LEARNING FROM THEMID-STAFFORDSHIRE

NHS FOUNDATION TRUST PUBLIC INQUIRY

Linda Pollard CBE JP DL, ChairJuly 2013

• Did you know that at Leeds Teaching Hospitals …

• We have 1,917 beds• We spend £80m per month• We have 6 sites – St James’s, LGI, Chapel Allerton,

Seacroft, Wharfedale, Leeds Dental Institute• We cover an area of 123.88 acres (5 main sites)• We treat 1,000,000 outpatients per year (19,230

per week)

• We carry out 240 operations per day (40 emergencies)

• 200,000 people attend our A&E departments every year; 3,850 per week; 550 per day

• We deliver 27 babies per day• We have an average 8 deaths per day

• We serve 39,900 meals per week• 192,308 pieces of linen are washed every

week• 520,000 sq m of flooring is cleaned every

week• We use 1,800 litres of hand gel per month

LEARNING FROM THE MID-STAFFRDSHIRE

NHS FOUNDATION TRUST PUBLIC INQUIRY

Suzanne Hinchliffe CBE, Chief NurseCraig Brigg, Director of Quality

July 2013

Background

• High death rate (mortality)• Quality of care concerns• Rising complaints

Public inquiry chaired by Robert Francis QC

• 2005 – 2009 – Focus on how care was commissioned and the functions of

regulatory bodies in monitoring quality at Mid Staffordshire Hospital

• 2010 – 2013– Public hearings– Witness statements– Examination of key documents– Seven public seminars– Fact finding visits to healthcare organisations– Four independent health expert assessors

Final report of the Public Inquiry published on 6 February 2013

• Poor management practice with organisational focus on national financial and performance targets to the detriment of the quality of patient care

• Effectiveness of the regulatory bodies in identifying and tackling poor quality patient care

• 1 million pages of documentary evidence• 3 volumes + executive summary - 1,782 pages• 290 recommendations

Overarching Recommendation

“all commissioning, service provision, regulatory and ancillary organisations in healthcare should reflect on the report and its recommendations and decide how to apply them to their own work”

The report covered 10 key findings

1. Warning signs – taking action when things may be going wrong

2. Trust leadership3. Handling of complaints and learning from this4. Mortality rates – responding to this5. Patient and public involvement and scrutiny6. Certification and inquests relating to hospital deaths7. Culture of the organisation8. Values, standards, openness and candour9. Standards of nursing care, nurse staffing and leadership10. Care of older people

Next steps

• Focussed discussion at Trust Board• Identification of key areas for action arising from

report• Refresh of priorities June 2013• Key areas for consideration identified• Representation at wider health care meetings

Key areas identified for review

1. Values, behaviours, culture, organisational development

• Listening and learning activities to take place with Clinical Service Units with a focus on corporate values and behaviours

• Improvements to Trust communication channels• Review approach to ‘raising concerns’ and

support provided to staff

Key areas identified for review

2. Public and patient engagement and experience

• Review the way we can improve the overall patient experience in the Trust

• Change the way patient-centred care is influenced through engagement with stakeholders and involvement of carers and the public

• Build on front line initiatives to improve patient experience, including patient surveys and Friends & Family Test

• Review our approach to complaints and make sure this is more patient-centred, responsive and sensitive to the needs of people who use our services

Key areas identified for review

3. Care of the older personWork programmes in place to improve the care of thispotentially vulnerable group include:

• Infection prevention• Dementia awareness• Falls prevention and management• Pressure ulcers• Continence• Nutrition• Pain management• Privacy and dignity• Discharge arrangements/information

Key areas identified for review

4. Clinical quality and standards

• Develop measures that we can use to define and monitor quality of care

• Spread culture of continuous quality improvement, support staff and provide them with the tools and training to do this

• Greater focus on the leadership role and support of clinicians• Develop a plan for improving quality in the Trust

Key areas identified for review

5. Leadership

• Have a clear Trust strategy and vision that is developed with and understood by people at all levels of the organisation

• Support leadership development at all levels of the organisation

• Review and refresh governance processes in the Trust to ensure the key risks to quality and safety are considered

• Ensure Clinical Service Units are supported effectively by corporate teams

• Assess the potential impact on quality and safety for all service changes and cost improvements

Thank youPlease feel free to ask questions