Health Care Risk Report Vol 15 Issue 2 – December 2008/January 2009

This issue of Health Care Risk Report (HCRR) provides coverage of the key case of Birch v University College and its ramifications. The case shows that Mrs Birch, when asked to consent to an investigation which resulted in her having a stroke, was not given sufficient information before making a decision. She was asked to sign a form that did not accurately reflect the true picture of risk for her as an individual. Stuart Marchant provides a legal perspective and Dr Jeff McIlwain gives a clinical viewpoint on its implications for consent. As Dr McIlwain has previously pointed out in HCRR, such a form should be the conclusion of a proper discussion between clinician and patient, not a substitute for it.

Over the years the balance has swung away from medical paternalism and towards patient empowerment, as evidenced by both legal cases and society in general. The Department of Health (DH) is trying to ensure that society does not ignore the rights of the most vulnerable – those who do not have capacity to make decisions for themselves (whether temporarily or permanently). To this end, the independent mental capacity advocacy (IMCA) service has been introduced and has now been in operation for 18 months. Referrals to this have not been as high as expected so the DH is urging NHS clinicians to refer more often for serious medical treatment decisions. Where referrals are being made (by psychiatrists, psychogeriatricians or hospital social workers) patients are benefiting. Two case studies are contained in this issue of HCRR that provide evidence of this.

Frail older patients and those with learning difficulties are also vulnerable within the physical environment of care, and Phil Gifford looks at the issue of deaths associated with poorly-fitted bedrails. Injuries and deaths from this cause are a perennial problem for hospitals and for residential or nursing homes, and can lead to substantial fines as well as the personal cost to patients, their families and staff involved.

Also in this issue, Claire Bentley covers violence and aggression towards NHS staff, including a look at the important issue of violence by mental health service users. The DH code of practice to the revised Mental Health Act, which came into force in November 2008, contains useful guidance on this.

Last, but not least, HCRR also covers, in separate articles, patient safety in general practice and the issue of loss of patient data. Preserving patient confidentiality is essential and the information commissioner views general practice as a key area where data must be protected.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

ACCA and Department of Health NHS governance survey document now available online

On 27 March 2008 Healthcare Governance Review reported summary results of Understanding governance in the NHS - a research project by ACCA’s Health Service Network in collaboration with the Department of Health (click here for 27 March post).

The aim of the research was “to identify current understanding of governance in the NHS.” The report states that “It is…..interesting that this understanding is firmly based on the Cadbury Committee’s definition of corporate governance, rather than on any subsequent definition designed purely for the NHS.”

Unfortunately for ACCA and the Department of Health, their own understanding of the Cadbury Committee definition of corporate governance is seriously flawed. They state that the Cadbury definition is” ”The system by which an organisation is directed and controlled, at its most senior levels, in order to achieve its objectives and meet the necessary standards of accountability and probity.” The actual Cadbury definition is “….the system by which companies are directed and controlled.”

Interestingly, Healthcare Governance Review received the following written feedback from the launch of the ACCA/DH Understanding governance in the NHS from an NHS non-executive director with substantial governance knowledge and experience. She said that ”The lack of understanding of governance on the platform and in the audience was amazing – governance still means management to most of the people who spoke – and the lack of understanding about governance structures and systems in the NHS in particular FTs was surprising.” She also expressed concern at what she felt was a “very small” response rate to the questionnaire, and the fact that the report’s author, when questioned, apparently could not say whether any individual organisations had provided multiple responses – i.e. more than one board member from an organisation had responded to the questionnaire. From an academic research perspective, the report appears methodologically unsound, making its findings and conclusions suspect.

Healthcare Governance Review believes that all of the above adds to the body of evidence underpinning Professor Paul Stanton’s assertion of “confusion and muddle in the DH and NHS about the nature of governance” (click here). Sadly, it is difficult to take seriously a research report that is based on the wrong understanding of the Cadbury Committee report’s definition of corporate governance – a definition which is subsequently used elsewhere in the report to base findings on.

Healthcare Governance Review further believes that the ACCA/DH report should contain a ‘Government health warning’. Treat the report, and particularly its findings and conclusions with caution!

Download the full research report here.

