NHS Quality Improvement Scotland
Future Approach to Governance
Response to SGHD Discussion Paper issued for comment on 20 August 2010
Summary
The Director-General Health and Chief Executive NHSScotland asked NHS Boards to consider the Francis Report and also to consider and comment on a paper prepared by SGHD on the Future Approach to Governance. In particular he asked that Boards considered the potential implications of the proposed approach.
NHS Quality Improvement Scotland (NHS QIS) has considered the Francis Report and the paper on governance and we have identified considerable synergy between these papers and with the Quality Strategy. This paper sets out our response and identifies key action areas for NHS QIS to take forward.
1.Response to the Francis Report on Mid Staffordshire
NHS Quality Improvement Scotland (NHS QIS) has spent some time reviewing and considering the findings and lessons emerging from the Francis Inquiry and previous reports in relation to events at Mid Staffordshire NHS Foundation Trust. A paper on the implications of these reports for NHS QIS was presented to our Board on 26 August and in summary it was noted that while not all the recommendations apply (as we are not a territorial Board) there are a number that are directly relevant. We identified four main actions:
- Developing our Improvement Hub, together with the other Special Health Boards, to support NHS boards in developing cohesive and linked up programmes of improvement, particularly in relation to the delivery of up-to-date and high class standards of care
- Learning from and using the findings from the national audits, surgical profiles and confidential inquiries to reduce variation in care and drive continuous improvement
- Developing our scrutiny model to provide assurance across all levels of care from ‘board to ward’ while taking a risk based and proportionate approach that recognises that primary accountability for the quality of care rests with NHS boards
- Working with Scottish Government to refresh and further strengthen governance arrangements as part of action three, the development of our new scrutiny model.
The full Board paper is attached for reference at Appendix 1.
2.Response to Future Approach to Governance
As part of the establishment of Healthcare Improvement Scotland (HIS), NHS QIS has commissioned a piece of work with two objectives: to review the
- model we have traditionally used for scrutiny of clinical governance and risk management (CGRM) arrangements and for clinical care; and
- clinical governance and risk management support we provide to boards
This work was carried out working closely with a range of organisations including SGHD and other scrutiny bodies.
As a result we developed a revised scrutiny framework which was approved by the Board on 26 August 2010. Essentially we will continue to provide evidence based guidance and this will be as rich and informative as possible. What we will do differently in future is to be more focussed on key priorities and what is measured and how this drives improvement. The review of the clinical governance standards has allowed us to strengthen the focus on the elements we are responsible for leading on and we concluded our focus is on safe and effective patient care with the Scottish Health Council leading on person-centred care through the introduction of the Participation Standards. The other domains in the current CGRM standards are covered through other governance structures such as staff and information governance and reflect our efforts to bring these elements together in a cohesive way. The challenge we face in bringing these elements together may well be addressed by introducing the Quality Scorecard which is effectively a dashboard of combined indicators. We now have three criteria (compared to the previous 22) that will be used to provide a focus on safe and effective care and these will ‘book end’ 2-3 key clinical indicators which have an underpinning data infrastructure. For example, for stroke we would have five potential indicators to make up a ‘bundle’ that covers ‘board to ward’:
- patient safety and risk management indicator
- clinical indicator 1 (MRI within 24 hours)
- clinical indicator 2 (aspirin after stroke)
- clinical indicator 3 (swallow test within 24 hours)
- Assurance and accountability indicator
We will also introduce a new measurement tool with two dimensions, one on performance and one on capacity to improve. This combined approach will allow us to put in place more targeted support and to escalate concerns as necessary. This approach to scrutiny reflects the integrated cycle of improvement we now have in place.
3.Conclusion
We welcome this paper as successful implementation of the Quality Strategy depends on strong professional and executive leadership and on clear accountability. In our response we have focussed on clinical governance and risk management as the element where we can directly support boards and provide assurance although we believe it is essential the key elements of governance are brought together as collectively the intelligence they yield is powerful. Traditionally governance committees have considered specific governance strands and it may be that we need to consider joint governance fora.
We note the need for robust data that is collected once and used many times and we strongly support this approach. However there is still some way to go to achieve this in many areas and we need to make sure staff are confident about data collection, analysis, reporting and improving as a result at every level. We would also suggest we need to reduce the current levels of data collection and concentrate on priority topics where the data shows there is considerable variation in practice and there is evidence to show we can improve the quality of patient care.
As you can see we will make bold changes in support of delivering safe and effective person-centred care and we will make these in partnership with NHS boards and other public sector bodies to maximise our impact.
