Report for Medway NHS Foundation Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
June 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
8
4.
Review Findings
9
5.
Conclusions and support required
Appendices
297
30
Appendix I:
SHMI and HSMR Definitions
31
Appendix II:
Interviews Held
33
Appendix III:
Observations Undertaken
34
Appendix IV: Focus Groups Held
35
Appendix V:
Information Review
36
Appendix VI:
Unannounced visit agenda
45
Appendix VII: Theme and evidence base
46
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1. Introduction
This section of the report provides background to the review process and details of the key stages of the review.
Overview of review process
On 6 February 2013 the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
(HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1)
Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals, and this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, received
through the Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:
3


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
ii.
iii.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these Trusts to help them improve.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/data-pack-medway.pdf.

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involved
walking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains the findings from this stage of the review.

Stage 3 – Risk summit.
This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each Risk summit has been made publically available.
Methods of Investigation
The two day announced RRR visit took place at the Trust’s main site on Thursday 9th and Friday 10th May 2013. A variety of methods were used to investigate the Key
Lines of Enquiry (KLoEs) to enable the panel to analyse evidence from multiple sources and follow up any trends present in the Trust’s data.
The visit included the following methods of investigation:

Interviews
Fifteen interviews took place with key members of the executive team, non executive directors and selective members of staff based on the key lines of enquiry during the
visits. See Appendix II for details of the interviews undertaken.
4

Observations
Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where
observations took placed during visiting hours. They allowed the panel to speak with a range of staff and enabled the panel to analyse any observed handover processes
within wards, to ensure that the staff that are coming on duty are appropriately briefed on patients.
During the RRR announced visit, observations took place in 16 areas of the Medway Maritime Hospital. See Appendix III for details of the observations undertaken.

Focus Groups
Focus groups provide an opportunity to talk to staff groups individually, and to ask each area of staff what they feel is the contributing factor to the Trust’s high mortality
scores. They enable staff to speak up if they feel there is a barrier that is preventing them from providing quality care to patients.
Focus groups with nine staff groups, including a focus group open to all staff, were held during the announced site visit. See Appendix IV for details of the focus groups held.
The panel would like to thank all those who attended the focus groups and were open and balanced with the sharing of their experiences and their perceptions of the quality
of care and treatment at the Trust.

Listening events
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
th
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improving at the Trust. A listening event for the public and patients was held on the evening of 9 May 2013 at the Brook Theatre, Chatham and on the evening of 15 May
2013 in Liberty Hall, Isle of Sheppey. This was an open event, publicised locally, and attended by 85 members of the public and patients.
The panel would like to thank all those who attended the listening event and were open with sharing their experiences and balanced in their perceptions of the quality of care
and treatment at the Trust.

Review of documentation
A number of documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the site visit. Whilst the documents
were not reviewed in detail, they were available to the panellists to influence/verify findings as considered appropriate by the panellists. See Appendix V for details of the
documents available to the panel.

