for patients admitted

through the unscheduled care pathway

A&E is frequently at capacity and was recognized

as a problem area by many staff who the Panel

met, in particular the CDU, minors, resuscitation

and the children’s areas were observed to be below

what might be expected.

All staff focus groups frequently cited problems with

the timely assessment and treatment pathways at

the front door which were considered to critically

affect the safety of patients. This finding was

supported by Panel observations.






Flow Board to:



areas


satisfaction



- Achieve better patient flow


journey






of the programme.

Urgent plan to remodel/provide temporary

extra capacity.

Urgent

23

KLOE 5: What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves during their time in hospital?


The Trust operates a daily beds meeting and manages bed occupancy as far as possible

New nurse outreach weekend service – i.e. antibiotics at home and Saturday / Sunday pharmacy is helping with weekend discharge

Interim Director of Nursing leading on ‘Length of Stay’ programme

Plan for new contract of transport from A&E for discharges at evenings and weekends

Detailed Findings


lower)

Bed capacity is not sufficient to meet demand

To meet cost improvement programmes the Trust

closed a number of wards over the last 3 years

resulting in a loss of 60 beds. This has caused

significant pressures on the emergency wards such

as A&E, AMU and HDU which are frequently at

capacity and are understaffed to potentially unsafe

levels as observed by the Panel and reported by

Junior Doctors and nurses.

Throughout our visit, the Panel identified evidence

of poor bed management and flows including the

following frequent use of escalation areas. A

contributing factor to this is the number of patients

that are medically fit but are not discharged for a

The Trust has a target to meet 90% bed

occupancy through a Programme being

led by the Director of Nursing.

The End Of Life Matron has started a

project ‘PEACE’ to work with residential

and nursing homes to support them in

caring for the dying.

ECIST have recommended the Trust sets

up an ‘Improving Emergency Flow Board

to achieve the Trust goal to reduce bed

occupancy to below 90% by:

o ensuring safe care is delivered in


o Achieving better patient flow

o Reducing transfers in the patient

Understand the options available to

relieve pressure on emergency wards,

which should include revisiting the

decision to close wards.

Full implementation of real time patient

tracking, either through a single system or

automated links between those systems

used to track patients.

Wider health system engagement to

make better use of out of hospital care

including preventative strategies and

community care, including support to

ensure patients are supported to die in

their place of choice.

High

24


lower)

variety of reasons including access to care homes

and other community support.

Nurses reported problems with accessing social

services and the Trust needs to improve

partnership working with stakeholders to enable

more effective patient throughput and to ensure

patients die in their place of choice with appropriate

support.

journey.

Patient moves are not consistently tracked

The Panel requested data on patient moves for non

clinical reasons which the Trust was unable to

provide as it is not tracked.

None identified Improve processes to monitor patient

moves and improve consistency of care

High

25

Patient experience

Overview

The review into patient experience focussed on the systems and processes in place to collate and analyse patient experience and the consistency and timeliness of theTrusts response to patient feedback and complaints.

KLOE 6: How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is theTrust taking to address the key themes emerging?


The complaints process is advertised throughout the Trust.

The Trust regularly receives positive feedback from WOW awards, a nationally accredited customer service programme. The WOW nominations outweigh the number

of complaints received.

The Surgical Directorate have changed the way that they respond to complaints. The new process brings all individuals involved with the complaint together in a

meeting to analyse each point raised, and to enable attendees to challenge the decision making process and response. The agreed response is compiled and

submitted to the Complaints Team. The new process enables greater opportunity to learn from complaints and that learning will inform the Change Register to

demonstrate changes have been implemented as a result of complaints.

Detailed Findings


lower)

The Trust is not proactive enough in routinely seeking

feedback from its patients

Patients reported that the Trust is slow to respond to

patient feedback and complaints.

The patient feedback gathered during listening events

Develop and implement a programme

to fully engage with the patient

community. This should be a multi-

channel approach including formal

processes and more informal listening

events

High

26


lower)

fully supported the key messages contained in this

report.

Patients felt the Trust should do more to gather

feedback through the use of open listening events

which are considered to be particularly important in

harder to reach areas.

The Trust needs to improve its approach to diversity.

Patient complaints information is currently only

available in English despite the diverse local

population.

