Robert Francis QC’s report into the Mid Staffordshire Inquiry is due to be issued to the Secretary of State in January 2013. The terms of reference require the Inquiry to identify how “failing and potentially failing hospitals or their services” are identified as early as possible. However, it seems clear that the lessons in terms of internal governance and interaction with, and between, commissioning, regulatory and oversight bodies are ones which are likely to provide valuable learning beyond the NHS and across the entire health and social care sector.
Whilst the Inquiry’s detailed findings and recommendations are awaited, an examination of the evidence identifies a range of themes to which the sector should have regard in anticipation of the final report and beyond.
In this alert, we focus on the related quality governance themes of organisational culture and the structures for quality governance and learning to enable organisations to consider these and possible future developments in advance of the Inquiry’s report.
It is vital that there is a culture of openness, compassion and learning from experience rather than one which is closed and deferential. In order to embed a culture which is conducive to good care and where quality governance processes are valued and expected, the Inquiry identified a number of key areas:
Engagement with stakeholders
Providers need to ensure that they effectively gather and analyse the views of relevant stakeholders whose experience and knowledge is vital to identifying and preventing failings of care. In particular views of the following need to be sought:
- Providers need to gather evidence in a variety of ways from patients and the public about their experience. For the NHS, patient surveys are a major feed into the CQC’s Quality and Risk Profiles. However, it needs to be borne in mind that information highlighted by patient surveys may be historic. Consideration should be given by providers as to how to evidence user experience in a way which is up to date and representative. The introduction of the ‘friends and family’ test may assist in the NHS. Providers also need to ensure that mechanisms also enable the experience of the most vulnerable patients, who may not be able to participate in surveys, to be captured.
- Board members should not be totally reliant on what is reported to them by way of assurance, but have alternative ways of sampling patient and experience such as walking the floors.
- Staff provider organisations need to find increasing ways to engage with their staff, whether through formal surveys or other mechanisms. It is essential that such engagement provides staff with appropriate feedback on how their comments make a difference. The recent Engage for Success report shows the benefits of effective staff engagement extend beyond identifying matters of concern and have a positive impact on a range of factors including productivity, sickness absence and health and safety. The report also cites evidence of the relationship between increased staff engagement and improved rates of patient satisfaction and patient mortality.
- There was some level of pressure in the Inquiry from both, Counsel to the Inquiry and AvMA, for a duty of candour to be imposed on all providers as a CQC registration requirement so that enforcement could be taken against the provider if they failed to disclose relevant information when patient safety incidents occur. This is something Robert Francis QC will have to consider in his final report. Already, for NHS services, the Department of Health has proposed an enhanced duty of candour in the draft NHS Constitution.It is anticipated that the Government will launch a further consultation in the spring of 2013 on proposals to give the NHS Constitution greater traction so that patients have appropriate redress where constitution rights are not delivered.
- Management and clinicians need to engage with each other in actively raising, listening and acting on concerns. Clinicians should be encouraged to raise appropriate concerns about colleagues within trusts. NHS employers have recently launched their ‘Speaking Up’ charter and independent sector organisations need to ensure their own whistle blowing processes are effective and implemented in practice.
- Providers should consider whether it would be useful to have a forum for GPs so that they can raise any concerns about the services.
Effective quality governance cultures will also be embedded through staff appraisal. Clinicians need to embrace clinical governance principles and understand that there are consequences for failing to meet objectives. Equally, management needs to engage with clinicians and respond to concerns raised in appraisals. Organisations need to consider whether their medical appraisal systems properly reflect Good Medical Practice to facilitate revalidation. The revalidation process started on 3 December 2012 and it is expected that the majority of licensed doctors will be revalidated by March 2016.
Executives, non-executive directors and clinical governance leads may require greater leadership training in order to embed the principles of quality governance. In the NHS, the PSA’s recently published Standards for NHS Boards requiring board members to always put safety, quality of care and patient experience first; for the independent sector, the Government’s response to Winterbourne View highlights an intention to strengthen accountability of Boards and senior managers for the safety and quality of care their organisations provide.
Quality Governance Structures and Learning
Providers’ quality governance structures should be clear and not convoluted. The Inquiry may consider whether standardisation of clinical governance structures and processes would assist. Providers would then know what systems they should have in place whilst allowing for necessary local variation. Counsel to the Inquiry suggested that the assessment of the quality of clinical governance against a defined standard would assist and should be a matter for the CQC to undertake.
Providers will need to ensure that their quality governance structures maximise the opportunities for learning and improvement of quality within their organisation. They should ask themselves whether their systems properly take into account and reflect upon information from a wide range of sources including:
PALs (or similar): Providers need to have appropriate systems to identify issues being raised within the PALs service and to implement remedial actions.
Complaints: Implementation of action plans following complaints should be monitored and Boards need data of sufficient granularity to enable trends from complaints to be identified. If you would like to view our recent article setting out a checklist to consider when managing complaints click here.
Adverse and serious incidents: Drawing from the themes in the evidence in the Inquiry, providers need to ensure they properly encourage and support the reporting of incidents, have proper systems in place to ensure action plans following investigations are implemented and ensure Boards are aware of the trends of incidents to inform their decision making. It is possible that the Inquiry may extend the mandatory reporting of incidents to ‘no harm’ incidents.
Patient safety alerts: There has been much discussion in the Inquiry regarding the need to ensure compliance with patients’ safety alerts and providers should ensure this process is built into their quality governance systems
Patient and staff engagement surveys/ meetings: as mentioned above
Whistle blowing: When whistle blowing takes place not only must providers learn lessons from, they must also offer support and protection to the whistleblowers.
Inquests: Providers should ensure there are proper systems for capturing issues identified in inquests and, in particular, in any Rule 43 reports.
Mortality alerts: Providers need to consider whether they have appropriate processes for learning lessons from mortality outlier alerts identified either by CQC or Dr Foster Intelligence.
Death certification: Analysis of death certificates could assist quality governance. Organisations should also consider whether their processes for death certification are robust and that appropriate cases are being referred to the coroner.
Claims: Providers need to ensure that they incorporate the learning from claims (e.g. from the NHS LA’s risk management reports) in their quality governance processes.
Clinical audit: Appropriate clinical audits that are centrally co-ordinated need to be carried out and fed into the governance processes. In addition, providers should reflect on the findings of national clinical audits and national confidential enquiries
Peer review: Providers need to appreciate the importance of peer review findings. Counsel to the Inquiry commented that the peer review model appeared to be an efficient way of identifying risks to patient safety and it may be that the Inquiry will recommend that the peer review model is extended and embedded in the system of healthcare regulation.
Conclusion and next steps
It is highly likely that the Inquiry will make a number of recommendations to address issues of organisational culture and enhance systems of clinical governance. However, it is also clear that there is a lot which providers can do to ensure their systems comply with existing guidance and embrace the wealth of information which is already available to them to enhance quality governance systems.
Bevan Brittan’s team has a wealth of experience in advising healthcare organisations. If you require any advice or assistance with any of the issues highlighted in this article, please contact Nadia Persaud, Joanna Lloyd or Carlton Sadler .
Once the report is issued all colleagues will need to reflect on what its findings and recommendations mean for them. To help consideration of this, Bevan Brittan is hosting a series of seminars in February and March 2013 to consider the implications following its anticipated publication. The scheduled dates for these seminars are as follows:
Bristol: 20 February 2013
Birmingham: 26 February 2013
London: 1 March 2013
Details of the seminars will be available on our website shortly. In the meantime, if you would like to register interest in attending any of these events please email firstname.lastname@example.org