Unannounced visit
th
The unannounced site visit took place on the evening of Friday 17 May 2013. This focused on observations in identified areas from the announced site visit, see Appendix
VI.
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Next steps
This report has been produced by Liz Redfern, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check.
This report was issued to attendees at the risk summit, which focussed on supporting Medway NHS Foundation Trust (“the Trust”) in addressing the actions identified to
improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published.
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2. Background to the Trust
Context
The Trust is the largest single sited hospital in Kent, with 542 beds, 3670 WTE (whole time equivalent) staff and a £243m budget and has been selected for this review as a
result of its HSMR results for 2011 and 2012. In both years, the HSMR is statistically above the expected level.
Medway has a population of 400,000 with 10% of it belonging to non-White ethnic minorities. Obesity and smoking in pregnancy are significantly more common than in the
rest of England. Aspects of Medway’s health profile which relate to adults’ health and lifestyle are below the national average, with indicators relating to diabetes, obesity,
smoking and physical activity. It is, relative to the rest of England, a medium sized Trust for both inpatient and outpatient. The Trust has a higher level of outpatient activity
than inpatient activity. It has 59% market share of inpatient activity within a 5 mile radius of the Trust. As the radius increases, the market share falls to 39% within 10 miles
and 13% within 20 miles.
The Trust became a Foundation Trust in 2008, and provides a range of specialist services, including a cardiac catheter suite, vascular centre, cancer centre for Urology, a
stroke unit and the Macmillan Cancer Care Unit. Its commissioners for local services are Medway CCG, Swale CCG and for specialist services Kent and Medway Area Team.
Key messages from the Trust data pack
The Trust data pack identified a number of key areas of concern that were used to inform the Key Lines of Enquiry, these are outlined below:
Mortality
The Trust has an overall SHMI of 109 for the last 12 months, meaning that the number of actual deaths is higher than the expected level. Specialty-level analysis of SHMI
results highlight some key diagnostic groups within General Medicine which could potentially be reviewed: urinary tract infections, cancer of bronchus; lung, septicaemia.
Similarly, the Trust has an overall HSMR of 113, which is statistically above the expected range. Specialty-level analysis of HSMR results indicate that the following areas
should be considered: septicaemia, acute cerebrovascular disease, other perinatal conditions, acute myocardial infarction and intestinal obstruction without hernia.
The key lines of enquiry for the RRR targeted the panel’s observations and interviews to review the identified specialities in the Trust with higher mortality indicators.
Patient experience
Three measures of patient experience are rated ‘red”, specifically inpatients, complaints about clinical aspects of care, and patient voice comments. Medway has an inpatient
score lower than the national average. 55% of individual comments from patients and public received through the Keogh Review website as part of the patient voice were
negative, from a sample size of 10.
Data returns to the Health and Social care information centre show that for this Trust, the proportion of complaints relating to clinical treatment was broadly in line with the
average (52% compared to an average of 47%).
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The Ombudsman rates the Trust as B-rated for satisfactory remedies which indicates intermediate risk of non-compliance with their recommendations. The Ombudsman
investigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the
recommendations made at the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each
Trust’s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance.
Key lines of enquiry were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to this
feedback.
Workforce and Safety
Medway has a low prevalence rate of new pressure ulcers, compared to national rates and is steadily falling. The Trust is a net contributor to the Clinical Negligence scheme.
Their contributions to this ‘risk sharing scheme’ exceeded payouts to litigants. Medway’s response rate to the staff survey rate has fallen since 2011 and is below national
average rate for both years. The Trust’s staff engagement is below average when compared with trusts of a similar type. On all organisational questions, Medway is below the
national average.
Key lines of enquiry were included in the review focusing on workforce measures and what staff say about the quality of care and treatment.
Clinical and operational effectiveness
The Trust records a low percentage of diabetes patients receiving a foot risk assessment during their hospital stay, but is performing within normal range on the other two
safety indicators (severe hypoglycaemic episodes and medication errors). The Trust’s crude readmission rate is 11% and the average length of stay is 3.93 days, shorter than
the national average. With 95% of A&E patients seen within 4 hours, Medway are in line with the target level although there has been a dip in performance in recent months.
The referral to treatment (RTT) is 93.2% which is higher than the target level. Key lines of enquiry were included in the review focusing on management of deteriorating
patients and the effectiveness of clinical care processes.
Leadership and Governance
The Trust has been in significant breach of two terms of its authorisation since April 2011 due to failure to exercise its functions effectively, efficiently and economically, and its
governance duty. The Trust board has undergone significant leadership changes in the last year; The Chair was appointed in April 2012, a new Director of Finance started in
September 2012, a new Director of Strategy & Governance started in March 2013 and a new Director of Organisational Development and Communications started in May
2013. An Interim Director of Nursing has been in post since April 2013; a new substantive Director of Nursing has been appointed and will start in June 2013. A new Medical
Director has been appointed and will start in August 2013. A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard key line of
enquiry for the review.
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3. Key Lines of Enquiry
Based on the Trust data pack and background information available, including insights from the Trust’s lead Clinical Commissioning Groups (CCG), Medway CCG, Swale
CCG and review of the patient voice feedback received specific to the Trust prior to the site visit, the KLoEs for the Trust were the following:
Theme
Key Line of Enquiry
Governance and leadership
Can the trust articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all
levels of the organisation describe the key elements of the quality governance processes?
Are the leadership roles and responsibilities clearly defined for the quality processes?
Clinical and operational effectiveness
What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? What
actions is the Trust taking to improve mortality performance, particularly in general medicine and elderly care?
How does the Trust manage deteriorating patients?
What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves during
their time in hospital?
Patient Experience
How does the Trust seek views from patients about their experience? What are the key themes from patients on their
experiences? What action is the Trust taking to address the key themes emerging?
Workforce and Safety
What do staff groups interviewed (including trainee/student groups) say are the main barriers in the Trust to delivering
high quality treatment and care for patients?
How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed
effectively?
Trust specific – Diabetes
What specific contribution is the Trust making to improve the health outcomes of the local population with diabetes?
(This KLoE was covered in clinical and operational effectiveness)
Trust Specific – Quality Care Strategy and
Implementation
How have they refreshed their Quality Care Strategy (April 2012)? (This KLoE was covered in Governance and
Leadership)
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4. Review findings
Introduction
The following section provides a detailed analysis of the Panel’s findings and prioritisation based on the evidence received in the Trust data pack, interviews, observation
visits, staff focus groups and patient listening events. It is evident from the data Panel members have gathered that there are six key areas the Trust should focus on to
improve patient safety and these are summarised in the key messages. The findings and supporting evidence to underpin the key messages is contained in more detail in the
following tables.
Key Messages
1.
Need for greater pace and clarity of focus at Board level for improving the overall safety and experience of patients
The capacity of the Board and Clinical Executive Group has been diminished by changing personnel and the work associated with the possible merger with Darent Valley
Hospital in Dartford and Gravesham NHS Trust. This has led to a lack of clear focus and pace at Board and Executive level for improving the overall safety and experience of
patients. The Trust urgently needs a single visible strategy and action plan based on a recognised patient safety improvement model and underpinned by systematic staff
training and roll out.
Accountability needs to be threaded through the organisation, via the clinical directorates, to embed responsibility for patient safety and experience at every level of the Trust.
In order to achieve the required pace and focus the Trust should drive it through a strong programme delivery structure, with accountability for delivery at Board level.
Responsibility for developing and delivering a coordinated action plan should be the full-time day job of one individual (Programme Director – Patient Safety) with input from
the current Head of Audit and Patient Safety Lead accountable via one of the clinical executives to the CEO. The Programme Director should be supported by an
appropriately staffed project management office.
The Programme Director will require the full support of the Board and Clinical Executive Group to ensure blocks are removed and improvement measures are implemented
consistently in every Directorate and every Ward in the Trust without exception.
2.
Review of staffing and skill mix to ensure safe care and improve the patient experience
The Panel observed that in some areas of the Trust it was clear that staffing levels and skill mix are potentially unsafe. The proposal for additional nursing staff is a good start
but a holistic medical staffing review and recruitment strategy needs immediate attention. Reducing the level of locum usage for consultants indicates a clear starting point for
this work.
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3.
Redesign of unscheduled care and critical care pathways and facilities
Poor A&E admission processes and a lack of early senior review means the Trust is failing to take enough opportunity to prevent admission. The impact of this failure to
properly manage admissions in A&E is felt right across the Trust with frequent use of escalation wards, overstretched staff and a failure to predictably and systematically
manage patients on the correct care pathway, including critical care. The review team recognise the totally unsuitable layout of the A&E department and the constant work
arounds staff are using to try and cope with working in an environment unfit for purpose. This is not a new problem and the lack of Board and Executive capacity and the
diversion of the merger work appears to have delayed a solution being planned for earlier.
4.
Improved senior clinical assessment and timely investigations
Insufficient senior medical assessment of acute medical and surgical admissions and timely investigations and interventions for them means the Trust is not taking enough
early opportunity to prevent deterioration. This is particularly so out of hours and at weekends, but not exclusively. As a result of this and pressure on meeting A&E waiting
times there is also evidence that patients are potentially being admitted unnecessarily.
The Medical and Nursing Director must urgently agree a single model to assess the deteriorating patient and a clear protocol for escalating concerns which is rapidly
implemented on every ward. Junior Doctors must be trained in the system so when they are called by nursing staff they understand how to respond, including asking for
consultant help, and that the single model is part of the induction process for all staff.
5.
Need to galvanise the good work that is already going on in Wards and to adopt and spread good practice
We met a large number of committed and concerned staff who frequently reported that they feel unable to raise patient safety concerns and when they do, little or no action is
taken. The Trust needs to create a culture that welcomes improvement, galvanises the good work that is already going on in some Wards and adopts and rapidly spreads
good practice.
Staff feedback on patient safety must be taken seriously by the Board and Clinical Executive Group. This will require the Executive to engage all staff in suggesting ideas for
improvement, and where good ideas are identified action plans must be developed and implemented to deliver improvements consistently. Staff need to know that they are
not only being listened to but that their concerns are being acted upon. The Big Conversation staff engagement and empowerment methodology adopted by the CEO over
the last year is a good start to this.
6.
Improve public reputation
The review team held two public meetings in Gillingham, Kent and in Minster, Isle of Sheppey, Kent. The public meetings identified a number of common themes about the
way this Trust is viewed by the public that attended and in many cases supported the key themes emerging from interviews, observations and data review. Many of the
patient stories we heard had common threads of inconsistent and inaccurate communication with patients, poor identification and management of deteriorating patients,
inappropriate referrals and medical interventions, delayed discharges and long A & E wait times. Some of the stories were historical in nature, but not all. The Trust needs to
improve the methods and frequency with which it engages with the public and as a starting point extend its staff Big Conversation work to the public.
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The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
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Governance & Leadership
The review into governance and leadership focussed on understanding the Trust’s ability to identify and respond to issues regarding mortality performance through the
following areas:

The quality governance process and the sub-committees and groups through which the Board delivers the patient safety agenda

Who is accountable for patient safety and quality and how do they deliver their responsibilities

How does the Trust embed responsibility for patient safety at every level of the organisation, consistently and without exception
KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all levels describe key
elements of quality governance processes?
Good Practice identified

The Chief Executive recently launched ‘The Big Conversation’ in July 2012 which has received very positive feedback from all staff groups. This was seen as a
significant step towards engaging Trust staff in the improvement journey and closing the gap between the Board and the Ward.

There is evidence of increased clinical engagement in cost improvement programmes which is starting to rebalance the focus between finance and patient safety and
experience.

The Trust has a high level Patient Safety Improvement Plan (April 2013) and has agreed Quality Account Priorities for 2013/14.

The Trust held an away day on Friday 26 April 2013 to progress the patient safety strategy. Attendees included the executive team, clinical directors, heads of nursing
and general managers.