Lack of awareness or planning in trying to engage

patients from minority groups was evidenced during a

meeting with the PALS Officer.

The Trust understands the key themes arising from

patient experience data but this information is not

translated into action

There were clear messages from the patient listening

event which were consistent with the findings of the

Panel as documented in this report.

The Panel observed only limited evidence that patient

feedback is being acted upon and that the Trust

understands the key themes arising from its feedback.

The Panel observed that it is not clear how patient

feedback is being communicated to the Board and

subsequently embedded in to action plans to deliver

change within the hospital.

The Panel noted that the Trust had a higher than

anticipated update of the Friends and Family Test

(planned 15% for April and has achieved 30%).

None identified The Trust needs to demonstrate that it

is responding to patient feedback and

embed patient feedback within its care

quality strategy.

High

27

Workforce and safety

Overview

The two KLOEs in the area of workforce and safety focused on identifying the key barriers in the Trust to effectively managing quality and patient safety and how the Trustapproaches its staffing levels and skill mix to deliver quality and safety.

KLOE 7: What do staff groups interviewed (including trainee / student groups) say are the main barriers in the Trust to delivering high quality treatment and carefor patients?

Detailed Findings

Theme Outstanding Concerns based on evidencegathered


lower)

Morale amongst many staff in the Trust is low and this is reflected in the feedback the Panel received from all staff groups. It was recognised that the CEO has made positive

steps to engage staff but this needs to be translated into action plans and improvements quickly. The Board will need to tackle this issue if it is to succeed in transforming the

hospital.

The key themes and concerns identified in this KLOE have been covered elsewhere and can be summarised as follows:

Lack of accountability for patient quality and safety

Potentially unsafe emergency care pathway

Inconsistent processes for reporting and learning from incidents

Inconsistent clinical management

Cost Improvement Programmes have left staff stretched

Lack of senior oversight particularly out of hours and at weekends

Poor IT support, for example it took a radiologist 6 months to get a password to use the x-ray system. This was a frequent complaint.

28

KLOE 8: How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed effectively?


The Board asked for Nursing Establishment to be reviewed in January 2013. This has resulted in the Interim Director of Nursing undertaking a detailed review of

nursing skill mix in each clinical area.

Detailed Findings


lower)

Patient safety has not been at the heart of workforce

planning

The Panel were unable to obtain a clear strategy that

addresses the staffing requirements for all grades

and directorates.

The Nurses Focus Group reported that there is a lack

of multidisciplinary working across the Trust and staff

operate in professional silos. This was supported by

Panel observations during the announced and

unannounced visit.

There is a difference in views at Board level as to

what represents a safe vacancy factor and there is

no set policy.

Staff reported that the recruitment process is slow

and can take up to 9 weeks.

Director of Nursing – undertaking a

staffing review for nursing.

A high level Workforce Strategy was

approved by the Board in April 2013 but

further detailed work is now required.

The Annual Plan 2013/14 includes a

capacity plan: including workforce plan

to deliver 7 day services, new roles and

ways of working to replace traditional

staffing models.

Develop a single workforce strategy and

recruitment plan.

Medical staffing review especially to

address the high use of medical locums

at consultant and other grades.

Review how multi-disciplinary teams

should work together to break down

professional silos.

Urgent

29

5. Conclusions and support required

Conclusions

This is a Trust undergoing multiple changes at Board and executive level with a new Chair appointed in April 2012, a new Director of Finance appointed in September 2012, anew Director of Strategy & Governance appointed in March 2013 and a new Director of Organisational Development and Communications appointed in May 2013. An InterimDirector of Nursing has been in post since April 2013 and a new substantive Director of Nursing has been appointed and will start in June 2013. A new Medical Director hasbeen appointed and will start in August 2013.

Whilst the leadership team is undergoing change, the members of the Trust Board need to ensure that they remain focussed on delivering significant improvements in patientsafety and quality. The Trust has been under scrutiny from Monitor for an ongoing period and as a result the Trust has generally been reactive rather than proactive in dealingwith issues and staff morale has suffered. One significant area to enable improvement at the Trust is a period of stability and an increased focus on safety and quality at theBoard and Executive level.

The Trust is under extreme service pressure with high activity levels evident throughout our visit. Cost Improvement Programmes have undoubtedly impacted the quality andsafety of patient care and urgent attention is needed to reassess the impact of these programmes.