Jay Bevington says “PCT boards must take urgent action if they are to stand a chance of implementing world-class commissioning”

In a recent edition of In View, the NHS Institute for Innovation and Improvement’s board development journal, Dr Jay Bevington, a director in Deloitte’s public sector assurance and advisory practice, and formerly associate director of board development with the NHS Clinical Governance Support Team, outlines some of the current concerns that threaten to deflect PCT boards course in their attempts to meet the aspirations of world-class commissioning.

These concerns were elicited from nine PCTs that agreed to help the NHS Institue review its online Board Development Tool against world-class commissioning standards.

The key concerns facing PCT boards include:

- the impact on forward plans of splitting commissioning and provider functions and the search for an appropriate governance model.
- their capacity and capability as commissioning organisations with relatively few staff. Most PCTs currently have too much on their agenda and do not have the management capacity to deliver everything that is expected of them.
- how to ’stimulate the market’ to encourage new entrants in response to identified gaps.
- how to secure real clinical engagement – through practice-based commissioning or other means – in an environment where GPs tend to dominate clinical representation. How representative are GPs of the rest of the clinical community?
- concerns over PCTs sliding into deficit.

Read the full interview with Jay in In Viewonline here.

“There is too little evidence to support many of the generally accepted tenets of corporate governance” – ACCA publishes its ‘Corporate Governance and Risk Management Agenda’

The Association of Certified Chartered Accountants (ACCA) has published its policy paper – Corporate Governance and Risk Management Agenda. The publication launch was announced by Healthcare Governance Review on 28 October 2008 (click here).

ACCA’s Corporate Governance and Risk Management Agenda sets out ten principles for corporate governance and risk management which ACCA believes are fundamental to all systems of corporate governance that aspire to being the benchmark of good practice. They are intended to be relevant to all sectors, globally, including healthcare.

ACCA see their document as “being a statement of intent that will be refined and developed over time as knowledge and understanding improve generally. To this end,” they say, ”further research providing empirical evidence of best practice in corporate governance and risk management is needed. There is too little evidence to support many of the generally accepted tenets of corporate governance. These tenets should be questioned in an open and constructive manner and evidence sought to justify, improve or refute them.”

The full ACCA Corporate Governance and Risk Management Agenda publication can be downloaded here.

‘Microgovernance’ – the latest fad to hit healthcare boards in the USA?

Here at Healthcare Governance Review we thought that with the introduction of Governance between Organisations, healthcare governance simply couldn’t become more of a ‘muddle.’

We were wrong.

Enter the latest fad to hit healthcare boards in the USA – MICROGOVERNANCE!

‘Microgovernance’ is the subject of a keynote talk by James E. Orlikoff at the US Center for Health Governance winter symposium on leading and governing healthcare organisations. The symposium, titled Rethinking Governance: The  Shifting Roles of Management and Governance takes place in Phoenix, Arizona on 15-18 February 2009.

Mr Orlikoff’s talk, aptly (?) titled ‘Finding Balance on Shifting Sands: Microgovernance and the Changing Roles of the Board and Management’, will examine the difference between governance and management. According to the symposium brochure, Mr Orlikoff believes that “As the forces and challenges affecting health care and the entire economy become more volatile and intense, the role of the board and the distinction between governance and management is quickly changing.There is a rapidly emerging new and necessary component of board work which at first glance seems less like governance and more like micro-management.Yet, this “microgovernance” is now a key and growing component of effective board work. [His] presentation will summarize and synthesize the trends that are driving this significant transition in governance, and outline how boards and CEOs can effectively re-examine and refine a unique and productive governance/management balance that is increasingly essential to ongoing organizational survival and success. It will outline the challenges facing boards which must also integrate microgovernance into their work and balance strategic governance with microgovernance to generate a robust and integrated system of effective governance in an unforgiving environment.”

Elsewhere on the symposium programme there is a presentation on ‘The Relationship between Governance Commitment and Clinical Outcome Performance’ by David B. Pryor,MD, Chief Medical Officer, Ascension Health, St. Louis, Missouri. Ascension Health has, apparently, “demonstrated remarkable clinical performance. As part of that work, they formally assessed the relationship between the commitment and involvement of Ascension Health boards to the quality outcomes observed. Dr. Pryor will describe the quality journey of Ascension Health and connect the outcomes observed to the key role of the board.”

Download the symposium brochure here.

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Introducing the US Institute for Diversity in Health Management

Given relatively recent press regarding diversity and NHS boards (click here), Healthcare Governance review was intrigued to happen across the Institute for Diversity in Health Management in the USA.