A new patient safety lead has been appointed. The patient safety lead has redesigned the current patient safety committee so it meets on a monthly basis and has
increased the membership and focus on the learning from serious incidents, DATIX and complaints.
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Detailed Findings
Outstanding Concerns based on evidence gathered
Lack of clarity around the governance processes
for assuring the quality of treatment and patient
care is leading to a lack of accountability, pace and
focus





Planned Improvements

There is insufficient attention on this issue at Board 
level, focus has been diverted on the merger and
addressing capability gaps in Board membership as
evidenced through Board agendas and discussion
with Board members.
Interviews with Board members and the Chair of
the Quality Committee indicated that the Board
does not have a comprehensive and clear strategy
for addressing patient safety and quality of care
backed up by action plans.
The Board does not sufficiently hold individuals to
account for implementing existing improvements
into clinical directorates in a consistent and timely
manner leading to a lack of pace and focus as
reported in staff focus groups.
Multiple groups and sub-committees are involved in
the governance process for patient quality and it is
not clear where responsibilities lie between the
Board, Quality Committee, Clinical Executive Group
and Mortality Working Party.
The Trust Board has focused significant attention
on the merger with Darent Valley, as a result there
is no improvement strategy for the Medway site in
terms of clinical services and estate, evidenced
through a meeting with the Finance Director and
The appointment of new Board
members means that the Board has
the relevant expertise and capacity
to take control of patient safety and
quality of care issues.
The appointment of a Programme
Director – Patient Safety will enable
a focused programme of work to be
delivered for the Board.
Recommended Action




The Board (supported by the Programme
Director – Patient Safety) must quickly develop
a single strategy and action plan for
addressing patient safety and quality of care
issues.
Ensure key themes arising from the ‘Big
Conversation’ are communicated to staff and it
is clear what actions are being taken to
respond.
Consider a Board development Programme to
support delivery of improvement plans.
Urgently agree an estate strategy to develop
the Medway site and address the disparity
between demand and capacity, particularly in
unscheduled care. Partnership working with
health and social care providers will be critical
to the success of this.
Priority
(urgent, high,
lower)
Urgent
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Outstanding Concerns based on evidence gathered
Planned Improvements
Recommended Action
Priority
(urgent, high,
lower)
Director of Strategy and Governance.
Staff at all levels cannot articulate the quality
governance process




None identified
Interviews with individual staff members and Focus
Groups indicated that staff could not describe the
quality governance process or the key procedures
to ensure patient safety and quality of care. This
was particularly apparent amongst Junior Doctors.
Lack of clarity over the governance process meant
that staff were unsure how to raise concerns or
spread good practice this was a consistent
message in the nurses and Junior Doctors Focus
Group.
Training on quality is not currently embedded in the
Junior Doctor training program or Ward inductions
for new permanent staff, locums and agency staff.


Clearly document the quality governance
process and roles and responsibilities of key
individuals and groups, including the Medical
Directorate agenda.
Embed quality training in to the Junior Doctor
training program and Ward inductions.
High
(dependent on
completion of the
strategy and
action plan)
KLOE 2: Are the leadership roles and responsibilities clearly defined for the quality processes?
Good Practice identified

The Trust has documented its governance and committee structures following a recent review, this has provided greater clarity on the terms of reference of Board subcommittees and working groups

The Trust has identified a clinician who is keen to lead on patient safety issues and is part of the Clinical Executive Group but they have yet to formalize this
arrangement through an updated job description

The Trust recently appointed a Programme Director – Patient Safety to provide greater focus on this area working closely with the Trust Chief Executive
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Detailed Findings
Outstanding Concerns based on evidence gathered
Planned Improvements
Lack of clarity around the leadership roles and
responsibilities for quality and patient safety





There is a lack of clarity around leadership roles
and responsibilities for quality and patient safety at
all levels of the Trust leading to a lack of focus and
pace for delivering improvement evidenced through
meetings with staff who should have responsibility
for quality and patient safety.
The Panel observed that existing improvement
plans are inconsistently implemented and in some
areas are ignored completely. There is no evidence
that this issue is being tackled as a priority by the
Clinical Executive Group, including the Medical
Director and Nursing Director.
A lack of clarity over the leadership roles and
responsibilities for quality and patient safety means
the issue has been given insufficient attention in
Cost Improvement Programmes.

A PMO office is being developed to
support the Programme Director Patient Safety.
This team will collaborate with the
executive team to support the
increase in pace that this programme
will require.
Three new clinical patient safety
leads have been appointed to
strengthen the clinical leadership
across the Trust.
Recommended Action




The Board should agree a patient safety
improvement methodology.
The Programme Director – Patient Safety
should ensure the action plan is implemented
consistently and quickly in to every Ward with
the full support of the Board and in particular
the Medical Director and Nursing Director.
Individuals should be held to account for
implementation of the plan.
A project management office must be put in
place to support and monitor delivery of the
action plan.
Priority
(urgent, high,
lower)
Urgent
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Clinical and operational effectiveness
The review into clinical and operational effectiveness focused on how the Trust is implementing actions to monitor mortality performance and identify areas where clinical
effectiveness is potentially impacting patient quality and safety, this included the following:

How the Trust reviews deaths to understand if trends can be identified and lessons learned

How clinical effectiveness is monitored

How actions to improve mortality performance are implemented in the Trust
KLOE 3: What processes are in place to support monitoring mortality data and clinical effectiveness? What actions are being taken by the Trust to improve
mortality performance, especially for General Medicine and Elderly Care?
Good Practice identified

Safety thermometer and mortality metrics are reported to the Patient Safety Committee and Quality Committee

The Trust requested an Emergency Care Intensive Support Team (ECIST) review which was held on 15 May 2013
Detailed Findings
Outstanding Concerns based on evidence
gathered
Planned Improvements
Limited evidence of effective processes for
monitoring mortality data and clinical
effectiveness



It is not clear who has responsibility for analysing
the root cause of all deaths to identify trends and
report key messages to the Board as evidenced
during a meeting with the Clinical Executive

Establishing mortality review process –
rapid review at the time of death by
senior nurse team, issues identified and
actions escalated immediately.
Implementation of monthly meetings for
the Medical Director and Director of
Nursing to review deaths.
Reviewing learning from incidents
Recommended Action


The Clinical Executive Group should
monitor monthly trends in mortality and
oversee action plans to address areas of
concern.
The Trust needs to understand the high
mortality rate in the medical HDU and
develop an action plan to address it. This
should include implementing an admissions
Priority
(urgent, high,
lower)
Urgent
17
Outstanding Concerns based on evidence
gathered





Group.

Heads of Nursing reported that the Daily Death
Review Meetings only require review of patient
notes by a nurse; if the death is unexpected then
the notes are reviewed by a consultant. This is not
necessarily a multidisciplinary meeting although it
does work well in some areas.
The medical HDU (High Dependency Unit) activity
analysis (April 2012 – March 2013) has indicated
a high mortality rate (24%). The Panel saw no
evidence this is being reviewed in depth by the
Medical Director to understand the root causes
and develop an action plan to understand if, for
example, the mortality rate is due to poor
implementation of the admissions policy or lack of
out of hours dedicated specialist cover for the
unit.
Patients and staff reported that complaints are not
investigated in a timely manner. There is also
limited evidence of complaints being followed
through to implemented action plans and learning,
this was a consistent message from all staff focus
groups.

The Panel found little evidence of downward
dissemination of lessons from Serious Incidents
or DATIX data. Action plans are not consistently
developed and implemented as a result of
incidents. Junior Doctors and Nurses reported
that they raise incidents but get no response and
nothing changes as a result.
The Nurse and Junior Doctor Focus Group
attendees reported that they are encouraged not
Planned Improvements
Implementation of findings from the
ECIST team review. The ECIST team

visited the Trust on 15 May and
following this visit the Trust has agreed
to establish an Improving Emergency
Flow Board to:
- Improve patient safety by
reducing delays in assessment
areas;
- Increase patient experience and
satisfaction
- Ensure safe care is delivered in
the right environment
- Achieve better patient flow
- Reduce transfers in the patient
journey
- Implement the Enhanced
Quality Programmes of Care
- Develop a set of metrics to
support and monitor the
implementation and outcomes
of the programme
Recommended Action
Priority
(urgent, high,
lower)
policy for the medical HDU.
The Trust must ensure learning from
serious incidents and complaints is
disseminated in a timely manner and that
actions to prevent a recurrence are
implemented.
CHKS are implementing the Qlab
approach in line with Darent Valley
Hospital and to provide external review
of the Trust mortality data and patient
safety metrics. The findings will be fed
back through the current clinical audit
structure for investigation and action.
18
Outstanding Concerns based on evidence
gathered



Recommended Action
Priority
(urgent, high,
lower)
to report incidents on DATIX.
Consultants reported that Mortality and Morbidity
meetings are sporadic and were suspended in
medicine until recently.
Limited evidence of actions to improve mortality
performance being implemented consistently
across the Trust

Planned Improvements


The Clinical Executive Group are not overseeing
mortality implementation plans.
There are examples of good practice such as the
Sepsis Bundle, however the ‘Think Sepsis’
programme has been in place for two years and
has lacked pace. The Sepsis Bundle was only
recently implemented in A&E and has not yet
been implemented in other high dependency
wards.
Consultants and Junior Doctors reported that
there is no GI bleed rota which presents a
significant risk to patients.
The sepsis bundle will be rolled out
across the Trust but this needs to be
accelerated.
The GI bleed rota will be agreed if the
merger goes ahead.


