Transcript Slide 1

Stafford Hospital
Lessons Learnt
Manjit Obhrai MD
What did we find?
Key Message
‘A realisation very early on that the pattern
of failure at the hospital was not only true,
but it was serial, repetitive and deep in the
organisation’
‘They had lost the plot’
(A Sumara – Chief Executive)
Context
• Patients died at the Trust that should not
have – worst mortality statistics in the
country
• Public resentment and poor reputation
• Staff morale was low
• Nurse staffing levels too low for safe care
• Poor line of sight from Board to Ward
• Denial
The recipe for disaster
• Complete lack of insight
• Not listening to patients, their families or staff
• Poor governance systems for safety,
experience or effectiveness of care
• Focus on targets and finance to the
exclusion of compassion for patients
• Poor communication lines
• Trust Board and the Board of Governors
kept in the dark
• Lack of openness and transparency
The recipe for disaster
• Lack of genuine clinical engagement
• Poor decision making with little or no risk
assessments
• Dilution of the nursing establishment – to
save money
• Focus on process not on outcome
• Inward looking organisation with poor
networks
• Poor leadership – invisible leaders –Board
to Ward disconnection
• Denial of responsibility and accountability
• Unsure about assurance and governance
Early thoughts
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Poor understanding of accountability
Staff not being held to account
Virtually no organisational learning
Unstructured, unsympathetic and poorly
co-ordinated care
Standards of practice are ill defined and
inconsistent
Lack of insight into key policies
CQR with the PCT was an embarrassment
No organisational memory in the senior team
Lack of compassion & poor attitude
[Patient]:We were awaiting daily results now from
different procedures, and one evening, when
[my daughter] and I was together, the staff nurse
was just leaving to go off duty. She popped
around the curtain and she said: I have got
some good news and some bad news for you;
the good news is you have got no secondaries.
That was from the whole-body CT scan. But the
bad news is you have multiple pulmonary
embolism in both lungs. She said: that’s very
serious. Did she say serious or dangerous?
[Daughter]:That’s quite serious. One false move
and you are out of here. And then she went.
Lack of effective teamwork & clinical
leadership
• Lack of clinical engagement
• Insufficient involvement of senior clinical staff in the
care of vulnerable patients
• Insufficient involvement in clinical audit and poorly
conducted MDT’s
• No relationships with other trusts and weak clinical
networks
• Poor prioritisation of sick patients
• Poor communication between doctors and nurses
History repeating itself
• Mr Rodney Ledward Inquiry 2000
– The Royal Colleges should agree a list of
untoward non clinical events which should
trigger the filling in of an incident report form
– Absence of an untoward incident form in
respect of complaints should be immediately
investigated
– All clinicians should participate in clinical audit
– All complaints should be dealt with by a single
department
– A confidential hotline should be set up in which
staff can notify confidential concerns
History repeating itself
• The Bristol Royal Inquiry Report 2001
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Confusion about who was responsible for monitoring care
Concerns raised at the hospital not taken seriously by staff
Lack of openness at the Trust
No culture that the Trust Board was involved
Clinical negligence litigation was acting as a barrier to openness
Clinical audit should be compulsory for all
Trust Boards must be able to lead healthcare at local level
Culture of safety requires the creation of an open free and non
punitive environment
– Failing to report serious incidents should be a disciplinary
offence
– The public voice should be embedded in all organisations
– Whistle blowing should be an important tool in improving patient
care
History repeating itself
• 2001 - Epsom and St Helier
– Urgent action to implement trust wide and untoward
incident policy
– Strategic approach to involving both patients and the
public in setting the quality agenda and ensuring both
safe and adequate care to patients
– Action as requested to ensure that complaints are
dealt with expeditiously and sensitively and were
shared with staff and used to improve clinical
standards
– Urgent action was needed to ensure staff felt safe to
raise concerns
– Action was required to ensure that staff were involved
in clinical audit process
Our 5 themes
1. Creating a culture of caring
2. Seeing zero harm as our target by
keeping patients safe
3. Listening and responding and acting on
what our patients and community are
telling us
4. Supporting our staff to become excellent
5. Continuing to do what we need to do to
satisfy our regulators