Appendix 1
NHS QUALITY IMPROVEMENT SCOTLAND
BOARD MEETING
MEETING DATE: 26 August 2010
DIRECTOR:Chief Executive
SUBJECT:The Francis Report on Mid Staffordshire NHS Foundation Trust
PURPOSE:Discussion and Approval
______
- Background
This paper describes the key findings of the Francis Inquiry into the care failings at the Mid Staffordshire NHS Foundation Trust and their implications for NHS Quality Improvement Scotland (QIS) as the national scrutiny and improvement organisation for the NHS in Scotland.
It should be read in conjunction with the paper on Governance (Agenda Item 16)
- Response Required
The Board is asked to consider and note the findings and how NHS QIS will ensure these are built into our processes and procedures for performance assessment of healthcare services in future.
- Anticipated further action and timescale
The new healthcare scrutiny model will consider the relevant recommendations and ensure that we can demonstrate from our assessments on healthcare providers that they are able to evidence good governance from point of care to their boards.
- What, if any, are the governance implications for the organisation?
This paper demonstrates that we have reflected on the findings of the Francis Report and have taken the key recommendations for good governance and built them into our healthcare scrutiny model for the future.
GOOD GOVERNANCE – a consideration of the Francis Report.
BOARD MEETING
26 August 2010
1 / THE CONTEXT.1 / “The experience of listening to so many accounts of bad care, denial of dignity and unnecessary suffering made an impact of an entirely different order to that made by reviewing written accounts.”
(Para 17, Page 14)
“The omissions described left patients struggling to care for themselves; this led to injury and a loss of dignity, often in the final days of their lives. The impact of this on them and their families is almost unimaginable. Taken individually, many of the accounts I received indicated a standard of care which was totally unacceptable. Together, they demonstrate a systematic failure of the provision of good care.” (Para 21, Page 15)
“I went home in tears; I had seen enough. The confused man in the next bay was once again being shouted at and told to stay in bed. I was exhausted, since my mother’s fall she had not slept one night.”
(A Daughter’s Account:Page 49)
Robert Francis QC
2 / BACKGROUND
2.1 / This paper provides an overview of the recommendations of the Francis Report into the care failings in the Mid Staffordshire NHS Foundation Trust and the implications for NHS Quality Improvement Scotland (QIS) in terms of our future performance assessment of healthcare providers.
2.2 / The Francis Inquiry into the care provided at Mid Staffordshire NHS Foundation Trust between 2005 and 2008 had the following terms of reference:
• to investigate any individual case relating to the care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2008 that, in its opinion, causes concern and to the extent that it considers appropriate;
• in the light of such investigation, to consider whether any additional lessons are to be learned beyond those identified by the inquiries conducted by the Healthcare Commission, Professor Alberti and Dr Colin-Thomé; and, if so,
• to consider what additional action is necessary for the new hospital management to ensure the Trust is delivering a sustainably good service to its local population; and
to prepare and deliver to the Secretary of State a report of its findings
To support all NHS organisations to learn from and respond to the recommendations of the report, three reports have been published in England that help embed effective governance and detect and prevent such serious failures occurring again. These reports are:
Review of Early Warning Systems in the NHS (DoH, Feb 2010
This describes the systems and processes, and values and behaviours which make up a system for the early detection and prevention of serious failures in the NHS. It emphasises that everyone has a role to play – from doctors and nurses, to commissioners in PCTs, system managers in SHAs and DH, and the regulators – in safeguarding quality of care to patients
Assuring the quality of senior NHS managers (PriceWaterhouseCooper 2010)
This report of a working group sets out recommendations to further raise the standards of senior NHS managers. The report recognises that while the overwhelming majority of NHS managers meet high professional standards everyday, a very small number sometimes demonstrate performance or conduct that lets down the patients they serve as well as their staff and organisations. The group's recommendations include replacing the Code of Conduct for NHS managers with a new statement of professional ethics and consultation on a system of professional accreditation for senior NHS managers.
The Healthy NHS Board
This document sets out the guiding principles that will allow NHS board members to understand the collective role of the board, governance within the wider NHS, approaches that are most likely to improve board effectiveness, and the contribution expected of individual board members.
3 / THE KEY FINDINGS
3.1 / The Report highlighted the following key themes identified during the course of the Inquiry:
• a corporate focus on process at the expense of outcomes;
• a failure to listen to those who had received care through proper consideration of their complaints;
• staff disengaged from the process of management;
• insufficient attention to the maintenance of professional standards;
• lack of support for staff through appraisal, supervision and professional development;
• a weak professional voice in management decisions;
• a failure to meet the challenge of the care of the elderly through provision of an adequate professional resource. Some of the treatment of elderly patients could properly be characterised as abuse of vulnerable persons;
• a lack of external and internal transparency;
• false reassurance taken from external assessments; and
a disregard of the significance of the mortality statistics.
