The Dudley Group NHS Foundation
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
Key Findings and Action Plan following Risk Summit
July 2013
Contents
1.
Overview
3
2.
Summary of Review Findings
6
3.
Risk Summit Action Plan
Appendices
Appendix I:
14
18
Risk Summit Attendees
19
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1. Overview
A Risk Summit was held on 6 June 2013 to discuss the priority findings and actions of the Rapid Responsive Review (“RRR”) of The Dudley Group NHS Foundation Trust.
This report provides a summary of the discussion held, including the Trust response to the findings, any support required from the risk summit attending organisations,
including the regulatory bodies and the agreed actions and next steps.
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
1
(HSMR) .
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.
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Definitions of SHMI and HSMR are included at Appendix I of the full Rapid Responsive Review report published here http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
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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:


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 followed a three stage process and this report documents the conclusions of Stage 3:

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 http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/publishedreports.aspx
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.
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The two day announced RRR visit took place at the Trust’s main site on Tuesday 7 and Wednesday 8 May 2013 and the unannounced visit was held on the evening of
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Tuesday 14 May 2013. A further unannounced visit took place on Wednesday 15 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 pack. The KLOEs and methods of investigation
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are documented in the Rapid Responsiveness Review Report (RRR) for The Dudley Group NHS Foundation Trust. A full copy of the report was published on 16 July 2013
and is available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

Stage 3 – Risk summit.
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies. The risk summit 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. (Please see Appendix I for a list of attendees).
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The Dudley Group NHS Foundation Trust Risk Summit was held on 6 June 2013. The meeting was Chaired by Paul Watson (Regional Director - Midlands and East, NHS
England) and focussed on supporting the Trust in addressing the urgent actions identified to improve the quality of care and treatment. The opening remarks of the Risk
Summit Chair and presentation of the RRR key findings were recorded and are available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/publishedreports.aspx
This report documents the Trust response to the priority RRR findings and summarises the discussions and actions arising.
Conclusion and Priority Actions
The RRR identified that the Trust was on an improvement journey in relation to quality and patient experience and there were a number of areas of good practice, although
these could not be evidenced as in place systematically throughout the organisation.
The Trust has not taken opportunities to use its mortality review process to systematically improve quality of care across pathways and at speciality level. The panel found
some urgent concerns which may impact on the quality of care and treatment being provided to patients. These included:

Inadequate qualified nurse staffing levels on some wards, including two large wards which needed to be reviewed in light of concerns raised by the panel

Shortfalls in learning from serious incidents and complaints

A complaints process which is not fit for purpose and does not adequately respond to patients needs

A number of patient safety and quality processes not being consistently applied at ward level – these were escalated to the Trust and immediate action taken by
management

Further work is needed at Board level to simplify the quality governance processes and communicate this to staff, as well as reviewing the performance information
required to obtain more complete assurance on quality improvement.
Staff were committed to the Trust and to providing great care but improved clinical leadership at all levels of the organisation and better communication of quality priorities is
needed to harness this and drive real improvement.
The Trust has responded positively to the review process with some urgent issues already addressed and many others actions are well underway. The Trust accepted the
findings and welcomed the support of risk summit members to increase the pace and focus of improvement. Further support was offered to develop clinical leadership with
input from NHS England and NHS Leadership Academy to embed accountability and ownership for quality improvement in the organisation.
Next Steps
A detailed plan addressing each of the recommended actions in the RRR report would be completed by the Trust by the end of July 2013. Progress against this will be
monitored by the local Quality Surveillance Group and a follow up review will be undertaken in November 2013 to review the actions taken by the Trust.
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2. Summary of Review Findings
Introduction
The following section provides a summary of the Review Panel’s findings and the Trust’s response to the risks identified. The detailed findings are contained in The Dudley
Group NHS Foundation Trust RRR Report.
Overview of Trust’s response
The Trust’s response was presented by Paula Clark, Chief Executive, who was also supported by the Medical Director and Director of Nursing. The Trust thanked the panel
for their review and reflected that the findings recognised that the organisation was on a development journey. The Trust’s Board had already identified many of the issues
found by the panel and was already making improvements. The Trust was committed to providing high quality services for its patients and would continue to progress on its
journey and provide ongoing assurance that the issues identified by the review were being addressed.
Summary of Review Findings
1.
