RESPONDING TO CONCERNS; NHS AYRSHIRE AND ARRAN (INTERNAL) GENERAL MEDICINE (JUNE 2018) Introduction Following the NHS Education for Scotland Deanery visit in November 2016, the Deanery noted specific concerns regarding General (Internal) Medicine at University Hospital, Ayr which were shared with Healthcare Improvement Scotland due to the potential impact on patient care. In addition, in April 2017 junior medical staff wrote to Healthcare Improvement Scotland highlighting similar concerns. The concerns related to: - the safety of boarded patients - the review of patients within the respiratory ward prior to discharge - how workforce issues are being addressed, and - the governance arrangements in place to ensure accountability, governance and performance management within General (Internal) Medicine. Healthcare Improvement Scotland has a duty to respond to potential concerns relating to the quality of care, so we have a better understanding of any potential factors that may impact on the quality of care provided. We therefore had a number of discussions with NHS Ayrshire & Arran to understand how these concerns have been/are being addressed. We also established an independent review team to support this work. Alongside reviewing the information provided by NHS Ayrshire & Arran and NHS Education for Scotland (in relation to the concerns raised), the team met with staff on the 10 May 2018 to hear their experiences of what s working well and what the challenges are. Detailed below are our findings and conclusions from this review. Management of boarded patients In December 2016, NHS Education for Scotland provided information to Healthcare Improvement Scotland which highlighted concerns about the management of boarded patients. It was noted that it was possible for boarded patients care to be delayed or the potential for boarded patients to be missed from consultant ward rounds and be discharged without being reviewed by a consultant. It was felt that these challenges were partly due to the system used to track boarded patients, which was open to human error. There had also previously been challenges relating to agreeing and communicating which consultant was responsible for each boarded patient s care. NHS Ayrshire & Arran advised that a new policy was introduced in January 2017 to manage boarded patients, with further detailed guidance provided in a standard operating procedure which was implemented in August 2017. A list of medical patients boarded into non-medical wards is updated every day by the clinical operational manager. This list is circulated at daily safety huddles. The clinical operations manager allocates consultants to boarded patients, taking into consideration annual leave and base specialty ward. Staff are reminded of the need for timely review of these patients at the 08:00 huddle. If a boarded patient has not been reviewed by 14:00 on a weekday, the ward senior charge nurse or team leader contacts the clinical team and if necessary escalates the need for a review at the afternoon safety huddle.
The review team agreed that these arrangements appeared robust and feedback from all staff confirmed that the processes in place are working well. One ward is now being used for boarded patients and it is very rare for patients to be missed from the boarders list (which was previously a regular occurrence). Robust arrangements are in place for having identified consultant responsibility for boarded patients. We heard of the positive impact this has had on improving patient safety and reducing workload. Healthcare Improvement Scotland is content that no further follow up is required at this time in relation to the safety of boarded patients. Management of respiratory ward patients Information provided by NHS Education for Scotland in December 2016 indicated that patients could be admitted to the respiratory ward, treated and discharged without further consultant review, since review took place once a week. NHS Ayrshire & Arran provided an outline of the duty physician s responsibilities at University Hospital Ayr. However, this did not outline the duty of consultants to review patients before discharge. We also received an overview of induction for the respiratory ward which covers the roles and responsibilities for trainees and consultants but this does not indicate a requirement for consultants to review patients prior to discharge. NHS Ayrshire & Arran reported that an additional specialist doctor had been recruited which had improved continuity in the ward and reduced the workload by supporting procedures and assessing specialty referrals. At the NHS Education for Scotland Deanery visit on 28 February staff confirmed that all patients in the respiratory ward are now receiving two consultant reviews which ensures that all patients are seen prior to discharge. There is appropriate consultant review and the team are content that this is no longer an issue. This area was therefore not covered at the Healthcare Improvement Scotland visit on 10 May. Healthcare Improvement Scotland is content that no further follow up is required at this time in relation to the review of patients within the respiratory ward prior to discharge. Workforce Trainee doctors wrote to Healthcare Improvement Scotland in April 2017 noting concerns regarding the staffing in place within General (Internal) Medicine to support the opening of the Combined Assessment Unit (CAU). We were told that there were no permanent acute medical consultants employed at University Hospital, Ayr at that time. A locum acute medical consultant had been in post for around six months. They also raised concerns about gaps in the trainee medical rota leading to fatigue since existing staff needed to fill additional on-call shifts. This had the potential to make patient care less safe. NHS Ayrshire & Arran advised that their immediate response to the concerns raised by their junior medical staff was to defer the opening of inpatient beds at the CAU by four weeks from May to June 2017. They also moved the medical high care area to the front door to improve the efficiency of senior staff assessing and treating the seriously ill. NHS Ayrshire & Arran also provided information on how they had secured additional locum junior medical staff in the few weeks before the opening of the CAU in response to these concerns. Additional clinical support workers and advanced nurse practitioners were also deployed to support the opening of the unit.