Our review identified a number of areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there is more for the Trust Boardto do in ensuring good practice consistently across all of the Trust, all of the time. Our review also identified a number of areas of concern across all key lines of enquiry. Forthe majority of the areas of concern, we identified a number of improvements already underway at the Trust or planned improvements evidencing the Trust’s continuedprogress and improvement. Further recommended action for each area has been included and prioritised as urgent, high, medium or lower priority.

Action Plan

This section summarises the immediate actions arising from the review.

30

Suggested high priority actions for consideration at the risk summit

The Panel identified suggested areas of focus for further discussion at the risk summit.

Problem identified Recommended Action for discussion Support required by theTrust

1. Need for greater pace andclarity of focus at Board level forimproving the overall safety andexperience of patients

i. The Trust urgently needs a single visible strategy and action plan based on a recognisedpatient safety improvement model and underpinned by systematic staff training and roll out.

ii. Accountability needs to be threaded through the organisation, via the clinical directorates, toembed responsibility for patient safety and experience at every level of the Trust.

iii. The Trust must ensure learning from serious incidents and complaints is disseminated in atimely manner and that actions to prevent a recurrence are implemented.

2. Review of staffing and skillmix to ensure safe care andimprove the patient experience

i. Holistic medical staffing review and recruitment strategy needs immediate attention. Reducingthe level of locum usage for consultants provides a suggested starting point for this work.

3. Redesign of unscheduledcare and critical care pathwaysand facilities

i. Urgent review of the design and layout of the emergency department, admission and criticalcare areas to be incorporated in an estate strategy. Partnership working with health and socialcare providers will be important to the success of this.

4. Improved senior clinicalassessment and timelyinvestigations

i. Ensure appropriate consultant cover for acute medicine and medical HDU at night and

weekends.

ii. Review care provided in the Admission and Discharge Lounge.

iii. Develop a clear universally known and understood, mandated, unambiguous, graded, activation

protocol for escalating, monitoring or summoning a response to a deteriorating patient. This

should be standardised across the whole hospital.

31

5. Need to galvanise the goodwork that is already going on inWards and to adopt and spreadgood practice

i. The Trust should develop a strategy and action plan to create a culture that welcomesimprovement, galvanises the good work that is already going on in some Wards and adopts andrapidly spreads good practice.

6. Improve public reputation i. The Trust should improve the methods and frequency with which it engages with the public andas a starting point extend its staff Big Conversation work to the public.

32

Appendices

33

Appendix I: SHMI and HSMR definitions

HSMR definition

What is the Hospital Standardised Mortality Ratio?

The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you wouldexpect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by thehospital. However, it can be a warning sign that things are going wrong.

How does HSMR work?

The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for acase-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence ofpalliative care, number of previous emergency admissions and financial year of discharge.

How should HSMR be interpreted?

Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify ifvariation from this is significant confidence intervals are calculated. A distribution model is used to calculate 95% and 99.9% confidence intervals and only when these havebeen crossed is performance classed as higher or lower than expected.

SHMI definition

What is the Summary Hospital-level Mortality Indicator?

The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMIfollows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm forpotential deviations away from regular practice.

How does SHMI work?

1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data

2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time

34

3) The Indicator will utilise 5 factors to adjust mortality rates by

a. The primary admitting diagnosis

b. The type of admission

c. A calculation of co-morbid complexity (Charlson Index of co-morbidities)

d. Age

e. Sex

4) All inpatient mortalities that occur within a Hospital are considered in the indicator

How should SHMI be interpreted?

Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted

Some key differences between SHMI and HSMR

Indicator HSMR SHMI

Are all hospital deaths included? No, around 80% of in hospital deaths are included,which varies significantly dependent upon theservices provided by each hospital

Yes all deaths are included

When a patient dies how many times is this counted? If a patient is transferred between hospitals within 2days the death is counted multiple times

1 death is counted once, and if the patient istransferred the death is attached to the lastacute/secondary care provider

Does the use of the palliative care code reduce therelative impact of a death on the indicator?

Yes No

Does the indicator consider where deaths occur? Only considers in hospital deaths Considers in hospital deaths but also those up to 30days post discharge anywhere too.

