CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.1 Report of: Paper prepared by: The Medical Director and the Chief Nurse/Deputy Chief Executive Associate Director of Clinical Effectiveness Date of paper: September 2013 Subject: Purpose of Report: Outline proposal on internal quality review Indicate which by Information to note Support Resolution Approval Consideration of Risk against Key Priorities Recommendations The issues identified in this report impact on the organisational ability to deliver safe, high quality care. The Board of Directors is asked to approve this proposal Purpose of the Quality Review Darzi 2008, Francis Feb 2013, Keogh July 2013 and Berwick August 2013 all share one key finding; to improve the quality of care being delivered, Boards must drive that quality of care by fully understanding clinical outcomes and addressing problems as soon as they arise. The purpose of this proposed quality review is first to ensure that the organisation can be fully assured of the quality of care being delivered and that it can identify, quickly, and respond where improvement is required. To that end the Chief Executive has commissioned an internal quality review to strengthen clinical quality assurance information. This review will be led by the Medical Director and Chief Nurse/Deputy Chief Executive. The CQC have set out five questions against which they intend to review care going forward; Is care safe? Is care effective? Are staff caring? Is the organisation responsive? Is the organisation well led? The proposed process for the quality review outlined in this paper is aligned with those questions and seeks to provide organisational assurance on quality of care. Most importantly, it should provide confidence going forward to all patients and service users that they will receive the best experience and the best care at the right time.

2 Terms of reference These are simple and designed to give an understanding and balanced view of the way we deliver care to patients. The approach is straight forward and largely based on that used by Keogh. To understand how we deliver care To identify areas of good practice and share Determine whether there are any sustained failings in quality of care or treatment Identify whether these problems are known to the Division and whether appropriate action is planned and underway Identify and advise on any additional remedial action required Identify and escalate and areas of serious concern relating to safety or quality of care Proposed methodology Staff and patient representatives will be invited to join a team, led by a Divisional Director, to visit each Division in the trust and make an assessment of the services provided. Those teams will be selected from interested applicants and will be representative of all staff groups, all levels of experience and service users. It is proposed that the review teams will also make use of the experiences of Governors and patient groups. An initial invitation will ask for expressions of interest (Appendix A). Once the teams have been selected they will be trained and provided with a pack of information about the Division they are to visit. When the teams are prepared, the review will consist of: A period of presence in the Division talking to staff, patients and visitors, reviewing documentation and gaining an understanding of the environment of care Interviews with key staff Focus groups talking to staff (Support Workers, Staff Nurses, Senior Nurses, Consultants, Middle Grades and Junior doctors) One, unannounced, out of hours visit, to take place either at night or during a weekend. Team composition It is proposed that each team is led by a Divisional Director and a Head of Nursing (from different Divisions) and that they review a Division other than their own (the proposed allocation is set out at Appendix B). Board members will not be members of the review teams, the idea being that the views of front line staff and patient groups are paramount in this process. The Board will receive feedback, and from this, will look for assurance on quality of care throughout the organisation. The rest of the team of 8-10 people would be constituted as follows: A minimum of 2 trained ward or department based nurses 1 junior doctor A minimum of 2 consultants 1 student nurse 1 admin and clerical staff member 1 allied health professional

