Monday 04 Feb 2008 @ 16:43
Care Quality Commission
Care Quality Commission
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GOOD LEADERSHIP AND MANAGEMENT ARE KEYS TO AVOIDING FAILINGS IN PATIENT
Healthcare Commission sends message to NHS on learning from 14 investigations
The Healthcare Commission today (Monday) urged boards of all NHS trusts in England to heed the lessons from serious failings in healthcare services.
It highlighted the importance of good leadership, effective management and systematic use of information.
The Learning from investigations report reviewed all investigations undertaken by the Commission under its statutory powers from August 2004 to April 2007. Investigations are undertaken where patient safety is seriously at risk.
The report highlights clear common trends in the investigations the Commission has undertaken: poor leadership, ineffective management, inadequate teamwork with staff feeling unable to communicate problems and a lack of clarity about who was responsible for what across the trust.
A common trend in failing trusts has been NHS boards concentrating on some of their activities, such as the delivery of targets or mergers, at the expense of others.
The Commission said all organisations face change and have to deliver on objectives. The message from the findings of investigations is that trust boards need to do this and deliver on the basics of quality of care and safety.
The Commission was surprised that many boards involved in investigations did not have systems in place to ensure they were routinely informed of key information such as rates of infection and measures of quality of care. This meant that boards were unable to spot problems and take steps to fix them.
In the time period covered by the report, the Commission’s investigation team dealt with more than 200 referrals claiming serious breakdowns in healthcare in NHS trusts.
Referrals came from a range of sources, including staff at the Commission, organisations representing patients, members of the public or even the trusts themselves.
All referrals were thoroughly considered and many were followed up by undertaking spot checks and interviews with staff.
About one in six cases resulted in some form of intervention by the Commission’s investigations team, including 14 cases in which it launched a full formal investigation. The Commission will launch an investigation where it finds evidence of serious failure but the causes are unclear or the trust’s ability to rectify the problems itself is in doubt.
The Commission has carried out 14 investigations since August 2004. The report covers the first 13 investigations. The latest investigation into infection control at Maidstone and Tunbridge Wells NHS Trust, published in October 2007, highlighted many of the same concerns.
The Commission conducted two investigations into learning disability services, three into maternity services, two on infection control and two about bullying and harassment. Other investigations covered specific clinical areas such as gastroenterology, cardiac services, management of medicines and emergency care.
Following an investigation, the Commission makes recommendations aimed at addressing immediate problems and making improvements in the longer term, as well as recommendations on national practice where appropriate.
The Commission works with the trust and the strategic health authority to ensure action plans are implemented and improvements are made. The Commission makes follow-up visits to each trust after one year to ensure progress is on track and make further recommendations if necessary.
The Commission always aims to work cooperatively with trusts on improvements and avoid formal escalation to the Secretary of State unless absolutely necessary.
However, on three occasions, the Commission deemed that the trust was not capable of implementing the necessary change without outside help and formally recommended “special measures” to the Secretary of State.
Anna Walker, the Commission's chief executive, said: "Good leadership means not taking your eye off any aspects of the trust’s activities - no ifs and no buts.
“In practice, this means ensuring staff are encouraged to speak up about concerns. Given that modern medicine involves risk, it means monitoring these risks and ensuring that issues such as infection control are high on the management agenda.
“It also means never underestimating what it takes to manage change, as well as ensuring those most in need are looked after properly. Above all, it means boards putting systems in place to turn their vision of quality care into a reality on the wards.
"There are trusts across the country that are succeeding at doing all of this while still managing change and meeting targets.”
Ms Walker added: “We have produced this report to help trusts understand the factors underlying the serious failures we have investigated. If it helps patients get better care and trusts avoid problems, it will have achieved its objective.
“As a Commission, we have been very encouraged by trusts’ willingness to debate and learn from our investigations. In all cases where we carried out an investigation, the trust concerned has made significant improvement as a consequence.”
The Learning from Investigations report highlights striking common themes in the Commission’s investigations:
· Leadership and management: Poor leadership was a problem in nearly all of the investigations carried out by the Commission.
Some boards had been focused on mergers or targets at the expense of their broader activities.
Lack of continuity in leadership was a problem in some trusts, where
frequent changes in management were a factor in poor care. Bullying
and harassment by managers was a factor in two cases investigated.
The Commission found there was a fine line between promoting change
vigorously and bullying.
Investigations often uncovered a breakdown in leadership and
management, with a lack of clarity on responsibilities from board to
ward. Poor teamwork, either between management and clinicians or
between clinicians themselves was another common factor in failings.