Is this applied to all health care providers? Yes No, does not apply to specialist hospitals

35

Appendix II: Interviews held

Interviewee Date held

Mark Devlin, Chief Executive 9 May

Denise Harker, Chair of the Board 9 May

Dr Gray Smith-Laing, Medical Director and Susan Osborne, Director of Nursing (interim) 9 May

Claire Harrison, PALS and Lyndsay Barrow, Complaints Officer 9 May

John Sands, Chair of Quality Committee (Non Executive) 9 May

Andy Brown, HR Director (Interim) and Raj Bhamber, Director of Organisational Development and Communications 10 May

Ruth Jenner, Senior Governor 10 May

Susan Osborne, Director of Nursing (interim) 10 May

Jason Seez, Director of Strategy and Governance 10 May

Howard Marsh, Urologist and Patient Safety Lead, and Paul Hayden, Intensivist and Audit Lead 10 May

David Meikle Director of Finance 10 May

Bov Jani, Director of Medical Education and Marietta Higgs, Foundation Training Programme Director 10 May

36

Appendix III: Observations undertaken

Observation area Date of observation

Care of the elderly wards – Byron, Tennyson and Milton 9 May

Accident and emergency (A&E) 9 May and 17 May

Acute Medical Unit (AMU) 9 May and 17 May

Trauma and Orthopedics - Arethusa 9 May and 17 May

Surgical Assessment Unit – Kingfisher Ward – Handover

ENT – SHO to SHO

General Surgery – Registrar / SHO / F1 and SHO Urology from day to Registrar / SHO night

9 and 17 May

Delivery Suite – Handover

Obstetrics and Gynae

Consultant in call / Registrar / SHO to Registrar / SHA

9 May

Admission Discharge Lounge - Site Practitioners Office – Handover

Medical Registrar / SHO to Registrar / SHO

Medical Outreach Team

Hospital Site Team

9 May

HDU – Trafalgar 17 May

HDMU – Bronte 17 May

Elderly Care – Byron 17 May

37

Appendix IV: Focus Groups held

Focus group invitees Focus group attendees Date held

Junior Doctors 5-10 attendees; attendees were all Junior Doctors (the Panel had to hold two Junior Doctor Focus Groups as

the first session was dominated by a member of senior staff)

9 May

Student Nurses 15 attended; attendees were majority student nurses Year 1-3 and 2 student midwives 9 May

Nurses / Care Support workers 2 sessions on 9 and 10 May 9 and 10 May

All staff Approx 30 attendees; attendees included nurses, housekeeping, porters 10 May

Consultants Approx 15 attendees plus 5 clinical directors 10 May

Heads of Nursing Approx 10 attendees 10 May

Clinical Executive Group Approx 10 attendees 10 May

Trust Governors 6 attendees 10 May

Non Executive Directors Approx 15 attendees 10 May

38

Appendix V: Information Review

Document Name Description

Quality Strategy 2012Board Quality strategy (incorporating Patient Safety, Patient Experience and ClinicalEffectiveness).

Board Assurance Framework 2013-13Board Assurance Framework and Trust Risk Register.

Corporate Risk Register

IAC Jul12 135 Clinical Audit Dept

Clinical Audit plans for 2013/14 and latest Clinical Audit Annual Report.IAC Jul12 135 Appendix 1 MFT

Clinical Audit Plan 13-14

Appendix 1 MFT Clinical Audit 2013-14

CIPs 2012-13

List of all Cost Improvement Programmes for 2012/13 and 2013/14 and details of the process forassessing the quality impact of these

CIPs 2013-14

Briefing for QIA Session

Workbook for QIA Form

QIA Sign off Form

NHSCB- everyone counts plan

Quality Committee Report QGF Most recent self assessment or external assessment of quality governance (against Monitor’sQuality Governance Framework or equivalent)Monitor QGF Benchmarking

Organisation structure chart April

Organisation structure and CVs of Executive team

Mark Devlin CV

Gray Smith - Laing CV

Jason Seez CV

Susan Osborne CV

39

Patrick Jonhson CV

David Meikle CV

Andrew Brown CV

Committee Structure

Governance and Committee Structures and terms of reference for assuring quality includingmortality

