1 Lessons from Investigations and other work Prof Sir Ian Kennedy Chairman, Healthcare Commission 25 th April 2007 – RCOG / ENTER Conference.

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Lessons from Investigations and other work

Prof Sir Ian KennedyChairman, Healthcare Commission

25th April 2007 – RCOG / ENTER Conference

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Why do we exist?

To promote improvements in the quality of healthcare and public health through independent, authoritative, risk-based and patient-centred assessments of the performance of those who provide services

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What do we do?

• our remit covers NHS, private and voluntary sectors

• we review both safety and quality of care and value for money

• we assess performance in light of national standards (including targets) laid down by government

• we encourage improvement in public health

• we carry out investigations where there are significant failings in the provision of healthcare, relating to the safety of patients

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Principles of our Approach

Assessments that are relevant to patients, public and the NHS

No unnecessary regulation:• build on organisation’s own responsibilities• intelligent use of information• partnership with other agencies inspecting, regulating & auditing healthcare: the ‘concordat’• focus visits where they are most valuable

Fair judgements, reported clearly to each of our audiences

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Legal powersThe Health and Social Care (Community Health and Standards) Act 2003 provides powers to:

• Investigate the provision of healthcare by or for English NHS bodies

• Require information, documents and records, including personal records

• Enter and inspect NHS premises unannounced

• Require explanation of any matters which are subject to investigation

• Recommend that the Secretary of State take special measures

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Investigations - why do them?

• Establish the root cause of failure in a healthcare organisation

• Help that organisation to improve the quality of the healthcare it provides

• Take action to build or restore public confidence in the services provided

• Help the organisation and the NHS

to learn lessons about the safe care of patients

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Why should we be concerned?

“An inquiry is under way at a Scottish hospital where surgeons removed a cancer patient’s healthy kidney by mistake.

“…we want to be sure that no other family experiences this in future.”

The Times, Friday March 17th 2006

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Déjà vu?

“In April 2000, the National Assembly for Wales invited the Commission for Health Improvement to undertake an investigation into the Carmarthenshire NHS Trust…

“The immediate trigger for this was an incident at the Prince Phillip Hospital, Llanelli, in which a patient had the wrong kidney removed.”

CHI Investigation into Carmarthenshire NHS Trust, Nov 2000

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Criteria for embarking on an investigation• Higher than anticipated, or

unexplained, death(s)• Serious injury or harm to patient(s)• Events which risk public confidence in

healthcare or the NHS• A pattern of adverse events or

evidence of high-risk activity• A pattern of failures or concerns• Allegations of abuse, neglect or

discrimination against patients

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Sources of Referral

• Local Staff of Healthcare Commission – monitoring performance

• Patterns of complaints • Declarations relating to core standards• Issues raised by media, public, MPs, lawyers, through helpline, e-mail, letter

• SHAs, PCTs, Trusts, Department of Health

• Other regulators – Monitor, CSCI, HSE• Supervisors of midwives / LSAMOs

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Referrals during 2005/6

• 119 requests for investigation received

• Some clearly not within our criteria

• 85 ‘initial considerations’ were managed, many resulting in intervention and the trust’s agreeing to our recommendations

• 5 new investigations launched

• 7 reports published

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Of 13 published reports – 3 concern maternity services

• Wolverhampton– Maternity

• Mid Yorks– Gastroenterolgy

• Bolton, Salford & Trafford Mental Health

– Controlled drugs• North West London Part

1– Maternity (system

failure)• Devon Partnership

– Bullying• Mid Cheshire

– Alleged murder• East Sussex

– Bullying

• Hull and Humberside– Death following discharge

• Cornwall Partnership– Learning disabilities

• Buckinghamshire– Outbreaks of C. Diff

• North West London Part 2

– Maternal Deaths

• Sutton and Merton PCT

– Learning Disabilities

• Oxford Radcliffe

– Cardiothoracic service

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Published recommendations (June 04 - March 06)

Recommendation relates to: Total:

Staffing, HR & training 24

Management (inc. handling of risk) 14

Adherence to clinical and other guidelines 14

Learning from audits, complaints & incidents 10

Serious problems with working in teams 7

Care and treatment of patients 6

Leadership and governance 6

Use of information 5

Accountability, roles & responsibilities 5

Role of the Board 3

Communication 3

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North West London NHS Trust – key issues