The Institute – an affiliate of the American Hospital Association - is a nonprofit organization that works closely with health services organisations and educators to expand leadership opportunities for ethnic minorities in health services management. The Institute’s mission is to increase the number of people of color in health services administration to better reflect the increasingly diverse communities they serve, and to improve opportunities for professionals already in the health care field. To accomplish this, the Institute has designed several initiatives to generate significant long-term results through educational programs, summer internships, professional development and leadership conferences.

The Institute’s vision is one of “Leadership of health care institutions that reflects the ethnic, racial, and cultural diversity of the communities they serve, resulting in the delivery of culturally competent health care to all constituent communities.”

Notable quote – Improvement

“Improvement is a continuous process and for health care especially, it’s one where the target is constantly moving.”

Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission, USA

NHS backlog maintenance putting patient safety at risk?

According to the Telegraph (27 December 2008), “Patients are being put in danger because of a backlog of hundreds of millions of pounds of urgent repairs at hospitals.” The actual backlog maintenance figure quoted is £310 million.

“More than half of hospital trusts have a backlog of repairs which” according to the Telegraph “ the NHS says need to be urgently completed to ensure patient safety.”

The Telegraph further goes on to say that “The NHS defines the work is so pressing that it “must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution”.

Read the full Telegraph article here.

In the USA, a Joint Commission report finds that hospitals are showing gains in safety and quality

In some very critical areas, Joint Commission-accredited hospitals in the USA have steadily improved the quality of patient care over a six-year period, saving lives and improving the health of thousands of patients, according a Joint Commission report – Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2008.

An analysis of National Patient Safety Goal compliance and hospital quality measures related to heart attacks, heart failure, pneumonia, or surgical conditions, provides scientific evidence of improved patient care.

There were some dramatic improvements over the six-year period of data collection, especially in providing smoking cessation advice. For example, hospitals provided this advice to 98.2 percent of heart attack patients in 2007 compared with 66.6 percent in 2002. Hospitals greatly improved their results from 2002 to 2007 in providing this advice to heart failure patients (from 42.2 percent in 2002 to 95.7 percent in 2007) and patients with pneumonia (from 37.2 percent to 93.7 percent). Other strong improvements included providing discharge instructions to heart failure patients (from 30.9 percent to 77.5 percent) and providing pneumococcal screening and vaccination to pneumonia patients (from 30.2 percent to 83.9 percent).

However, the report does show that, for the third consecutive year, not all hospitals deliver the same level of quality and that some hospitals perform better than others in treating particular conditions. For example, hospitals provided discharge instructions to heart failure patients on average 92.1 percent of the time in the highest performing state, but provided discharge instructions 56.5 percent of the time in the lowest performing state. The performance difference among states is greater than 10 percentage points on 12 of the 24 quality measures tracked by The Joint Commission in 2007. There are exceptions to this variability. For example, virtually all-99.1 percent to 100 percent-accredited hospitals in the United States report that they measure oxygen in the bloodstream of patients with pneumonia.

On some of the measures reported by the Joint Commision more than 90 percent of  hospitals perform at rates of 90 percent or more. “However, there is more work to be done,” says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “Improvement is a continuous process and in health care especially, it’s one where the target is constantly moving. The wide range of performance on some measures serves as a reminder that we must continue to work to improve patient care.”

The performance results released in the 2008 report reflect The Joint Commission’s tracking of hospital performance on 25 individual quality measures reflecting the best evidence-based treatments. There are eight measures of care relating to heart attack, four to heart failure, eight to pneumonia, and five to surgical care. Data from more than 3,000 hospitals show:

- The heart attack care result improved from 86.9 percent in 2002 and from 94.4 percent in 2006 to 96 percent in 2007. (A 96 percent score means that hospitals provided an evidence-based treatment 96 times for every 100 opportunities to do so.)
- The heart failure care result improved from 59.7 percent in 2002 and from 84.1 percent in 2006 to 88 percent in 2007.
- The pneumonia care result improved from 72.3 percent in 2002 and from 87.3 percent in 2006 to 89 percent in 2007.
- On 11 of the 18 requirements of the 2007 National Patient Safety Goals, 90 percent or more of the 1,466 hospitals that received accreditation surveys during 2007 demonstrated compliance. National Patient Safety Goals provide strategies to prevent common health care errors such as medication mix-ups and surgery on the wrong body part.

