NHS WEST MIDLANDS STRATEGIC HEALTH AUTHORITY
PATIENT SAFETY AND QUALITY ASSURANCE
REPORT ON THE RAPID ASSESSMENT VISIT TO
UNIVERSITY HOSPITALS OF NORTH STAFFORDSHIRE
on 20 April 2009
1. INTRODUCTION
The SHA, through its performance assessment process of safety and quality of care provided
by acute hospitals, identified four acute hospitals that appeared to under perform. In order to
clarify and better understand the quality of care provided by these hospital trusts the SHA
board agreed a formal visit to the trusts should be undertaken in conjunction with paper based
analyses of safety and quality performance indicators. University Hospitals of North
Staffordshire Hospitals NHS Trust (UHNS) as one of four hospital trusts was the first of these
visits and as such, the learning by the SHA team has informed subsequent visits. For UHNS
the predominant concerns related to the urgent care pathway.
The Trust was informed of the visit through discussion with the Chief Executive with
subsequent follow up in writing. Both Stoke PCT (as the coordinating commissioner) and the
Care Quality Commission were briefed and invited to join the visit.
The visits were not intended to be a full clinical service review, nor were they a formal
inspection (as would be undertaken by a regulator) but an appreciative enquiry that sought to
complement policy and indicator analyses with considered views from patients and staff and
direct observations of clinical settings. As such, the visiting team was mindful of the limitations
of this approach i.e. anecdotal comment and observations may or may not reflect the reality of
the situation and therefore the team has sought to undertake a balanced approach to the visit
and the considerations contained within this report.
2. SCOPE OF THE REVIEW
The purpose of the visit was to undertake a rapid assessment of the trust’s overall position on
the provision and governance of clinical services pertaining to the urgent care pathway,
including an assessment of patient safety and experience. In addition, a brief assessment of
the critical care pathway was undertaken given the previous serious untoward incidents.
The visit focussed on:
•
Leadership and governance arrangements within the Trust on quality and safety
issues
•
Rapid review of the aforementioned clinical areas which included
a. visiting the areas
b. meeting a cross-section of clinical staff to see and hear first-hand about
the provision of patient services
c. meeting a cross-section of patients and carers in a focus group setting or
similar to assess their experience of these services
d. assessment of clinical staffing levels in the clinical areas visited
•
Issues/concerns raised through a number of different sources available to the
SHA such as national reporting from regulators, serious untoward incident (SUI)
reporting and actions taken, performance against key clinical indicators such as
Health Care Associated Infections (HCAIs) and reports from the postgraduate
medical training visits.
•
Other matters that arose from the visit.
The visiting team included three SHA Directors accompanied by clinical staff from the
coordinating PCT and external clinical staff. In addition, the Care Quality Commission was
invited to send an observer. Full details of the visiting team and the schedule for day 1 of the
visit are detailed in appendices 1 and 2 respectively.
The visit took place on Monday 20 April 2009 with two unannounced visits (out of hours) on
Wednesday 22 and Thursday 23 April.
At the end of the first day, feedback was given to the chief executive that comprised immediate
actions that needed to be taken and actions that need to be undertaken in short term, within
the next 3-6 months as well as areas of good practice observed by the team.
3. IMMEDIATE FEEDBACK TO CHIEF EXECUTIVE
Good Practice
• Every patient observed and spoken to was positive about the care they were receiving
and appeared well cared for
• The Patient Stakeholder Group involving patient groups was very complimentary about
the transparency of the Board
• Clinical management of patients with fracture neck of femur
• Productive Ward – these wards felt calm and organised and had a positive feel about
them
• Electronic handover system on Ward 21
• Control Centre at Infirmary site in A&E was impressive
• Preceptorship on Thoracic Ward
• Good Consultant Physician engagement was observed by the team
Immediate Issues for Urgent Action
• Cardiothoracic Ward – there were concerns about environmental cleanliness, dirty
commodes, dirty linen
• There were concerns regarding linen trolleys and waste management in a number of
ward areas
• Patient wash bowl policy was not aligned to best practice and compromised patient
safety
• Concerns about low level of staffing, nursing staff ratios in paediatric A&E
• The Trust doesn’t comply with the mixed sex accommodation guidance in relation to
signposting toilets
• On Ward 24, the most senior nurse was a Band 6 with no clearly defined nurse
leadership role for the ward
• In the Medical Review Area, the sluice was in a poor state.