At the time of our visit, the current consultant workforce position across general internal medicine reflects 13 consultants, five locum consultants and five vacancies. We heard positive feedback from all staff in relation to the current provision of care within the CAU. Staff explained that there is no substantive consultant leadership within the CAU; leadership is provided through the clinical nurse lead and the unit is well-led. Input from consultants in general medicine can be sought as required. Whilst staff reported there are no concerns regarding patient care, they suggested having an identified consultant lead would be of benefit, for example in reducing the potential for inappropriate referrals to general medicine. NHS Ayrshire & Arran report that they have continuously monitored activity since the CAU opened and the medical workforce is planned to reflect periods of the day/week when they know they receive a higher volume of patients and to prevent handover of un-clerked patients to the night shift teams. The board provided a detailed breakdown of staffing for medicine, surgery, overnight and weekends: Period General Medicine Staffing Surgery Staffing Mon-Fri 5 trainees (FY1, junior, and senior middle grade, 9am-9.30pm) 1 FY1 for surgical receiving (9am- 9.30pm) 2 middle grade doctors covering 1 FY1 (2pm-9pm) ambulatory care and rapid assessment 1 specialist registrar (hospital based 2 clinical teaching fellows (covering 2pm- 9am-9pm) 9pm and 5pm-9pm) 1 middle grade doctor (9am -9pm, 2 acute medical consultants to cover rapid assessment and the in-patient area based in CAU but covering receiving and theatre) of CAU Designated consultant available to 1 on-call physician support/supervise trainees for each 1 CSW providing 24 hour cover 24 hour period. 3 senior charge nurses and 16 senior registered nurses ACE practitioner cover ANP support Overnight 1 Junior middle grade based in CAU and additional middle grade to support 1 surgical trainee based in CAU (covering general surgery, vascular 1 FY1 for CAU (and the rest of the and urology receiving) hospital) 1 on-call consultant available for 2 ANPs to provide support at back door medicine, surgery, urology and 2 CSWs to provide support at back door vascular 1 on-call consultant available for medicine, surgery, urology and vascular 1 CSW providing 24 hour cover 3 senior charge nurses and 16 senior registered nurses Weekend As per Mon-Fri cover for junior and middle grade As per Mon-Fri cover for junior and middle grade 1 FY1 for medicine 1 FY1 in surgery covering CAU and 2 medicine consultants surgical wards Urology and surgical consultants oncall
NHS Ayrshire & Arran acknowledge the workforce challenges that remain and described the ongoing recruitment drive to fill the long term consultant vacancies (in gastroenterology, endocrinology, care of the elderly and acute medicine) and to address the reliance on locums to cover consultant rotas within General (Internal) Medicine. This recruitment drive has been ongoing for a considerable period of time with little success in recruiting to these posts in NHS Ayrshire &Arran. The five consultant vacancies were, at the time of the review, all occupied by locums. Within the junior medical workforce, there remains four gaps in the rota and these are currently filled by locum staff. A number of staffing initiatives have been introduced to ensure the safe delivery of the service including the use of the same middle grade locums wherever possible to support continuity, physician s assistants and specialty doctors. Advanced nurse practitioners have also been recruited and are being trained to provide additional support to junior doctors in undertaking tasks which would have previously been carried out by trainee medical staff. We heard of the value and contribution of the advanced nurse practitioner role, particularly if they can also prescribe. Nursing staff also shared with us the benefit of the clinical support workers in supporting the tasks of FY1 trainees. Regular reporting of workforce matters is provided to the board via the medical workforce planning group. We also heard of the current work to reconfigure all wards to 24 beds where there will be one sub specialty and two consultants. The nursing staff reported that those wards that have reconfigured so far are working much better. NHS Ayrshire & Arran advised that they have also recruited a rota administrator to support the rota lead in liaising with junior medical staff about the best way to cover rota gaps. The management team are also engaged in managing rota gaps. When we spoke with staff they highlighted the rota gaps which remain but noted that the CAU is functioning well and delivering a safe service. They described the supportive mechanisms in place to raise concerns regarding staffing pressures and safety, including through the daily huddles. Nursing staff also noted the positive relationships between the CAU, emergency department and general medicine wards. It was also highlighted that the reduction in the number of boarders has also had a positive impact on workload. Impact on staff On the Healthcare Improvement Scotland visit on the 10 May, staff described a busy district hospital. Due to the ongoing challenges related to workforce, staff we spoke with described the impact this was having. This included: A lack of robust consultant medical support when colleagues are on leave (the example provided was in relation to one of the 30-bedded wards, where challenges are faced when one of the two assigned consultants are on leave). This can result in: o significant delays in a consultant reviewing patients and difficulty in managing workload (an example of this was described within Station 9), and o not being able to complete routine paperwork contemporaneously. Low morale amongst staff and at times difficult working relationships between different staff groups. Instances where trainees are unable to attend ward rounds potentially due to workload and time pressures. This then has a knock on effect for teaching opportunities and involving staff if they are not present. More senior trainees being expected to work long, unsociable hours.
