Francis-and-Keogh-for-NAGG-9.2013.ppt

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Promoting quality forbetter health services

Francis, Keogh and Berwick

the implications for clinical audit

Presentation for NAGG, 18thSeptember 2013


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The Francis Report 2010

The Mid Staffordshire NHS Foundation Trust InquiryIndependent Inquiry into care provided by Mid Staffordshire NHS

Foundation Trust January 2005March 2009

Chaired by Robert Francis QC

Independent Inquiry covered January 2005 to March 2009 and was

set up to enable those affected by poor care an opportunity to tell

their stories.

Terms of reference also allowed for the views and experiences of

staff to be gathered, and for the inquiry to seek explanations from

management and directors.

Reported in 2010


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The Francis Report 2010Key findings

Serious deficiency in the performance and resourcing of clinical audit

in at least some areas of activity. The impression given is that practice

and attitudes in relation to this are considerably out of date.

Lack of leadership the trust generally performed poorly on clinical

audit. There was no one taking the lead for clinical audit for a yearand the trust-wide group did not meet at all during this period

Lack of clinical engagementfor example - a surgeon stated that

the medical lead and head of surgery had no interest in clinical audit

and reviews because of lack of time.

Clinical audit not carried out accordance with national standards ineacharea of activity.


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Key findings cont.

Limited participation in national clinical auditsthe trust did not

participate in many of the national audits run by the specialist societies

Inconsistency across trustperception was that in some clinical

areas there were good clinical audit programmes whilst in othersperformance was very poor in comparison with the same speciality in

other trusts

Confusion over role of clinical audit staff and support

Re-audits not carried out


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Recommendation 5:The Board should institute a programme of

improving the arrangements for audit in all clinical

departments and make participation in audit

processes in accordance with contemporary

standards of practice a requirement for all relevant

staff. The Board should review audit processes and

outcomes on a regular basis.

Midstaffs Public Inquiry Website

Kings Fund Presentation by Robert Francis Lessons from Stafford
http://www.midstaffspublicinquiry.com/reporthttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-staffordhttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-staffordhttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-staffordhttp://www.midstaffspublicinquiry.com/reporthttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-stafford


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To examine the operation of the

commissioning, supervisory and

regulatory organisations and other

agencies, including the culture and

systems of those organisations in

relation to their monitoring role at MidStaffordshire NHS Foundation Trust

between January 2005 and March

2009 and to examine why problems at

the Trust were not identified sooner,

and appropriate action taken.

February 2013


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Clinical audit?

It seems quite extraordinary that the general acceptance of the

importance of clinical governance, and in particular clinical audit,

which had been recognised nationally from the time of the Bristol

Royal Infirmary Public Inquiry report in 2000, if not before, had

failed to permeate sufficiently into Stafford to result in a

functioning, effective system by 2009

Francis Inquiry Report 2013 section 2.352

When audits were carried out, there was no robust mechanism

to ensure that changes were implemented.

When re-audits were required, they were often not undertaken. The trust did not participate in many of the national audits


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The Keogh Review

Selected as mortality outliers

Intensive review by experienced teams making extensive use of

available data

Although all 14 trusts face a different set of circumstances,

pressures and challenges ahead, this review has also been able

to identify some common themes or barriers to delivering highquality care which I believe are highly relevant to wider NHS.

Keogh review final report (16 July 2013)

Review into the quality of care and treatmentprovided by 14 hospital trusts in England

Professor Sir Bruce Keogh KBE
http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdfhttp://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdfhttp://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf


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The Keogh Review

Key themes include

The capability of hospital boards and leadership to use data to

drive quality improvement. More clearly needs to be done to

equip boards with the necessary skills to grip the quality agenda.

Some boards use data simply for reassurance, rather than theforensic, sometimes uncomfortable, pursuit of improvement

The fact that some hospital trusts are operating in geographical,

professional or academic isolation


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The Keogh Review

Ambition 1

We will have made demonstrable progress towards reducing

avoidable deaths in our hospitals, rather than debating what

mortality statistics can and cant tell us about the quality of

care hospitals are providing.

Professor Nick Black has been commissioned to study mortality

data, which will lead to the introduction of a new a new national

indicator on avoidable deaths in hospitals, measured through the

introduction of systematic and externally audited case note

reviews.


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The Keogh Review

Ambition 2

The boards and leadership of provider and commissioning

organisations will be confidently and competently using data

and other intelligence for the forensic pursuit of quality

improvement. They, along with patients and the public, will have

rapid access to accurate, insightful and easy to use data aboutquality at service line level.

All those who helped pull together the data packs produced for this

review must continue this collaboration to produce a common,

streamlined and easily accessible data set on quality which can

then be used by providers, commissioners, regulators and membersof the public in their respective roles. The National Quality Board

would be well placed to oversee this work.


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The Keogh Review

Ambition 2 (continued...)

Boards of provider organisations - executives and non-executives

- must take collective responsibility for quality within their

organisation and across each and every service line they provide.

They should ensure that they have people with the specific expertise

to know what data to look at, and how to scrutinise it and then use it

to drive tangible improvements. Over the last decade, many hospitalsin the United States have recognised the importance of this by

creating board level Chief Quality Officers. Creating a new board role

is not essential, but having someone with the breadth of skills

required is.

