NHS Lanarkshire Response

Mid Staffordshire and Future Approach to Governance

  1. NHS Lanarkshire’s consideration of Mid Staffordshire Inquiry Report and review of local Governance Arrangements

The letter dated 20 August 2010 from Dr K. Woods requested notification of the outcome of discussions on the findings and lessons to emerge from the Francis Inquiry and previous reports in relation to events at Mid Staffordshire NHS Foundation Trust. The letter also requested consideration of the Scottish Government paper “Future Approach to Governance” in the context of current governance discussions within health boards.

In NHS Lanarkshire there has been extensive consideration of the Francis Inquiry and the previous reports, the strengthening of governance arrangements as well as how this learning influences NHS Lanarkshire’s response to the Healthcare Quality Strategy for NHS Scotland.

In summary the main actions completed and underway are:

  • Development of monthly Clinical Governance Board report from April 2009 and from September 2010 the introduction of a monthly Quality Dashboard
  • Mid Staffordshire Action plan in 2009 informing “Strengthening Quality in Lanarkshire” clinical governance work programme for 2009/10
  • Strengthening of governance committees with review of terms of reference, work programmes, annual reports and annual review of effectiveness
  • Risk assessment against the care governance recommendations of the Mid Staffordshire Inquiry
  • Staff involvement in a skill mix review to ensure appropriate skills
  • Active management of corporate risk registers including clinical governance risk register
  • Strengtheninvolvement in Scottish Patient Safety Programme Walk rounds with Executive and Non Executive involvement
  • Strengthen systems of compliance assurance in relation to legislation and alerts
  • Improved system of policy control
  • Improved escalation routes for clinical governance issues
  • Action plan in relation to QIS Clinical Governance and Risk ManagementStandards
  • Assessment of Board governance arrangements against good governance guide for public services
  • Introduction of Healthcare Quality Improvement Portal at a ward level to support continuous quality improvement and provide information for Board assurance
  • Informing the “Strengthening Quality in Lanarkshire” clinical governance work programme for 2010/11with the inclusion of: improving “closing the loop” of lessons learnt from critical incident reviews, complaints and external reviews; improved reporting arrangements for quality assurance and continued strengthening of clinical governance structures and processes
  • Internal audit report on corporate governance arrangement
  • Board Members assessment against the National Board Effectiveness Initiative being used to inform the development of a Board Development Action Plan
  • Board Seminars on Mid Staffordshire, Quality and Board Governance

Appendix 1 outlines in more detail the mechanisms through which this consideration has taken place,actions developed and their impact. This work culminated in Board Seminars on 23 June 2010 on Mid Staffordshire and Quality and on 20 September 2010 on Board Governance. This response was agreed by the Lanarkshire NHS Board at its meeting on 30 September 2010.

As requested an organogram of current governance structure is attached (Appendix 2).

  1. Future Approach to Governance

The Board reviewed the “Future Approach to Governance – Discussion Paper” at a Board Seminar on 20 September 2010 at which members of the Patient Partnership Forums and the Chief Internal Auditor were in attendance. Comments are provided against the main themes of the paper:

  • Future Approach
  • Use of data and audit
  • Board preparation for future arrangements

2.1Future Approach (building on existing governance arrangements)

Proposal

  • Focuses to a greater extent on outcome, and is risk based and proportionate
  • Recognises baseline assurance does not provide sufficient incentive to improve services
  • Has strong leadership, professional values, well developed governance arrangements, supports transparency and accountability
  • Is more focused on quality improvement with capacity to respond robustly and promptly to indicators of poor performance
  • Ensures a clear connection between strategic to operational levels
  • Builds on NHS Scotland Framework for Developing Board, Board Diagnostic Tool

NHS Lanarkshire view

Agree with this as an approach to Clinical Governance however it was noted that much of the emphasis in the paper is on quality assurance provided through improved “real time”, outcome based data, however this alone will not mitigate against the occurrencesidentified in Mid Staffordshire. Rather, data needs to be complemented by Executives, Non Executives, senior managers, clinicians and supervisory staff “walking the patch” and interacting with staff and patients as well as supporting a culture that values openness, encouraging staff and patients to provide feedback and raise concerns. NHS Lanarkshire has a robust policy on “Voicing Concerns” or whistle blowing however this is still challenging for individuals to enact. The Board reflectedthat the values set out in the Healthcare Quality Strategy for NHS Scotland although rightly focussed on aspects which are important to patients and the public maybe does not emphasis sufficiently the importance of ensuring a culture of openness for staff.

The paper focuses on Clinical Governance which is understandable with its background of the events in Mid Staffordshire NHS Foundation Trust and the Healthcare Quality Strategy for NHS Scotland. However, the paper also moves into wider questions of Corporate Governance, without necessarily providing a cohesive, comprehensive model of assurance and governance. There are a number of references to wider Corporate Governance issues which do not appear fully to reflect existing Corporate Governance guidance or linkages to other governance strands, as well as some areas where the distinction between Corporate and Clinical Governance does not appear to have been drawn.