Junior doctors describing a lack of understanding between medical trainee and nursing roles which exacerbates the challenges in managing workload. For example, it was noted that there are some routine tasks which are carried out by trainee staff which may be better allocated to nursing staff. Examples of some unprofessional behaviours between nursing staff and doctors in training. On occasion, inappropriate referrals from the CAU and emergency department and potential patient safety concerns relating to the perceptions of movement of patients from the CAU (without consultant review) to inappropriate ward areas resulting in delays in management of patients. Junior doctors are not always clear on why decisions have been taken regarding patients care plans in the context of clinical guidelines. It was highlighted that this was only in relation to a small number of consultants. We heard there are two consultants in particular whose decisions they would not trust. Junior doctors noted that although they can be hesitant about raising concerns with some consultants, there is no-one they wouldn t approach as patient safety was their prime concern. They stated that they can challenge decisions and are encouraged to ask questions, however, there was a need to ensure guidelines are followed. The examples provided were in relation to the management of anti-depressants and anti-microbial prescribing. In discussions with nursing staff, it was noted that anti-microbial prescribing has been identified as an improvement project following review of the data. However, the junior doctors we spoke to were unaware of this improvement work being undertaken. Whilst it is recognised that the board has ongoing recruitment challenges and rota gaps within General (Internal) Medicine these are being identified and managed on a daily basis, and actions are being taken forward to support staff in managing the workload and delivering safe care. While supportive actions are being taken forward there continue to be challenges, both process and cultural, that are impacting on the workforce. This includes a lack of clarity on roles and responsibilities for general medicine staff, examples of unprofessional behaviour, inappropriate referrals and movement of patients from the CAU, a lack of confidence in relation to decision making of a small number of consultants, a potential lack of consultant medical support during periods of leave and the attendance of trainee staff at ward rounds. Recommendations The improvements identified above through the Healthcare Improvement Scotland visit align with the following requirements set out by NHS Education for Scotland after their most recent visit: Requirement 7.3: Training and service leads must engage to ensure good multidisciplinary team working in all clinical areas. Requirement 7.6: Doctors in training must be able to access senior support on site at all times to ensure they are never put in a position of working beyond their competence, and to ensure management plans reflect those of senior decision makers. Requirement 7.8: The appropriate level of staffing for the workload currently expected of FY1 at weekend must be in place. Requirement 7.9: Doctors in training must receive feedback on their contributions to the management of at least one third of their workload of acutely unwell medical patients to inform their learning and development.
While these requirements relate mainly to doctors in training and those responsible for supporting and supervising these staff, the board should reflect on these actions in relation to all staff groups. Our findings highlighted above will form part of the data and intelligence that will be considered as part of the Healthcare Improvement Scotland board level review of NHS Ayrshire & Arran currently being scoped. We will therefore follow up on these areas and seek assurance that improvements are being made as part of the review. Governance arrangements Healthcare Improvement Scotland sought assurance from NHS Ayrshire & Arran in relation to the governance arrangements employed to ensure accountability within General (Internal) Medicine, including how this feeds in to board wide arrangements. The review team was keen to understand how the safety and quality of the service delivered is monitored and reported. Previous information shared with Healthcare Improvement Scotland (from NHS Education for Scotland and the trainee concerns letter) had highlighted a reluctance from trainees to raise concerns due to their perception of NHS Ayrshire & Arran s management of the complaints made by more senior trainees. Trainees stated that they did not feel that concerns raised through the trainee forum were acted upon and this had a negative impact on staff culture and morale. The NHS Ayrshire & Arran executive team noted that in relation to the perception that specific concerns raised in relation to the behaviours and attitudes of colleagues were not managed at that time, actions have now been taken to address this which have involved the appropriate human resources processes. NHS Ayrshire & Arran advised Healthcare Improvement Scotland of the governance routes which should be used by trainees to raise concerns and noted that a non-executive director had been identified to lead on training and educational governance. This board member chairs the healthcare governance committee and reports directly to the board, escalating issues raised by trainee doctors as appropriate. The NHS board also provided information on the hospital and board wide governance arrangements, and the processes in place for monitoring and providing an assurance on the quality and safety of the care being delivered.