• Shortages of staff and poor working relations between midwives and consultants

• Too much left to unsupported junior staff• Slow responses to high-risk situations• Common patterns of behaviour not

identified and mistakes repeated• Inadequate training• Isolated maternity service• Board slow to act (NB Vast improvement since special

measures in April 2005)

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Other indicators Absence of, or poor

• Engagement and involvement of women and their families

• Communication and cultural awareness

• Levels of staffing and demand on services

• Dialogue with and reporting through PCT and SHA

• Systems of reporting and involvement of trust’s board

• Availability and maintenance of equipment

• Training and audit

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Reasons for four recent investigations of Maternity Services

1. Ashford and St. Peter’s Hospitals NHS Trust, 2003 – range of concerns following a merger

2. Royal Wolverhampton Hospitals NHS Trust 2004 – concerns about perinatal mortality

3. North West London NHS Trust 2005 – concerns about maternity services and systems failure

4. North West London NHS Trust 2006 – concerns about maternal deaths

NB Merger a common thread

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Complaints – Lessons

• Delivery phase triggers most complaints

• Catastrophic circumstance (eg loss or haemorrhage) most common cause

• Poor documentation exacerbates complaint

• Communication is the underlying theme

• How can we support improvement together?

• Good News - recent survey funded by Healthcare Commission of women’s experience showed that proportion of women who felt doctors spoke to them in a way that they understood rose from 66& in1997 to 93% in 2006.

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Review of Maternity Services 2007 themes

• Organisational– What, where, why– Staffing and training– Management and leadership

• Progress in meeting recommendations of investigations

• Clinical outcomes– Data and demographics

• Experience of women– How does it feel?

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Process of Review

• Questionnaire developed with interested parties– Use lessons from investigations, standards, eg NSF,

NICE– Measuring what matters

• Gather data from others – eg CNST– Optional survey of staff on themes, eg communication

within and between teams

• Involvement of interested parties– What will be useful for you to know

• Roll-out – May, completion October, publication December/Jan

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December - data, CD and comparative software back to you

Staff will be provided with the following collated information that they need so as to make the case for improvement

• Staffing, costing and facilities comparable with other units• Outcomes – including near-misses and incidents such as

PPH• Demographic details and complexity of case-load• How staff are working and (optionally) staff’s views on

what it is like to work in the unitWe will help staff to use this information to self-assess where

improvements needed – we expect them to be learning from incidents etc

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Our challenge: To find the balance

• being critical of failure, as a strong and independent regulator on behalf of patients

and…

• encouraging and recognising improvement, as a fair commentator

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Your challenge: to learn the lessons

• act on the lessons and recommendations arising from published investigations

and…

• ensure that your teams and systems can identify problems before they become serious… because …

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These must not re-occur…..

• Weak risk-management with poor reporting of incidents and handling of complaints

• Poor working relationships and poor working in multidisciplinary teams

• Inadequate training and supervision of clinical staff

• Poorly defined and conducted audit / review

• Shortages of staff, high demand, poor management of temporary employees

• Poor engagement with women and their families

• Inadequate communication and cultural awareness

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And be vigilant in responding to Current Challenges (1)

Reconfiguration• Changes proposed in “Making it Better for Babies” will be beneficial but must be based on sound evidence about risk and response – “escalation protocols”

• Proposal in “Maternity Matters” re choice in maternity care – much depends on allocation of funding.

• Meanwhile, all involved in maternity care must seek to ensure that robust systems in place for safe birth, with clear accountability and leadership, during times of

major structural changes

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Current Challenges (2)

Safety

CEMACH – “Why Mothers Die” – recent evidence that Eastern European women becoming high risk group through language, co-morbidity and general health

Continuing risk factors: both partners unemployed (20 times greater risk of death of mother); black African women 7 times more likely to die than white women

Obesity increasing as a problem and needs to be planned for

67% of women had sub-optimal care

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Conclusion - our priorities

• Using information to assess performance• Engaging the Boards of Trusts• Safety and Quality of care – from the woman’s

perspective and with her involvement• Clinical leadership and professional teams

essential, clinicians at the forefront of improvement and innovation

• Clinicians’ role is the key

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‘If you always do what you’ve always done you’ll always get what you always got’

‘Every process is perfectly designed to produce the outcomes it does’

Don Berwick

Improvement is everybody’s business!

Joint RCOG/ENTER MEETING

Risk Management and Medico-Legal Issues In Women’s Health

25 to 26 April 2007