The Trust’s quality governance arrangements are complex and were not embedded consistently below Board level
The Trust’s quality governance arrangements are complex and included numerous patient safety, incident reporting and other quality groups, with unclear reporting
lines in practice. The Clinical Quality Patient Safety and Experience Committee agenda is very full and the Trust has recognised that more time is needed to be spent
on patient experience and workforce performance.
Many staff, including clinical directors could not articulate their clinical governance roles effectively and the Board’s quality priorities were not embedded at ward level.
Finally there is more clarity needed on the arrangements for ensuring the quality impact of cost improvement plans are monitored once implemented.
The Risk Summit discussed the fact that clinical leadership development would be important and the Trust asked for further support from NHS England to develop a
robust plan to engage and upskill its clinical directors as well as other clinical leaders.
Recommendation:
The Trust should review its quality governance arrangements to develop and consider how it can embed these further at directorate and ward level.
Trust response
The Trust has engaged Deloitte’s to conduct a review of our quality governance structure against the Monitor quality governance framework. This will be reported to
Audit Committee. This review will take into account the planned operational restructure. It will also review communication and information cascade systems in general
and specifically in relation to quality governance to improve staff understanding of the key processes
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2.
Systematic learning from incidents, reviews and complaints was not clearly evidenced by the Trust
The Trust did not demonstrate that it systematically uses learning from incidents, root cause analysis (RCAs) reviews and insights from feedback and complaints to
improve the quality and safety of care in the hospital. Detailed findings included:
 Reviews of incidents and root cause analysis were mixed in terms of the quality of analysis and identifying lessons for sharing across the Trust.
 There were a number of areas of the Trust which could not demonstrate clear actions taken following incident reviews and external reviews.
 Response to complaints were not always compliant with the requirements and did not always meet complainants need.
 Missed opportunities for triangulation of data and targeting areas for improvement.
 Lessons learnt from reviews, RCAs and complaints did not appear to be disseminated effectively at ward level.
Recommendation
The Trust should review how it can embed a culture of learning from incidents, RCAs, complaints and mortality reviews, including reviewing data more systematically to
target improvements. The Trust should also review its complaints process to ensure that it is fully addressing the Ombudsman’s requirements and there is adequate
resource to support this.
Trust response
The Trust plans to include these actions and improvements in its quality governance review but has already taken immediate action, including:
• Appointment of an Investigation Manager, tasked with ensuring that incident reporting is robust, investigations are completed in a timely manner and there is better
sharing learning and monitoring of results.
• Amalgamation of complaints and Patient Advice and Liaison Services (PALS) teams from October 2013 as part of the planned organisational restructure.
• Review of complaints processes against the Ombudsman’s requirements.
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3.
The Trust’s mortality review process is currently not identifying opportunities for systematic improvement
The Panel was concerned that the Trust’s understanding of mortality data has focused mainly on improving coding to date and many senior staff interviewed referred to
inaccurate coding and the health of its patients being a root cause of its higher mortality indicators during the review period. The Trust is not maximising the
opportunities to use the available data and its mortality system to improve services and care pathways, for example targeting specialities with high mortality indicators
The Board has had insufficient scrutiny on mortality at a diagnosis/speciality level and has not aligned its review process within its overall quality governance
arrangements. There were also differences noted in terms of the approach and quality of directorate mortality reviews and how this learning was being applied.
Recommendation
The Trust needs to consider how it will review mortality data more systematically and use this alongside its learning from directorate reviews to target improvement
actions more effectively.
Trust response
The Mortality and Morbidity (M&M) review meetings are now clearly in the performance structure through the Clinical Safety Quality & Patient Experience committee
and directorate performance review meetings.
It is now linking mortality tracker to M&M meetings and involving the clinical coders at those meetings. Further the Trust is planning to join the North West Advancing
Quality Alliance (AQuA) programme and has started auditing against the AQuA checklist.
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4.
The Trust has capacity challenges which its operational management procedures are not addressing fully
The Trust has had consistently high activity levels in recent months and has had challenges with meeting accident and emergency (A&E) waiting time targets. Staff and
patients interviewed consistently spoke of how busy the hospital was. Throughout the RRR visit the panel identified evidence of poor bed management and flows
including:
• Use of escalation areas over extended periods.
• Emergency Assessment Unit (EAU) being used for longer term stays.
• Inconsistent management of patients who were outliers on wards.
• A number of patients were found to be waiting on trolleys in EAU on an early morning visit.
