Education Quality Standards and Standards for Quality Patient Care-are they synonymous?

1. Education Quality Standards and Standards for Quality Patient Care-are they synonymous? Dr E A Hughes Regional Postgraduate Dean West Midlands

2. NHS Trusts with the West Midlands

3. Quality of Education • Assurance of quality in higher education is the collections of policies, procedures, systems and practices internal or external to the organisation designed to achieve, maintain and enhance quality

4. Quality in healthcare Effective Safe Q Good Experience

5. Making quality the organising principle of the NHS Bring clarity to quality Measure quality Publish quality performance Recognise & reward quality Raise standards Safeguard quality Stay ahead

6. Quality of Education

7. Royal Colleges

8. Deanery visits

9. Regulators

10. Quality Assurance • Royal Colleges • Deanery • PMETB • GMC • QAA • EQUIP • EQC • NMC • QABME

11. Maintaining Quality of Care Standards

12. Maintaining Quality of Care Standards • Healthcare Commission • CQC • NHSLA • SHA • Monitor

13. Impact model applied to Healthcare (adapted from Mackinnon Partnership 2000, SfH 2007)

14. How can we ensure such systems work together to achieve high quality care?

16. Educational change • 2005 PMETB established –substantial change to roles of Colleges and Deaneries • PMETB –risk based approach • 2007 MMC commenced.

17. PMETB Quality Framework Autumn 2007 • QM Visits -Deanery • ‘All such visits will be targeted and proportionate to the concerns identified prior to the visit • Wherever possible, autonomy should be given to the Trusts, Health Boards and other LEPs to monitor their own performance against PMETB standrards and requirements. • Visits should have a very clear and articulated purpose and should be kept to the minumum needed to ensure that PMETB’s standards are met

18. Stafford Hospital • Visited by Deanery for Foundation training 2005 –some issues found around induction. Visited by Head of Foundation and revisited 2006 –satisfactory • RCP reviewed medical training 2006 on behalf of PMETB –satisfactory • PMETB survey 2006 –all green triangles • PMETB survey 2007-5 green triangles and 2 red triangles –clinical supervision noted to be high satisfaction

19. Stafford Hospital • Foundation visit in May 2008 with intervening informal visit from Associate Dean for Foundation School • Foundation visitors highly experienced – Associate Dean, Senior Clinical tutor (A and E consultant) and Dean of Keele Medical School • Report notes ‘review well attended by trainees with strong engagement and people prepared to speak out’

20. Stafford Hospital • A and E noted to have high level of work although it is a very challenging and a good learning environment. Hours in A and E noted to be good • One consultant only but good use made of Associate specialists and practitioners in supervising FY2 doctors • Well prepared for appraisal in A and E • All consultants considered approachable • PMETB survey results indicated that some very good training was occurring with no evidence of an endemic problem with all training

21. Stafford Hospital • SpR in A and E raised concerns regarding training with regard to lack of supervision, training and lack of cover out of hours • Would not discuss this with the Dean so completed JEST survey – suggested that patient safety was low in Trust’s priority • Disparity between his views and those of FY2 doctors –why? • HCC had identified concerns with high HSMR and care issues and were undertaking an Inquiry

22. Stafford Hospital • Intensive action plan with weekly monitoring, SHA involvement, A and E task force , recruitment of middle grades and 4 new consultants with immediate locum input at both levels • External visits confirmed improvement • Multiple visits by Deanery, CQC and SHA over last 3 years

23. Can poor educational quality be used in isolation as evidence of a poor standard of clinical care? • Is good educational quality an indicator of high quality care?

24. GMC Survey 2010 Total Red Outliers by LEP – Mid Staffs is 6th in league table (Taken from GMC survey online tool – total outlier summary matrix) GMC Survey 2008-09 Total Red Outliers by LEP – Mid Staffs 10th in league table (Taken from GMC survey online tool – total outlier summary matrix)

25. Surviving the Storm • ‘How did we let it happen?’ • ‘It is sobering to realise how one can get used to such poor standards • In retrospect more of us should have made it clear that there were unacceptable staffing levels and practices in emergency care’ • Paul Woodmansey Clinical Medicine 2011

26. What lessons have we learned from Mid Staffs? • How are we bringing education and quality together to identify areas of potential concern and also of good practice?