Accelerate roll out of the sepsis bundle
across the Trust.
Agree a GI bleed rota (involving clinicians
from Dartford if necessary) regardless of
the merger.
Urgent
KLOE 4: How does the Trust manage deteriorating patients?
Good Practice identified

Consultant led multidisciplinary handover on delivery suite every evening

24/7 critical care outreach team

The Trust has a ‘Think Sepsis’ campaign
19
Detailed Findings
Outstanding Concerns based on evidence gathered
No consistent process for managing deteriorating
patients







Consultants and Junior Doctor Focus Groups
reported that there is no single process for
recognising and managing deteriorating patients
that is implemented consistently in every Ward.
The Panel observed that the Sepsis Bundle was not
implemented in every Ward.
The Panel observed that the design of the
observation charts are not user friendly and have
no clear escalation criteria.
Ward staff reported that agency staff are not given
orientation time to understand the process for
managing deteriorating patients .
Junior Doctors reported that their training does not
give sufficient attention to patient safety and the
Early Warning System.
Junior doctors felt they frequently had to make
clinical decisions above their level of competency in
the management of unwell patients (particularly
hematology and orthopedics departments).
Inconsistent assessment and referral processes

Planned Improvements
Junior Doctors and nurses reported that there is a
lack of senior staff to assess and refer patients
leading to inconsistency. This was supported by
Panel review of a sample of Ward rotas and
observations during the announced and


Simplify process for managing
deteriorating patients and involve
stakeholders and users in designing a
system for an effective chain of
prevention.
Recommended Action
Priority
(urgent, high,
lower)

Develop a clear universally known and
understood, mandated, unambiguous,
graded, activation protocol for escalating,
monitoring or summoning a response to a
deteriorating patient. This should be
standardised across the whole hospital.
Urgent

It must include specific responsibilities of
senior medical and nursing staff, including
consultants and identify the maximum
response times. When patients continue to
deteriorate after non-consultant review there
should be escalation of patient care to a
consultant. If this is not done, the reasons for
non-escalation must be documented clearly
in the case notes.
The Board asked for Nursing

Establishment to be reviewed in
January 2013. This has resulted in the 
Interim Director of Nursing undertaking
a further detailed review of nursing skill
mix in each clinical area.

The Trust Board have recognised that
Complete a holistic medical staffing review
and recruitment strategy.
Ensure appropriate consultant cover for
acute medicine and medical HDU at night
and weekends.
Review care provided in the ADL.
Urgent
20
Outstanding Concerns based on evidence gathered



unannounced visits.
The Trust has no acute physicians for AMU (Acute
Medical Unit) out of hours and there is insufficient
cover during the day. There are no intensive/ HDU
specialists for out of hours cover on medical HDU.
This was reported by Junior Doctors and evidenced
through a review of staff rotas and Panel
Observations during the visit.
Low nursing staff levels were reported on AMU,
particularly when escalation wards are being used.
A review of staff rotas did not support this finding,
however nurses reported that they are often moved
from AMU at short notice to go and work on
escalation wards resulting in low staff numbers.
The Trust needs to review its measures to ensure
adequate care is provided in an appropriate
environment in the ADL, the Panel noted concerns
in this area during the unannounced visit.
Poor design and layout of critical care areas



Planned Improvements
The Panel observed that the design and layout of
critical care areas needs urgent attention.
Concern was raised by Junior Doctors and
Consultants on the practicalities of staffing and
covering several critical care areas d in different
parts of the trust especially overnight and at
weekends.
Junior Doctors reported that they were frequently
left in charge of the medical HDU areas with no
senior oversight and low staff numbers, particularly
when escalation wards are in operation. This was
Recommended Action
Priority
(urgent, high,
lower)
Urgent review of the design and layout of
admission and critical care areas
Urgent
the Medical and A&E physicians are
understaffed. There has been recent
investment in A&E consultants. The
Clinical Executive Group agreed in
March to invest in a further 5
Consultants in medicine and recruitment
is underway. Two substantive
physicians have been appointed and it
is expected that the Trust will shortly
appoint one more.

Implementation of findings from the

ECIST team review. The ECIST team
visited the Trust on 15 May and
following this visit the Trust has agreed
to establish an Improving Emergency
Flow Board to:
- Improve patient safety by
reducing delays in assessment
areas
- Increase patient experience and
satisfaction
- Ensure safe care is delivered in
the right environment
21
Outstanding Concerns based on evidence gathered
Planned Improvements
reported as a frequent occurrence.
-
Poor admission processes for patients admitted
through the unscheduled care pathway


A&E is frequently at capacity and was recognized
as a problem area by many staff who the Panel
met, in particular the CDU, minors, resuscitation
and the children’s areas were observed to be below
what might be expected.
All staff focus groups frequently cited problems with
the timely assessment and treatment pathways at
the front door which were considered to critically
affect the safety of patients. This finding was
supported by Panel observations.

Recommended Action
Priority
(urgent, high,
lower)
Urgent plan to remodel/provide temporary
extra capacity.
Urgent
Achieve better patient flow
Reduce transfers in the patient
journey
Implement the Enhanced
Quality Programmes of Care
Develop a set of metrics to
support and monitor the
implementation and outcomes
of the programme
Implementation of findings from the

ECIST team review. The ECIST team
visited the Trust on 15 May and
following this visit the Trust has agreed
to establish an Improving Emergency
Flow Board to:
- Improve patient safety by
reducing delays in assessment
areas
- Increase patient experience and
satisfaction
- Ensure safe care is delivered in
the right environment
- Achieve better patient flow
- Reduce transfers in the patient
journey
- Implement the Enhanced
Quality Programmes of Care
- Develop a set of metrics to
support and monitor the
implementation and outcomes
of the programme.
22
KLOE 5: What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves during their time in hospital?
Good Practice identified

The Trust operates a daily beds meeting and manages bed occupancy as far as possible

New nurse outreach weekend service – i.e. antibiotics at home and Saturday / Sunday pharmacy is helping with weekend discharge

Interim Director of Nursing leading on ‘Length of Stay’ programme

Plan for new contract of transport from A&E for discharges at evenings and weekends
Detailed Findings
Outstanding Concerns based on evidence gathered
Bed capacity is not sufficient to meet demand


To meet cost improvement programmes the Trust
closed a number of wards over the last 3 years
resulting in a loss of 60 beds. This has caused
significant pressures on the emergency wards such
as A&E, AMU and HDU which are frequently at
capacity and are understaffed to potentially unsafe
levels as observed by the Panel and reported by
Junior Doctors and nurses.
Throughout our visit, the Panel identified evidence
of poor bed management and flows including the
following frequent use of escalation areas. A
contributing factor to this is the number of patients
that are medically fit but are not discharged for a
Planned Improvements



The Trust has a target to meet 90% bed
occupancy through a Programme being
led by the Director of Nursing.
The End Of Life Matron has started a
project ‘PEACE’ to work with residential
and nursing homes to support them in
caring for the dying.
ECIST have recommended the Trust sets
up an ‘Improving Emergency Flow Board
to achieve the Trust goal to reduce bed
occupancy to below 90% by:
o ensuring safe care is delivered in
the right environment
o Achieving better patient flow
o Reducing transfers in the patient
Recommended Action



Understand the options available to
relieve pressure on emergency wards,
which should include revisiting the
decision to close wards.
Full implementation of real time patient
tracking, either through a single system or
automated links between those systems
used to track patients.
Wider health system engagement to
make better use of out of hospital care
including preventative strategies and
community care, including support to
ensure patients are supported to die in
their place of choice.
Priority
(urgent, high,
lower)
High
23
Outstanding Concerns based on evidence gathered

variety of reasons including access to care homes
and other community support.
Nurses reported problems with accessing social
services and the Trust needs to improve
partnership working with stakeholders to enable
more effective patient throughput and to ensure
patients die in their place of choice with appropriate
support.
Patient moves are not consistently tracked

Planned Improvements
Recommended Action
Priority
(urgent, high,
lower)
journey.