• The current beds management and discharge process did not appear to be effectively addressing the capacity challenges.
It was noted in the risk summit that the area’s urgent care pathway plan was not currently sufficient to address the capacity challenges so the Trust, NHS England area
team and Dudley Clinical Commissioning Group (CCG) would need to work together to improve this by the next submission in July 2013.
Recommendation
The Trust’s system for bed management, patient flows and discharge need to be urgently reviewed and improved to address operational effectiveness issues and
improve patient experience
Trust response
The Trust has already invited the Emergency Care Intensive Support Team invited in and is planning to invite them back at end of 2013 to review progress against their
recommendations. It is planning a specific review and follow up in its elderly care specialty, given the issues noted in this area.
The Trust is rolling out electronic whiteboards for wards to improve bed management. These are currently being installed and will enhance the system already in place
for Admission, Discharge and Transfer.
The Trust will continue to work with the CCG and Local Area Team on urgent care planning and management as part of the wider Urgent Care Strategy work.
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5.
The Board’s patient experience strategy needs further development and embedding at ward level
The Board has not agreed an effective patient experience strategy with measurable outcomes. Its current strategy was discussed by the Risk Summit attendees and,
whilst it was recognised that there had been work undertaken by the Trust to develop the strategy, it needed a full review to ensure it was owned off by the Board before
it can be properly embedded in the organisation.
Patient experience measures, including the Friends and Family Test (FFT), were not embedded in all wards and many staff could not describe the action taken in
response to feedback. There was a perception from senior medical staff that FFT was seen to be a nursing not a medical issue.
There were consistent patient feedback themes identified in the review that the Trust did not have a strategy to address effectively. These included poor communication,
admission and discharge issues as well as a lack of nursing care on wards.
Recommendation
The Trust Board has more work to do to agree a patient experience strategy with clear performance metrics, embed this and demonstrate that it is effectively monitoring
performance.
Trust response
The Trust will agree the delivery of a Patient Experience Strategy including metrics, linking with the CCG to further develop this during summer 2013. The Trust has a
real time in house patient feedback system (which had over 10,000 patient comments in 2012) so it will build on this, along with the outputs of a patient experience rapid
improvement event last year, to improve staff engagement on this important area.
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6.
The Trust’s nurse staffing levels/skill mix need urgent review along with some other staffing issues identified
The Board has not reviewed overall staffing levels since 2011 and it does not monitor workforce information systematically to focus on risk areas, for example wards
with high numbers of falls or incidents.
The review identified that management of ward staffing was inconsistent on wards and e-rostering was not routinely in use. Nurse registered to unregistered staffing
ratios on some wards were found to be below national recommended benchmarks. The Trust has two large wards with 72 and 48 beds which had serious staffing level
concerns and needs urgent further review.
Other high priority issues noted related to staffing included:
 The Trust has very low national staff survey response rates which needs further investigation and action.
 The Trust’s mandatory training rates are lower than expected in some key areas.
 The panel identified concerns that staff engagement in theatres may be an issue and there was further investigation needed to ensure the findings from a whistleblowing incident had been fully addressed.
Recommendation
The Trust should review its current staffing levels for nursing and medical staff using a nationally recognised tool; it should then action any changes required for
improving both the quality and safety of care. There is an urgent action identified to make sure that nurse staffing levels are assessed using an evidence based
methodology. This should be reviewed in conjunction with the clinical teams to ensure each ward has appropriate nurse staffing levels and the appropriate ratio of
registered to unregistered nurses on all wards.
The Trust should review how it can improve engagement in the national staff survey. It should further review staff engagement in theatres, following up the external
review undertaken in 2012.
Trust response
The Trust has included staffing levels in the high risk wards on the corporate risk register. It is now following through on a second tranche of the £1.4m investment in
nursing staff over two years, resulting in 18 more qualified nurses. It has added the nurse to patient ratio to its Nursing Care Indicators reviewed by the Board from June
2013. The Trust has already split its 72 bedded ward so it is managed as two separate wards and it has committed to reviewing how it can split the 48 bedded ward
urgently.
The Trust is acting on recommendations for the use of a nationally accepted tool and visiting Coventry to view AUKUH/Safer Nursing Care tool. By Autumn 2013 the
Trust will have implemented a new e-rostering system with Allocate which should improve consistency.
The Trust is implementing its nursing strategy, “The way we care” to reinforce a positive compassionate culture and reporting to the Board quarterly on agreed metrics.