We received a copy of correspondence sent from the chief executive to staff describing the process to be followed to report any adverse events, including a new adverse event escalation policy. The note also emphasised the importance of an open and fair reporting culture. NHS Ayrshire & Arran advised that the board uses a variety of hospital standardised mortality ratio (HSMR) data to govern the safety and quality of care provided at University Hospital Ayr. The board shared with us their success in relation to reducing HSMR and noted this has been achieved in the context of the challenges they face in terms of consultant numbers and pro-rata trainee allocations. It is noted that within this Healthcare Improvement Scotland supported programme, the Scottish average has fallen by 9.9% over the index period compared with the NHS Ayrshire & Arran reduction of 15.8%, as per the latest release. However, the NHS board also accepted that HSMR data is not an absolute measure of quality. Governance in action impact on staff The review team was keen to understand if staff were aware of, and utilised, the governance arrangements and adverse event reporting arrangements and if the cultural aspects had improved. We heard from staff the benefits of: the mortality and morbidity meetings which are held every two months and doctors in training are encouraged to present cases and share learning the trainee forum which meets monthly and any concerns from this forum are escalated and fed into the medical directors meeting, and the consultants meeting which trainees can attend and is valuable for raising and discussing. We also heard from all staff about the new orange box that has been introduced as an informal way to provide feedback or raise concerns anonymously. Staff are encouraged to discuss concerns or issues with their managers but can use this route to report. Feedback will be shared on a you said, we did notice board. Staff also described the value of the daily huddle as a forum for raising concerns and felt supported to do so. However we also heard of some ongoing challenges in relation to the reporting and management of adverse events. Examples of this included:
Varying levels of understanding of the Datix system (potentially influenced by lack of induction). A lack of confidence and awareness in Datix reporting from doctors in training and a culture of being told not to report as this contributed to additional paperwork. Those who had submitted Datix reports noted that they rarely received feedback on what happened with the information. An example cited by a trainee and a consultant was the risks they had identified in securing blood results/laboratory support out of hours, and they were unaware of any actions being taken forward in response to the issues identified. While the use of Datix was considered to be limited, doctors in training told us that there are other avenues which they can use to raise issues. The nursing staff we spoke to described a culture of encouraging and supporting doctors in training to submit Datix reports and noted consultant colleagues are becoming better at utilising the system and encouraging others to do so. Datix awareness raising sessions have been planned for over the summer. We also heard from some consultants a lack of feedback in relation to the outcomes from complaints process and that this would be welcomed in terms of learning and improving. NHS Ayrshire & Arran appears to have a clearly defined governance structure in place to allow the appropriate flow of information in relation to monitoring the safety and quality of care. However there remain challenges in developing and supporting a culture of openness and learning, which includes the reporting and management of adverse events. Recommendations The improvements identified above through the Healthcare Improvement Scotland visit align with the following requirements set out by NHS Education for Scotland following their most recent visit: Requirement 7.5 in the NHS Education for Scotland report states that the concerns raised by doctors in training that have potential implications for the safety of care must be investigated and addressed if confirmed. Progress against this will be monitored through the NES follow-up. Requirement 7.7 in the NHS Education for Scotland report states that there must be a culture supporting engagement of all doctors in training in raising concerns including Datix incident reporting. This must be promoted (including inductions) and valued by the organisation and lead to improvements where appropriate, and also must ensure those who raise concerns receive feedback in their submission. While these requirements relate mainly to doctors in training and those responsible for supporting and supervising these staff, the board should reflect on these actions in relation to all staff groups. Our findings highlighted above will form part of the data and intelligence that will be considered as part of the Healthcare Improvement Scotland board level review of NHS Ayrshire & Arran currently being scoped. We will therefore follow up on these areas and seek assurance that improvements are being made as part of the review. END