None identified

Improve processes to monitor patient
moves and improve consistency of care
High
The Panel requested data on patient moves for non
clinical reasons which the Trust was unable to
provide as it is not tracked.
24
Patient experience
Overview
The review into patient experience focussed on the systems and processes in place to collate and analyse patient experience and the consistency and timeliness of the
Trusts response to patient feedback and complaints.
KLOE 6: How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is the
Trust taking to address the key themes emerging?
Good Practice identified

The complaints process is advertised throughout the Trust.

The Trust regularly receives positive feedback from WOW awards, a nationally accredited customer service programme. The WOW nominations outweigh the number
of complaints received.

The Surgical Directorate have changed the way that they respond to complaints. The new process brings all individuals involved with the complaint together in a
meeting to analyse each point raised, and to enable attendees to challenge the decision making process and response. The agreed response is compiled and
submitted to the Complaints Team. The new process enables greater opportunity to learn from complaints and that learning will inform the Change Register to
demonstrate changes have been implemented as a result of complaints.
Detailed Findings
Outstanding Concerns based on evidence gathered
The Trust is not proactive enough in routinely seeking
feedback from its patients


Patients reported that the Trust is slow to respond to
patient feedback and complaints.
The patient feedback gathered during listening events
Planned Improvements

Recommended Action

Develop and implement a programme
to fully engage with the patient
community. This should be a multichannel approach including formal
processes and more informal listening
events
Priority
(urgent, high,
lower)
High
25
Outstanding Concerns based on evidence gathered






Recommended Action
Priority
(urgent, high,
lower)
fully supported the key messages contained in this
report.
Patients felt the Trust should do more to gather
feedback through the use of open listening events
which are considered to be particularly important in
harder to reach areas.
The Trust needs to improve its approach to diversity.
Patient complaints information is currently only
available in English despite the diverse local
population.
Lack of awareness or planning in trying to engage
patients from minority groups was evidenced during a
meeting with the PALS Officer.
The Trust understands the key themes arising from
patient experience data but this information is not
translated into action

Planned Improvements

None identified

The Trust needs to demonstrate that it
is responding to patient feedback and
embed patient feedback within its care
quality strategy.
High
There were clear messages from the patient listening
event which were consistent with the findings of the
Panel as documented in this report.
The Panel observed only limited evidence that patient
feedback is being acted upon and that the Trust
understands the key themes arising from its feedback.
The Panel observed that it is not clear how patient
feedback is being communicated to the Board and
subsequently embedded in to action plans to deliver
change within the hospital.
The Panel noted that the Trust had a higher than
anticipated update of the Friends and Family Test
(planned 15% for April and has achieved 30%).
26
Workforce and safety
Overview
The two KLOEs in the area of workforce and safety focused on identifying the key barriers in the Trust to effectively managing quality and patient safety and how the Trust
approaches its staffing levels and skill mix to deliver quality and safety.
KLOE 7: What do staff groups interviewed (including trainee / student groups) say are the main barriers in the Trust to delivering high quality treatment and care
for patients?
Detailed Findings
Theme
Outstanding Concerns based on evidence
gathered
Planned Improvements
Recommended Action
Priority
(urgent, high,
lower)
Morale amongst many staff in the Trust is low and this is reflected in the feedback the Panel received from all staff groups. It was recognised that the CEO has made positive
steps to engage staff but this needs to be translated into action plans and improvements quickly. The Board will need to tackle this issue if it is to succeed in transforming the
hospital.
The key themes and concerns identified in this KLOE have been covered elsewhere and can be summarised as follows:
 Lack of accountability for patient quality and safety
 Potentially unsafe emergency care pathway
 Inconsistent processes for reporting and learning from incidents
 Inconsistent clinical management
 Cost Improvement Programmes have left staff stretched
 Lack of senior oversight particularly out of hours and at weekends
 Poor IT support, for example it took a radiologist 6 months to get a password to use the x-ray system. This was a frequent complaint.
27
KLOE 8: How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed effectively?
Good Practice identified

The Board asked for Nursing Establishment to be reviewed in January 2013. This has resulted in the Interim Director of Nursing undertaking a detailed review of
nursing skill mix in each clinical area.
Detailed Findings
Outstanding Concerns based on evidence gathered
Patient safety has not been at the heart of workforce
planning




Planned Improvements


The Panel were unable to obtain a clear strategy that
addresses the staffing requirements for all grades
and directorates.

The Nurses Focus Group reported that there is a lack
of multidisciplinary working across the Trust and staff
operate in professional silos. This was supported by
Panel observations during the announced and
unannounced visit.
There is a difference in views at Board level as to
what represents a safe vacancy factor and there is
no set policy.
Staff reported that the recruitment process is slow
and can take up to 9 weeks.
Director of Nursing – undertaking a
staffing review for nursing.
A high level Workforce Strategy was
approved by the Board in April 2013 but
further detailed work is now required.
The Annual Plan 2013/14 includes a
capacity plan: including workforce plan
to deliver 7 day services, new roles and
ways of working to replace traditional
staffing models.
Recommended Action