· Use of information: The Commission was surprised that most of the trusts investigated did not have adequate systems in place to routinely inform the board of trends or potential problems. Board members must assure themselves about the quality of services for which they are responsible and need data to do this professionally.
· Mergers and restructures: Seven of the trusts investigated had recently undergone mergers or significant organisational change. The message from the Commission’s investigations is that where significant change is taking place, the management task should not be underestimated.
· Safeguarding vulnerable adults: Poor understanding of adult protection procedures and responsibilities was a serious problem in the two investigations into learning disability services and also a number of interventions in trusts. The Commission said staff need good training to understand their crucial role in protecting vulnerable adults.
· Poor care on general wards: When its investigations looked at acute hospital care, the Commission noted that care on general wards fell well below the care provided on specialist wards. Older patients were most at risk as they were often most dependent on good nursing care. The Commission will monitor this aspect in future investigations to identify whether this
is an emerging common theme.
The Commission made recommendations to the wider NHS based on its experience of conducting investigations. It said that:
· Senior managers must actively elicit views about safety from frontline staff.
· Every board member should ensure that information and trends are reported to them and acted on.
· Boards and senior managers must allocate time to look at whether they are meeting the needs of vulnerable patients
· Trusts should have systems to improve services and safeguard patients that are part of its everyday functions, not added on at the end
Notes to editors
The Healthcare Commission conducted 13 investigations from August 2004 to April 2007: (1) Royal Wolverhampton Hospitals NHS Trust; (2) Mid Yorkshire Hospitals NHS Trust; (3) Bolton, Salford & Trafford Mental Health NHS Trust; (4) North West London Hospitals NHS Trust; (5) Devon Partnership NHS Trust; (6) East Sussex Hospital NHS Trust; (7) Mid Cheshire Hospitals NHS Trust; (8) Hull Royal Infirmary and Humberside Ambulance Service NHS Trust; (9) Cornwall Partnership NHS Trust; (10) Buckinghamshire Hospitals NHS Trust; (11) North West London Hospitals NHS Trust; (12) Sutton and Merton Primary Care Trust; (13) Oxford Radcliffe Hospitals NHS Trust. There was a 14th investigation completed after April 2007 at Maidstone and Tunbridge Wells Hospitals NHS Trust.
Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.
Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.
The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.
For further information contact the press office on 0207 448 0868, or on 07795 548 541 after hours.
The Healthcare Commission today (Monday) urged boards of all NHS trusts in England to heed the lessons from serious failings in healthcare services.
It highlighted the importance of good leadership, effective management and systematic use of information.
The Learning from investigations report reviewed all investigations undertaken by the Commission under its statutory powers from August 2004 to April 2007. Investigations are undertaken where patient safety is seriously at risk.
The report highlights clear common trends in the investigations the Commission has undertaken: poor leadership, ineffective management, inadequate teamwork with staff feeling unable to communicate problems and a lack of clarity about who was responsible for what across the trust.
A common trend in failing trusts has been NHS boards concentrating on some of their activities, such as the delivery of targets or mergers, at the expense of others.
The Commission said all organisations face change and have to deliver on objectives. The message from the findings of investigations is that trust boards need to do this and deliver on the basics of quality of care and safety.
The Commission was surprised that many boards involved in investigations did not have systems in place to ensure they were routinely informed of key information such as rates of infection and measures of quality of care. This meant that boards were unable to spot problems and take steps to fix them.
In the time period covered by the report, the Commission’s investigation team dealt with more than 200 referrals claiming serious breakdowns in healthcare in NHS trusts.
Referrals came from a range of sources, including staff at the Commission, organisations representing patients, members of the public or even the trusts themselves.
All referrals were thoroughly considered and many were followed up by undertaking spot checks and interviews with staff.
About one in six cases resulted in some form of intervention by the Commission’s investigations team, including 14 cases in which it launched a full formal investigation. The Commission will launch an investigation where it finds evidence of serious failure but the causes are unclear or the trust’s ability to rectify the problems itself is in doubt.
The Commission has carried out 14 investigations since August 2004. The report covers the first 13 investigations. The latest investigation into infection control at Maidstone and Tunbridge Wells NHS Trust, published in October 2007, highlighted many of the same concerns.
The Commission conducted two investigations into learning disability services, three into maternity services, two on infection control and two about bullying and harassment. Other investigations covered specific clinical areas such as gastroenterology, cardiac services, management of medicines and emergency care.
