The Francis Report: Patients First and Foremost The Findings – What went wrong • Patients and families were not listened to • Multiple warning signs not spotted or acted on • Information not shared and inadequate action taken “The system failed in its most essential duty, to protect patients.” The Findings – Keys themes • • • • • Values and Standards Openness, Transparency and Candour Leadership Compassion and Care Information Addressing the Themes • The CNO’s vision and strategy for Nursing, Compassion in Practice • Authorisation process for CCGs with a clear focus on quality, shaped by the first Francis report • Commitments made in planning guidance, Everyone Counts • Respond to the final report on Winterbourne View • Organisation Development Strategy, as a key driver of cultural change • The National Quality Board and the NHS Leadership Academy will play key roles in shaping the new culture • Sir Bruce Keogh’s investigation into hospitals which are outliers on measures of mortality Patient First and Foremost Collective Commitment • Apologises for failures • Commits to putting patients first and listening • Commits to doing the business of the patient, before that of the organisation or the system, with a direct connection to patients and frontline staff • Commits to working together to tackle poor care and promote excellent care in a spirit of openness and candour “Changing ourselves, our behaviour, individually and institutionally, is difficult, but we pledge to do so.” Patient first and Foremost: Initial Response Preventing Problems Detecting Problems Quickly • Time to Care and Space to lead • Focus on Safety (Berwick Report) • Chief Inspectors • Staff and Patient voice • Ratings • Statutory duty of Candour Taking action Promptly • Fundamental Standards • Single Failure Regime Ensuring Robust Accountability • HSE Powers • Professional Regulation • Barring Failed Managers Ensuring Staff are Trained and Motivated • Training • Leadership • Revalidation