Making sick hospitals better: important lessons for all John Tingle
ospitals, like people, can get sick. Staff may become depressed and disengaged. Leadership may fail. And mistakes can be made that compromise patient safety, even leading to death. The terrible patient safety failings at Mid Staffordshire (Francis, 2013) showed the devastation that can occur when hospitals are not performing properly—or, for want of a better word, become ‘sick’. The lessons from Mid Staffordshire are still being digested by the NHS and the Government, and the NHS has been very positive and forthright in its responses. Sir Bruce Keogh, the National Medical Director for NHS England, led a review of trusts that had high mortality rates (Department of Health (DH), 2013).
The CQC has just published individual reports on each of the 14 inspections and an overview report of the progress made by the 11 trusts put into special measures (CQC, 2014). The overview report makes clear that there are a number of common reasons why hospitals fail and a number of common measures needed to improve them: a ‘prescription for recovery’. From the report, it does seem that the NHS is ‘turning the corner’ on failing hospitals and has found the right formula, processes and mechanisms to bring about recovery. Nevertheless, there is clearly still a long way to go before the failing trusts can be said to have made a full recovery and the report does make for depressing reading in places. Evidently, the improvement messages are still not getting through to some trusts and some are stubbornly resistant to brining in a safe and patient-centric culture.
Special measures
CQC overview report
The review identified significant failings in all the trusts, relating to leadership and serious patient-safety and quality issues. In July 2013, 11 of the 14 trusts were put into special measures, which are described as involving:
Overall, the report’s tone is positive. The Chief Inspector of Hospitals concluded that significant progress has been made at 10 of the 11 trusts:
H
‘Close scrutiny from Monitor (for foundation trusts) or the NHS Trust Development Authority (NHS TDA) (for NHS trusts), combined with the appointment of an improvement director and in most cases linkage with a partner (or ‘buddy’) trust that is performing well in areas where improvement is needed. In some cases it has also involved changes being made at board level’ (CQC, 2014: 2)
CQC re-assessment
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
908
The CQC re-assessed these failing trusts using its new, more robust assessment regime, building on the methodology shown in the original Keogh review (DH, 2013), but also taking the review process further. The process (CQC, 2014) involves inspection by teams that include clinicians, experts by experience and CQC inspectors. Eight core services are always inspected. Each service is assessed against five key questions: ■■Is it safe? ■■Is it effective? ■■Are staff caring? ■■Is the service responsive to patients’ needs? ■■Is the service well-led? Trusts’ services are rated on these questions with a four-point scale (‘Outstanding’, ‘Good’, ‘Requires improvement’ and ‘Inadequate’).This is all then followed by the award of an overall trust rating.
‘Two have made exceptional progress and have been rated ‘good’ overall. A further three have made good progress … For five further trusts, the Chief Inspector has recommended a further period in special measures, with a further inspection in around six months to ensure that they are continuing to make progress. One trust … has so far failed to make significant overall progress’ (p 2) The report does stress that the trusts’ improvement efforts do not stop here and that more progress needs to be made, especially in relation to safety and responsiveness.
Factors that account for the improvements made No single factor accounts for the improvements that have been made or for the varying pace of change at different trusts: ‘Trusts did not all start from the same baseline. The size of the task was larger for some trusts than for others, especially for those covering two or more locations that are widely separated geographically. In addition, some of these trusts were known to have been struggling to provide high quality care for several years’ (p 2) That final sentence is particularly worrying. Why were the poor care, safety and quality in these struggling hospitals tolerated for so long? And why did the improvement measures directed at these trusts not work effectively much sooner? The answer must be that the NHS did not have the right tools, measures and systems at the time to put matters right. The
© 2014 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission’s (CQC) report into the progress made at 11 NHS put into ‘special measures’ last year
British Journal of Nursing, 2014, Vol 23, No 16
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY Francis report (2013) conveys all too well the failings of the NHS quality and safety infrastructures.
CQC overall findings The report’s findings are categorised according to the five key questions that the CQC always ask: safety, effectiveness, caring, responsiveness and well-led.