Issues/Concerns to be addressed within the next three to six months
On discussion with the Chief Executive, it was apparent that the Trust itself had already
identified it needed to take action in most if not all of the following areas. However, the team
would recommend that the trust accelerates its action on:
• Collecting and responding to patient experience metrics in real time feedback
• Developing and implementing a patient and public engagement strategy
• Staff engagement strategy that includes internal communication
• Training and development of staff, especially in A&E but perhaps more generally
across the Trust
• A proactive information campaign with external partners about the trust’s priorities,
including the local media
• Development of an overall quality plan that incorporates the five points above
• Review of the Matron’s role as currently the role has a disproportionate amount of the
matron’s time focussed on administrative/managerial tasks and not enough on direct
contact clinical care duties
• Clarify for staff as to how patients with particular conditions entering the urgent care
pathway are managed such that they are not being moved unnecessarily and frequently
from one clinical area to another
• Undertake audits of the implementation of the policies and processes of the patient
pathway flows in urgent care to ensure success of the change in policies and that safety
and patient experience are improved within the urgent care pathway.
4. OTHER FINDINGS
Leadership
Whilst in our meetings with both staff and patient groups there was positive recognition of the
Board’s transparency and in particular the visibility of the Chief Executive. We are aware that
the Trust have made changes to nurse leadership since our visit. In addition, it was noted that
the trust is aware of the need to strengthen leadership and management in Medicine and A&E,
both managerial and clinical and is in process of addressing this.
Strategy & Governance
With respect to an explicit strategy for safety and quality, whilst the trust has lots of good
documentation there is lack of clarity about the priority areas. This was tested in our
conversations with the Chief Executive, Medical Director or Nurse Director and it was not
readily evident what the focus for the trust is in relation to quality.
We would recommend that the trust needs a quality plan/strategy that incorporates the
following:
• Clear articulation of priorities in relation to patient safety, patient experience and clinical
effectiveness
• Clarity about the respective roles of the Chief Executive, Board Directors, in particular
the role of the Medical Director and Nurse Director
• Clear ownership within the organisation with staff engagement
• Monitoring and learning from implementation – in essence the grounding of the plan.
Infection Prevention & Control
Whilst there have been significant improvements achieved in MRSA and Clostridium difficile
infection rates over the last 12 months, more needs to be done to build a strong culture and
sustainable improvements in infection prevention and control within the Trust. Our evidence
for forming this conclusion is based on our observations during the visit, separate HCAI team
visits and other source documentation (such as the audit undertaken in the renal unit).
We would recommend the trust gives attention to:
• Ownership of the HCAI agenda from board to ward with particular ownership and
accountability at directorate level. There is heavy reliance on one individual, which has
enabled the trust to achieve the reductions in infection; however, this now needs
embedding and owning so that the impetus for infection prevention is not resting on one or
more individuals
• Enforcing accountability across the multidisciplinary team, particularly medical staff
• Engagement of the multidisciplinary teams that at times has not been evident in root cause
analysis (RCA) or some of the outbreak meetings
• Need for clear process and pace for the management of outbreaks which ensures that
there is executive leadership driving the management of the outbreak and associated
actions
• Lack of ownership at ward/divisional level for the management and maintenance of clean
clutter free environments. Recent observation of clinical environments has indicated clutter,
overstocking, inappropriate storage, inconsistent levels of cleanliness within the
environment and equipment and in places poor waste management.
We recommend that the Trust urgently re-visits its Infection, Prevention & Control delivery plan
as a central part of the quality strategy mentioned elsewhere in this report. This delivery plan
should focus on how sustainable best practice and systems are embedded in the Trust with
strong leadership to create a culture where every member of staff sees infection prevention &
control as their personal responsibility and not solely the job of the infection control team.
Triggered Visit by Workforce Deanery
Concerns had been raised regarding the number of patients being ventilated in theatre
recovery and the potential safety considerations. This was identified via the junior doctor
evaluation forms submitted to the Deanery. The issue was when there was lack of ITU beds;
this resulted in junior anaesthetists and recovery nurses having to manage patients. A number
of recommendations have been made to the trust for immediate action and the Deanery will be
following up actions at 3 and 6 months.
Mortality
UHNS has consistently had a low hospital standardised mortality ratio (HSMR) as published
by Dr Foster and to the SHA’s knowledge the trust has not been subject to a (RTM) alert that
leads to a CQC letter asking for further information.