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7.
A number of the Trust’s processes relating to patient safety and quality were not being consistently applied at ward level
The panel found that key equipment and safety checks were found not undertaken and recorded consistently in wards visits including resuscitation and suction
machines, equipment safety checklists, controlled drugs checks.
Recommendation
The Trust should review its processes to ensure all equipment and safety checks are undertaken appropriately.
Trust response
The Trust has acknowledged this is an urgent issue and has rectified it immediately. Daily equipment checks including lead nurse and matron checklists and audits of
compliance now form part of the Nursing Care Indicators (NCIs) June 2013 reported to the Board. The Trust has notified CQC with the steps taken and requested these
are reviewed.
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8.
Consistency of pressure ulcer care including prioritisation of patients and access to equipment
The Panel found that pressure ulcer preventative care was inconsistent across wards and care for pressure ulcers sometimes diverge from the Trust’s guidance. Caring
for patients at risk of pressure ulcers was made more challenging due to equipment availability (some of which related to an external provider).
Recommendation
The Trust should review its processes to provide appropriate care and equipment for patients that are high priority for pressure ulcer prevention. The Trust should also
audit compliance with its pressure ulcer care bundles.
Trust response
•
•
•
Pressure ulcer care remains a high priority reinforced by the Board’s public commitment in the quality accounts focusing on acute and community.
The Trust has immediately rectified the availability of pressure relieving mattresses and now have a buffer stock of 20 on site from Karomed.
The Trust is reviewing the pressure ulcer care bundle audit processes to assess compliance.
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3. Risk Summit Action Plan
Introduction
All attendees agreed the report accurately reflects the current position of the Trust and there was no new information raised. The following section provides a summary of the
discussion and actions agreed at the Risk Summit. The discussion and action plan focused on nine key areas the Trust should urgently prioritise to improve patient safety and
these are documented in more detail in the following table:
Action Plan
Key Issue
1. A review of quality
governance arrangements
and better
communication of them to
staff is required.
Agreed Action & support required
The Trust has engaged with Deloitte to carry out a review on the governance
structure. The "monitor quality governance framework" is being used as a standard
to audit the Trust's structure against. The review with Deloitte will cover how the
Trust monitors the impact of ongoing Cost Improvement Plans.
Owner
Trust
Given that the panel were concerned by the limited understanding of quality
governance from clinical directors, the Trust has agreed to address clinical
understanding as part of a wider development programme following its
organisational restructure. It will be given support by NHS England to develop its
education programme.
2. The Trust needs to
embed a culture of learning
from when things go wrong
and improve its processes to
capture themes from:
 Incidents and RCAs
 Feedback and complaints
 Mortality reviews
The Trust has appointed an investigation manager to ensure that incidents are
addressed and investigated in a timely manner, and there is learning shared to the
Trust from the investigation results.
The Trust has additionally brought in datex checks on incidents. However the route
cause analysis and learning is not always triangulated. The Trust will get external
support to develop a thorough process of incident reporting with regards to learning
and the quality of route cause analysis.
The Trust will additionally implement a daily morning review any serious incidents
that have occurred in the last 24 hours, so that they can immediately follow these up.
Timescale
The Trust has already engaged
with Deloitte, who are currently
scoping the work and
deadlines.
The Trust agreed an
implementation date of end of
August/start of September
2013.
Trust
The investigation manager has
already been appointed.
The Trust will devise an action
plan with external support by
June end 2013, and then
implement this in July/August
2013.
To be followed up at the end of
June 2013.
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Key Issue
Agreed Action & support required
Owner
Trust
Timescale
3. The Trust needs to
consider how it will review
mortality data more
systematically and use this
alongside its learning from
directorate reviews to target
improvement actions more
effectively.
To ensure that every death is looked at appropriately, the Trust will provide data on
deaths at a granular level of detail to the board. The mortality and morbidity review
meetings now are linked to a mortality tracker and involve clinical coders at these
meetings, enabling a more detailed understanding of the Trust's mortality.
4. The Trust’s system for
bed management,
patient flows and discharges
need to be urgently
reviewed and improved to
address operational
effectiveness issues and
improve patient experience.
Emergency Care Intensive Support Team (ECIST) has been invited in to review
processes and their recommendations will be implemented by October 2013. ECIST
will be invited in to review progress at the end of the year.
Trust
October 2013.
Specific follow up of elderly care review will be undertaken.
