Being Reviewed By CHI: A First Hand Experience November 2000 - July 2001 John Coakley Medical Director Homerton Hospital

Being Reviewed By CHI: A First Hand Experience

November 2000 - July 2001

John Coakley

Medical Director

Homerton Hospital

CHI

Established in 1999 “to help the NHS in England and Wales to assure, monitor and improve the quality of clinical care.”

CHI’s role

Leadership Scrutinise local clinical governance arrangements Ensure local and national implementation of

national guidelines External NHS incident enquiries in England and

Wales

The Clinical Governance Review

National programme of four-yearly reviews to:– examine clinical governance arrangements– publish a report for each Trust– facilitate the Trust’s action plan for

improvement– process began at Homerton in November 2000

CHI: a first hand experience

Effective Clinical Governance should lead to:

– Continuous improvement of patient services and care

– A patient centred approach• treated with courtesy

• involved in decision making

• kept informed

– Commitment to quality

– Prevention of errors where possible, learning form mistakes and sharing that learning


H O M E RT O N H O S PI T A L - M A N A GE M E N T A RRA N GE M E N T S (as at N ovember 2 0 0 1)

Note: Shaded boxes indicate broad areas ofresponsibility .

Clear boxes are specific com m ittees or groups

* S tat/Legal Requirem ent

8 th Novem ber 2001

Ex ecut ive Clinical

Gover nance Committee

Clinical A udit Committee

Complaints M onitor ing Gr oup

H ospital D r ugs

& T her apeutics Committee*

Clinical R isk M anagement

CG S uppor t T eam

Clinical Pr act ice E thics Committee

Clinical Govenance

Committee

* Radiat ion Pr otect ion

A dvisor y Committee

I nf ect ion Contr ol

Committee

R isk Facilitator s

For um

Local R isk

M anagement Gr oup (x 7)

T r ust R isk M anagement

Committee

Contr ols A ssur ance

S teer ing Gr oup

Cor por ate R isk

Contr ol

S uppor t / HQ

Direct orat es (x4)

Est ablishment

Cont rol Group

Homert on Lif e

Edit or ial t eam

Ex ecut ive T eam

Clinical D irect orat es (x4)

D ischarge Planning

Homert on/ Hackney

Discharge Planning

Commit t ee

I nf ormat ion Management

and T echnology

Project Board

Emer gency Car e

Committee

D ata Pr otect ion

S teer ing Gr oup

W ait ing L ist

S teer ing Gr oup

Resear ch Committee

(Culyer )

Procurement Group

Medical Devices

A dvisory Group

A ccommodat ion

Group

Capital Planning

and Review Gr oup

Clinical Boar d

Ex ecut ive and

O per at ional Per f or mance

S er vice D evelopment

& Par tner ships

Pr imar y Car e

Liaison Gr oup

U ser I nvolvement

S teer ing Gr oup

H ealth S hop S tr ategy Gr oup

H I M P/ H A Z Boar d

Cancer S er vices

D evelopment Gr oup

PA LS S teer ing

Gr oup

Per sonal S af ety

Gr oup

Local N egot iat ion

Commit t ee (Medical)

J oint S taff Consultat ive

Committee (J CC)

Equal O ppor tunit ies

S teer ing Gr oup

M edical M anpower

Planning Gr oup

M edical S chool

J oint L iaison Committee

PGM E Boar d

CPD S teer ing Gr oup

(M ult i D isciplinar y)

M edical Council

J unior D octor s For um

H R S ub Committtee N ur sing and M idwif er y

S tr ategy Gr oup

W or kf or ce

(Pr of essional Regulat ions)

Remuner at ion S ub

Committee

T r ust A udit Committee

(F inance pr obilty and

Contr ols A ssur ance)*

Char itable T r ustees*

L iaison Gr oup

H ospital A r twor k

Committee

Fundr aising

Committee

N ew Lectur e T heatr e

Gr oup

O ther Gr oups

T r ust Boar d


C linical A udit D irectorate L eads

C omplaints M onitoring R isk M anagement

L itiga tion M onitoring C linical Practice E thics

E ducation and T raining C linical Effectiveness

C linica l G overnance S upport C linica l R isk M anagement

D rugs and Therapeutics e t ce tera

C linical Governance

E xecutive C linical G overnance


What aspects did they examine? – Consultation and patient involvement– Clinical risk management – Clinical audit – Research and effectiveness– Staffing and staff management– Education, training and development – Use of clinical information


CHI’s areas of interest – general surgery

– general medicine

– maternity and neonatal care

– radiology, pharmacy, anaesthetics, pathology, therapies


The Assessment Team – Doctor

– Nurse

– Manager

– Other clinical professional

– Lay member

– CHI Review Manager Methodology

– information collection, interviews, observation,


The Clinical Governance Review

– Long process

– Paperwork + + + +

– Time consuming

– Homerton in first wave - > 50 reports published to date

CHI: a first hand experience The 24 Week Timetable!