Integrated Audit Committee Terms of Reference

Performance and Investment committee Terms of Reference

Quality Committee Terms of Reference

Workforce Committee Terms of Reference

Clinical and Executive Group Terms of Reference

Mortality Working Party draft Terms of Reference

Feb 2013 Board Agenda and Papers

Trust Board (private and public) papers and minutes for the last 2 meetings

Chairman’s Report from Integrated Audit Committee - 20th Feb 2013

E&Y Financial Governance Follow up draft report 26th Feb 2013

Draft and report financial governance follow up review 14th Feb 2013

Outline business case for the provision of services at the Queen MarySidcup hospital 26th Feb 2013

Minutes of Performance and Investment committee meeting 24th Jan2013

Minutes of the Quality committee 15th Jan 2013

Minutes of the Workforce Committee 15th Jan 2013

March 2013 Board Papers

Kings Fund Report Urgent and Emergency care 11th March 2013

Information Governance Toolkit

Internal Audit information governance toolkit 21st Feb 2013

40

Information Governance Toolkit Self Assessment 26th March 2013

Workforce Committee Minutes 15th Feb 2013

Minutes of the Integrated Audit Committee 28th Feb 2013

Minutes of the Performance and Investment Committee 21st Feb2013

Agenda and Papers Quality Committee Feb 2013

Board Sub Committee with delegated responsibility for assuring quality and safety - papers andminutes for the last 2 months (public and private)

Agenda Quality Committee March 2013

Quality Committee Papers March 2013

Morality Working Party Agenda Feb 20th 2013

Mortality Review Group papers and minutes for the last 2 months

Complaints Management and Engagement within the Trust

Health Statistic User Group Key Points

Minutes December 2012 Meeting

Patient Safety Action Plan Jan 2013

Mortality Working Party Agenda March 2013

Minutes of Feb 2013 Meeting

Mortality Action Plan

GSL to Mr Sherlaw-Johnson

Septicaemia Review Final

120524 Think Sepsis Project Brief

Draft Mortality Dashboard

Complaint legal claims and investigations

National Advisory Group Membership

TOR NCB Mortality Outlier

41

HSMR Trend

MWP Audit March 2013

MOF Mortality Report

British Thoracic Society - Adult Community Acquired Pneumonia AuditTool Analysis

British Thoracic Society - Adult Community Acquired Pneumonia AuditTool Analysis

Review of hospital mortality data (Cerebrovascular Disease) 2011-12

Readmissions mortality Audit March 2013

Patient Experience performance 2012/13

Summary of Key Performance Measures 2012/13 including finance, performance, quality andpatient experience

Patient Safety Performance 2012/13

Performance Scorecard April 2013

Quality Indicators for PCT 2012/13

MFT Annual Plan 12/13Annual plan submission to Monitor or equivalent for NTDA for 2013/14

Medway Annual Plan presentation 13/14

120524 Think Sepsis Project Brief

CQC Mortality Alert Actions Plans and Implementation

20121119 Medway NHS FT Septicaemia


Mortality Working Group Action Plan Jan 2013

Septicaemia Review for CQC 16213

20110720 Medway NHS FT (RPA) / Acute Renal Failure Alert

Charlson Coding and Weights

Copy of CQC report Acute Renal Failure

CQC Closure letter Acute and unspecified

42


2010 December 22 Medway NHS FT RPA

2011 Feb 17 Medway NHS FT RPA

Action Plan re-High HSMR Jan 11

EQ Pneumonia Data Form


Pneumonia Data for CQC response

Clinical Governance Due Diligence - MFTAny independent reviews of quality in the last year

Clinical Governance DD Action Plan update

MFT Intermediate care providersLocal care providers - services and capacity that support your models of care e.g. Localintermediate care beds

Summary of Mortality in Medway NHS Foundation Trust.pptDated 21/12/12 (day of first Mortality Working Party meeting).Overview and explanation of mortality statistics.

SHMI mortality report 2013-04-24.doc An analysis of mortality in Medway NHS FT, dated 24/04/13.

HSMR trend 2013-04-02.xlsx Excel graph (before rebasing) and HSMR data for Medway, from Dr Foster.