3 1 Governor 1 other patient representative 1 manager (Directorate Manager level or above) It is proposed that the manager would support the Divisional Director in the collation of information and production of the final report. The reviews are a new process and will take place over a period of time to allow for adjustment in the methodology if required, that will also apply to team composition. The time requirements of team members would be as follows: Divisional Director and Directorate Manager 8½ days max. Training ½ day Document review and briefing session 1 day Visits 2-4 days Report writing 2 ½ days Feedback session ½ day Other team members 5 days Training ½ day Document review and briefing session 1 day Visits 2-4 days Report writing ½ day The team membership will be selected on the basis of their expression of interest. All applicants will be asked to describe their relevant experience and detail why they would like to take part in the process. The successful applicants will receive a letter thanking them and outlining the requirements in relation to confidentiality and escalation of concerns. It is likely that 70+ team members will need to be selected in addition to the Divisional Directors. Applications will be sought via the Staffnet and local briefings. Organisation Leadership It is proposed that in addition to the detailed training given to all team members, Board members will participate in a seminar focused on the quality reviews. This will include an outline of the data packs and methodology. This will enable Board members to challenge and interrogate the outcomes having a full understanding the process and methodology. Information requirements There is a balance to be struck on the document review, the trust collects large volumes of information and the challenge will be giving team members the information they need without overwhelming them. To that end it is proposed that the information outlined at Appendix C is reviewed and put together as a pack by a group prior to review by the team members. This will summarise and provide analysis of the large amount of data currently available. The identification of key lines of enquiry, (KLOE) will be part of this process and enable team members to focus on particular areas of interest. The information should constitute the following: An overview of the Division including services, staffing numbers, locations and key functions. Patient safety information Patient experience information Clinical outcomes information

4 Governance arrangements Regulatory framework information The KLOE will be aligned with the five key focus areas safe, effective, caring, responsive and well led. Quality Review process The visits will be led by the Divisional Directors and will constitute ward and departmental visits, interviews with senior teams and focus groups of staff and patients/service users. It is proposed the focus groups are facilitated by non-team members and both the service improvement team and the OD&T team may have a role in this. These will need to be scheduled in advance. All team members will have template reporting forms to make notes on their findings (see Appendix D) and these will be submitted in full to the lead Divisional Director at the end of the visit. The lead and the manager will then collate the information and provide a report using the template at Appendix E. There will also need to be a summary meeting with the team to discuss findings, this will aid in the preparation of the final report. All team members will be provided with clear guidance on confidentiality and escalation processes and this is included in the Terms of Reference at Appendix F. A feedback session will be scheduled at which it is proposed that feedback is given to the Senior Divisional Team. Arrangements for this are to be confirmed. Going forwards it is anticipated that the Trust would look to partner with other acute teaching Trusts to undertake cross organisational quality review. The timeline is for the process to commence immediately and for the feedback sessions to be completed by the end of December 2013.

5 Appendix A Room 217 Medical Director s Office Trust Headquarters Manchester Royal Infirmary Oxford Road Manchester M13 9WL 06 September 2013 Tel: Fax: To All Staff / Patient Representatives / Governors Dear Colleague, In order to ensure that the quality of care we deliver is of the highest standard possible, the organisation is seeking to undertake an internal quality review of each of its Divisions. This review will be in the form of a multi-disciplinary visit to the Divisions to talk to staff and patients, look at the environment of care and review key documents. Many of you will be familiar with the recent Keogh reviews and the proposed visits will be similar to those. We would very much like this to be an inclusive process with the assessment teams made up of patient representatives (from patient groups or current Governors) and a multi-disciplinary team of staff currently working in the trust. (Trust staff includes doctors, nurses, student nurses, AHPs, nonregistered staff such as house keepers and porters and clerical staff). The trust has also approached the Central Manchester Commissioning Group for their involvement and support. Staff team members will not be assessing their own areas of work but will be joining teams looking at services in another Division. You will be given training and support to undertake the assessment and every team will be led by a Divisional Director. The quality reviews will find areas of excellence in practice and areas where improvement is needed, this information will be shared at the end of the review to enable all areas to learn from the findings. The reviews will require approximately 5 days of your time and Staff members should consult their line manager before applying. Managers are requested to release staff for this review unless there are exceptional circumstances. We would like expressions of interest in the form of a short letter or with your current role, contact details, outlining what experience you have and why you would like to be involved. It is hoped many staff and patient representatives would like the opportunity to be involved in this review but it will not be possible to select everyone. However, any un-successful applicants will certainly be considered for future work of this type. Applications should submitted by to sarah.corcoran@cmft.nhs.uk or sent in hard copy to Sarah Corcoran, Associate Director of Clinical Effectiveness, Room 214 Cobbett House, Manchester Royal Infirmary. The closing date for applications will be 17.00hrs Friday 6 th September Yours Faithfully Professor R.C.Pearson, Medical Director Mrs G Heaton Chief Nurse / Deputy Chief Executive