Data collection November 2000 Self Assessment December 2000 Data analysis Dec - Jan Community involvement January 2001 Patient diaries February 2001 Pre visit brief/report Jan-Feb 2001 Assessors’ visit (5½ days) 19th March

2001 Final report published May 2001 Action plan July 2001


Outcomes – Published report– Identification of areas of good practice and key

issues – Action plan for change management– Monitoring by London Regional Office


The draft report– nice noticeboards– the Trust has a high mortality– stillbirth and neonatal death rates high– emergency readmission rates higher than

average


The draft report Action is required to:

– improve supply of TTAs– streamline admissions process– improve monitoring of feeding– to ensure that consideration continues to be

given to cultural issues regarding minority groups


Action stations!


Final report layout– Trust’s context– Patient’s experience– Use of information– Resources and processes– Strategic capacity– Action following the review


Trust’s context– deprived area

– inequalities, including access to and outcomes from healthcare

– lots of illness ( e.g. TB)

– unemployment high

– ethnic minority profile

– new buildings

– financial balance


Patient’s experience– many examples of good practice (BAP, WL)

– high post-op surgical mortality

– stillbirth and neonatal deaths high (clinical practice good)

– readmission higher than average

– need to improve patient pathways particularly for stroke and #NOF

– notable practice in cultural issues


Use of information– use of patient experience is made at strategic and

planning levels, but not at operational level

– action required to ensure cohesive approach to involving clinical staff and the public

– complaints – confidentiality – IM + T ×


Resources and processes (users)– good strategic grasp of the need for consultation

– community feels sense of ownership

– advocacy services an example of notable practice

– many patient surveys, little evidence of coherent strategy

– need to use patient feedback other than complaints


Resources and processes (risk)– clinical risk management - staff felt confident to report

incidents

– bottom up approach OK, but cautions apply

– resuscitaires bad, disconnected nitrous oxide in A+E good

– urgent action on histopathology

– urgent action by wider health community on neonatal deaths


Resources and processes (audit)– worthwhile development of clinical audit at operational

level, but little link with strategy and planning

– widespread commitment to clinical audit

– several examples of audit leading to changes in practice

– few examples of multi-disciplinary or cross-directorate audit

– open and constructive discussion of audit


Resources and processes (effectiveness)– significant progress in development at strategic and

planning levels

– more work needed to develop process by which effectiveness of clinical procedures is evaluated

– how do we ensure NICE and NSF implementation

– Trust in a unique position to contribute to national body of research


Resources and processes (staff)– good strategic grasp of staffing issues

– very good working relationship between executive and staff at all levels

– Trust attempts to overcome recruitment difficulties by providing support for education and professional development

– appraisal for all staff, staff felt valued, IIP

– Stress - no formal system to identify it


Strategic capacity– enthusiasm and strong leadership for clinical

governance

– Trust supports CG as a grass roots activity, with real benefits and progress in terms of staff commitment. Not clear how it is all brought together

– no vision of how it will lead to improvement of patient services

– needs to be evaluated - will it meet the needs of the future

CHI: a first hand experience - what else did they pick up?

Staff work hard despite shortages relative to comparable Trusts

There is evidence of staff stress - some surrounding workload and some because of violent and abusive behaviour of users

Trust’s partner organisations universally complimentary of our participation in cross-boundary partnerships

CHI: a first hand experience - what else did they pick up?

Local PCT found us to be a good partner Senior clinical staff generally accessible for advice

and support

A confidential issue

CHI: a first hand experience - Action Plan

Review Clinical Governance Strategy Review information management Improve patient experience of admission process Understand reasons for high re-admission rates

and high post-emergency surgery death rates Attempt to understand reasons for high stillbirth

and neonatal death rates and reduce them

CHI: a first hand experience - Action Plan Modernise medicines management Histopathology review Feeding User involvement Stress in the workplace

CHI: reflections

Hard work Potentially damaging Stressful Praise seems a little grudging at times Press handling Ultimately OK

CHI: suggestions

Be honest Make sure you allocate enough management

time - 1 WTE! Work hard at detail of draft report - contest

where you can with hard evidence Be prepared for stressed staff Try to use the visit to achieve change to the

benefit of your organisation

Documents

Being Reviewed By CHI: A First Hand Experience November 2000 - July 2001 John Coakley Medical Director Homerton Hospital