27. Quality Review Visit Framework:Checking our Evidence Base Framework Description Responsible Scheduled LEP Review Scheduled Review Head of School and School Quality Lead Exceptional LEP Review Level 1: Exceptional Paper-Based Review Head of School and School Quality Lead Head of School and School Quality Lead Level 2: Exceptional Review Visit by School Level 3: Exceptional Trigger Visit by Deanery with Externality Associate Dean for Quality Level 4: Exceptional Regulatory Body Trigger Visit (i.e. GMC) Postgraduate Dean Programme Review Planned Programme Review Associate Dean for Quality / Head of School Deanery Review Regulatory Body Deanery Visit (GMC) Postgraduate Dean

28. Quality Assurance Visit Reviews:Reviews 2010/11 – Approx 60-80 reviews per year

29. Visit Database:Monitoring and Closing the Loop • All process points documented • Flags up if monitoring not completed • Allows performance management

30. Questionnaires:GMC Survey • Shared with all levels of Deanery (Strategic, School, Programme, LEP) • Analyse red outliers similar to JEST to allow comparison

31. Questionnaires:JEST (Local tool) • Local survey for Trainees • Electronic • Accessible by LEPs and Deanery • Analysed for themes and QA evidence base • Significant work undertaken in thematic analysis

32. Patient Safety Concerns during Postgraduate MedicalQuality Review Visits • During Deanery monitoring visits to Local Education Providers and their training units, trainees and consultants are routinely asked by the visiting team if they perceive any risk to patient safety in the clinical service at the Trust.

33. Patient Safety Concerns during Postgraduate MedicalQuality Review Visits • Organisational Hazards • 1. Inadequate facilities (e.g. A&E units without ready access to urgent imaging and lab services). • 2. Departmental rules preventing ready access to required services by junior doctors. • 3. Protocols which impede timely medical care (e.g. care before patient transfer to suitable wards / • internal referral systems allow for patients to get ‘lost in the system’).

34. Patient Safety Concerns during Postgraduate MedicalQuality Review Visits • 4. Protocols / facilities which regularly lead to patient care within inadequately / unsuitably staffed areas • (e.g. acute medical patients moved to T/O or rehab wards). • 5. Rotas which do not provide enough doctors for the work to be done (e.g. covering excess numbers of • ward patients over the weekend). • 6. Doctors routinely expected to perform tasks for which they are untrained (e.g. take consent for surgery • / insert central lines / lead paediatric resuscitation without relevant training - NLS, PLS) • 7. A pattern of poor clinical work by other, non medical, professional workers.

35. Patient Safety Concerns during Postgraduate MedicalQuality Review Visits • Supervision and Senior Cover • 1 If any junior doctor cannot access the immediate support (by phone, followed, if necessary, immediately by personal presence) of a more senior doctor to deal with a clinically dangerous situation, then this is a patient safety risk. The senior does not need to be from the junior’s own firm or subspecialty, but must be of the same “ branch” (medicine, surgery, T/O, paediatrics etc) • 2 Senior doctors with acute care responsibility should be on the hospital site, within daytime hours, and without other responsibilities for the relevant period.

36. Patient Safety Reporting Process:Lead Visitor Responsibilities

37. Quality Governance:Joining the QA Framework Together Organisational Levels Governance Groups Quality Review Processes Regulator (i.e. GMC, formerly PMETB) Regulatory Body (i.e. GMC) SHA Governance / Patient Safety Group Royal Colleges Deanery quality review, report and action plan Deanery PMDE Board Annual Deanery Report PMDE Quality Committee School Programme quality review, report and action plan School Boards (i.e. PMDE and FPMB) School Annual Report LEP quality review, report and action plan LEP LEP Annual Report LEP Local Education Meetings

38. Patient Safety Oversight Group • Formal subcommittee of the SHA Board • Medical Directors, DoN Postgraduate Dean and deputy • Director of Patient Safety, Regional CQC Director, Performance Director, HCAI specialists and mental health • Others as appropriate are co-opted