6 Appendix B Divisional Director / Head of Nursing Allocation Director Division Beth Weston Kathy Murphy Sue Lunt Debra Armstrong Team Leads for the assessment of: Trafford Hospitals Division of Surgery Specialist Medicine Royal Manchester Children s Hospital Notes To include MRI based outpatient services across all Divisions Length of Assessment 3 days To include CAMHS. 4 days Karen England John Logan Division of Surgery Division of Acute Medicine Hospital based services only. To include A&E 3 days David Pearson Margaret Israel Mark Edwards Sue Langley Karen Connolly Jane Grimshaw Stephen Dickson Annette Weatherly Clinical and Scientific Services Division of Acute Medicine Division of Specialist Medicine Clinical and Scientific Services St Mary s Hospital Community Services* REH and Dental Division To include satellite renal services at Tameside, Wythenshawe and Prestwich To focus on ICU, HDU, Radiology, Pharmacy and Mortuary services. AHP services to be picked up on ward visits to other Divisions. *NB Mortuary services also at Trafford General Hospital Will need a member of staff with Community Services knowledge to assist. 3 days 3 days 3 days St Mary s Hospital To include Midwifery led services at Salford. 3 days Alwyn Hughes Cheryl Casey Royal Manchester Children s Hospital Trafford Hospitals* To include A&E, ICU and Acute Medicine Ward. 3 days Kathy Evans Ann Woodward Research and Innovation REH and Dental Division * 1 day Dental / 2 days REH 3 days *To be undertaken in the new calendar year.

7 Appendix C Information Requirements PATIENT SAFETY S,E,C,R,WL INFORMATION REQUIREMENT SOURCE C,R S Being Open Audit Incident Data IQP Data S Never Events Information S Falls IQP Data S,R Divisional incident escalation procedures Divisional CE Lead S,R Investigation and analysis processes Divisional CE Lead S,R Themes and actions Divisional CE Lead S,R S,E,C,R,WL S,E,R S,E S,E,C S,E Clinical Claims - Last 12 months notifications - Review process Staffing - Medical Staff Consultant ratio - Nurse per patient bed day - Nurse staff qualified ratio - Patient acuity information - Sickness and absence - Suspensions - Turnover - Vacancies - Staff survey related questions - Night staffing ratios Infection Control - MRSA - CDiff - MSSA - E Coli Medication Safety - Number of incident reports - Themes Legal Services Divisional CE Lead Medical Staffing Corporate Nursing Team Human Resources Corporate Nursing Team Human Resources Human Resources Human Resources Human Resources OD&T Human Resources IQP Data IQP Data Pressure Ulcers IQP Data VTE - Risk assessment - Incidence - Completed RCA as % of above IQP Data S,R,WL GMC Survey data Medical Education S,E Health Records Audit Clinical Audit Department IQP Data S,E,R Surgical Safety Checklist Audit results Clinical Audit Department S,E,C DNAR / ICP Audit results Clinical Audit Department

8 S,E Communication of Test Results arrangements and incident data Divisional CE Lead S Alerts management and response times PATIENT EXPERIENCE S,E,C,R,WL INFORMATION REQUIREMENT SOURCE S,WL Clean environment IQP Data S,R,WL Ensuring patient safety tracker data IQP Data S,R,C Communication IQP Data S,R,C Nutrition IQP Data S,C,R Management of pain IQP Data C,WL Privacy and dignity IQP Data C,R,WL Meeting equality and diversity needs IQP Data C,R Involving patients and carers IQP Data S,C,R,WL,E Overall quality IQP Data C,R Friends and family test IQP Data C,R Complaints information - Number of complaints - Themes - Reducing complaints - Action and response times - Ombudsman Review reports C,R Patient Survey Results PPI Team C,R C,R,S,WL PALS enquiries - Themes - Example responses Cancellations - Operations / procedures - Appointments Complaints Department Complaints Department IQP Data Complaints Department Complaints Department Complaints Department Complaints Department C,R,S,E,WL NHS Choices Information Service Improvement Team