Following an investigation, the Commission makes recommendations aimed at addressing immediate problems and making improvements in the longer term, as well as recommendations on national practice where appropriate.
The Commission works with the trust and the strategic health authority to ensure action plans are implemented and improvements are made. The Commission makes follow-up visits to each trust after one year to ensure progress is on track and make further recommendations if necessary.
The Commission always aims to work cooperatively with trusts on improvements and avoid formal escalation to the Secretary of State unless absolutely necessary.
However, on three occasions, the Commission deemed that the trust was not capable of implementing the necessary change without outside help and formally recommended “special measures” to the Secretary of State.
Anna Walker, the Commission's chief executive, said: "Good leadership means not taking your eye off any aspects of the trust’s activities - no ifs and no buts.
“In practice, this means ensuring staff are encouraged to speak up about concerns. Given that modern medicine involves risk, it means monitoring these risks and ensuring that issues such as infection control are high on the management agenda.
“It also means never underestimating what it takes to manage change, as well as ensuring those most in need are looked after properly. Above all, it means boards putting systems in place to turn their vision of quality care into a reality on the wards.
"There are trusts across the country that are succeeding at doing all of this while still managing change and meeting targets.”
Ms Walker added: “We have produced this report to help trusts understand the factors underlying the serious failures we have investigated. If it helps patients get better care and trusts avoid problems, it will have achieved its objective.
“As a Commission, we have been very encouraged by trusts’ willingness to debate and learn from our investigations. In all cases where we carried out an investigation, the trust concerned has made significant improvement as a consequence.”
The Learning from Investigations report highlights striking common themes in the Commission’s investigations:
· Leadership and management: Poor leadership was a problem in nearly all of the investigations carried out by the Commission.
Some boards had been focused on mergers or targets at the expense of their broader activities.
Lack of continuity in leadership was a problem in some trusts, where
frequent changes in management were a factor in poor care. Bullying
and harassment by managers was a factor in two cases investigated.
The Commission found there was a fine line between promoting change
vigorously and bullying.
Investigations often uncovered a breakdown in leadership and
management, with a lack of clarity on responsibilities from board to
ward. Poor teamwork, either between management and clinicians or
between clinicians themselves was another common factor in failings.
· Use of information: The Commission was surprised that most of the trusts investigated did not have adequate systems in place to routinely inform the board of trends or potential problems. Board members must assure themselves about the quality of services for which they are responsible and need data to do this professionally.
· Mergers and restructures: Seven of the trusts investigated had recently undergone mergers or significant organisational change. The message from the Commission’s investigations is that where significant change is taking place, the management task should not be underestimated.
· Safeguarding vulnerable adults: Poor understanding of adult protection procedures and responsibilities was a serious problem in the two investigations into learning disability services and also a number of interventions in trusts. The Commission said staff need good training to understand their crucial role in protecting vulnerable adults.
· Poor care on general wards: When its investigations looked at acute hospital care, the Commission noted that care on general wards fell well below the care provided on specialist wards. Older patients were most at risk as they were often most dependent on good nursing care. The Commission will monitor this aspect in future investigations to identify whether this
is an emerging common theme.
The Commission made recommendations to the wider NHS based on its experience of conducting investigations. It said that:
· Senior managers must actively elicit views about safety from frontline staff.
· Every board member should ensure that information and trends are reported to them and acted on.
· Boards and senior managers must allocate time to look at whether they are meeting the needs of vulnerable patients
· Trusts should have systems to improve services and safeguard patients that are part of its everyday functions, not added on at the end
Notes to editors
The Healthcare Commission conducted 13 investigations from August 2004 to April 2007: (1) Royal Wolverhampton Hospitals NHS Trust; (2) Mid Yorkshire Hospitals NHS Trust; (3) Bolton, Salford & Trafford Mental Health NHS Trust; (4) North West London Hospitals NHS Trust; (5) Devon Partnership NHS Trust; (6) East Sussex Hospital NHS Trust; (7) Mid Cheshire Hospitals NHS Trust; (8) Hull Royal Infirmary and Humberside Ambulance Service NHS Trust; (9) Cornwall Partnership NHS Trust; (10) Buckinghamshire Hospitals NHS Trust; (11) North West London Hospitals NHS Trust; (12) Sutton and Merton Primary Care Trust; (13) Oxford Radcliffe Hospitals NHS Trust. There was a 14th investigation completed after April 2007 at Maidstone and Tunbridge Wells Hospitals NHS Trust.
Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.
Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.
The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.
For further information contact the press office on 0207 448 0868, or on 07795 548 541 after hours.
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