Develop a single workforce strategy and
recruitment plan.
Medical staffing review especially to
address the high use of medical locums
at consultant and other grades.
Review how multi-disciplinary teams
should work together to break down
professional silos.
Priority
(urgent, high,
lower)
Urgent
28
5. Conclusions and support required
Conclusions
This is a Trust undergoing multiple changes at Board and executive level with a new Chair appointed in April 2012, a new Director of Finance appointed in September 2012, a
new Director of Strategy & Governance appointed in March 2013 and a new Director of Organisational Development and Communications appointed in May 2013. An Interim
Director of Nursing has been in post since April 2013 and a new substantive Director of Nursing has been appointed and will start in June 2013. A new Medical Director has
been appointed and will start in August 2013.
Whilst the leadership team is undergoing change, the members of the Trust Board need to ensure that they remain focussed on delivering significant improvements in patient
safety and quality. The Trust has been under scrutiny from Monitor for an ongoing period and as a result the Trust has generally been reactive rather than proactive in dealing
with issues and staff morale has suffered. One significant area to enable improvement at the Trust is a period of stability and an increased focus on safety and quality at the
Board and Executive level.
The Trust is under extreme service pressure with high activity levels evident throughout our visit. Cost Improvement Programmes have undoubtedly impacted the quality and
safety of patient care and urgent attention is needed to reassess the impact of these programmes.
Our review identified a number of areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there is more for the Trust Board
to do in ensuring good practice consistently across all of the Trust, all of the time. Our review also identified a number of areas of concern across all key lines of enquiry. For
the majority of the areas of concern, we identified a number of improvements already underway at the Trust or planned improvements evidencing the Trust’s continued
progress and improvement. Further recommended action for each area has been included and prioritised as urgent, high, medium or lower priority.
Action Plan
This section summarises the immediate actions arising from the review.
29
Suggested high priority actions for consideration at the risk summit
The Panel identified suggested areas of focus for further discussion at the risk summit.
Problem identified
1. Need for greater pace and
clarity of focus at Board level for
improving the overall safety and
experience of patients
Recommended Action for discussion
i.
The Trust urgently needs a single visible strategy and action plan based on a recognised
patient safety improvement model and underpinned by systematic staff training and roll out.
ii.
Accountability needs to be threaded through the organisation, via the clinical directorates, to
embed responsibility for patient safety and experience at every level of the Trust.
iii.
The Trust must ensure learning from serious incidents and complaints is disseminated in a
timely manner and that actions to prevent a recurrence are implemented.
2. Review of staffing and skill
mix to ensure safe care and
improve the patient experience
i.
Holistic medical staffing review and recruitment strategy needs immediate attention. Reducing
the level of locum usage for consultants provides a suggested starting point for this work.
3. Redesign of unscheduled
care and critical care pathways
and facilities
i.
Urgent review of the design and layout of the emergency department, admission and critical
care areas to be incorporated in an estate strategy. Partnership working with health and social
care providers will be important to the success of this.
4. Improved senior clinical
assessment and timely
investigations
i.
Ensure appropriate consultant cover for acute medicine and medical HDU at night and
weekends.
ii.
Review care provided in the Admission and Discharge Lounge.
iii.
Develop a clear universally known and understood, mandated, unambiguous, graded, activation
protocol for escalating, monitoring or summoning a response to a deteriorating patient. This
should be standardised across the whole hospital.
Support required by the
Trust
30
5. Need to galvanise the good
work that is already going on in
Wards and to adopt and spread
good practice
i.
The Trust should develop a strategy and action plan to create a culture that welcomes
improvement, galvanises the good work that is already going on in some Wards and adopts and
rapidly spreads good practice.
6. Improve public reputation
i.
The Trust should improve the methods and frequency with which it engages with the public and
as a starting point extend its staff Big Conversation work to the public.
31
Appendices
32
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have
been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
33
3) The Indicator will utilise 5 factors to adjust mortality rates by
a. The primary admitting diagnosis
b. The type of admission
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
d. Age
e. Sex
4) All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted
Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital
If a patient is transferred between hospitals within 2
days the death is counted multiple times
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in hospital deaths
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
No
Considers in hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
34
Appendix II: Interviews held
Interviewee
Date held
Mark Devlin, Chief Executive
9 May
Denise Harker, Chair of the Board
9 May
Dr Gray Smith-Laing, Medical Director and Susan Osborne, Director of Nursing (interim)
9 May
Claire Harrison, PALS and Lyndsay Barrow, Complaints Officer
9 May
John Sands, Chair of Quality Committee (Non Executive)
9 May
Andy Brown, HR Director (Interim) and Raj Bhamber, Director of Organisational Development and Communications
10 May
Ruth Jenner, Senior Governor
10 May
Susan Osborne, Director of Nursing (interim)
10 May
Jason Seez, Director of Strategy and Governance
10 May
Howard Marsh, Urologist and Patient Safety Lead, and Paul Hayden, Intensivist and Audit Lead
10 May
David Meikle Director of Finance
10 May
Bov Jani, Director of Medical Education and Marietta Higgs, Foundation Training Programme Director
10 May
35
Appendix III: Observations undertaken
Observation area
Care of the elderly wards – Byron, Tennyson and Milton
Date of observation
9 May
Accident and emergency (A&E)
9 May and 17 May
Acute Medical Unit (AMU)
9 May and 17 May
Trauma and Orthopedics - Arethusa
9 May and 17 May
Surgical Assessment Unit – Kingfisher Ward – Handover
ENT – SHO to SHO
General Surgery – Registrar / SHO / F1 and SHO Urology from day to Registrar / SHO night
9 and 17 May
Delivery Suite – Handover
Obstetrics and Gynae
Consultant in call / Registrar / SHO to Registrar / SHA
9 May
Admission Discharge Lounge - Site Practitioners Office – Handover
Medical Registrar / SHO to Registrar / SHO
Medical Outreach Team
Hospital Site Team
9 May
HDU – Trafalgar
17 May
HDMU – Bronte
17 May
Elderly Care – Byron
17 May
36
Appendix IV: Focus Groups held
Focus group invitees
Focus group attendees
Date held
Junior Doctors
5-10 attendees; attendees were all Junior Doctors (the Panel had to hold two Junior Doctor Focus Groups as
the first session was dominated by a member of senior staff)
9 May
Student Nurses
15 attended; attendees were majority student nurses Year 1-3 and 2 student midwives
9 May
Nurses / Care Support workers
2 sessions on 9 and 10 May
All staff
Approx 30 attendees; attendees included nurses, housekeeping, porters
10 May
Consultants
Approx 15 attendees plus 5 clinical directors
10 May
Heads of Nursing
Approx 10 attendees
10 May
Clinical Executive Group
Approx 10 attendees
10 May
Trust Governors
6 attendees
10 May
Non Executive Directors
Approx 15 attendees
10 May
9 and 10 May
37
Appendix V: Information Review
Document Name
Quality Strategy 2012
Description
Board Quality strategy (incorporating Patient Safety, Patient Experience and Clinical
Effectiveness).
Board Assurance Framework 2013-13
Board Assurance Framework and Trust Risk Register.
Corporate Risk Register
IAC Jul12 135 Clinical Audit Dept
IAC Jul12 135 Appendix 1 MFT
Clinical Audit plans for 2013/14 and latest Clinical Audit Annual Report.
Clinical Audit Plan 13-14
Appendix 1 MFT Clinical Audit 2013-14
CIPs 2012-13
CIPs 2013-14
Briefing for QIA Session
Workbook for QIA Form
List of all Cost Improvement Programmes for 2012/13 and 2013/14 and details of the process for
assessing the quality impact of these
QIA Sign off Form
NHSCB- everyone counts plan
Quality Committee Report QGF
Monitor QGF Benchmarking
Most recent self assessment or external assessment of quality governance (against Monitor’s
Quality Governance Framework or equivalent)
Organisation structure chart April
Mark Devlin CV
Gray Smith - Laing CV
Organisation structure and CVs of Executive team
Jason Seez CV
Susan Osborne CV
38
Patrick Jonhson CV
David Meikle CV
Andrew Brown CV
Committee Structure
Integrated Audit Committee Terms of Reference
Performance and Investment committee Terms of Reference
Quality Committee Terms of Reference
Governance and Committee Structures and terms of reference for assuring quality including
mortality
Workforce Committee Terms of Reference
Clinical and Executive Group Terms of Reference
Mortality Working Party draft Terms of Reference
Feb 2013 Board Agenda and Papers
Chairman’s Report from Integrated Audit Committee - 20th Feb 2013
E&Y Financial Governance Follow up draft report 26th Feb 2013
Draft and report financial governance follow up review 14th Feb 2013
Outline business case for the provision of services at the Queen Mary
Sidcup hospital 26th Feb 2013
Minutes of Performance and Investment committee meeting 24th Jan
2013
Trust Board (private and public) papers and minutes for the last 2 meetings
Minutes of the Quality committee 15th Jan 2013
Minutes of the Workforce Committee 15th Jan 2013
March 2013 Board Papers
Kings Fund Report Urgent and Emergency care 11th March 2013
Information Governance Toolkit
Internal Audit information governance toolkit 21st Feb 2013
39
Information Governance Toolkit Self Assessment 26th March 2013
Workforce Committee Minutes 15th Feb 2013
Minutes of the Integrated Audit Committee 28th Feb 2013
Minutes of the Performance and Investment Committee 21st Feb
2013
Agenda and Papers Quality Committee Feb 2013
Agenda Quality Committee March 2013
Board Sub Committee with delegated responsibility for assuring quality and safety - papers and
minutes for the last 2 months (public and private)
Quality Committee Papers March 2013
Morality Working Party Agenda Feb 20th 2013
Complaints Management and Engagement within the Trust
Health Statistic User Group Key Points
Minutes December 2012 Meeting
Patient Safety Action Plan Jan 2013
Mortality Working Party Agenda March 2013
Minutes of Feb 2013 Meeting
Mortality Action Plan
Mortality Review Group papers and minutes for the last 2 months
GSL to Mr Sherlaw-Johnson
Septicaemia Review Final
120524 Think Sepsis Project Brief
Draft Mortality Dashboard
Complaint legal claims and investigations
National Advisory Group Membership