The skills deficit amongst commissioners must be addressed

The requirements for Quality Accounts will be reviewed for 2014-15


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The Keogh Review

Ambition 3

Patients, carers and members of the public will increasingly feel

like they are being treated as vital and equal partners in the

design and assessment of their local NHS. They should also be

confident that their feedback is being listened to and see how

this is impacting on their own care and the care of others.

Involving patients and staff was the single most powerful aspect of

the review process.

All NHS organisations should seek to harness the leadership

potential of patients and members of the public.


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The Keogh Review

Key areas for improvement

In patient safety

poor quality root cause analysis of incidents and limited

dissemination of learning from when things go wrong

Understanding and use of data

the complexity of the data and the difficulties this presents forprofessionals, patients and the public who want to understand

and use it;

the shortage of key skills in data analysis and interpretation

available to trust boards and management teams; and

consistency of metrics and information to be used to monitorquality on an ongoing basis.


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The Berwick Report

Our job has been to study the various accounts of Mid

Staffordshire, as well as the recommendations of Robert Francisand others, to distil for Government and the NHS the lessons

learned, and to specify the changes that are needed.

Advisory group chaired by Don Berwick, President Emeritus and

Senior Fellow of the Institute for Healthcare Improvement

The Berwick Report (August 2013)

A promise to learna commitment to actImproving the Safety of Patients in EnglandNational Advisory Group on the Safety of Patients in England
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdfhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf


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The Berwick Report

The most important single change in the NHS in response tothis report would be for it to become, more than ever before, a

system devoted to continual learning and improvement of

patient care, top to bottom and end to end.

Give the people of the NHS career-long help to learn, master and

apply modern methods for quality control, quality improvement andquality planning.

Rules, standards, regulations and enforcement have a place in the

pursuit of quality, but they pale in potential compared to the power

of pervasive and constant learning.


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The Berwick Report

All leaders concerned with NHS healthcarepolitical,regulatory, governance, executive, clinical and advocacy

should place quality of care in general, and patient safety

in particular, at the top of their priorities

Recognise that the most valuable information is about risks and

things that have gone wrong

Give help to learn, master and apply modern improvement

methods

Use data accurately, even where uncomfortable, to support

healthcare and continual improvement


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The Berwick Report

Patients and their carers should be present, powerful andinvolved at all levels of healthcare organisations from

wards to the boards of Trusts.

Patients and their carers should be represented throughout the

governance structures of NHS-funded healthcare providers, for

example by sitting on and actively participating in safety andquality committees.

The recommendations of the Keogh Review were endorsed


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The Berwick Report

Mastery of quality and patient safety sciences andpractices should be part of initial preparation and lifelong

education of all health care professionals, including

managers and executives.

Collaborative learning through safety and quality improvement

networks can be extremely effective and should be encouragedacross the NHS. The best networks are those that are owned

by their members, who determine priorities for their own

learning.

Every NHS organisation should participate in one or more

collaborative improvement networks as the norm.


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The Berwick Report

Most health care organisations at present have very little

capacity to analyse, monitor, or learn from safety and qualityinformation. This gap is costly, and should be closed.

Commissioners should increase funding for NHS organisations to

analyse and effectively use safety and quality information.

The current NHS regulatory system is bewildering in itscomplexity and prone to both overlaps of remit and gaps

between different agencies. It should be simplified.

An in-depth, independent review of structures and the regulatory

system should be completed by the end of 2017, once current

proposed changes have been operational for three years


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The Berwick Report

Key actions include: Government and NHS England Leaders must support

investment in the improvement capability of the NHS

NHS Organisation Leaders and Boards must:

Monitor the quality and safety of care constantly, includingvariation within the organisation.

Embrace complete transparency

Join multi-organisational collaborativesnetworks

System Regulators must simplify, clarify, and align theirrequests and demands from the care system


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The Berwick Report

Key actions (continued):

Professional Regulators and Educatorsmust assure the

capacity and involvement of professionals as participants,

teammates, and leaders in the continual improvement of the

systems of care in which they work.

NHS Staff and Clinicians must:

Participate actively in the improvement of systems of care.

Acquire the skills to do so.


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The way forward?

Clinical audit must take its place in an integrated view of

healthcare quality management and service improvement

How can we help to develop the skills:

For commissioners

For trust boards and the senior leaders in other healthcareproviders

For clinicians, of all grades and from all specialties

For healthcare managers

For clinical audit staff


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The way forward?

If there is one lesson to be learnt, I suggest it is that people must

always come before numbers. It is the individual experiences that

lie behind statistics and benchmarks and action plans that really

matter, and that is what must never be forgotten when policies

are being made and implemented. Robert Francis QC

HQIP has an established Service User Network

HQIP Service User Network web page

We have produced a range of guidance on patient and public

engagement in clinical audit

HQIP PPI Guidance
http://www.hqip.org.uk/hqip-patient-network/http://www.hqip.org.uk/ppi-guidance/http://www.hqip.org.uk/ppi-guidance/http://www.hqip.org.uk/hqip-patient-network/


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Contact us

Healthcare Quality Improvement Partnership020 7469 2500 07946 545279

E-mail: [email protected]

[email protected]

Website: www.hqip.org.uk

Promoting quality improvement for better healthcare
mailto:[email protected]:[email protected]://www.hqip.org.uk/http://www.hqip.org.uk/mailto:[email protected]:[email protected]