Trust
Geriatric review: complete by
end June 2013.
Investment in electronic whiteboards for wards is in place and they are currently
being installed.
Trust
E-boards: To be followed up at
the end of June
Educating Clinical Directors
and matrons to be completed
by end of August 2013, and
educating consultants by end of
October 2013.
The Trust needs to address the inconsistent understanding in depth-of-knowledge
around mortality data, especially at a clinical director level. They will provide training
on this for clinical directors and matrons initially, and this training can then be filtered
down to consultants. Non executive directors and governors should also understand
the detail behind mortality data.
Urgent care plan completion - work linked to bed management is part of a wider
externally supported programme that is looking at urgent care planning and
management.
This action is already being
addressed.
Urgent care plan: end July
Trust, CCG and 2013.
Area Team
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Key Issue
Agreed Action & support required
Owner
Timescale
5. The Trust has more work
to do to embed a
patient experience strategy
and demonstrate
that it is effectively
monitoring performance.
The Trust has agreed to review its patient experience strategy with the Board to
incorporate metrics into it’s monitoring. It will meet with local HealthWatch and the
CCG to review this and agree how it can be further developed and embedded in the
organisation.
Trust
Mid July 2013
6. The Trust’s nurse staffing
levels and skill mix
were not found to be
consistently in line with
nationally accepted good
practice.
The Trust will focus on improving the registered to unregistered ratio for nursing staff Trust
in its general wards. The Trust will identify a plan by the end of June 2013 and then
look to appropriately increase the registered staff percentage by the start of October
2013.
October 2013
The Trust has already split the 72 bedded ward down in to at two separately
managed wards and is reviewing its 48 bedded ward to consider how it could
similarly split.
Action to be taken by end June
2013
7. Consistency of safety and
equipment checks.
The Trust has taken immediate action on this issues, with daily lead-nurse and
matron checks are now implemented. Audits of safety and equipment are also
carried out.
Trust
Already actioned but ongoing
Trust
Already actioned but ongoing
No additional support was required.
8. Consistency of pressure
ulcer care including
prioritisation of patients and
access to
equipment.
The Trust has reviewed pressure ulcer care bundles and implemented bundle usage
and compliance as part of a monthly audit review.
No additional support was required.
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Key Issue
9. Theatre staff engagement
Agreed Action & support required
The Trust has agreed to undertake a follow up review of theatres, specifically around Trust
staffing levels and response to an earlier whistle-blowing issue. The Trust will
devise and sign off an action plan for this by the end June 2013.
Owner
Timescale
Once the detailed review has
been completed it will produce
a more detailed action plan by
end of July 2013.
No additional support was required.
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Appendices
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Appendix I: Risk Summit Attendees
Organisation
Role
Name
NHS England
Summit Chair and Regional Director Paul Watson
NHS England
Area Team Director
Wendy Saviour
NHS England
Area Team Deputy
Fay Baillie
NHS England
Regional Dir Ops and Delivery
Sarah Pinto-Duschinsky
NHS England
Regional Medical Director
David Levy
NHS England
Regional Deputy MD
Alistair Lipp
NHS England
RRR Chair & Reg Chief Nurse
Ruth May
NHS England
Regional Deputy Chief Nurses
Sylvia Knight and Lyn McIntyre
NHS England
Senior Regional Support
Alastair McIntyre
The Dudley Group NHS
Foundation Trust
Chief Executive
Paula Clark
The Dudley Group NHS
Foundation Trust
Director of Nursing
Denise McMahon
The Dudley Group NHS
Foundation Trust
Medical Director
Paul Harrison
Dudley CCG
Accountable Officer
Paul Maubach
Dudley CCG
Chair
Dr David Hegarty
CQC
CQC Regional Director
Andrea Gordon
CQC
CQC
Sue Howard
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Organisation
Role
Name
CQC
CQC
Lisa Thacker
Monitor
Monitor Representative
Laura Mills
Healthwatch
Healthwatch Representative
Jayne Emery
Health Education England
HEE Representative
Rob Cooper
RRR Panel
RRR panel rep 1
Ronan Fenton
RRR Panel
RRR panel rep 2
Marcelle Michail
RRR Panel
RRR panel rep 3
Heather Moulder
RRR Panel
RRR panel lay rep
Leon Pollock
PwC
Moderator
Kathy Nelson
PwC
Recorder
Randeep Nandhra
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