The Future of Aged Care: What can we learn about Clinical Governance in a changing landscape? Adjunct Professor Alan Lilly Chief Executive, BlueCross Thursday 21 September 2017 @ceobluecross
Acknowledgment of Country
About today s presentation What is Clinical Governance? Why Clinical Governance matters What we have learned (or should have learned) from others A call to action my Top 3 focused priorities Questions and comments
What is Clinical Governance?
Why does it matter? Because we are care providers How do we know our care is safe and effective? We need to validate our assumptions Do we consider the views of residents, clients and their family? We need to prevent care and system failures for those in our care Effective clinical governance processes will stand the test of time
Looking outward and learning from others
Looking outward to be inspired
Let s take a closer look at
Could a Mid Staffs happen in a Aged Care Service near you?
What is a Mid Staffs? Hospital-wide poor care and treatment substantiated through many formal inquiries story after story of poor care and neglect > 350 000 Google hits on mid staffs scandal (March 2014) wall of shame at Cure the NHS headquarters Unnecessary deaths the Hospital Standardised Mortality Ratio (HSMR) results predicted that between 400 and 1200 patients died (above recognised thresholds) compared with expected rates for similar patient groups in similar organisations Primary focus on Stafford Hospital
Key Timelines Julie Bailey s mother died at Stafford Hospital in 2007 She established Cure the NHS to demand changes in Nov 2007 Many complainants came forward Late 2007/early 2008 HSMR data released Healthcare Commission (HC) review instigated based on HSMR HC review Mar Oct 2008 and full report released March 2009 Scathing report, highly critical of organisation This was just the beginning
Who s who at Mid Staffs? ng journey of improvement The context of an evidence based framework It s not all about the money But what did work on our journey? Where are we now and where to next?
Key Timelines - continued Healthcare Commission report released March 2009 Independent Inquiry (Robert Francis QC) then announced Inquiry operates from July 2009 to February 2010 Incoming Government commits to Public Inquiry in June 2010 Trust services reduced > June 2010 on quality & safety concerns Public Inquiry commenced Nov 2010 report released Feb 2013 Public Inquiry Report includes 290 recommendations Monitor appoints Special Trust Administrators April 2013 Mid Staffs NHS Foundation Trust to be dissolved - February 2014 Stafford Hospital and Cannock Hospital to split Julie Bailey from the heroine to the hated
So what can we learn? Reflections from Julie Hendry Mid Staffs Director: Patient Experience Weak leadership and leaders inaccessible Not listening to patients Poor culture No accountability including poor governance (clinical and non clinical) No regular use of formal risk assessments Focus always on targets not patient outcomes Inward not outward looking Disconnection from ward to the board Low nursing numbers and ratios Leadership and culture is the key
So what can we learn? Reflections from Robert Francis QC 1m pages of documents, 250 witnesses, 139 days of hearings, > 10m Heed the Warning Signs external organisation review results & audits professional college reviews patient stories mortality rates complaints about patient care staff concerns responses to whistleblowers governance issues financial focus came before quality care in pursuit of Foundation Trust status staff reductions without appropriate supervision culture of fear disengaged clinical staff
So what can we learn? Reflections from Robert Francis QC passive challenging from the Board Board failed to identify care issues clinical governance did not permeate the organisation lack of focus on standards of care and service nursing standards of care were poor including nursing leadership did not listen to the community GPs had concerns but not raised in a timely manner regulation bodies failed in their duties DoH not a good steward as the system manager The word hindsight is mentioned often in so many reports 120 in the BRI, 123 in the oral hearings and benefit of hindsight 378 times
Don Berwick says. A promise to learn a commitment to act, 2013 Place the quality of patient care, especially patient safety, above all other aims. Engage, empower, and hear patients and carers at all times. Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work. Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge..in the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime
Let s take a closer look at
Could an Oakden happen in a residential care service near you?
What occurred at Oakden? Mistreatment and neglect of residents High use of mechanical restraint Rough-handling of residents Staff discontent and bickering staff sent to Oakden as a form of discipline High level of apathy amongst staff View that there was no money so don t ask and it prevailed The last straw.
And what happened next? Family raised formal complaints about care following admission of a resident to the Emergency Department with unexplained bruising Matter was escalated to Health Service Chief Executive Review led by the SA Chief Psychiatrist, Dr Aaron Groves Recommends closure of Oakden Generates three broader reviews: Review of Quality & Regulatory processes Senate Inquiry AACQA own inquiry
And could this have been prevented?
Considerations for all care providers Preach and practise Person Centred Care Ensure that Experience of Care reports are read and acted on Reinforce focus on leadership, values and culture Leadership and leaders must be visible ensuring a culture of caring Leaders need to understand strategy and operations Listen always to residents, clients, carers, staff and professional bodies Develop unit based level data repository go local, go big, go global Look at the down-side of the data Probe scorecard results and improvement plans Communicate learnings from incidents From reactive to proactive with the benefit of knowledge (not hindsight) Commit to a duty of openness, transparency and candour Recognise and reward good practice
At last, we are now shifting our focus
My Top 3 focused priorities Develop a Positive Workplace Culture Starts at the top and is about a commitment to People, Customers & Performance Use lead indicators Consider a local Scorecard for your workplace Live and Breathe Clinical Governance Adopt an agreed framework Monitoring and reporting from the ward to the Board Never lose sight of why we re here and for whom we care Did we do everything we could and should have done?
Thank You