Even with the improvements of the past six years, the report makes clear that more improvement is still needed. For example, treatments were still not being performed consistently in 2007 on some measures introduced in 2002:

- Discharge instructions for heart failure patients – only 27.5 percent of hospitals achieved 90 percent compliance
- Pneumococcal screening for pneumonia patients – only 38.6 percent of hospitals achieved 90 percent compliance
- ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) prescribed at discharge for heart failure patients – only 57.7 percent of hospitals achieved 90 percent compliance
- ACE inhibitor or ARB prescribed at discharge for heart attack patients – only 68.8 percent of hospitals achieved 90 percent compliance

The Joint Commission has issued this report as part of its ongoing efforts to emphasize the importance of accountability and continuous improvement for hospitals, and to empower consumers with information that will make them more active participants in their health care. Hospital-specific performance on specific measures for Joint Commission accredited organizations can be found on Quality Check® at www.qualitycheck.org.

For a copy of the full Joint Commission report, click here.

Sir Michael Parkinson appointed NHS dignity ambassador

The Government has asked Sir Michael Parkinson, the chat-show host, to act as an ambassador for its “dignity in care” campaign to establish how well hospitals throughout England look after patients, in particular elderly people.

Ministers say they want to know if patients were treated with dignity and respect, about cleanliness and the nature of staff teamwork.

Comments should be posted on the NHS Choices website at www.nhs.uk

Source: Times Online

‘What gets measured gets done’ says Sir Ian Kennedy as Healthcare Commission prepares to bow out…..

The Healthcare Commission (HCC) will be replaced by the new Care Quality Commission (CQC) from 1 April 2009.

In the final State of Healthcare report for 2008, Professor Sir Ian Kennedy, Chair of the HCC, believes that the Commission has painted a ‘richer picture’ of NHS performance than has existed in this past. This, he says, “has led boards of trusts to concentrate ever more intensively on what matters.” Indeed, his parting words of wisdom for the NHS appears to be the old maxim “what gets measured gets done.”

According to the HCC, the NHS must now focus on enhancing the quality of care by doing more to measure outcomes for patients, the experience of patients, and the journey people make through the system of care.

Sir Ian Kennedy said: “It is crystal clear that there have been major improvements in the care provided by the NHS over the past five years.

“We have seen more money going in, more staff providing services and more patients being treated. People are getting care much more quickly than they used to, notably for cancer. NHS trusts have, for the first time, a clear understanding of the core standards of service that they should be providing. We are seeing signs of real progress in driving down rates of healthcare-associated infection. People are living longer and there have been some remarkable reductions in premature deaths from the major killer diseases.

“But there are a small number of trusts trapped at a level of performance that is unacceptably poor. It’s also clear that, while patients overall indicate high levels of satisfaction with care, the NHS is still playing catch up when it comes to consistently providing the patient-centred care that people rightly demand. This is particularly true for those least able to make themselves heard when it comes to getting the best care, such as older people, children and those with mental health needs or learning disabilities. There have been some real improvements in mental healthcare but significantly more remains to be done to support people, especially young people, in the community.”

He added: “We have made the safety of care our highest priority. Safe care is the first building block of good quality care. It’s clear that safety is higher on the agenda than ever, but we are also a long way from an NHS that hungrily and systematically examines its own performance, gathers in and learns from mistakes, reinforces good practice, and does things differently for the future.

“The Healthcare Commission is four years into what was planned as a long-term project. The improvements so far are clear but the pace of change has varied. It is very important that the momentum be maintained.”

Key points from the report include:

- The NHS has benefited from major increases in funding and now has more resources than at any time in its history
- Demand for care has also risen dramatically
- The health of the nation is improving
- There have been sustained improvements in meeting the government’s standards and targets, with dramatic    improvement in waiting times
- There is a small number of trusts trapped at a level of performance that is unacceptably poor
- Services are still not always as patient-centred as they should be and there are groups of patients whose needs are still not sufficiently well served
- The safety of care is higher up the NHS agenda but trusts are still not doing enough to monitor and learn from incidents and ensure good practice is followed
- Commissioning must improve, as must measurement of patient outcomes, the experience of patients, and the journey people make through the system of care.