39. n/a Awaiting Data

40. Escalating Concerns NHS West Midlands Postgraduate Medical Trainees are encouraged to raise concerns when appropriate regarding their training programme via a number of mechanisms such as the GMC Survey, Job Evaluation Survey Tool (JEST), Reviews/Visits to Local Education Providers (LEPs), Annual Review of Competency Progression (ARCP), Appraisals, and Incident Reporting etc. When issues arise that are not appropriate or out of sequence with these processes, Trainees may raise concerns by using the following pathways as appropriate to their concern. Concerns may cover any issue including patient safety and quality of education and training. Trainees should invoke pathways appropriately and in order of priority. http://www.westmidlandsdeanery.nhs.uk/Home/EscalatingConcerns.aspx

41. Lay Advisors • Currently have pool of 35 Lay Advisors • Activity Organiser / Activity Lead Guidance has been developed. • April 2010/March 2011 – 71 Activities Attended which included QA Reviews, Programme Reviews, ARCP/RITA, Assessment, Recruitment etc. • Feedback from both Lay Advisors and Activity Leads has been extremely positive “Utilisation of Lay Advisors has been valuable due to their independency and professional knowledge and skills from business and other non-health sectors”

42. Was Mid Staffs an Isolated Case? • An NHS hospital is to face a lawsuit launched by more than 20 families who claim their loved ones were subjected to "appalling and humiliating" treatment. Law firm Leigh Day & Co intends to argue that the standard of care offered at Redditch's Alexandra Hospital was so bad that it breached the human rights of several patients, including a 73-year-old man whose ribs are alleged to have been "broken open" by the use of a hoist after heart surgery. The action includes allegations of neglect such as dehydrated patients not being given water or not being fed.

43. DO GMC SURVEYS GIVE US INDICATORS OF POOR QUALITY OF CARE? All trainees by post specialty by local education provider

44. Dawn of a New Era

45. GP Consortia NHS Outcomes Framework NHS OUTCOMES FRAMEWORK Domain 1 Domain 1 Domain 2 Domain 2 Domain 3 Domain 3 Domain 4 Domain 4 Domain 5 Domain 5 Preventing Preventing Enhancing Enhancing Recovery Recovery Ensuring a Ensuring a Safe Safe people from people from the quality the quality from from positive positive environment environment dying dying of life for of life for episodes of episodes of patient patient free from free from prematurely prematurely people with people with ill health / ill health / experience experience avoidable avoidable LTCs LTCs injury injury harm harm NICE Quality Standards NICE Quality Standards Duty of quality Duty of quality (Building a library of approx 150 over 5 years) Duty of quality Duty of quality Provider payment mechanisms Provider payment mechanisms Commissioning Commissioning Commissioning Commissioning Outcomes Outcomes standard standard Guidance Guidance tariff tariff CQUIN CQUIN QOF QOF Framework Framework contract contract Commissioning / Contracting Commissioning / Contracting certain specialist services and primary care NHS Commissioning Board – – certain specialist services and primary care GP Consortia – – all other services all other services Duty of quality Duty of quality

46. Plan, develop and secure supply of a capable patient –centered workforce Meet standards set by independent regulatory/ statutory bodies Educational Outcomes Framework Architecture ver 3 dated 26 Aug Excellent quality care in training environments Promote health and wellbeing and health inequalities Excellent experience for students and trainees Competent and capable staff Support the NHS constitution Specific Indicators (using where possible already established metrics) Effectiveness Fitness for purpose & leadership Promote research and innovation Promote effective team and interdisciplinary working Excellence of education training & development Safety Respond to changing service demands Individuals & professional groups aligned with workforce demand Meets strategic local workforce & commissioning plans LETB/HEIs Healthcare Org 46 46 SoS/DH HEE

47. Outcomes • Excellent quality care in training environments • Competent and capable staff • Fitness for purpose and leadership • Excellence of education training and development • Individuals and professional groups aligned with workforce demand 47

48. Relationship between health care education and quality of care Quality healthcare education and training can directly and substantially benefit care. The EOF will provide a framework to make these benefits explicit and enable further research to directly link education and learning to improvements in patient care outcomes.

49. Professionalism

50. Origins of “Professionalism” • from Latin by way of Middle English, • professiō, the taking of vows of a • religious order