3.2 / There are a number of the recommendations that are directly relevant to NHS QIS for our future work, particularly but not exclusively, our new model of performance assessment. These are set out with an indication of how we will ensure they are built into our work programme.
3.3 / Recommendation 3: The Trust, together with the Primary Care Trust, should promote the development of links with other NHS trusts and foundation trusts to enhance its ability to deliver up-to-date and high-class standards of service provision and professional leadership.
We act as a knowledge broker to identify and synthesise evidence into guidance and standards or indicators and provide this evidence in a form that is easily accessible and assimilated by frontline clinicians. We hold a number of national events to disseminate our advice and guidance and work with Managed Clinical Networks to ensure guidance is implemented in practice. The Hub will promote collaborative work on executing quality improvement activity.
We also facilitate national professional improvement networks to promote learning and sharing from experience.
3.4 / Recommendation 5: The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis.
We support a range of national audits, surgical profiles and medical profiles. We will build into our new model of scrutiny testing of healthcare providers own audit and review arrangements. We work with boards to learn from their local audit programmes and use the intelligence gathered to inform our work.
3.5 / Recommendation 9: In the light of the findings of this report, the Secretary of State and Monitor should review the arrangements for the training, appointment, support and accountability of executive and non-executive directors of NHS trusts and NHS foundation trusts, with a view to creating and enforcing uniform professional standards for such posts by means of standards formulated and overseen by an independent body given powers of disciplinary sanction.
NHS QIS will have a key role in delivering against this recommendation with our “Boards on Board” work with IHI. We will also feed lessons learned into our network with the Chairs of Clinical Governance Committees and we are commencing work to support Area Clinical Fora.
3.6 / Recommendation 15: In view of the uncertainties surrounding the use of comparative mortality statistics in assessing hospital performance and the understanding of the term ‘excess’ deaths, an independent working group should be set up by the Department of Health to examine and report on the methodologies in use. It should make recommendations as to how such mortality statistics should be collected, analysed and published, both to promote public confidence and understanding of the process, and to assist hospitals to use such statistics as a prompt to examine particular areas of patient care.
We already work with boards to ensure that lessons that can be learned from profiles and other data are considered in local systems and we ask boards to provide evidence of action taken to improve care as a result. We have a key role working with Information Services Division (ISD) and NHS Education for Scotland (NES) through the Hub to deliver education and training on the use of data for improvement. We will be supporting the introduction of the quality scorecard by working with communities of interest in boards to understand what they say about the quality of care in that area. These data will also be used as part of the self evaluation element of the new healthcare scrutiny model.
3.7 / Recommendation 16: The Department of Health should consider instigating an independent examination of the operation of commissioning, supervisory and regulatory bodies in relation to their monitoring role at Stafford hospital with the objective of learning lessons about how failing hospitals are identified.
We will review the output from the Department of Health proposals for scrutiny bodies in England to ensure we build any relevant recommendations into our work.
3.8 / Recommendation 18: All NHS trusts and foundation trusts responsible for the provisions of hospital services should review their standards, governance and performance in the light of this report.
As a result of Scottish Government Health Directorates (SGHD) updating of their governance guidance for health boards we will be working with SGHD and health boards to review governance arrangements as the next stage of developing our new healthcare scrutiny model.
3.9 / Recommendations 4, 7, 8 and 10 relate to staff governance arrangements and are not directly relevant to us.
In addition to the recommendations above, it is clear that the report was heavily influenced by the testimony and accounts from patients, relatives and carers. Further development of patient experience of care through the Better Together Programme will enhance the mechanisms for early warning and reporting.
4 / GOOD GOVERNANCE
4.1 / The diagram below illustrates boards’ existing governance responsibilities - clinical, staff and financial – but adds the above principle of demonstrating that patient experience is at the heart of what clinicians and managers do as professionals and leaders in their organisations to deliver personalised, reliable and quality assured care.
4.2 / This work will also feed into the revised governance framework that SGHD will be launching shortly and this will guide the development of our new performance assessment model.
5 / CONCLUSION
5.1 / This paper demonstrates how we will incorporate the key findings in the Francis Report on the failings in care at the Mid Staffordshire NHS Foundation Trust of direct relevance to us as the national improvement body for healthcare in Scotland.
RECOMMENDATIONS
6.1 / The Board is asked to:
(i) consider and discuss the paper;
(ii) approve the proposals for how NHS QIS will take forward relevant recommendations from the Francis Report to support good governance in healthcare organisations.
Dr Frances M Elliot