CQC CEO wants to “ring alarm bells in the boardrooms” of poorly performing organisations

The Care Quality Commission (CQC) has published performance ratings for 2008/09 all 392 NHS trusts in England. Their assessment, also known as the ‘annual health check,’ shows big improvements for patients. According to the CQC, there is a reduction in MRSA and Clostridium difficile, and more people are:

- seen in A&E within four hours;
- receiving treatment within eighteen weeks of referral; and
- screened for Chlamydia.

Overall, the CQC says that the NHS is performing well on quality and has significantly improved its financial management.

However, the Commission is concerned about the 20 trusts rated weak on quality, particularly those rated weak over a number of years, and trusts rated fair for too long without improving.

Cynthia Bower, CQC Chief Executive, says:

“I want to ring the alarm bell in the boardrooms of these organisations. Next year, all trusts must register with us to legally function. It is clear that many have significant work to do to and a short time in which to do it. They should be in no doubt that we will take firm action if we deem it necessary.”

Of particular interest is the self-reported state of compliance with the Core standards for better health. The standards with highest rate of compliance are:

C08a (100% compliance) – support for staff to raise concerns about services
C10b (100%) – professionals abide by relevant codes of professional practice
C14a (99.8%) – providing information about how to complain
C22a&c (99.8%) – organisations cooperate to improve health of the community
C06 (99.6%) – health and social care organisations cooperate
C07b (99.6%) – promote openness, honesty, probity, and accountability

Core standards with lowest rate of compliance are:

C11b (87.6%) – participation in mandatory training
C09 (88.3%) – systematic and planned approach to records management
C04c (88.3%) – reusable medical devices are properly decontaminated
C04b (89.6%) – minimise risks of medical devices
C07e (90.5%) – challenge discrimination, promote equality and respect human rights
C02 (90.7%) – protect children by following national child protection guidelines

Full information on the 2008/09 annual health check can be found here.

In defence of targets…..

The negative impacts of targets in the NHS have been well documented over recent years. But what about their positive effects?

A recent episode of the BBC’s Radio 4 Analysis programme looked at the case for targets. The programme asks “Can their combination of statistical and managerial rigour improve our public services?”

The BBC says that  ”[Targets are] often hated by frontline staff, criticised by statisticians and now even their political backers seem to be drifting away. But there’s a lot more to targets than just ticking boxes – this programme finds evidence [actually, with reference to the comment by Howard Clark, below, what the programme appears to find is more 'opinion' than hard 'evidence' - Ed.] that they really can work to raise standards. Contributors include Liam Byrne, Minster for Public Service Reform; Richard Hamblin of the Care Quality Commission; John Seddon, Vanguard Consulting; and Gwyn Bevan of the LSE.”

For further information, click here.

A podcast of the programme is available for a short time and can be downloaded here.

Readers might like to visit the Vanguard Consulting website The Systems Thinking Review, which contains a wealth of interesting information and guidance on Vanguard’s ‘Systems Thinking’ approach, including a video introduction by John Seddon.

Organisational health: a new perspective on performance improvement?

The NHS Institute for Innovation and Improvement believes that “One of the biggest mindset issues is the way we think about performance and how to manage it. In recent years, we have focused much of our performance management effort on immediate payoffs by achieving short term targets. Evidence suggests that this might be a risky strategy longer term. It can stifle ambition, even incapacitate organisations, leaving them unable to achieve more than specific deadlines or targets.”

In response to the challenge of ‘changing mindsets’ around performance management, the Institute has published a ‘paper’ titled Organisational Health: a new perspective on performance improvement?

The paper begins as a synthesis of the key themes connected to organisational health in the literature and then draws inference from wider concepts to extend these core ideas. It is a research paper that requires some deep concentration and reflection to read. Yet it contains some true insights for thinking about organisational and system performance in the future.

According to Healrn Bevan, Chief of Service Transformation at the NHS Institute for Innovation and Improvement, “Whether we are leaders of provider organisations, or PCTs commissioning for quality, or SHAs overseeing the performance of the wider system, the ‘health’ challenges are fundamentally similar. We need to find ways to balance our efforts and energy between achieving short term results and building organisational health for the future.

Making our organisations ‘healthy’ is one of the most effective ways of creating organisational resilience in the coming economic climate. Part of the reason why we currently focus so strongly on managing performance is because it is such a tangible and measurable thing to do. Part of the challenge for the future is to make organisational and system health as much part of the way we think and work as the current performance perspective.”

The paper, Organisational Health: a new perspective on performance improvement?, can be freely downloaded here (requires registration and login).

 

Missed appointments cost NHS £575million annually says Dr Foster

According to Dr Foster Intelligence, around 6 million appointments per year are being missed at a cost, in terms of lost income, of almost £100 per appointment.

Read what Dr Foster says here.

Read a BBC news article based on the Dr Foster figures here.

NHS Governance 2009 conference a success

The Health Service Journal’s (HSJ) annual NHS governance conference held over 3-days at Earls Court in London this week attracted over 300 delegates across the different days, with some attending two or all three days.

The conference was a great success with a host of excellent speakers plus good audience participation during panel sessions, etc.