Attachment 6 HSMR trend.ppt Ppt version of Excel graph above

Attachment 4 MFT Action Plan.docx Mortality Working Group Action Plan dated January 2013

Attachment 7 Mortality Dashboard.xlsxExcel data showing the number of deaths in top 4 diagnostic groups: pneumonia, septicaemia, #neck of femur, acute cerebrovascular disease by month over the last three years

Agenda 19-04-13.docx Agenda for Mortality Working Party on 19/04/13

Attachment 2 complaints report.doc

Detailed report of complaints against MFT, authored by PH consultant (on behalf of the MortalityWorking Group), dated 04/03/13.Summary of the main themes from complaints during November –December 2012

GSL letter to Mr Edward palfrey MD Frimley Park Hospital20032013.doc

Letter from MFT Medical Director to Frimley Park MD after the latter's visit. Dated 20/03/13.

Attachment 1 minutes of 8 MARCH 2013ab.docx Minutes from Mortality Working Party meeting on 08/03/13

43

MFT complaints taken from Board Report - Feb 2013.docx Patient experience scorecard and complaints report from February board papers

MFT complaints report - July 2012.doc32 page report to the Quality Committee (08/06/12) with information about recent feedback frompatients and the public from 1 February to 31 March 2012

MFT complaints report - November 12.doc27 page report to the Quality Committee (08/10/12) with information about recent feedback frompatients and the public from 1 June – 31 July 2012

MFT complaints report - September 2012.doc14 page report to the Quality Committee (08/08/12) with information about recent feedback frompatients and the public from 1 April to 31 May 2012

Complaints summary from NK report Nov 12.docx Complaints summary for July 2011- July 2012. Not clear what the source or author of this is.

MFT Complaints report - Jan 13.pdf12 page report to the Quality Committee (undated) with information about recent feedback frompatients and the public from 1 August – 30 September 2012

Trust Workforce Report for CCG pack for National Review Team.docxTrust Workforce Report for CCG pack for National Review Team.Undated.

Medway Foundation Trust Metrics 2012-13.xlsx Excel workforce graphs (assume it accompanies the report above)

MFT issues time line 12-13.xlsx Log of issues that CCG has with MFT, with details of how these are being followed up

MFT CQRG Attendance 1213.xlsx Clinical Quality Review Group (CQRG) attendance record

SI Report 30.4.13.doc report on Serious Incidents and Never Events within MFT April 2012 to March 2013

national head and neck cancer audit 2011.pdf National audits on cancer

national lung cancer audit 2012.pdf

national bowel cancer audit 2012.pdf

ssnap-acute-organisational-audit_2012-public-report.pdf Sentinel Stroke National Audit Programme. December 2012

NHFD National Report 2012.pdf The National Hip Fracture Database National Report 2012

BS_fullreport NCEPOD.pdf A review of the care of patients who underwent bariatric surgery

nati-diab-inp-audi-12-comp.xlsx National Diabetes Inpatient Audit 2012

IRof_Mortality_Rates_at_MH_v5.1_final_02042013[1].pdf Independent Review of Mortality Rates at the Manor Hospital

KM HCAI overview trajectories.docx Kent and Medway Healthcare-Associated Infections (HCAI) Overview

44

Medway Foundation trust.docx Background information drawn from the QSG in March/April 2013

MFT 2012 Patient Survey.pdf 2012 patient survey downloaded from CQC website

MFT Inpatient Survey Briefing.docx 2012 adult inpatient survey: key findings.

Email complaint about Medway.docx Email complaint dated 14 February 2013 to NCB

Copy of Medway NHS FT NE 2012-13.xlsx Medway NHS Foundation Trust Never Events 2012-13

Kent & Medway Area Team Quality Handover Alison Walton.docxKent & Medway Area Team Quality Handover – Patient Safety for 01.04.2012 to 04.03.13Includes information for the area on SIs, never events and incident reporting

CAB refs by provider Apr 12 to Jan 13 300413.xlsx REFERRALS VIA CHOOSE AND BOOK

Medway NHS FT NE 2012-13_Further info.xlsx Updated version of Item 35

N Nathan and P Green to D Harker 5 April 2013.pdfLetter from Dr Nathan Nathan (Chief Clinical Officer, Medway CCG) to Denise Harker (Chair,MFT), following the Board to Board meeting on 25 March 2013

Single Equality Scheme - Action Plan Jan2013 update v2.doc Single Equality Scheme 2011-2014 Action Plan, based around strategic themes with measures,actions, completion dates and accountable officers (who are either: Trust Board, Council ofGovernors Directors, Committees or Steering Groups)

An insight into Medical Assessment Unit facility usage between theevening of 27th September.doc

A patient's insight into Medical Assessment Unit facility usage between the evenings of 27thSeptember/early morning 28th September 2011.Includes the details of her stay and brief details of four other patients' experience in the waitingroom.