Safety Only 40% of services were rated as ‘good’ for safety, which is clearly a concern.The report says: ‘A large number were rated as “requiring improvement”. The most frequent reasons for a rating of “requires improvement” were suboptimal nursing and/or medical staffing levels and low levels of completion of mandatory training’ (p 10) The report also states that a small number of services across the 25 locations were rated as ‘inadequate’ for safety: ‘These included three medical care services, three outpatient services, two critical care services, two surgical care services, one service for children and young people and one A&E service’ (p 10)
Effectiveness Over 60% of services were judged as ‘good’ on effectiveness. Lack of the use of recognised clinical guidelines was a common reason for the CQC giving a ‘requires improvement’ rating here.
Caring This was the best category of improvement across the trusts with the overall majority of services being rated as ‘good’ for caring. There were no ‘inadequate’ ratings here and two services were rated as ‘outstanding’.
Responsiveness Again, the findings here are very worrying, just over half (54%) of all services were rated as good on responsiveness: ‘The most common reasons for being judged as requiring improvement or inadequate on responsiveness included poor management of the flow of patients through the hospital from the A&E onwards … Complaints processes also required improvement in several trusts. Of significant concern was the poor management of outpatient’s services, leading to delays and cancellations in over half of the trusts’ (p 10)
© 2014 MA Healthcare Ltd
Well-led This was the most concerning part of the report. A well-led organisation, by definition, is going to be responsive, proactive and good at what it does. A poorly led organisation will fall between the cracks and will be travelling in a myriad number of directions, in many instances, quite poorly. Only two of the 11 trusts were judged to be good on being wellled with eight requiring improvement and one being judged as inadequate:
British Journal of Nursing, 2014, Vol 23, No 16
‘In around half of the trusts the new leadership team had only recently been established, making it difficult to assess the leadership with confidence. Seven of the 11 were judged as requiring improvement on 50% or more of their individual core services’ (p 10)
Specific changes made by some trusts The changes made by some trusts included (CQC, 2014: 13) ■■ Recruitment of additional nursing and medical staff. Several trusts recruited nurses from Spain and Portugal ■■ A stronger emphasis on management of patients whose clinical condition is deteriorating. Steps taken include use of early warning scores, better escalation processes, implementation of care bundles and pathways for specific conditions ■■ Steps to improve the flow of patients through the hospital from the A&E department through acute medical units or surgical assessment units to medical and surgical wards and to discharge ■■ A greater focus on quality and safety at board level with improved governance processes.
Important factors for success A number of success factors are identified in the report (CQC, 2014) that can turn around a failing trust: ■■ Strength of leadership ■■ Acceptance of the scale of the problems faced by the trust ■■ Engagement with staff and, in particular, alignment on the quality agenda between senior managers and senior clinical staff, leading to a common sense of purpose ■■ Willingness to accept external support and advice from ‘buddy’ trusts.
What next? According to the report, some failing trusts can exit ‘special measures’, others must remain, and one trust, Medway NHS Foundation Trust, has failed to make significant overall progress (further urgent support is being given). All in all, the progress report makes for salutary reading. Although improvements are clearly being made, progress is incremental and many gaps are present overall in trust performances. It is worrying that only 40% of services were rated as ‘good’ for safety. The airline industry would crumble if it had similar ratings. Hospitals should have similar safety records to the airline industry, and share the same safetyobsessed working environment and service culture. The progress report functions as an important testament to what can go wrong—and what needs to be done to put matters right. There are important lessons here to be learnt for all trusts, not just the failing ones. Performance may begin to deteriorate even in a good, well-run trust, so there is no room for complacency. At the very least, trusts now know the BJN warning signs to look out for. Francis R (2013) The Mid Staffordshire NHS Foundation Trust: Final Report of Public Inquiry Chaired by Robert Francis QC, HC 947. TSO, London Department of Health (2013) Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report by Professor Sir Bruce Keogh. DH, London Care Quality Commission’ (2014) Special measures: one year on. http://www. cqc.org.uk/content/special-measures-one-year (accessed 1 September 2014)
909
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
ospitals, like people, can get sick. Staff may become depressed and disengaged. Leadership may fail. And mistakes can be made that compromise patient safety, even leading to death. The terrible patient safety failings at Mid Staffordshire (Francis, 2013) showed the devastation that can occur when hospitals are not performing properly—or, for want of a better word, become ‘sick’. The lessons from Mid Staffordshire are still being digested by the NHS and the Government, and the NHS has been very positive and forthright in its responses. Sir Bruce Keogh, the National Medical Director for NHS England, led a review of trusts that had high mortality rates (Department of Health (DH), 2013).
