Quality During Transition

National Quality Board

Quality During Transition

Ian CummingNational Director for Quality During

Transition

TIME OF GREAT CHANGE A patient led NHS

Putting patients at the heartof everything we do - “Nothing about me without me”

Delivering better healthFocus on outcomes -e.g. 1 yr cancer survival

Autonomy and AccountabilityEmpowering physicians and improving efficiency

The Public’s healthPrioritise prevention

CHANGE IS NOT JUST DRIVEN BY THE BILL

• In addition to the challenges of reform, the NHS is having to adjust to much slower growth in recurrent funding:

• In 2010/11 we had +5.5% growth. In 2011/12 – 2014/15 we will have basically “flat real”. This is unprecedented in the history of NHS

• This will create a financial challenge for the NHS of £15-20 billion over 4 years (20%) – the QIPP challenge. £2.5 billion of this will be in growth in prescribing costs.

Savings Examples Classified

technological innovation

frontline redundanciescut services

improve efficiencyimprove procurement

rationalise support services

early interventionpreventionself care

deny access to new health technologiescut training budgets

increase generic prescribing

decrease use of drugs/procedures of limited clinical value

Quality including reducing errors

impact on health

times

cale

for

sav

ing

to b

e re

alis

ed

negative neutral positive

long term

medium term

short term

Ever higher expectations

Demand driven by aging

Health in an information age

Changing nature of disease

Advance in treatments

Changing NHS and Social Care

Workplaces

NOT JUST £ : GLOBAL DRIVERS OF CHANGE

MAINTAIN QUALITY DURING

TRANSITION

IDENTIFY NEW QUALITY

ARCHITECTURE

SINGLE OPERATING MODEL

FOR Q&S IN SHA CLUSTERS

STANDARD SET OF QUALITY METRICS

MID STAFFS PUBLIC INQUIRY

Implement phase 1 of NQB report, including an assurance process for Quality Legacy Documents fromPCTs & SHAs.

Lead phase 2 of the NQB report, clarifying where accountabilities for quality will sit at system level April 13+

Identify best practice and devise a single quality operating model

Produce a ‘good enough’ set of indicators to aidmonitoring and management during transition

Ensure rapid dissemination and implementation of recommendations

THE CREATION OF A NATIONAL QUALITY TEAM

Quality During Transition

EVIDENCE SHOWS THAT QUALITY IS AT RISK DURING ANY CHANGELearning the lessons from the past and elsewhere

Body of evidence exists for mitigating actions to reduce risk in clinical handovers, including:

• Face-to-face verbal updates between incoming/outgoing teams

• Outgoing team writes summary

• Incoming team assesses current status and review historical data

• Outgoing team shares knowledge from previous handover and declares stance toward planned changes

• Unambiguous transfer of responsibility

• Private sector practice of due diligence

• NASA formal state of ‘heightened alert’.

LESSONS FROM ELSEWHERENHS HISTORY TEACHES US... One of the key risk factors for serious failure is a

recent history of mergers or major structural change (CHI, Lessons from CHI Investigations 2000-2003)

Mergers have a negative effect on delivery of services because of a loss of managerial focus on services (Fulop et al 2002, study of London Trusts)

NHS has a clear line of accountability for finance and robust hand over processes between finance professionals

NHS does not have the same clarity or robustness for quality handovers

NHS is a people-based organisation with a strong tradition of verbal culture

The scale of the anticipated change and the amount of knowledge it will take out of the system cannot be dealt with in traditional ways – NHS needs to raise its game to manage the risk

ACTIONS TO REDUCE RISK: HANDOVER PROCESS FOR PCT AND SHA CLUSTER

PCT

PCT

PCT

PCT CLUSTER SHA SHA

CLUSTER

NHSCB

CCG

NTDA

Each PCT within a cluster to produce handover document

SHA handover document to inform

face to face handover between

SHA and NHS Commissioning

Board

Cluster handover document to inform face

to face handover between cluster and

Clinical Commissioning Groups before March

2013

SHA Legacy document to inform

face to face handover between SHA and

NHS Trust Development

Authority

Board discussion of the document(s) should take place at PCT or Cluster

level

CQC and Monitor to feed into the

production of SHA document

2012/13

First full version of

cluster wide handover document

produced by 30th June 2011

SHA to produce regional

handover document by 3rd October

2011

New System Quality Architecture

As the quality curve shows, the quality of care will vary between and within providers of NHS care, from unsafe to excellent

The NHS defines quality as good patient experience, high levels of patient safety and care that is effective. The challenge for the whole system is to move services and organisations along the curve to the right

Unsafe Substandard Adequate Good Excellent

Proportion of services

2

3 Who’s responsible for driving continuous quality improvement?

How do we spot and tackle pre-failure?4

How do we respond to a serious /systemic failure?6

How do we response to a specific service failure?5

1 Who sets the bar on quality?

Who’s responsible for maintaining the bar?