In relation to Clinical Governance, whilst there have been a number of recent developments including the introduction of the Healthcare Quality Strategy for NHS Scotland; the guidance relating to the role, remits and purpose of Clinical Governance Committees and indeed the fundamental purpose of Clinical Governance, has not been substantially amended since 1998. Any revision could also usefully set out the relationship between Clinical Governance and ‘Care Governance’ as defined in Box A.

The measures outlined in paragraph 14and 16 indicate an enhanced role for the Scottish Government in the investigation and resolution of data outliers. It is presumed that this will be based predominately around the Quality Scorecard however; it may be helpful for Boards to receive a fuller understanding of the criteria and rules of engagement for government intervention in Board’s safety and quality systems as soon as possible.

As noted above, the paper frequently refers to wider Corporate Governance arrangements. For example, in para 2three main strands of governance are identified. However, the SIC guidance issued by the Scottish Government covers overall good governance and four specific strands ofgovernance

  • Clinical Governance
  • Staff Governance
  • Financial Governance
  • Information Governance

Information Governance is absolutely integral to Boards’ ability to deliver fast, accurate data as required by these proposals (see Para 9) and a number of recent incidents have highlighted the importance of rigorous information governance.

A learning point from Mid Staffordshire is that their balance around Corporate Governance was skewed with an emphasis on financial governance and achieving Foundation status at the detriment of Clinical Governance (patient care, mortality) and Staff Governance (staff anxious, overworked, lacked skills). Given the extremely challenging economic climate should the paper outline the need to ensure that the strands of Corporate Governance are kept in balance in order to maintainsafe, quality care.

In para 3,there is an implication that current governance systems are neither risk-based nor proportionate. Risk management is an integral element of Corporate Governance and all NHS Boards have been specifically assessed by QIS on their arrangements in relation to risk management.

The last guidance on overall Corporate Governance was MEL(1994)80 which obviously precedes a number of important corporate governance developments including the adoption of Clinical, Staff and Information Governance for NHSScotland as well as significant advances in Corporate Governance approaches in the private and public sectors. The paper as well as Annex B, seems to imply the Healthcare Quality Strategy for NHS Scotland, rather than a holistic and comprehensive model of governance and assurance, is the key driver of overall Corporate Governance. Annex B in particular demonstrates a focus on clinical assurance to the exclusion of assurance on all other governance strands.

As noted above, Care Governance should be incorporated into any revised Clinical Governance guidance to avoid duplication andensure consistency. The Care Governance framework is agreed and is viewed as integral to operational care but it is not clear if there will be a central driven initiative around this and how it will be integrated into existing initiatives such as Leading Better Care, SPSP and Better Together. The resources driving and facilitating these initiatives locally are time limited and will become under increasing pressure with CRES, while operational staff will have limited capacity to respond to “new” initiatives.

2.2Use of Data and Audit

Proposal

  • Greater focus on monitoring quality data which is better and real time with built in tolerances
  • Uses the increasingly robust data on quality (Scottish Patient Safety Programme, HAI, HSMR), Surgical profiles
  • Aims to ensure that systems of monitoring patient care and outcomes are streamlined and managed locally and that all those involved from frontline service to the NHS Board are fully aware of their individual and collective accountability
  • Shift in emphasis from funding and support for national audit activity towards use of relevant and real time local information to support governance and quality improvement

NHS Lanarkshire view

It is agreed that data has been increasingly detailed and responsive and key in driving quality improvements, for example around Scottish Patient Safety Programme and HAI, however much of the data is locally collected and although this is completed as efficiently as possible it is dependent on front line staff collating measures and data entering withthe support of clinical effectiveness (clinical quality in NHS Lanarkshire). In an increasingly challenging financial environment frontline staff will be focused on direct patient care and support services such as clinical effectivenessmay be depleted, thus much of this data could dissipate.

We recognise the value of moving to less but better data with a clear connection between strategic and operational levels and in NHS Lanarkshire a strategic Clinical Quality Board report has been developed with a Healthcare Quality Improvement Portal at a ward level. However this assurance infrastructure has been developed over an extensive timeframe and is limited by available resource and expertise.

The paper makes a number of references to assurance and audit processes. However, it is not clear whether these merely refer to assurance on clinical activity and clinical audit; or whether a more comprehensive review is proposed. If the latter, then it would be appropriate to ensure that the audit community, particularly Audit Scotland, have been consulted and the Crerar principles applied. The final bullet point could be taken to imply that a clear governance and accountability framework is not already in place in NHS Boards. If so, this would appear to contradict the Statements on Internal Control provided by NHS Boards across NHS Scotland which were supported by a series of internal and external assurances.

We welcome the proposal for national clinical audit to move from more traditional audit approaches to the use of relevant and “real time” local information to support governance and quality improvement. However, there is little indication to date of a reduction in requirement for national and regional audits within a planned timescale and, even as resourcesare released, the expertise required for “real time” monitoring can differ. At the same time demand for clinical quality / effectiveness is growing with the expansion of the Scottish Patient Safety Programme into new areas and the anticipated reduction in short-term nationally funded staff tied tonew initiatives which require on going support (e.g. HAI surveillance reporting and MCN clinical governance).