The CQC has just published individual reports on each of the 14 inspections and an overview report of the progress made by the 11 trusts put into special measures (CQC, 2014). The overview report makes clear that there are a number of common reasons why hospitals fail and a number of common measures needed to improve them: a ‘prescription for recovery’. From the report, it does seem that the NHS is ‘turning the corner’ on failing hospitals and has found the right formula, processes and mechanisms to bring about recovery. Nevertheless, there is clearly still a long way to go before the failing trusts can be said to have made a full recovery and the report does make for depressing reading in places. Evidently, the improvement messages are still not getting through to some trusts and some are stubbornly resistant to brining in a safe and patient-centric culture.
Special measures
CQC overview report
The review identified significant failings in all the trusts, relating to leadership and serious patient-safety and quality issues. In July 2013, 11 of the 14 trusts were put into special measures, which are described as involving:
Overall, the report’s tone is positive. The Chief Inspector of Hospitals concluded that significant progress has been made at 10 of the 11 trusts:
H
‘Close scrutiny from Monitor (for foundation trusts) or the NHS Trust Development Authority (NHS TDA) (for NHS trusts), combined with the appointment of an improvement director and in most cases linkage with a partner (or ‘buddy’) trust that is performing well in areas where improvement is needed. In some cases it has also involved changes being made at board level’ (CQC, 2014: 2)
CQC re-assessment
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
908
The CQC re-assessed these failing trusts using its new, more robust assessment regime, building on the methodology shown in the original Keogh review (DH, 2013), but also taking the review process further. The process (CQC, 2014) involves inspection by teams that include clinicians, experts by experience and CQC inspectors. Eight core services are always inspected. Each service is assessed against five key questions: ■■Is it safe? ■■Is it effective? ■■Are staff caring? ■■Is the service responsive to patients’ needs? ■■Is the service well-led? Trusts’ services are rated on these questions with a four-point scale (‘Outstanding’, ‘Good’, ‘Requires improvement’ and ‘Inadequate’).This is all then followed by the award of an overall trust rating.
‘Two have made exceptional progress and have been rated ‘good’ overall. A further three have made good progress … For five further trusts, the Chief Inspector has recommended a further period in special measures, with a further inspection in around six months to ensure that they are continuing to make progress. One trust … has so far failed to make significant overall progress’ (p 2) The report does stress that the trusts’ improvement efforts do not stop here and that more progress needs to be made, especially in relation to safety and responsiveness.
Factors that account for the improvements made No single factor accounts for the improvements that have been made or for the varying pace of change at different trusts: ‘Trusts did not all start from the same baseline. The size of the task was larger for some trusts than for others, especially for those covering two or more locations that are widely separated geographically. In addition, some of these trusts were known to have been struggling to provide high quality care for several years’ (p 2) That final sentence is particularly worrying. Why were the poor care, safety and quality in these struggling hospitals tolerated for so long? And why did the improvement measures directed at these trusts not work effectively much sooner? The answer must be that the NHS did not have the right tools, measures and systems at the time to put matters right. The
© 2014 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission’s (CQC) report into the progress made at 11 NHS put into ‘special measures’ last year
British Journal of Nursing, 2014, Vol 23, No 16
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY Francis report (2013) conveys all too well the failings of the NHS quality and safety infrastructures.
CQC overall findings The report’s findings are categorised according to the five key questions that the CQC always ask: safety, effectiveness, caring, responsiveness and well-led.
