The new CQC approach to hospital inspection The role of clinical audit

Transcription

1 The new CQC approach to hospital inspection The role of clinical audit Professor Sir Mike Richards Chief Inspector of Hospitals February

2 Our purpose and role Our purpose We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve Our role We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care 2

3 The new CQC hospital inspection programme We recognise that the previous CQC approach was flawed but it had good elements, in particular in relation to rigorous evidence gathering. We will build on the Keogh Reviews process for 14 acute hospitals with high mortality. We are aiming to bring together the best of both approaches (and more) We aim to be robust, fair, transparent and (hopefully) helpful. 3

4 The Chief Inspector of Hospitals task To inspect all acute NHS hospital Trusts/FTs by December To assess 5 key questions: Is a trust/service safe, effective, caring, responsive to patients needs and well-led? To provide a rating on each Trust: Outstanding Good Requires improvement Inadequate To re-inspect when necessary and to undertake focused reviews in response to specific concerns. To extend the programme to include mental health, community service and ambulance trusts. To extend the programme to equivalent organisations/services in the independent sector 4

5 CQC s approach 3 phases: 1. Preparation 2. Site visits 3. Report 5

6 Phase 1: Preparation Early planning with the Trust/provider Development of a datapack combining Intelligent Monitoring (Safety, effectiveness, caring, responsiveness, well-led) Local data from the Trust Data from other sources (e.g. CCG, NHS England, HEE, Healthwatch, Royal Colleges, GMC) Development of Key Lines of Enquiry (KLOEs) Recruitment of inspection team members 6

7 Phase 2: Site visits Announced and unannounced components Announced Interviews: CEO, MD, DoN, COO, Chair + NEDs Focus Groups: Doctors (senior/junior), nurses (registered/student), AHPs, Governors, admin + others Patient and public listening event Direct observation (e.g. wards, A+E, OPD) Unannounced visit will pick up on issues identified at the announced visit. 7

8 Inspection Teams Chair Team Leader Doctors (senior and junior) Nurses (senior and junior) AHPs/Managers Experts by experience (patients and carers) CQC Inspectors Analysts Programme management support Total: Around 30 people 8

9 Core services The following 8 core services will always be inspected (as they carry the highest risk): 1. A+E 2. Medical care, including frail elderly 3. Surgical care, including theatres 4. Critical care 5. Maternity 6. Children and young people 7. End of Life Care 8. Outpatients (selected) We will also assess other services if there are concerns (e.g. from complaints or from focus groups) The inspection team will split into subgroups to review individual areas, but whole team corroboration sessions are vital 9

10 Specialist services We are aware that many services will not be routinely covered through these inspections e.g. Diagnostics Specialist services (e.g. ophthalmology, dermatology, renal) The current model will not be appropriate for assessing specialist Trusts (e.g. Alder Hey, Royal Marsden). Further work is in progress on this. Accreditation and peer review programmes will be vitally important. 10

11 Rationale for ratings The public want information about the quality of services presented in a way which is easy to understand The approach taken by Ofsted is seen as a model, though we recognise that hospitals are more complex than schools. Patients/public may, for example, be interested in a particular service (e.g. maternity or frail elderly care) rather than a single global rating Ratings of services and of Trusts should hopefully be a driver for improvement 11

12 Ratings: Proposed approach (1) A four point scale will be used for all ratings Outstanding Good Requires Improvement Inadequate Ratings will always take account of all sources of information Intelligent monitoring tool Information provided by Trust Other data sources Findings from site visits Direct observations Staff focus groups Patient and public listening events Interviews with key people 12

13 Ratings: Proposed approach (2) Trust X Accident & Emergenc y Safe Effective Caring Responsiv e Well Led Overall G RI G G G G Medicine RI G G G G G Surgery G G G G G G Critical Care G G G G G G Maternity & Family Planning Paediatric s End of Life Outpatien ts G G O G O G G G G O G G G G G G G G G RI G RI RI RI Overall G G G G RI G 13

14 The five key questions 1. Safe 2. Effective 3. Caring 4. Responsive 5. Well led 14

15 Safety Data/Surveillance Observations on site Never events Safe environment Serious incidents Safe equipment Infections Safe medicines Safety thermometer Safe staffing* Staff survey (selected items) Safe processes Safe handovers Safe information/records Care bundles Pathways 15

16 Caring Data/Surveillance Direct observation Inpatient survey Staff/patient interactions Cancer patient survey Comfort rounds Friends and Family Test Patient stories Response to buzzers 16

17 Responsive Data/Surveillance Direct observation Waiting time standards Patient reports Cancelled operations Translation facilities Ambulance stays Comfort factors Analyses of complaints (e.g. TVs, seating areas, rooms for parents) 17

18 Well-led Data/Surveillance Direct observation Staff survey (7 items) Interviews (CEO, MD, DoN etc.) Staffing levels Focus groups Sickness rates Board/ward interactions Flu vaccination rates Staff reports (e.g. of bullying) Board minutes Quality governance minutes Mortality reviews Handling/learning from complaints Risk register 18

19 Effectiveness How would you assess whether a hospital is providing effective treatment and care i.e. achieving good outcomes? Mortality indicators (HSMR and SHMI) may act as smoke alarms, but can we measure effectiveness of the 8 core services? Clinical audit is essential for this 19

20 Measuring effectiveness in A+E College of Emergency Medicine (CEM) audit Consultant sign off for patients presenting with specific problems (e.g. non-traumatic chest pain; febrile children; unplanned returners <72 hours). Assessment of vital signs in Majors: <20 minutes Abnormal vital signs being repeated within 60 minutes Renal colic: pain management and investigations Fractured neck of femur Severe sepsis and septic shock 20

21 Measuring effectiveness of medical care Audits of individual conditions Stroke (SSNAP) Myocardial Infarct (MINAP) Heart failure Diabetes (NADIA) Lung cancer (LUCADA) Mortality outliers 21

22 Measuring effectiveness of surgical care Hip fracture audit Emergency laparotomy audit (pilot) Colorectal cancer audit Society for cardiothoracic surgeons Audits of WHO surgical checklist usage 22

23 Measuring effectiveness of critical care Congratulations to intensivists! Almost all critical care units participate in ICNARC and can produce their data when asked Metrics include infection rates and mortality presented as funnel plots 23

24 Measuring effectiveness in maternity care RCOG audit but data for individual units are not yet in the public domain Almost all maternity units have a dashboard of metrics unlike most other core services we have visited so far 24

25 Measuring effectiveness in children s and young people s care RCPCH 10 clinical standards Measures of structure and process, rather than outcomes Pain in children audit (2011) Children presenting to A+E with fractures Neonatal audit (2012) Paediatric Intensive Care (PICANet) Paediatric asthma audit (2009) 25

26 Measuring effectiveness in end of life care National Care of the Dying Audit Audits of DH Quality markers for end of life care Audits of NICE Quality Standards implementation 26

27 Measuring effectiveness of outpatient services Surprisingly difficult! How would you know if outpatient services are delivering good outcomes? - Suggestions welcome 27

28 Summary The new CQC approach to inspecting hospitals represents a radical change National Clinical Audits are an essential part of our assessments, especially for the effectiveness domain 28