The general state of chaos and confusion around governance and management was a key issue to come out of the event. The speaker from the new Care Quality Commission added to the confusion by saying that “governance relates to consistent management, cohesive policies, processes and decision rights for a given area of responsibility.” This is a new definition that does not align with the myriad definitions already in place in various NHS guidance documents, and does not conform to key thinking about governance. Interestingly, another speaker coined a ‘new’ governance term at the event. Professor Paul Stanton spoke about “intelligent governance.” Healthcare Governance Review looks forward to the day that the subject of governance in the NHS will be addressed ‘intelligently’ by the Department of Health and associated agencies and bodies, including the new Care Quality Commission!

The presentations from the event should be posted on the web for free download by 3 July. When available, download the presentations by clicking here.

USA report – A Board of Directors Dashboard for Driving Quality in Acute Care

On November 10, 2008, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services and the U.S. Health Care Compliance Association (HCCA) co-sponsored a government- industry roundtable called Driving for Quality in Acute Care: A Board of Directors Dashboard.

This roundtable focused on how a hospital’s board of directors can use performance scorecards, or dashboards as a tool to promote quality of care in its institution. Dashboard reports use graphics to concisely present critical data in summary form.

Many questions were asked about the creation and use of the dashboard. For example, how do hospitals determine the quality measures to be used? Should the board’s quality committee or medical staff be involved with the creation of the measures? Who, in addition to the board, should be given the dashboard? How frequently should the dashboard be updated? What actions should the board take in response to the information presented in the dashboard? How
can the dashboard be linked to the organization’s strategic plans or objectives? These questions formed the basis of the roundtable presentations and discussions.

Download the roundtable report  Driving for Quality in Acute Care: A Board of Directors Dashboard here.

Guide to measurement for patient safety improvement

The Patient Safety First Campaign has launched a ‘How to Guide’ for Measurement for Improvement.

The guide helps managers and clinicians demonstrate if changes are really improvement by providing them with the ability to test changes and measure the impact successfully. This is essential for any area that wants to continuously improve safety. To do this, the guide says you may only need a few specific measures linked to clear objectives to demonstrate that changes are going in the right direction.

The guide is based on previously published guidance from the US Institute for Healthcare Improvement and will be of great practical value to anyone in healthcare that wants to demonstrate safety and other types of improvement brought about by implementing changes.

Download the How to Guide for Measurement and Improvement here.

‘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.

Trust boards need to learn different approach to performance management required to engage staff in improving quality

Responding in the Health Service Journal (20 November 2008) to the Department of Health’s recently published framework for improving the quality of NHS care, Royal Salford NHS foundation trust chief executive, David Dalton, says that ”many trust boards would need to learn the different approach to performance management required to engage staff in improving quality.”

“Without it,” he says ”there will be no real ownership and there will be dis-satisfaction when existing approaches to performance management are not seen to bring results.”

For further information, click here.

DH publishes framework for improving the quality of NHS care

The Department of Health (DH) has sent details to all NHS organisations on how they should approach the commitments made in Lord Darzi’s next stage review, which makes improving quality the centrepiece of the next decade of the NHS.

Each tier of the NHS – from local clinical teams to boards, strategic health authorities and the National Quality Board – is being asked to select the indicators it wants to use to measure, compare and improve the quality of services.

The full suite of quality framework documentation can be accessed on the DH website here.

The Health Service Journal (HSJ – 20 November 2008) has produced an excellent article summarising the DH requirements and reporting on an interview with Lord Darzi. There is also a video on the quality framework.

For further information, and to watch the quality framework video, access the HSJ article here.

NHS board members “face sack” if their organisations fail to improve

According to an article in the Daily Telegraph (25 October 2008), “Ministers are drawing up a list of failing NHS organisations which will be handed to new management, including private sector firms, if they do not improve. Under the plans, chief executives and their whole board of directors would be sacked without pay-offs.”

The article goes on to say that “Between 30 and 40 hospital, primary care and ambulance trusts are expected to be labelled as “underperforming” in a Government list set to be published before Christmas.

About six of them will be classed as “seriously underperforming”. If they have not improved by April, they will be deemed to be “challenged” and their entire board could be sacked in a matter of months.

The remainder will face the same threat later next year if their performance does not improve, triggering a second round of takeovers in 2010.

The Royal National Orthopaedic Hospital, the Scarborough and North East Yorkshire Healthcare trust, the East of England Ambulance service, along with primary care trusts in Great Yarmouth and Waveney, North Yorkshire and York, and Brent are likely to be issued with the most urgent warning.”

Read the full Daily Telegraph article, and related content, here.

Healthcare Commission ratings show ‘major improvement’ in NHS performance

The performance of the NHS in England appears to have significantly improved since publication of last year’s Healthcare Commission ratings.

Figures published on Thursday 16 October 2008 show that “trusts are improving the quality of services and managing money more effectively.”

Interestingly, Foundation trusts continue to outperform non-foundation trusts. Thirty-eight out of the 42 trusts rated “excellent-excellent” have foundation trust status. Eight foundation trusts were “fair”, while just one was “weak” for quality of services.

For further information click here.