Para 12outlines a need for systems for monitoring patient care and outcome to be streamlined and managed locally. Clarity is sought on this on how this fits with the wide range of monitoring information on activity and outcomes which is already required nationally. The Quality Measures Framework proposes a reduction in measures however the draft Quality Outcome Measures introduces new measures such as Patient Reported Outcome Measures (PROMs). While, in itself, PROMs would be a valuable addition it is not clear what will no longer be required. Similarly, the Patient Experience Surveys completed under Better Together although extremely valuable are not “real time” and cannot be used as a feedback mechanism to ongoing quality improvement such as PDSAs hence local data is required which involves resources in time and staff.

2.3Board preparation for future arrangements

Proposal

  • Boards to reflect and review their current governance structures and intelligence to consider where there is scope to strengthen assurance about quality of care and how to minimise the risks of serious incidents
  • Consider the role of the Board and its principle reporting committees together with an explicit examination of the connections between strategic and operational levels
  • Board and staff at all levels become focussed on the monitoring and use for performance, quality and safety data to identify any issues that need to be addressed
  • Board have robust arrangements to identify quality and performance issues and take follow up action in an organised and systematic way
  • Commitment to promoting self regulation for delivery of outcomes (through clinical governance, staff governance and corporate governance frameworks)
  • Clear governance and accountability framework, with clear and defined roles and responsibilities

NHS Lanarkshire view

NHS Lanarkshire has undertaken work to strengthen the roles and functioning of governance structures including the Board and main Committees of the Board and this is ongoing. Greater use of data is made at the Board and throughout the clinical governance structures however the provision of local quality and safety data is based on front line staff undertaking non direct patient care and “back office” functions both of which are vulnerable in the current financial climate.

Since 2009 the Board has received a monthly Board report on Clinical Governance and this is balanced with Financial, Staff Governance and Performance Management reports. This Clinical Governance report has recently been supplemented by a Quality Dashboard (Appendix 3). Information on Scottish Patient Safety Programme and HAI is widely circulated and considered at all levels in the Board including ward displays which are discussed with Executives and Non Executives as part of the Scottish Patient Safety Programme Leadership Walk rounds. Expanding this to other quality data is planned such as patient experience and Clinical Quality Indicators.

The particular focus on data and analysis throughout the paper, although important to the success of the Board, could be seen to overshadow other fundamental Board functions such as leadership, strategy, prioritisation and stewardship. Hence, there is a risk that the Board could focus on how well it is undertaking healthcare activities to the exclusion of fundamental discussions of how best to improve the health of all of the population it is responsible for.

A move to use of greater self regulation for delivery of outcomes is welcomed and a recent example of where this has been effective is the HMIe inspection in South Lanarkshire.

Response ratified by Lanarkshire NHS Board: 29 September 2010

Appendix 1

NHS Lanarkshire consideration of Francis Inquiry and previous reports, strengthening of governance arrangements and Healthcare Quality Strategy

Activity / Date / Consideration and Actions / Impact
NHS Lanarkshire “Strengthening Quality Strategy” / March 2009 / Board ratified NHS Lanarkshire “Strengthening Quality Strategy” on clinical governance which strengthened and clarified clinical governance arrangements and set a medium term aim to develop a scorecard / clinical dashboard monitoring tool to give an overview of performance information on quality of care at a ward, team, department and service level as well as at a corporate level. / Governance, Quality Strategy:
Strengthened clinical governance arrangements, leadership framework, assurance and measurement.
Board Paper on “Systems to Ensure Quality Assurance” / 29 April 09 / Board paper advising the Board of the development of systems to ensure quality assurance including a monthly Board report on quality assurance commencing April 2009.
Board considered and agreed the draft response to the letter from Dr Kevin Woods on systems to ensure quality assurance. / Governance and Mid Staffordshire:
Agreed plans to improve quality assurance reporting to Board.
Mid Staffordshire Action Plan / July 2009 / Development of a Mid Staffordshire Action Plan in response to the Healthcare Commission Investigation report in March 2009. Led to actions including:
  • Preparation for considering the national “early warning information for deteriorating quality outcomes”
  • Assurance through active management of the clinical governance risk register
  • Commencement of an annual review process of clinical governance structures and lines of responsibility
  • Strengthening of clinical governance arrangements for emergency care
  • Improved escalation and cascade system for clinical governance, continued encouragement for recording and learning from near miss and incident data and expansion of the Scottish Patient Safety Programme walk rounds
  • Improved learning from feedback on patient experience by reviewing complaints trends, utilising local debriefing for complaints and implementation of Better Together surveys
These actions were absorbed into the “Strengthening Quality in Lanarkshire” clinical governance work programme for 2009/10. / Governance and Mid Staffordshire:
Improved assurance in terms of reporting and annual review of clinical and other governance structures, improved escalation and development of ward dashboards for quality