Unsafe Substandard Adequate Good Excellent

Proportion of services

2

3 Who’s responsible for driving continuous quality improvement?

How do we spot and tackle pre-failure?4

How do we respond to a serious /systemic failure?6

How do we response to a specific service failure?5

1 Who sets the bar on quality?

Who’s responsible for maintaining the bar?

As the quality curve shows, the quality of care will vary between and within providers of NHS care, from unsafe to excellent

Christopher Mellor Acting Chair, Monitor and National Quality Board member

Dame Jo Williams DBE Acting Chair, Care Quality Commission and National Quality Board member

Sir David Nicholson KCB CBE NHS Chief Executive and Chair, National Quality Board

( )

( )

( )

( )

( )

The NHS early warning system

Revised EWS:• Board retains prime responsibility for quality, but in the event of a

serious failure, the Risk Summit model should be built upon, drawing upon experiences of Child Safety

• When triggered, it would provide a framework for bringing everyone together, sharing and aligning action plans, reviewing progress and actions etc.

• The commissioner should chair the discussion and coordinate any action, as they hold the NHS pound and geographical population, not replacing accountability of individual orgs

• Relationships and knowledge built through pro-active Quality Surveillance and Assurance Group, meeting regularly to share comparative data on quality across the local and regional Sector.


Proposed Quality Surveillance and Assurance Model (proactive part)

LOCAL

Provider 1e.g. Acute, Community,

Primary Care, NHS Continuing

Care, Ambulance, Independent

Sector,




Sector,




Sector,

Commissioner 1e.g. CCG,

NHSCB, Joint CCG + Local

Authority



Authority



Authority

Patient & Public Engagement(Including via Local Healthwatch

NHSCB Local Office Footprint

Quality Surveillance &

Assurance Group

Chair: NHSCB

MembershipCCG Leads

Local Authority Leads Local Healthwatch

CQC

NHSCB Sector Footprint


Assurance Group

Chair: NHSCB

MembershipNHSCB Local Offices

CQCMonitor

NHS Trust Development AuthorityNational Healthwatch

Day to Day Monitoring Monthly Meeting Quarterly Meeting

A B C D

LOCAL




Sector,




Sector,




Sector,



Authority



Authority



Authority

Patient & Public Engagement(Including via Local Healthwatch

NHSCB Local Office Footprint


Assurance Group

Chair: NHSCB

MembershipCCG Leads

Local Authority Leads Local Healthwatch

CQC

NHSCB Sector Footprint


Assurance Group

Chair: NHSCB

MembershipNHSCB Local Offices

CQCMonitor

NHS Trust Development AuthorityNational Healthwatch

Day to Day Monitoring Monthly Meeting Quarterly Meeting

A B C D

Single Quality Dashboard

17

Never events reported Jan 11- Dec 11 Rolling YearNever Event Description Number of

OccurencesRetained Foreign object post operation* 139Wrong Site Surgery* 60Wrong implant/prosthesis 22Misplaced naso or orogastric tubes* 20Intravenous administration of epidural 7Misidentification of patients 5Inappropriate administration of daily 4Maladministration of Insulin 3Maladministration of potassium-containing solutions (modified) 3Transfusion of ABO-incompatible blood 2Wrong route administration of oral / enteral treatment 2Escape of a transferred prisoner* 1Falls from unrestricted windows 1Potassium Chloride 1Wrong gas administered 1Wrong route administration of 1Total 272

Thousands of patients suffer avoidable harm across the NHS in England every year........

If you listen for the whispers you won’t have to

hear the screams – Cherokee Indian saying

Public Inquiry Mid Staffordshire Foundation

Trust

Mid Staffordshire Public Inquiry

139 days of oral evidence 181 witnesses nearly 2 million pieces of written evidence 7 expert seminars looking to the future Robert Francis, QC visits to exemplar practice within the NHS Final report expected…


Mid Staffs Public Inquiry cont..

“The Inquiry has conducted the most intricate examination of the working of the NHS and its regulatory and supervisory bodies since the inception of the NHS”

“…it is not logical to assume that there cannot be other Trusts failing in a similar way across the country”

“…proper regulation should be able to deliver what patients and carers want:- - a good standard of care

- a degree of compassion- to be kept safe”

Tom Kark, QCCounsel to the Inquiry


Mid Staffs....• Roles and Responsibilities• Communications and use of information• Assurance, monitoring and oversight• People and Culture• Patient and Carer Voice• Statutory Changes and Guidance• Workforce Planning and Information• Finance• Governance

Consistently emerging issues….• Serious Untoward Incidents• Complaints• NPSA Alerts• Staff and Patient Surveys• Workforce Surveys• Cost Improvement Plans• HSMR• Annual Reports and Board Papers• Whistleblowers• Media Analysis