Rugby Borough Council - Community Leadership Panel 25th March 2004

1. Rugby Borough Council - Community Leadership Panel 25th March 2004 Update on the Commission for Health Improvement Action Plan and Clinical Governance at UHCW NHS Trust Paul Martin - Head of Clinical Governance UHCW

2. Commission for Health Improvement • CHI is the independent, inspection body for the NHS. • CHI publishes reports on NHS organisations in England and Wales. They highlight where the NHS is working well and the areas that need improvement. • Their work includes: • routine inspections (clinical governance reviews) • investigating serious service failures • reporting on key issues, such as coronary heart disease • publishing performance ratings • publishing data on staff and patient surveys • joint inspections with other bodies • managing the clinical audit programme

3. Patient & Public Involvement Clinical Audit Clinical Effectiveness Clinical Risk Management Staffing and Staff Management Training & Education Use of Clinical Information Clinical Governance Clinical governance can be defined as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

4. The CHI Review 2001 • Feb 2001 - Jun 2001 • Report published September 2001 • Report highlighted 5 major areas of concern that required immediate action • Widespread public concern • 2 star Trust to 0 star Trust

5. The Findings • The practice of placing a fifth bed in a four-bed bay • Death rates for non-emergency admissions are significantly higher than the national average • The organisation of care between the accident and emergency (A&E) departments and the emergency admissions unit (EAU) is unacceptable • Relationships between some consultant medical staff and senior managers have broken down. • A new hospital development is planned, but the Trust has serious service problems now.

6. The resulting action plan • Action plan with over 360 separate actions • Trust was re-reviewed by CHI after three months - found to have made some or satisfactory progress in all major areas with the exception of ‘Relationships’. • Action Plan was regularly reviewed and monitored by the Trust Board. • By May 2003 was 95% complete - some actions were longer term and others had been overtaken by events. • Trust was re-reviewed on behalf of CHI by the West Midlands South Strategic Health Authority in May 2003.

7. The SHA / CHI Review • Review undertaken by SHA managers and external assessors from other Trust’s in the SHA area • Covered all the clinical governance elements but in particular concentrated on issues from the CHI Review • Trust had to provide supporting evidence - 7 lever arch files • Met with a range of Trust clinicians and managers to question them directly on clinical governance and CHI issues • Visited wards and departments and spoke to staff

8. The findings The following comments are taken directly from the SHA’s report to CHI

9. Patient Experience • How has the escalation policy been developed and has the Trust ensured that additional beds have not been placed in bays with the exception of response to a major incident? • Have the areas where clinical care was delivered in inappropriate environments been addressed to an acceptable standard

10. Confirmed on many occasions during the visit that 5 beds have not been placed in 4 bedded bays since August 2001 – it is clear that staff are comfortable to raise concerns and no staff raised this issue as a concern. • Escalation Policy – bed pressures not evident in EAU for many months. • Reduction of delayed transfers for a number of months • Evidence in place of joint working with PCT and local authority for developing and implementing the bed management and escalation policies • Escalation Policy, Bed Management Policy and practical trigger review list in place • Change Agent Team in place with Social Services and PCT • PEAT reports excellent despite the amount of progress required by previous PEAT report and building works on Walsgrave site. • Two discharge lounges needs attention from patient perspective i.e.. comfort, television available etc.. Role of the discharge lounges needs clarification

11. Patient, service user, carer and public involvement • How has the implementation of the patient and public strategy developed partnership working with local organisations and groups particularly in improving information for patients and carers?

12. PALS service up and running • PALS good service and user involvement, issues in engaging people and ethnic mix • PALS leaflets highly visible • PALS strategy done, needs implementing • Evidence of work with support groups to improve information for patients – Headway, Epilepsy and renal • Patient Council in place • Patient Council chair sits on Assurance and Governance Committee • Shadowing opportunity for lay people e.g. Physio – patient suggestion that physio should tape exercise programme for patient is to be implemented • Weakness – location of PALS service needs to be relocated to an area that is more accessible to patients

13. Risk management • Have robust and systematic risk assessment and management systems been effectively implemented across the trust and what are the ongoing monitoring arrangements?

