Methods of Regulation Inquiry Seminar

1. Methods of RegulationInquiry Seminar “We live life forwards but understand it backwards” Peter Homa Chief executive 13th October 2011

2. Agenda Biography and caveat emptor Creating an inspectorate Lessons from healthcare regulation Setting, monitoring, improving and enforcing healthcare standards A chief executive’s perspectives: how inspectors’ findings are best implemented Coda

3. Biography 1989 - 1998: CE, Leicester Royal Infirmary 1998 - ’99: Head, National Patients Access Team, Department of Health ’99 - 2003: Inaugural CE, Commission for Health Improvement 2003 - ’06: CE, St George’s Hospital, London 2006 - present: CE Nottingham University Hospitals

4. Creating an inspectorate Substantial, complex task to design and build an inspectorate including method development, staff recruitment and training and excellent governance structures and process Develop inspectorate’s values, strategic and operational plans Design and embed quality assurance processes to ensure inter-rater reliability Establish effective relationships with internal and external stakeholders including (sometimes with MOUs) patient and public groups, NHS, DH, 10 Downing Street, Treasury, other regulators, Royal Colleges and media

5. Creating an inspectorate Government often assumes that newly created inspectorates can operate more quickly than practical Considerable risk during a new inspectorate’s early days due to new legal duties, staff, methods untested QA and internal and external relationships

6. Lessons from healthcare regulation Focus on patient outcome, safety and experience c.f. The “Apple Ipad approach”: design methods “outside in” not “inside out” Inspection methods should be subject to the same rigorous continuous improvement as the organisations that are inspected. Avoid inspectorial methodological rigidity and develop effective change procedures for inspectorate staff. Benchmark inspectorate performance against global best practice

7. Lessons from healthcare regulation NHS and provider Boards are the focus of governance accountability and responsibility. They operate in a complex context that must be understood by the inspectorate Inspections should form part of an overall process for improvement lead by the Board and not an isolated event Establish open, transparent and published inspection methods and standards that Boards can use to guide and measure their own work to improve the quality of patient care

8. Lessons from healthcare regulation Well prepared peer reviews of organisations against agreed standards by lay people, practicing clinicians and managers help to improve the quality of patient care. Such peer review can be separate or integrated to inspections. Multiple benefits include providing inspections with a deep understanding of everyday healthcare practice and this experience is taken back to peer reviewers’ own organisations Inspectorates should try and anticipate and avoid unintended consequences of their inspection methods/standards for example…

9. Lessons from healthcare regulation Inspectorates should develop predictive analyses to try and anticipate major organisation healthcare failure before they occur e.g. small specialist geographically isolated units (See CHI’s Lakeland NHS Trust investigation 2000) There should be as few inspectorates as possible and those that exist should have a duty to operate as a coherent system where the whole is greater than the sum of the parts. Given inspectorates’ legal duties this is often challenging to achieve but essential if patient care is to improve as much as possible (See Michael Power, Inspection Society)

10. Lessons from healthcare regulation Inspectorate judgement of organisations’ performance should take into account the organisational context including PCTs, CCGs, SHA One of the Inspectorate's main contributions is providing a Board with a thoughtful, authentic, assessment of their organisation’s comparative performance. “Holding a mirror to the organisation” High quality data about the quality of clinical outcome, process and patient experience comprise the oxygen for service improvement. Data quality assessment should be made at all levels (see Nottingham case study)

11. Data Quality Kitemark

12. Data Quality Kite Mark This page gives guidance on how to update the Data Quality Kitemark for the Integrated Board report. For all indicators please state whether they adhere to the following measures or whether the measure is not relevant to the indicator. 12

13. Setting, monitoring, improving and enforcing healthcare standards Standards should draw on global best practise e.g. “matching Michigan”, infection control, stroke services and must incorporate assessments of the humanity of patient care. See Jocleyn Cornwell, The Point of Care, King’s Fund, and the Institute of Healthcare Improvement, Boston MA. Boards’ assessments against agreed standards should be published at least annually supplemented where possible by the inspector's judgements. Standards against which Boards’ self assessments and inspectorate’s assessments are made should be both “core” and “aspirational”.

14. Setting, monitoring, improving and enforcing healthcare standards Boards should have locally owned action plans to improve patient care delivery and these should be regularly reviewed. Progress should be measured through improvements in clinical outcome, process and patient experience. Inspectorates should have a repertoire of interventional instruments to require and where necessary compel organisations to improve patient care. These should be a clear, well understood interventional escalator. The intervention selected will be proportionate to the scale of performance failure. These instruments should be consonant with other inspectorate’s legal duties and requirements. Boards should be held to account to deliver improvements.

15. A chief executive’s perspective: how inspectors’ findings are best implemented Boards provide a vital role in setting the values, direction, tone and public accountability and responsibility for the organisation’s delivery of high quality patient care. The regulatory environment should be designed to take this into account. Boards must demonstrate that patient safety is the top priority. On occasions e.g. investigations into major service failure, inspectorates must examine the respective contributions of all levels of NHS/DH management Boards should compare their own organisation against others to understand their relative performance across the breadth of patient services. This requires high quality data and information and investment in information systems and analytical capacity.

16. A chief executive’s perspective: how inspectors’ findings are best implemented Boards should demonstrate the capacity to deliver high quality care using available resources wisely. Boards should avoid asymmetrical attention to the domains of money and patient safety and patient experience. There should be movement of staff between NHS providers and inspectors to ensure that both have a good understanding of the other’s perspective. This should help avoid “provider capture” but achieve “provider understanding” and vice versa. Inspectorates need to earn credibility among multiple stakeholders through sound, wise, thoughtful and proportionate judgements and responses. Such credibility is to a degree correlated to the inspectorate's access to contemporary provider working experience.

17. A chief executive’s perspective: how inspectors’ findings are best implemented Welcome the opportunity for staff to become peer reviewers as this develops skills and experience in the organisation to improve patient care (“trickle down” effect). Inspectors should recognise the interorganisational opportunities to improve patient care and ensure that all appropriate elements of the local healthcare system are assessed. Inspectorates must operate as a coherent system even though they may be statutorily separate. This is to avoid a conflicting inspectorial requirements upon providers.

18. Coda Excellent healthcare Boards focus on how to deliver high quality patient care within available resources. Excellent Boards do not describe this as mutually exclusive requirements but rather as a complex simultaneous equation that must be solved using the considerable commitment, energy and ingenuity that so often define healthcare staff. Constant NHS and inspectorial reorganisations inhibit development of well established relationships and inspectorial methods and improvement plans. This reduces momentum to improve services.

19. Coda The separation of financial/governance and quality functions between Monitor and CQC creates additional complexity for NHS providers and both regulators. The further a commentator from the healthcare front line the more time is devoted to speculating about “gaming” of inspectorial regimes.

20. Coda Regulators’ legal structures and duties provide the regulatory anatomy. However, it is the leadership of inspectorates that provide the physiology i.e how well they work. Sound legal structures can be confounded by insular leadership behaviours. Suboptimal legal arrangements can be made to work through well intended leadership. The tough economic environment in the NHS is going to place increasing pressure on providers, commissioners and inspectorates.