9 CLINICAL EFFECTIVENESS S,E,C,R,WL INFORMATION REQUIREMENT S,E,R Mortality information - HSMR (elective / non-elective and by Consultant, weekend) - SHMI - Deaths in low risk conditions - Alerts - % R Codes - % palliative care coding - Mortality Review process - Mortality review outcomes and action SOURCE S,E Emergency Bleep Review information S,E,WL Readmission and LoS data S,E,R S,E,R S,E Clinical Audit information - Annual audit plan - Number of completed audits - Number of limited / significant assurance audits - Sample action plans with progress on limited assurance - National audit data (e.g. everyone counts, PICANET, ICNARC) Specialty information - Advancing Quality Data - Time to treatment - RTT - #NoF - A&E performance - PROMs - Cancer Peer review - Discharge Letters VTE data - Risk assessment - Incidence Divisional Mortality Lead Divisional Mortality Lead Clinical Audit Department Clinical Audit Department Clinical Audit Department Clinical Audit Department Clinical Audit Department S,E,R CQUIN Data S,E,R,WL Pathway usage Clinical Audit Department GOVERNANCE S,E,C,R,WL INFORMATION REQUIREMENT SOURCE S E,WL Divisional Structure - Management - Committee Divisional CE Lead S,E,C,WL Staff Survey OD&T R,WL Internal Audit recommendations Internal Audit S,E,R NICE compliance Clinical Audit Department

10 S,E,R National Confidential Enquiry actions Clinical Audit Department S,E,R Rule 43 recommendations and actions Clinical Effectiveness Team S,R Risk Register S,WL S,WL Appraisal data - % completion - Staff survey data - Revalidation progress % Mandatory training completion (clinical and corporate) Human Resources OD&T Trust Assurance Manager OD&T REGULATORY FRAMEWORK S,E,C,R,WL INFORMATION REQUIREMENT SOURCE S E,WL Integrated Governance Tool Oct.12 (assessment against CQC Essential Standards) Trust Assurance Manager S,E,C,WL NHSLA Report (General, Trafford and Obstetrics) Clinical Effectiveness team R,WL HTA, MHRA, CPA Reports Clinical Effectiveness team S,E,R NHS Outcomes Targets S,E,R National Confidential Enquiry actions Clinical Audit Department S,E,C,WL,R White, Bronze, Silver, Gold Ward Status Service Improvement Team

11 APPENDIX D Review Notes Template 1. Overview of Division Prepared by the team reviewing the data and preparing the KLOE 2. Summary of findings Their thoughts on what they found during the assessment 3. KLOE Specific questions 3.1. Patient Safety e.g. do frontline staff understand the falls policy? 3.2. Patient Experience e.g. what are ward staff doing to improve pain mgmt.? 3.3. Clinical Effectiveness e.g. can medical staff describe mortality review processes? 3.4. Governance e.g. how does a junior doctor escalate a concern about staffing? 3.5. Regulatory Framework e.g. what do medical staff understand about NICE compliance? 4. Findings under each KLOE Question Findings Recommendations H/M/L

12 APPENDIX E Divisional Report Template 1. Contents 2. Overview of Division Prepared by the team reviewing the data and preparing the KLOE? 3. Executive summary of findings 4. Terms of Reference As set out in this paper 5. KLOE Specific questions 5.1. Patient Safety e.g. do frontline staff understand the falls policy? 5.2. Patient Experience e.g. what are ward staff doing to improve pain mgmt.? 5.3. Clinical Effectiveness e.g. can medical staff describe mortality review processes? 5.4. Governance e.g. how does a junior doctor escalate a concern about staffing? 5.5. Regulatory Framework e.g. what do medical staff understand about NICE compliance? 6. Findings under each KLOE 7. Recommendations for action Concern Planned Improvements Recommendations H/M/L