14. Incident reporting is embedded • Changes in practice resulting from clinical incident reporting include changes in the design of service, accommodation, access to beds, discharge, management of head injuries, communication with patients/GPs • ‘Positive outcome from Clinical Adverse Event’ reports published • Integrated risk assessment process in place • Clinicians engaged and working on a 4 part Terema (risk) programme - 30% consultants completed thus far • Clear evidence from staff that robust system in place to undertake risk assessment e.g. EAU undertook risk assessments in violence and aggression, patient handling, resulting in the installation of new doors, training, security and manual handling aids. • But some Departments are more successful than others in achieving support for the implementation of actions flowing from risk assessments – all bids are prioritised with the highest risk being addressed first • Excellent performance management framework in place

15. Clinical audit • Has the trust developed and implemented a clinical audit strategy with evidence of partner involvement and changes to practice?

16. Audit Strategy agreed and in the early stages of being introduced – a clear vision of multidisciplinary audit • Multi-disciplinary audits – e.g in A&E, Surgery, some departments more progressive than others in multidisciplinary audit • Guidelines issued to staff are all evidence-based e.g. as a result of a clinical audit, cardiac arrests reduced by 50% in Cardiology • Evidence of peer review with other Trusts and speciality groups such as cardiac and renal • 80% standard for Consultants to attend weekly multidisciplinary audit meeting

17. Staffing and staff management • How has the trust developed staff performance monitoring • Has the trust developed a strategy for maintaining accreditation for placements for medical, nursing and midwifery and allied health professionals and what has the impact been?

18. PDP and appraisal in place with strong links to corporate objectives • Well developed corporate induction programme • Some Support Workers encouraged to undertake NVQ levels 2 and 3 and have now been accepted onto nurse training • Ancillary staff seen to be active members of departmental/ward team • Good recruitment processes • Medical appraisal is variable with 360 degree appraisal for SHOs • Appraisal upto 100% in some areas • Trust is making good progress on junior doctors hours • Accreditation of placements – process varies to suit the needs of the profession involved • A significant increase in workforce numbers in clinical areas with an additional 26 wte qualified nurses and 53 wte medical, scientific and technical posts

19. Clinical effectiveness • Has the trust developed systems to ensure that clinical practice is evidence based and adheres to national guidance?

20. Trust is one of the dozen or so members of Pathfinder – a national collaboration aimed at producing evidence based clinical guidelines. • Guidelines written locally but are evidence based taking account of changes in guidance from NICE, royal Colleges etc. • All areas visited demonstrated change in practice. • About half of areas visited able to demonstrate changes in practice resulting from clinical audits undertaken • Trust was commended on the introduction of new guidelines on the use of Intrathecal Chemotherapy

21. Using information • How has the use of clinical information been developed to analyse and understand its significance and use in improving clinical services? • How effectively does the trust work with partner organisations and staff within the trust to ensure that clinical information is used to understand and develop services

22. Limited Intranet site in place at the time of the CHI review. Pathfinder introduced since then and contains clinical results reporting system (pharmacy, radiology and pathology), clinical guidelines, clinical training software, clinical letters • Staff are using the intranet – there are 2,500 ‘hits’ per month on the clinical guidelines module and 6,000 on CRRS • All staff have access (password protected) to in excess of 1,000 computers • Business plans demonstrate clearly that clinical information, and waiting times are regularly used • Plans in place to give email accounts to all staff • Clinicians keen that Intranet is further developed to order tests over the Intranet and to develop closer integration with primary care • While this was the exception, staff on one ward were not clear as to why information was being gathered

23. Strategic Capacity • How has the Trust worked with partner organisations in addressing issues of capacity and how has this impacted and improved patient care • Has the Trust board facilitated the development of an open, fair and just culture where all staff can confidently raise concerns and senior medical staff are engaged with management colleagues in the corporate agenda? What evidence does the Trust have to support development?

24. 5’s in 4’s – in excess of 20 intermediate care beds opened following reduction of 5 to 4 beds in bays • PFI – Cov and Warwicks chief executives now meeting to develop services strategy in preparation for opening of PFI in 2006/07 • Board is part of the Emergency Services Collaborative which includes PCT, Social Services & Ambulance • Consultant reported that since the new structures introduced ‘managers are now managing, not administering’ • 7 doctors and 7 managers manage the Trust • Executives take part in ‘Back to the Floor’ initiatives • Chief Executive briefings were clearly valued by staff

25. Outcome SHA provided a report based on the visit to CHI CHI subsequently advised that “the CHI clinical governance review should not prevent the Trust from achieving 3 stars”.