TOR NCB Mortality Outlier
40
HSMR Trend
MWP Audit March 2013
MOF Mortality Report
British Thoracic Society - Adult Community Acquired Pneumonia Audit
Tool Analysis
British Thoracic Society - Adult Community Acquired Pneumonia Audit
Tool Analysis
Review of hospital mortality data (Cerebrovascular Disease) 2011-12
Readmissions mortality Audit March 2013
Patient Experience performance 2012/13
Patient Safety Performance 2012/13
Performance Scorecard April 2013
Summary of Key Performance Measures 2012/13 including finance, performance, quality and
patient experience
Quality Indicators for PCT 2012/13
MFT Annual Plan 12/13
Annual plan submission to Monitor or equivalent for NTDA for 2013/14
Medway Annual Plan presentation 13/14
120524 Think Sepsis Project Brief
20121119 Medway NHS FT Septicaemia
GSL to Mr Sherlaw-Johnson
Mortality Working Group Action Plan Jan 2013
Septicaemia Review for CQC 16213
CQC Mortality Alert Actions Plans and Implementation
20110720 Medway NHS FT (RPA) / Acute Renal Failure Alert
Charlson Coding and Weights
Copy of CQC report Acute Renal Failure
CQC Closure letter Acute and unspecified
41
GSL to Mr Sherlaw-Johnson
2010 December 22 Medway NHS FT RPA
2011 Feb 17 Medway NHS FT RPA
Action Plan re-High HSMR Jan 11
EQ Pneumonia Data Form
GSL to Mr Sherlaw-Johnson
Pneumonia Data for CQC response
Clinical Governance Due Diligence - MFT
Any independent reviews of quality in the last year
Clinical Governance DD Action Plan update
MFT Intermediate care providers
Local care providers - services and capacity that support your models of care e.g. Local
intermediate care beds
Summary of Mortality in Medway NHS Foundation Trust.ppt
Dated 21/12/12 (day of first Mortality Working Party meeting).
Overview and explanation of mortality statistics.
SHMI mortality report 2013-04-24.doc
An analysis of mortality in Medway NHS FT, dated 24/04/13.
HSMR trend 2013-04-02.xlsx
Excel graph (before rebasing) and HSMR data for Medway, from Dr Foster.
Attachment 6 HSMR trend.ppt
Ppt version of Excel graph above
Attachment 4 MFT Action Plan.docx
Mortality Working Group Action Plan dated January 2013
Attachment 7 Mortality Dashboard.xlsx
Excel data showing the number of deaths in top 4 diagnostic groups: pneumonia, septicaemia, #
neck of femur, acute cerebrovascular disease by month over the last three years
Agenda 19-04-13.docx
Agenda for Mortality Working Party on 19/04/13
Attachment 2 complaints report.doc
Detailed report of complaints against MFT, authored by PH consultant (on behalf of the Mortality
Working Group), dated 04/03/13.
Summary of the main themes from complaints during November –December 2012
GSL letter to Mr Edward palfrey MD Frimley Park Hospital
20032013.doc
Letter from MFT Medical Director to Frimley Park MD after the latter's visit. Dated 20/03/13.
Attachment 1 minutes of 8 MARCH 2013ab.docx
Minutes from Mortality Working Party meeting on 08/03/13
42
MFT complaints taken from Board Report - Feb 2013.docx
Patient experience scorecard and complaints report from February board papers
MFT complaints report - July 2012.doc
32 page report to the Quality Committee (08/06/12) with information about recent feedback from
patients and the public from 1 February to 31 March 2012
MFT complaints report - November 12.doc
27 page report to the Quality Committee (08/10/12) with information about recent feedback from
patients and the public from 1 June – 31 July 2012
MFT complaints report - September 2012.doc
14 page report to the Quality Committee (08/08/12) with information about recent feedback from
patients and the public from 1 April to 31 May 2012
Complaints summary from NK report Nov 12.docx
Complaints summary for July 2011- July 2012. Not clear what the source or author of this is.
MFT Complaints report - Jan 13.pdf
12 page report to the Quality Committee (undated) with information about recent feedback from
patients and the public from 1 August – 30 September 2012
Trust Workforce Report for CCG pack for National Review Team.docx
Trust Workforce Report for CCG pack for National Review Team.
Undated.
Medway Foundation Trust Metrics 2012-13.xlsx
Excel workforce graphs (assume it accompanies the report above)
MFT issues time line 12-13.xlsx
Log of issues that CCG has with MFT, with details of how these are being followed up
MFT CQRG Attendance 1213.xlsx
Clinical Quality Review Group (CQRG) attendance record
SI Report 30.4.13.doc
report on Serious Incidents and Never Events within MFT April 2012 to March 2013
national head and neck cancer audit 2011.pdf
National audits on cancer
national lung cancer audit 2012.pdf
national bowel cancer audit 2012.pdf
ssnap-acute-organisational-audit_2012-public-report.pdf
Sentinel Stroke National Audit Programme. December 2012
NHFD National Report 2012.pdf
The National Hip Fracture Database National Report 2012
BS_fullreport NCEPOD.pdf
A review of the care of patients who underwent bariatric surgery
nati-diab-inp-audi-12-comp.xlsx
National Diabetes Inpatient Audit 2012
IRof_Mortality_Rates_at_MH_v5.1_final_02042013[1].pdf
Independent Review of Mortality Rates at the Manor Hospital
KM HCAI overview trajectories.docx
Kent and Medway Healthcare-Associated Infections (HCAI) Overview
43
Medway Foundation trust.docx
Background information drawn from the QSG in March/April 2013
MFT 2012 Patient Survey.pdf
2012 patient survey downloaded from CQC website
MFT Inpatient Survey Briefing.docx
2012 adult inpatient survey: key findings.
Email complaint about Medway.docx
Email complaint dated 14 February 2013 to NCB
Copy of Medway NHS FT NE 2012-13.xlsx
Medway NHS Foundation Trust Never Events 2012-13
Kent & Medway Area Team Quality Handover Alison Walton.docx
Kent & Medway Area Team Quality Handover – Patient Safety for 01.04.2012 to 04.03.13
Includes information for the area on SIs, never events and incident reporting
CAB refs by provider Apr 12 to Jan 13 300413.xlsx
REFERRALS VIA CHOOSE AND BOOK
Medway NHS FT NE 2012-13_Further info.xlsx
Updated version of Item 35
N Nathan and P Green to D Harker 5 April 2013.pdf
Letter from Dr Nathan Nathan (Chief Clinical Officer, Medway CCG) to Denise Harker (Chair,
MFT), following the Board to Board meeting on 25 March 2013
Single Equality Scheme - Action Plan Jan2013 update v2.doc
Single Equality Scheme 2011-2014 Action Plan, based around strategic themes with measures,
actions, completion dates and accountable officers (who are either: Trust Board, Council of
Governors Directors, Committees or Steering Groups)
An insight into Medical Assessment Unit facility usage between the
evening of 27th September.doc
A patient's insight into Medical Assessment Unit facility usage between the evenings of 27th
September/early morning 28th September 2011.
Includes the details of her stay and brief details of four other patients' experience in the waiting
room.
Minutes NHS Medway Clinical Commissioning Group Patient Council
meeting (13 March 2013) FINAL.pdf
Minutes of the meeting of the NHS Medway Clinical Commissioning Group (CCG) Patient Council
held at 6.00 pm on Wednesday 13 March 2013
User Feedback.pdf
Results from 4 users from the audit (Annual
audit of the practice and supervision of midwives) questionnaire for users
Midwives feedback.doc
Results from 8 midwives from the audit (Annual
audit of the practice and supervision of midwives) questionnaire for midwives
JH letter Medway 16.07.12.docx
Letter dated 16 July 2012 from Jenny Hughes, Consultant LSA Midwifery Officer to Head of
Midwifery and Director of Nursing with recommendations to the supervisory team following the
annual supervision audit
Keogh Briefing Report Medway.docx
Overview Report on Maternity Services and Supervision of Midwives at The Medway NHS Trust –
44
8th May 2013, in response to Keogh review. Written by Jenny Hughes, Consultant LSA Midwifery
Officer
Action Plan.doc
Recommendations / Action Plan from 2012 Audit
Action Plan Template App 3.doc
SoM Action Plan in Response to LSA Annual Audit Report 2012
Adult and Emergency Medicine phase 1 feedback.pptx
Summary of ECIST Phase 1
Unclear whether this is a follow-up to the review in April 2012 (see below) but appears to be. Not
dated or with any description.
ECIST feedback Medway FT 10 May 2012 draft.docx
Report to Director of Nursing, dated 10 May 2012, on ECIST review conducted on 26 April 2012
SAEIST.ppt
Directorate of Surgery, Anaesthesia and Critical Care Update Phase 1 EIST May 13
1 pager, brief summary
WHO Checklist letter 17.04.13.doc
Letter dated 17 April 2013 addressed to Surgeons & Anaesthetists (all grades) at MFT, signed by
Clinical Director Anaesthesia, Clinical Director Surgery, Head of Nursing and Interim General
Manager
Medway Annual Plan 13-14 v1 2 April Trust Board.pptx
Draft Annual Plan 2013/14 Overview 30th April 2013 presentation to Trust Board by Jason Seez, Director of Strategy and Governance
Patient Voice Feedback Batch 1.xlsx
Patient voice feedback from Keogh website.
9 feedback items posted - 2 sent through on 26 April and 7 on 10 May
Email text from Gillian Wells.docx
Gillian's observations of MFT
Med locum and agency Mar & Apr 2013.xlsx
Locum and agency spend in Mar and Apr 2013
Patient Voice Feedback
Key Message
Ward/ area
Timing
Nurses are dedicated and caring but have inadequate resources and facilities
Not known
Current
Poor communication of the implications of the Liverpool Care Pathway to patients or their family members
Not known
Current
45
Organisational culture does not encourage feedback from staff and patients
Not known
Current
Examples of perceived poor clinical treatment
Clinical Oncology
1-2 years
Inconsistent use of escalation processes e.g. emergency card
Paediatrics
Current
Communication to patients is inconsistent and inaccurate
Clinical Haematology
Current
46
Appendix VI: Unannounced site visit
Agenda item
Panel pre-meet
Entry into Medway Hospital Main Entrance and announced arrival to site manager via Porters desk
Observations undertaken of the following:
 Accident and emergency
 Surgical High Dependency Unit – Trafalgar Ward
 Surgical Assessment Unit – Kingfisher
 Admission and Discharge Lounge
 Trauma and Orthopedics – Arethusa
 High Dependency Medical Unit – Bronte
 Acute Medical Unit /Medical Assessment Unit
 Elderly – Byron Ward
Meeting held with site manager to understand current staffing and patient levels
Panel left Trust and announced exit
47
Appendix VII: Theme and evidence base
Theme
Evidence Base
KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all levels describe key
elements of quality governance processes?
Lack of clarity around the governance processes for assuring the quality of treatment
and patient care is leading to a lack of accountability, pace and focus
Interviews:
 Chair of the Quality Committee
 Trust Chairman
 Chief Executive
 Medical Director
 Nursing Director
Data
 Board minutes from January 2013 – March 2013
 Mortality Working Group minutes
 Quality Committee minutes
Staff at all levels cannot articulate the quality governance process
Interviews
 Chair of the Quality Committee
 Medical Director
 Nursing Director
Focus Groups
 Junior Doctors
 Heads of Nursing
 Nurses/ Care Support Workers
KLOE 2: Are the leadership roles and responsibilities clearly defined for the quality processes?
Lack of clarity around the leadership roles and responsibilities for quality and patient
safety
Interviews
 Clinical Executive Group
48
Theme
Evidence Base