However, the SHA is developing a methodology of examining deaths including rises in deaths
at weekends across the region and preliminary, unvalidated data suggests that trusts will need
to consider auditing mortality at weekends to ensure that this is not a reflection of poor staffing
levels and/or access to senior medical cover. This issue will be followed up separately with the
trust.
5. RECOMMENDATIONS
The Trust needs to:
1. Develop a quality plan that incorporates explicitly priorities around patient safety, patient
experience, and clarity around the leadership role of the board directors and has effective
staff engagement and ownership.
2. Urgently address the concerns raised by the RCN about senior nursing leadership.
3. Urgently revisit its Infection Prevention & Control delivery plan as a central part of the
patient safety strategy with a particular focus on how best practice and systems are
embedded within the Trust.
4. Strengthen clinical and managerial leadership within the A&E department.
5. Audit patient pathway flows within the urgent care pathway to assure itself and the
commissioner that patient safety and patient experience is not being compromised.
6. Ensure the role of the matron is rebalanced with respect to clinical and administrative
duties.
7. Review levels of nurse staffing in ward 24 and paediatric A&E.
8. Ensure compliance with recommendations arising out of the Deanery visit regarding
patients being ventilated in theatre recovery areas inappropriately.
9. Audit deaths that occur at weekends, with a focus on complex medical elderly admissions,
to determine if further action is required to maintain high quality, safe service.
6. SUMMARY
The Chief Executive and her team are tackling much of the work to address the concerns
identified in this report.
The PCT will be expected by the SHA to monitor progress via the PCT’s clinical quality review
process with support from the SHA as required.
Given that a number of actions are required to be completed within a 3-6 month timeframe,
and there is a need for ensuring sustainability of the actions taken, a further visit to the trust
will take place in October 2009.
NHS West Midlands Visit Team
May 2009
Update provided to the StHA. September 2009
Re: SHA Quality Assurance Visit to the University Hospital of North Staffordshire
(UHNS) on 20 April 2009
Following the Quality Assurance visit by the Strategic Health Authority at UHNS on 20th April
2009 which focussed on leadership and governance arrangements, a series of actions have
been in place, and are still ongoing to address the issues raised.
The report and a synopsis of the findings have been circulated and discussed by Executive
and Non Executive Directors within the Health Economy.
An outline of the work being undertaken is provided below.
Response to specific issues raised within the report from the Strategic Health Authority by
UHNS
An action plan to address all the areas has been developed by UHNS.
The immediate issues raised including the cleanliness of one ward, the sluice in one area and
linen trolleys and waste management were rectified immediately.
A review of staffing levels in A&E has been completed and is being addressed through the
Urgent Care Pathway work.
The signage to all bathrooms is being reviewed and will be completed by October 2009.
The role of band 6 nurses is being reviewed across all adult ward areas, and will be completed
by November 2009.
The issues requiring to be addressed within three to six months are all included in the action
plan.
A skills analysis of all nursing staff, the development of a quality strategy and a review of the
matrons roles have all been undertaken.
A series of initiatives are in place to improve communication. These include the development
of strategies to improve commutations both internally and with the public and patients.
Amongst these are the planned ‘Big Conversations’.
Clarity on the Emergency Care Patient Pathway is being addressed by a series of audits and
also the Health Economy work with ATOS.
The strengthening of clinical and managerial leadership has been addressed by the
recruitment to key posts inparticular the acting Chief Nurse at UHNS.
Clinical Quality Review Meetings
The visit and the actions from the visit have been discussed at each Clinical Quality Review
Meeting (CQRM) since the visit.
The full report was tabled on the 22nd July following receipt from the StHA on 13th July.
The Clinical Quality Review Meetings were assured that the immediate concerns had received
attention.
The issues / concerns to be addressed within three to six month were also being addressed.
These include the development of a Quality Strategy and real time patient metrics, and an
engagement programme with staff and partners, and the development of an Infection Control
Strategy.
The CQRMs continue to review, amongst other things, action taken in relation to patient safety
across the Trust, including A&E, Serious Untoward Incidents, CQUINS, action taken by the
Trust to review performance against CQC reports, performance reports, national reports and
guidance, clinical audits, Standards for Better Health compliance, compliance with NICE
guidance, quality metrics, and regular performance, patient, safety and Healthcare Associated
Infection reports.