Minutes NHS Medway Clinical Commissioning Group Patient Councilmeeting (13 March 2013) FINAL.pdf

Minutes of the meeting of the NHS Medway Clinical Commissioning Group (CCG) Patient Councilheld at 6.00 pm on Wednesday 13 March 2013

User Feedback.pdf Results from 4 users from the audit (Annualaudit of the practice and supervision of midwives) questionnaire for users

Midwives feedback.doc Results from 8 midwives from the audit (Annualaudit of the practice and supervision of midwives) questionnaire for midwives

JH letter Medway 16.07.12.docx Letter dated 16 July 2012 from Jenny Hughes, Consultant LSA Midwifery Officer to Head ofMidwifery and Director of Nursing with recommendations to the supervisory team following theannual supervision audit

Keogh Briefing Report Medway.docx Overview Report on Maternity Services and Supervision of Midwives at The Medway NHS Trust –

45

8th May 2013, in response to Keogh review. Written by Jenny Hughes, Consultant LSA MidwiferyOfficer

Action Plan.doc Recommendations / Action Plan from 2012 Audit

Action Plan Template App 3.doc SoM Action Plan in Response to LSA Annual Audit Report 2012

Adult and Emergency Medicine phase 1 feedback.pptx Summary of ECIST Phase 1Unclear whether this is a follow-up to the review in April 2012 (see below) but appears to be. Notdated or with any description.

ECIST feedback Medway FT 10 May 2012 draft.docx Report to Director of Nursing, dated 10 May 2012, on ECIST review conducted on 26 April 2012

SAEIST.ppt Directorate of Surgery, Anaesthesia and Critical Care Update Phase 1 EIST May 131 pager, brief summary

WHO Checklist letter 17.04.13.doc Letter dated 17 April 2013 addressed to Surgeons & Anaesthetists (all grades) at MFT, signed byClinical Director Anaesthesia, Clinical Director Surgery, Head of Nursing and Interim GeneralManager

Medway Annual Plan 13-14 v1 2 April Trust Board.pptx Draft Annual Plan 2013/14 Overview -30th April 2013 presentation to Trust Board by Jason Seez, Director of Strategy and Governance

Patient Voice Feedback Batch 1.xlsx Patient voice feedback from Keogh website.9 feedback items posted - 2 sent through on 26 April and 7 on 10 May

Email text from Gillian Wells.docx Gillian's observations of MFT

Med locum and agency Mar & Apr 2013.xlsx Locum and agency spend in Mar and Apr 2013

Patient Voice Feedback

Key Message Ward/ area Timing

Nurses are dedicated and caring but have inadequate resources and facilities Not known Current

Poor communication of the implications of the Liverpool Care Pathway to patients or their family members Not known Current

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Organisational culture does not encourage feedback from staff and patients Not known Current

Examples of perceived poor clinical treatment Clinical Oncology 1-2 years

Inconsistent use of escalation processes e.g. emergency card Paediatrics Current

Communication to patients is inconsistent and inaccurate Clinical Haematology Current

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Appendix VI: Unannounced site visit

Agenda item

Panel pre-meet

Entry into Medway Hospital Main Entrance and announced arrival to site manager via Porters desk

Observations undertaken of the following:

Accident and emergency

Surgical High Dependency Unit – Trafalgar Ward

Surgical Assessment Unit – Kingfisher

Admission and Discharge Lounge

Trauma and Orthopedics – Arethusa

High Dependency Medical Unit – Bronte

Acute Medical Unit /Medical Assessment Unit

Elderly – Byron Ward

Meeting held with site manager to understand current staffing and patient levels

Panel left Trust and announced exit

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Appendix VII: Theme and evidence base

Theme Evidence Base

KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all levels describe keyelements of quality governance processes?