Challenges to the NHS
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Focus on sustainable quality
Focus on continuous improvement
Meeting rising demand
Reducing inpatient activity
Decreasing financial resource
Our Philosophy
Doing the right thing at the right time
with the right people for patients is the
key to improving quality, safety and
reducing costs
The three elements of Quality
• Patient Safety
• Patient Experience
• Improving Patient Outcomes
Quality and Safety
• Reduce harm
• Review the Workforce
• Focus on processes including clinical
protocols and guidelines
• Clinical engagement and leadership
• Personal and professional accountability
Harm
• 1 in 10 patients are harmed in the NHS
• Reduction in harm will improve quality and will
save expensive resource
• Delayed diagnosis
• Delay in implementing appropriate care
• Lack of adherence to NICE guidance
• Failure to comply with the WHO safe surgery
checklist
Workforce
• Workforce numbers with the appropriate skills
and skill mix
• Training and supervision
• Consultant job planning to fit departmental and
organisation need
• Separation of Elective and Emergency work
– Acute physicians role
– Early access to senior opinion
– Reduction in Mortality in AMI, Heart Failure &
Pneumonia
General Surgery
• Is the concept of General Surgery valid in ’10?
• Specialists to concentrate on their areas of
expertise
• Appropriate surgical on call arrangements
– Role of doctors in training?
• Reduce waste in theatres
– Better scheduling of cases i.e. majors vs.
minors
– Appropriately staffed admissions area
Management of bed stock
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A & E admissions and target
Delayed discharges
Medical outliers on surgical wards
Cancelled operations
– Impact on patients
– Wasted resource
– Increase cost of WLIs
Accountability & Performance
• Dr Foster Data for appraisal and
performance management
• Mortality
• LoS
• Readmission rated
• Complaints and incidents
Accountability
• Leadership to remind colleagues
– Compliance with rule 43 Letters
– Compliance with NICE Guidance
– Obligatory responsibility to raise concerns re
issues affecting patient safety
A few words on leadership
Leadership focuses on
• Satisfying basic human needs for
achievement, belonging, recognition,
autonomy and self esteem
• Involving people in achieving the
organisations vision in a way that gives
them a sense of control
• Creating an environment in which
leadership skills can be role modelled
Participative Management
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Motivates professional employees
Focus on knowledge skill and expertise
Enhances individual potential
Requires vision
High level interpersonal skills to articulate the vision
Capable of inspiring
Encourages communication of ideas from the bottom up
Power influence and status should be based on
participant involvement, face to face communication and
information sharing
Our definition of Quality
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Complaints Data / incidents / SI / Nursing and Medical staffing
Mortality - show the human side!
How do we collate all of this and its impact on patient safety?
Visibility
– What added value do the visits of the Execs and NEDs add to the Organisation?
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Training to be observers
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Testing the right things
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How do we train people to do what some of us do intuitively?
Visibility– how is this assessed by the regulators?
Listen, observe and connect
Role of community groups
Build open and honest relationships
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Culture change - Openly thank and congratulate people who raise concerns
Ensure actions are completed and the ‘loops are closed’ when identified
Role of the Board
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The “buck” stops here!
Open Public Board Meetings
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Active public involvement and evaluation
Quality and Safety at the top of the agenda
Structured Board Agenda
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Start with a patient story
Putting patient issues first
Being brave – discussing SIs at the public board
Mortality discussion in public
Culture
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No quick fix
Trust values
Develop tests
How do we accurately measure attitude, engagement
and being open?
• Whistle blowing policy
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Not only relying on the traditional methods
Surgeries with the NEDs
Executive walkabouts
Power of the Inquiry
• Staff more comfortable raising concerns
• Making it explicit in all contracts the expectation to raise concerns
– Daily incident reports to the Executive Team
• Hot spots can be identified daily
Questions & Answers