Safety Only 40% of services were rated as ‘good’ for safety, which is clearly a concern.The report says: ‘A large number were rated as “requiring improvement”. The most frequent reasons for a rating of “requires improvement” were suboptimal nursing and/or medical staffing levels and low levels of completion of mandatory training’ (p 10) The report also states that a small number of services across the 25 locations were rated as ‘inadequate’ for safety: ‘These included three medical care services, three outpatient services, two critical care services, two surgical care services, one service for children and young people and one A&E service’ (p 10)
Effectiveness Over 60% of services were judged as ‘good’ on effectiveness. Lack of the use of recognised clinical guidelines was a common reason for the CQC giving a ‘requires improvement’ rating here.
Caring This was the best category of improvement across the trusts with the overall majority of services being rated as ‘good’ for caring. There were no ‘inadequate’ ratings here and two services were rated as ‘outstanding’.
Responsiveness Again, the findings here are very worrying, just over half (54%) of all services were rated as good on responsiveness: ‘The most common reasons for being judged as requiring improvement or inadequate on responsiveness included poor management of the flow of patients through the hospital from the A&E onwards … Complaints processes also required improvement in several trusts. Of significant concern was the poor management of outpatient’s services, leading to delays and cancellations in over half of the trusts’ (p 10)
© 2014 MA Healthcare Ltd
Well-led This was the most concerning part of the report. A well-led organisation, by definition, is going to be responsive, proactive and good at what it does. A poorly led organisation will fall between the cracks and will be travelling in a myriad number of directions, in many instances, quite poorly. Only two of the 11 trusts were judged to be good on being wellled with eight requiring improvement and one being judged as inadequate:
British Journal of Nursing, 2014, Vol 23, No 16
‘In around half of the trusts the new leadership team had only recently been established, making it difficult to assess the leadership with confidence. Seven of the 11 were judged as requiring improvement on 50% or more of their individual core services’ (p 10)
Specific changes made by some trusts The changes made by some trusts included (CQC, 2014: 13) ■■ Recruitment of additional nursing and medical staff. Several trusts recruited nurses from Spain and Portugal ■■ A stronger emphasis on management of patients whose clinical condition is deteriorating. Steps taken include use of early warning scores, better escalation processes, implementation of care bundles and pathways for specific conditions ■■ Steps to improve the flow of patients through the hospital from the A&E department through acute medical units or surgical assessment units to medical and surgical wards and to discharge ■■ A greater focus on quality and safety at board level with improved governance processes.
Important factors for success A number of success factors are identified in the report (CQC, 2014) that can turn around a failing trust: ■■ Strength of leadership ■■ Acceptance of the scale of the problems faced by the trust ■■ Engagement with staff and, in particular, alignment on the quality agenda between senior managers and senior clinical staff, leading to a common sense of purpose ■■ Willingness to accept external support and advice from ‘buddy’ trusts.
What next? According to the report, some failing trusts can exit ‘special measures’, others must remain, and one trust, Medway NHS Foundation Trust, has failed to make significant overall progress (further urgent support is being given). All in all, the progress report makes for salutary reading. Although improvements are clearly being made, progress is incremental and many gaps are present overall in trust performances. It is worrying that only 40% of services were rated as ‘good’ for safety. The airline industry would crumble if it had similar ratings. Hospitals should have similar safety records to the airline industry, and share the same safetyobsessed working environment and service culture. The progress report functions as an important testament to what can go wrong—and what needs to be done to put matters right. There are important lessons here to be learnt for all trusts, not just the failing ones. Performance may begin to deteriorate even in a good, well-run trust, so there is no room for complacency. At the very least, trusts now know the BJN warning signs to look out for. Francis R (2013) The Mid Staffordshire NHS Foundation Trust: Final Report of Public Inquiry Chaired by Robert Francis QC, HC 947. TSO, London Department of Health (2013) Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report by Professor Sir Bruce Keogh. DH, London Care Quality Commission’ (2014) Special measures: one year on. http://www. cqc.org.uk/content/special-measures-one-year (accessed 1 September 2014)
909
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