Medical Director
Nursing Director
Focus Groups
 Heads of Nursing
 Consultants
 Junior Doctors
KLOE 3: What processes are in place to support monitoring mortality data and clinical effectiveness? What actions are being taken by the Trust to improve
mortality performance, especially for General Medicine and Elderly Care?
Limited evidence of effective processes for monitoring mortality data and clinical
effectiveness
Interviews
 Director of Nursing
 Patient Safety Lead
 PALS/ Patient Complaints Officer

Focus Groups
 Junior Doctors
 Nurses
 Consultants
Public Listening Event
Data Analysis
 HDU activity analysis (April 2012 – March 2013
Limited evidence of actions to improve mortality performance being implemented
consistently across the Trust
Focus Groups
 Nurses
 Junior Doctors
 Consultants
Ward Observations
 A&E
49
Theme
Evidence Base


Assessment Units
Trafalgar, Bronte and Byron Wards
Public Listening Events
 Feedback specifically relating to Byron, Traflagar and Arethusa Wards
KLOE 4: How does the Trust manage deteriorating patients?
No consistent process for managing deteriorating patients
Focus Groups
 Nurses
 Junior Doctors
 Consultants
Interviews
 Director of Medical Education
 Foundation Training Programme Director
Inconsistent assessment and referral processes
Focus Groups
 Nurses
 Junior Doctors
 Consultants
KLOE 5: What processes does the Trust have to manage bed occupancy? How does the Trust manage patient moves during their time in hospital?
Bed capacity is not sufficient to meet demand
Interviews
 Director of Nursing
 Medical Director

Focus Groups
 Junior Doctors
 Nurses
 Consultants
Public Listening Event
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Theme
Evidence Base



Long A&E wait times
Delayed discharges
Medical outliers
Data Analysis
 Frequent use of escalation wards
 Use of non-medical areas for medical purposes
 Trust activity analysis
Patient moves are not consistently tracked

The review panel requested data on patient moves and it was not available
Focus Groups
 Junior Doctors
 Nurses
 Consultants
KLOE 6: How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is the
Trust taking to address the key themes emerging?
The Trust is not proactive enough in routinely seeking feedback from its patients
Public Listening Events
 Frustration that their voice is not being heard
 Raise complaints and hear nothing from the Trust
 Few public meetings held and not held in harder to reach parts of the Trust
catchment area
Interviews
 PALS
 Complaints Officer
The Trust understands the key themes arising from patient experience data but this
information is not translated into action
Interviews
 Clinical Executive Group
 Director of Nursing
 Medical Director
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Theme
Evidence Base
KLOE 7: What do staff groups interviewed (including trainee / student groups) say are the main barriers in the Trust to delivering high quality treatment and care
for patients?
Morale amongst many staff in the Trust is low and this is reflected in the feedback the Panel received from all staff groups. It was recognized that the CEO has made
positive steps to engage staff but this needs to be translated into action plans and improvements quickly. Many junior staff reported a culture of bullying where incidents are
covered up and ideas for improvements are discouraged. The Board will need to tackle this issue if it is to succeed in transforming the hospital.
The key themes and concerns identified in this KLOE have been covered elsewhere and can be summarized as follows:
 Lack of accountability for patient quality and safety
 Potentially unsafe emergency care pathway
 Inconsistent clinical management
 CIPS programmes have left staff stretched

Lack of senior oversight particularly out of hours and at weekends
KLOE 8: How does the Trust approach workforce planning including skill mix to ensure that patient safety is managed effectively?
Patient safety has not been at the heart of workforce planning
Interviews
 Director of Nursing
 Medical Director
 Director of Finance
 HR Director (interim)
 Director of Organisation Development and Communications
Public Listening Events
 Lack of staff in some Wards, particularly acute and elderly wards has led to low
staff morale and absence of staff to help patients use the toilet and eat
 Delays in assessment and referral and diagnostic tests
Focus Groups
 Nurses
 Junior Doctors
 Consultants
52