Infection Control and Prevention
The Health Economy continues to work together to address Healthcare Associated Infections.
A regular meeting of the Directors of Infection Prevention and Control takes a strategic
approach to problem solving and developments.
There is a Health Economy Root Cause Analysis (RCA) meeting which looks at the RCAs and
indentifies and acts on issues and agrees improvements. Due to the rise in HCAIs early in the
year a review of the RCAs was undertaken and suggestions for improvements made. The
StHA have also reviewed the RCAs and provided advice, support and guidance.
The SHA undertook a visit on 21st May 2009 to UHNS and it was reported that the visit was
positive, with improvements noted. An Infection Control Strategy has been developed within
UHNS.
A further meeting took place on 25th August 2009 with the StHA, Commissioners and the Trust
to discuss the current position. This included feedback from a visit to one ward by the StHA.
Quality Review Visits
Following the SHA visit UHNS agreed that a schedule of clinical service reviews to be
compiled and carried out by members of the UHNS Executive Team on a regular basis
mirroring the SHA review approach. All members of the Executive Team are to take part and
Directorates are to be required to provide an evidence file prior to the review date for
Executive Team to agree the areas to cover by the review team ahead of the visit. This was
approved at the Executive Committee and the first visit took place on 3rd July 2009 to
Neurosurgery.
The PCT also outlined their intentions to undertake reviews in line with the SHA approach via
the monthly Clinical Quality Review Meeting. It was agreed that we would meet with members
of the group to join up the proposed reviews to ensure that staff in areas were not
overwhelmed with too many visitors. The first joint visits took place on 14th August 2009 in
Cardiothoracic Surgery.
The PCTs will be fielding GP colleagues as well as Directors on the visits. A programme has
been agreed with UHNS, which will be undertaken in partnership with the UHNS Executive
team. These would then be reported back both within the organisations and at the Clinical
Quality Review Meetings.
Additional visits will be undertaken by the PCT as issues arise or as a follow up to the visit. A
subsequent visit following the August 2009 visit is already being arranged.
The programme of visits is outlined below.
Area
Neurosurgery
Cardiothoracic
Spines
Frail Elderly (inc hospital acquired VTE)
Gynaecology Cancer
Paediatrics
Renal
Maternity
Critical Care
Pathology
Month
July 2009
August 2009
September 2009
October 2009
November 2009
December 2009
January 2010
February 2010
March 2010
Ad hoc (to be slotted in as an extra visit)
West Midlands Quality Review Service
The West Midlands Quality Review Service has been set up, supported by funding from PCTS
and Trusts in the region to provide a robust framework of quality assurance across portfolio’s
of services. This service is only just being set up but the areas that have been prioritised are
critical care, end stage renal failure, paediatric critically ill follow up visits. These will provide
further assurance and information for the Health Economy. The current (and previous) system
of peer review visits already forms part of the review of clinical services. Colleagues from the
Health Economy are attending the training sessions schedules for September in relation to
undertaking these reviews.
Commissioning for Quality and Innovation (CQUIN)
High Quality Care for All included a commitment to make a proportion of providers’ income
conditional on quality and innovation, through the Commissioning for Quality and Innovation
(CQUIN) payment framework.
CQUINs have been agreed as part of the contract and for 2009/10 cover the following:•
•
•
•
•
•
Timely and effective discharge process
Sharing of open daily episodes file
Assessment by senior grade doctor of majors in A&E
Reducing clinic transit time
Inpatient dignity and respect
Serious untoward incident reporting
The CQUINs cover some of the areas raised with the Quality Review process and provide one
further source of feedback and evidence of quality improvement.
These are discussed at the CQRM, as well as specific meetings with UHNS. Discussions are
already taking place on the possible CQUINs for 2010/11.
Dr Foster
Both organisations are accessing the Dr Foster information and using it as part of the
approach for understanding the issues and improving quality. This is both in terms of routine
benchmarking data and also interrogation of specific pieces of information. Where these are
identified they are tabled at the CQRM and subsequent feedback requested.
We understand a further visit is planned for October 2009 and look forward to hearing from
you regarding the date and arrangements for this.
We have attempted to cover all of the items on which you requested assurance but, if we have
missed anything, please let us know as soon as possible.
Kind regards
Yours sincerely
J C BRIDGEWATER (MRS)
CHIEF EXECUTIVE
GRAHAM URWIN
CHIEF EXECUTIVE