13 APPENDIX F Review Terms of Reference 1. Aim 1.1. The overall aim of the review is to ensure all risks are appropriately identified and mitigated at the earliest opportunity and that the Divisional Management Team and Trust Board of Directors can be properly assured of the delivery of safe, clinically effective, high quality care throughout the Division. 2. Objectives 2.1. To understand how we deliver care 2.2. To identify areas of good practice and share 2.3. Determine whether there are any sustained failings in quality of care or treatment 2.4. Identify whether these problems are known to the Division and whether appropriate action is planned and underway 2.5. Identify and advise on any additional remedial action required 2.6. Identify and escalate and areas of serious concern relating to safety or quality of care 2.7. The review will carefully examine systems and processes in place for the management of care and will test associated evidence to assess the risk position The Division is responsible for producing a comprehensive and consolidated action plan to address all identified risk issues The review team will co-ordinate/interface with the Senior Management Team ensuring any work already being undertaken is taken into account as appropriate. 3. Methodology 3.1. Staff and patient representatives, led by a Divisional Director and Head of Nursing, will visit each Division in the trust and make an assessment of the services provided. Those teams will be representative of all staff groups, all levels of experience and service users Information will be gathered, reviewed and put together as a pack by a corporate group prior to review by the team members. This will summarise and provide analysis of the large amount of data currently available. The identification of key lines of enquiry, (KLOE) will be part of this process and enable team members to focus on particular areas of interest The information will constitute the following: An overview of the Division including services, staffing numbers, locations and key functions. Patient safety information Patient experience information Clinical outcomes information Governance arrangements Regulatory framework information

14 3.4. The KLOE will be aligned with the five key focus areas safe, effective, caring, responsive and well led The review teams will participate in a training session and an introduction to the information pack The review will then consist of: A period of presence in the Division talking to staff, patients and visitors, reviewing documentation and gaining an understanding of the environment of care Interviews with key staff Focus groups talking to staff (Support Workers, Staff Nurses, Senior Nurses, Consultants, Middle Grades and Junior doctors) One, unannounced, out of hours visit, to take place either at night or during a weekend Interviews will take place either on a one to one basis or in a group setting. Each interview will be recorded or notes taken (with consent) to ensure interpretation of the information is as accurate as possible The review team will consider processes in the following areas: Patient Safety Patient experience Clinical effectiveness Governance Regulatory framework 3.9. The final report will make a series of recommendations which will then inform the development of the action plan. 4. Confidentiality 4.1. The review reports will be published on the trust web pages and shared with stakeholder groups, this will be made clear to all participants in the process from the outset All team members will be reminded that they will have access to sensitive and confidential patient information. Patient or staff person identifiable will not be included in any notes or final report All team members will be reminded that notes made during the review could be disclosed in the future and must be prepared accordingly. 5. Escalation of concerns 5.1. All team members will have clear mechanisms for raising concerns An immediate serious patient safety concern must be raised with the Nurse in charge of the clinical area in the first instance. It must then be reported to the review team lead and the review team Head of Nursing for onward senior communication. No immediate patient safety threat must be ignored, 5.3. Any concern which is identified as being a risk of 15 or above by the review team leads must be immediately escalated to the medical Director or Chief Nurse / Deputy Chief Executive A concern which requires addressing in the short term, but does not constitute an immediate threat to patient safety, should again be notified to the nurse in charge of the clinical area at the time and reported later to the review team Head of Nursing.

15 5.5. In both instances above, the review team leadership have a responsibility to communicate the concerns to the senior management team in the Division Clear information will be given to all review team members on how to contact key individuals should the need to Any incident witnessed by the review team, for example a patient fall, should be reported in the usual way using the Trust incident reporting system. 6. Output 6.1. The review teams have been commissioned by the Medical Director and Chief Nurse / Deputy Chief Executive to ensure that, as far as possible, all immediate and potential safety risks within the Divisions have been identified The review team will identify immediate and potential patient safety risks within the Division, including the interface between care settings and advise on action required to secure sustainably safe services in these areas The review will result in three primary outputs: A report detailing the findings and making recommendations against which an action plan can be developed. A summary report will go to the Trust Board of Directors in March A feedback meeting to the Division at which those findings and recommendations can be discussed Shared learning across the organisation by publication of the reports and review at the trust Clinical Effectiveness Committee.