In relation to the safety of care, Sir Ian said Sir Ian said the issue of patient safety had risen up the Government’s and the NHS’s agendas. “But in my view the NHS is really only just out of the starting blocks,” he said. “There’s a great deal to do before we can be confident that the care patients receive is as safe as it reasonably can be.

“We are a long way from an NHS which systematically and hungrily examines its performance, reinforces safe practice, gets in and learns from things that go wrong and does things differently and more safely as a consequence.”

Download the HCC’s State of Healthcare 2008 report here.

NHS funds fraudulently used to import horse sperm?

According to an article in The Independent on Sunday (7 December 2008), police are investigating an allegation that a hospital manager imported equine semen for her stud farm, claiming it was for human IVF treatment.

Louise Tomkins (45) was employed as a senior general manager at the Imperial College NHS Healthcare Trust in west London. It is alleged that she diverted NHS funds to buy horse sperm that was then used to breed mares. Ms Tomkins was arrested by police and was bailed. It is understood that she recently left the trust, which she joined in 2004.

According to The Independent on Sunday, “NHS trust sources said police were alerted after internal audits revealed an unusual series of large purchases of human semen from overseas suppliers. Invoices said to be worth several hundred thousand pounds had allegedly been created to account for the transactions. When these were later checked it appeared that the companies had supplied thoroughbred horse sperm.”

Assuming the allegations are found to be true, this will have to go down as one of the most unusual frauds carried out by a manager in the NHS.

Readers might like to be reassured that “NHS trust sources…..stressed there has been no suggestion of any horse sperm being improperly or inadvertently used in the trust’s IVF treatments.”

Read the full Independent article here.

WISHING ALL OUR READERS A MERRY CHRISTMAS

‘Green’ travel plan almost brings NHS Chairman to a ’sticky end’

As reported in the Daily Telegraph (5 December 2008), Winchester and Eastleigh Healthcare Trust chairman Mike Gretton, who is trying to convince staff to cycle to work, admitted he had fallen foul of his trust’s ‘green’ scheme.

Mr Gretton suffered six broken ribs and punctured a lung after he collided with a car while cycling to work.

Speaking at the public trust board meeting, he said: “This green travel nearly brought me to a sticky end.

“I tested the accident and emergency department comprehensively.”

This particular story features in another story alleging that managers at Royal Hampshire County Hospital in Winchester, Hants are ‘wasting’ money buying umbrellas for staff in an effort, as part of its new green travel plan called ‘Saving Carbon, Improving Lives’, to encourage more staff to walk to work.

Read the full article here.

Guidance on board leadership for patient safety

The Patient Safety First campaign has published a ‘How to Guide’ for ’Leadership for Safety.

The purpose of the guide is to provide board members and senior leaders with an overview of how they can develop their role and responsibilities in leading a safety agenda in their organisation and actions they can undertake to achieve this. In summary, the guide proposes the following key actions to improve quality and reduce harm:

1. Develop explicit strategic priorities and goals
2. Provide demonstrable leadership
3. Ensure executive accountability
4. Establish and monitor explicit system level measures
5. Monitor progress and drive execution of plans
6. Build patient safety and improvement knowledge and capability

The guide appears to be largely based on information provided by the US Institue for Healthcare Improvement (IHI). Reassuringly, the guide does not appear to fall too much into the usual NHS trap of confusing governance with management.

Download the How to Guide for Leadership for Safety here.

Midlands NHS trust secretaries network launches on 9 December 2008 in Birmingham

Mills & Reeve LLP, solicitors, are launching a free network for NHS trust secretaries (or equivalent) in the Midlands in Birmingham on 9 December 2008.

Stuart Emslie, editor of Healthcare Governance Review, will be speaking at the launch event, which will be a full half day affair involving a legal update, a presentation on NHS board governance and a planning session to identify topics for future events.

Following on from the launch event, Mills & Reeve will be hosting a series of 08.30-10.30 ‘breakfast club’ meetings on alternate months from January 2009.

The Midland NHS trust secretaries network is chaired jointly by Moosa Patel, Director of Corporate Affairs, Leicestershire Country and Rutland PCT and Claire Lea, Company Secretary, Heart of England NHS foundation trust.

For further information on the network, including a list of possible topics for future sessions together with a booking form for the 9 December event and details on joining the network, download a brochure here.