How do you demonstrate effectiveness? Demonstrating Effectiveness Conference 25 November 2014 Professor Edward Baker Deputy Chief Inspector
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 We will be a strong, independent, expert inspectorate that is always on the side of people who use services
The new CQC hospital inspection programme We recognise that the previous CQC approach had flaws but it had good elements, in particular in relation to rigorous evidence gathering. We have built on the Keogh Reviews process for 14 acute hospitals with high mortality. We have brought together the best of both approaches (and more). We aim to be robust, fair and (hopefully) helpful. Our reports do not seek to apportion blame. We intend to promote transparency and honesty about standards in healthcare as a driver for quality.
What are we doing differently? Larger inspection teams including specialist inspectors, clinical experts, and experts by experience We will use intelligent monitoring to decide when, where and what to inspect. Inspections will focus on our five key questions about services KLOEs (key lines of enquiry) as the overall framework for a consistent and comprehensive approach Strong focus on talking and listening to staff and patients Ratings to help compare services and highlight where care is outstanding, good, requires and inadequate Quality summit is held with the provider and stakeholders to launch quality process
Inspection teams Chair Senior clinician or manager Team Leader Doctors (senior and junior) Nurses (senior and junior) AHPs/Managers Experts by experience (patients and carers) CQC Inspectors Analysts Around 30 people for a DGH more for a multi-site trust or a combined acute/community trust
Our key questions Our focus is on five key questions that ask whether a provider is: Safe? people are protected from abuse and avoidable harm Effective? people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence Caring? staff involve and treat people with compassion, kindness, dignity and respect. Responsive? services are organised so that they meet people s needs Well-led? the leadership, management and governance of the organisation assure the delivery of high-quality care, supports learning and innovation, and promotes an open and fair culture. 8
Initial findings from acute inspections But we also found marked variations in quality: Wide range of quality between hospitals In several hospitals, there were marked variations between services In some hospitals, there was variation within a service General areas for concern: A&E departments are under the greatest strain Staffing is a major concern in many services Outpatient services were badly managed in many cases Unacceptable variation in the rigour of risk management and quality assurance Many services don t know whether they are effective or not
Effective KLOEs E1: Are people s needs assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance? Use and monitoring of best practice guidance including NICE. Avoidance of discrimination. Meeting nutrition and hydration needs. Assessment and management of pain. Use of technology to enhance care. Adherence to Mental Health Act.
Effective KLOEs E2: How are people s care and treatment outcomes monitored and how do they compare with other services? Outcome data collected and monitored. Outcome data shows intended outcome achieved. How do outcomes compare? Participation in national audits, peer review, accreditation. Use of outcome analysis to improve service. Involvement of staff in outcomes analysis.
Effective KLOEs E3: Do staff have the skills, knowledge and experience to deliver effective care and treatment? Staff have the right qualifications, skills, knowledge and experience to do their job. Staff have appropriate training to meet their learning needs. Staff given opportunities to develop. Appraisals, coaching and mentoring, clinical supervision and revalidation. Poor staff performance identified and effectively managed. Staff are supported to improve.
Effective KLOEs E4: How well do staff, teams and services work together to deliver effective care and treatment? All necessary staff, including in different teams, involved in assessing, planning and delivering care. Care delivered in a coordinated way when different teams or services are involved. Staff work together to assess and plan ongoing care, including referral, discharge and transition. People discharged from a service at an appropriate time of day, all relevant teams and services are informed and ongoing care is in place.
Effective KLOEs E5: Do staff have all the information they need to deliver effective care and treatment to people who use services? All information needed to deliver effective care and treatment available, test and imaging results, care and risk assessments, care plans and case notes. At referral, discharge, transfer and transition, information needed for ongoing care is shared, in a timely way and in line with relevant protocols. Systems that manage information are effective, coordination between electronic and paper-based systems and appropriate access for staff to records.
Effective KLOEs E6: Is people s consent to care and treatment always sought in line with legislation and guidance? Consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children s Acts 1989 and 2004. People supported to make decisions. Mental capacity to consent to care or treatment assessed and, where appropriate, recorded. Staff make best interests decisions in accordance with legislation.
Rating four point scale High level characteristics of each rating level Innovative, creative, constantly striving to improve, open and transparent Consistent level of service people have a right to expect, robust arrangements in place for when things do go wrong May have elements of good practice but inconsistent, potential or actual risk, inconsistent responses when things go wrong Significant harm has or is likely to occur, shortfalls in practice, ineffective or no action taken to put things right or improve
How we rate Ratings 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 Bottom up approach: each of the 8 core services is rated on each of the five key questions (safe, effective, caring, responsive, well led). Where trusts provide services on different sites we rate these separately. We then rate the trust as a whole on the five key questions, with an overall assessment of well-led at trust level. We then derive a final overall rating.
Ratings example 1 Safe Effective Caring Responsive Well-led Overall A&E Inspected but not rated Medical care Surgery Critical care Maternity & family planning Children & young people End of life care Outstanding Outpatients Inspected but not rated Overall Overall
Ratings example 2 Safe Effective Caring Responsive Well-led Overall A&E Inspected but not rated Medical care Surgery Critical care Outstanding Maternity & family planning Inadequate Children & young people End of life care Outstanding Outpatients Inspected but not rated Overall Overall
Ratings example 3 Safe Effective Caring Responsive Well-led Overall A&E Outstanding Inspected but not rated 1 Outstanding Outstanding Outstanding Medical care Outstanding Outstanding Outstanding Outstanding Surgery Outstanding Outstanding Outstanding Critical care Outstanding Outstanding Outstanding Outstanding Maternity & family planning Children & young people Outstanding End of life care Outstanding Outstanding Outstanding Outstanding Outstanding Outpatients Inspected but not rated 1 Outstanding Overall Outstanding Outstanding Outstanding Overall Outstanding
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Initial findings from acute inspections We have inspected 68 acute trusts in the first year (42%). There are many positives for staff and the public to be proud of: Compassionate care is alive and well Critical care services were delivering high quality, compassionate care Maternity services were generally providing good quality care, and were good at monitoring their effectiveness Many of the trusts were making a determined effort to improve care for patients with dementia We have been impressed by the willingness of front line staff to discuss their concerns.
Early lessons Early findings showed that: 13% of trusts were inadequate and 63% required. Only 20% of hospitals were judged good for safety, none were outstanding. 60% of trusts needed to improve their leadership. Leadership at clinical team or directorate level was very variable and was often a critical factor in the quality and safety of a service. Formal and informal leadership was often in denial about the problems or blamed the system. Those services and hospitals that accepted their problems seemed to make more rapid quality s.
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