Lack of clarity around the governance processes for assuring the quality of treatment

and patient care is leading to a lack of accountability, pace and focus

Interviews:

Chair of the Quality Committee

Trust Chairman

Chief Executive

Medical Director

Nursing Director

Data

Board minutes from January 2013 – March 2013

Mortality Working Group minutes

Quality Committee minutes

Staff at all levels cannot articulate the quality governance process Interviews

Chair of the Quality Committee

Medical Director

Nursing Director

Focus Groups

Junior Doctors

Heads of Nursing

Nurses/ Care Support Workers

KLOE 2: Are the leadership roles and responsibilities clearly defined for the quality processes?

Lack of clarity around the leadership roles and responsibilities for quality and patient

safety

Interviews

Clinical Executive Group

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Theme Evidence Base

Medical Director

Nursing Director

Focus Groups

Heads of Nursing

Consultants

Junior Doctors

KLOE 3: What processes are in place to support monitoring mortality data and clinical effectiveness? What actions are being taken by the Trust to improvemortality performance, especially for General Medicine and Elderly Care?

Limited evidence of effective processes for monitoring mortality data and clinical

effectiveness

Interviews Director of Nursing Patient Safety Lead PALS/ Patient Complaints OfficerFocus Groups Junior Doctors Nurses Consultants

Public Listening Event

Data Analysis HDU activity analysis (April 2012 – March 2013

Limited evidence of actions to improve mortality performance being implemented

consistently across the Trust

Focus Groups Nurses Junior Doctors Consultants

Ward Observations A&E

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Theme Evidence Base

Assessment Units Trafalgar, Bronte and Byron Wards

Public Listening Events Feedback specifically relating to Byron, Traflagar and Arethusa Wards

KLOE 4: How does the Trust manage deteriorating patients?

No consistent process for managing deteriorating patients Focus Groups Nurses Junior Doctors Consultants

Interviews Director of Medical Education Foundation Training Programme Director

Inconsistent assessment and referral processes Focus Groups Nurses Junior Doctors Consultants

KLOE 5: What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves during their time in hospital?

Bed capacity is not sufficient to meet demand Interviews Director of Nursing Medical DirectorFocus Groups Junior Doctors Nurses Consultants

Public Listening Event

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Theme Evidence Base

Long A&E wait times Delayed discharges Medical outliers

Data Analysis Frequent use of escalation wards Use of non-medical areas for medical purposes Trust activity analysis

Patient moves are not consistently tracked The review panel requested data on patient moves and it was not available

Focus Groups Junior Doctors Nurses Consultants

KLOE 6: How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is theTrust taking to address the key themes emerging?

The Trust is not proactive enough in routinely seeking feedback from its patients Public Listening Events

Frustration that their voice is not being heard

Raise complaints and hear nothing from the Trust

Few public meetings held and not held in harder to reach parts of the Trust

catchment area

Interviews

PALS

Complaints Officer

The Trust understands the key themes arising from patient experience data but this

information is not translated into action

Interviews Clinical Executive Group Director of Nursing Medical Director

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Theme Evidence Base

KLOE 7: What do staff groups interviewed (including trainee / student groups) say are the main barriers in the Trust to delivering high quality treatment and carefor patients?

Morale amongst many staff in the Trust is low and this is reflected in the feedback the Panel received from all staff groups. It was recognized that the CEO has made

positive steps to engage staff but this needs to be translated into action plans and improvements quickly. Many junior staff reported a culture of bullying where incidents are

covered up and ideas for improvements are discouraged. The Board will need to tackle this issue if it is to succeed in transforming the hospital.

The key themes and concerns identified in this KLOE have been covered elsewhere and can be summarized as follows:

Lack of accountability for patient quality and safety

Potentially unsafe emergency care pathway

Inconsistent clinical management

CIPS programmes have left staff stretched

Lack of senior oversight particularly out of hours and at weekends

KLOE 8: How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed effectively?

Patient safety has not been at the heart of workforce planning Interviews

Director of Nursing

Medical Director

Director of Finance

HR Director (interim)

Director of Organisation Development and Communications

Public Listening Events

Lack of staff in some Wards, particularly acute and elderly wards has led to low

staff morale and absence of staff to help patients use the toilet and eat

Delays in assessment and referral and diagnostic tests

Focus Groups

Nurses

Junior Doctors

Consultants