NAO report points to a “lack of systematic learning from complaints to improve services”

The National Audit Office (NAO) has published its report on learning from complaints handling in health and social care.

The report examines the performance, capability and capacity of current systems for complaints handling in health and adult social care, and identifies the issues that need to be addressed in the introduction of the single comprehensive NHS and social care complaints system.

According to Tim Burr, head of the NAO, “The complaints systems for health and social care are not yet as accessible and responsive as they could be. There is a lack of learning from complaints, and providers are not making clear to users that services are being improved as result. Adequate staff training; proper tackling of complaints; and evidence of improvements in response to complaints are key pointers for the planned introduction of a new comprehensive complaints system across health and social care next year.”

Download the full report Feeding back? Learning from complaints handling in health and social care, along with separate reports on the results of a survey of health and social care users and an international review of complaints handling in health and social care, here.

How healthcare boards can prioritise quality and patient safety

A new monograph from the Center for Healthcare Governance in the USA describes how hospitals boards can weave quality and patient safety into the fabric of their organisations.

In Putting Quality First: How Boards Can Make Quality Improvement a Higher Priority, the author, David Bjork discusses formal and informal processes boards can use for moving quality higher up on the organisation’s agenda, focusing on the components of performance management. The monograph also examines how less formal processes can be used to signal a greater emphasis on quality, and provides practical tips and tools boards can apply to improve quality in their own organisations.

For further information, and to order a copy of the monograph, click here.

The Center for Healthcare Governance is the American Hospital Association’s resource for governance information, tools and counsel to promote excellence in health care governance.

DH consults on failure regime for NHS organisations

The Department of Health’s (DH) publication Developing the NHS performance regime, published 4 June 2008, announced the Government’s intention to “establish a failure regime for state-owned providers that reflects the Government’s obligations to ensure service continuity and protect public assets.”

The DH is now consulting on their proposals for such a regime and seeks views on them by 3 December 2008.

Meanwhile, according to a Health Service Journal (HSJ) report (18 September 2008), up to 92 trusts could be “culled” as part of the “NHS failure regime.” For further information, read the HSJ article here.

Download the consultation document Consultation on a regime for unsustainable NHS providers here.

UPDATE 19 September 2008 – Read Paul Dutton’s article (19 September 2008) on failing NHS foundation trusts in the Health Service Journal here.

Research report finds public release of performance results leads to improved quality of care

The Health Foundation has published a report, based primarily on research from the USA, that finds public reporting of performance results in improved quality of care.

In theory, according to the Health Foundation report, disclosing performance results increases the accountability of healthcare providers as managers will be concerned about maintaining their public image and increasing market share. It also motivates quality improvement activities in healthcare organisations, especially by targeting underperforming areas identified by the performance results. The report did indeed find that the public release of poor data was a major driving force in hospitals improving their quality of care. In New York, poor results also led to an increase in surgeons resigning.

The report also suggests that even in a country with an established market in healthcare, patient choice of hospital is not affected by poor results.

Download the report here.

Research fails to find link between mortality, quality of care and hospital performance

As reported in the Health Service Journal (HSJ – 24 August 2008), “Academic research has cast serious doubt on the link between hospital mortality rates and quality of care, raising questions over Department of Health moves towards routine publication of death rates.”

The NHS West Midlands Strategic Health Authority commissioned research by Birmingham University’s department of public health and epidemiology after five of its trusts were listed as “poor performing” on mortality in Dr Foster Intelligence’s Hospital Guide 2007, published in April last year.

In its report, the University is highly critical of the way hospital standardised mortality ratios produced by  Dr Foster Intelligence were reported and published, describing the Dr Foster mortality ratio as “a metric which is at best ambiguous and at worst potentially misleading”. The report states “We found little or no evidence that a high standardised mortality ratio systematically reflects poor quality of care or a failing hospital.”

Read the full HSJ article here.

Minister orders governance review of Welsh NHS trust

According to WalesOnline.co.uk, Health Minister Edwina Hart has raised serious concerns about the leadership of one of Wales’ busiest NHS trusts. She has ordered Cardiff and Vale NHS Trust to carry out two investigations after it persistently breached key waiting times targets.

In a letter to the trust’s chairman Simon Jones (who is also Chair of the NHS Confederation in Wales and a regular contributor on governance in the Health Service Journal) she said she believes that the waiting times breaches – in orthopaedics and accident and emergency – are likely to get “significantly worse without unplanned corrective activity”.

She added: “I have concerns as to the fitness for purpose of the trust’s leadership, processes and governance arrangements.

“I have specific concerns about waiting list management within the trust, particularly in orthopaedics.”

Mrs Hart has ordered the trust to carry out a review into waiting list management within the trust, which runs Wales’ largest hospital, the University Hospital of Wales.

And she wants an assurance review of the trust’s processes, leadership and governance to be carried out.

For further information, click here.

How come we know so little about the outcomes of care in an industry that annually spends £100 billion of taxpayer’s money?

In a thought provoking opinion column article in the Health Service Journal (HSJ), Dr Andrew Jones, group medical director of Nuffield Hospitals and health policy advisor to Andrew Lansley, conservative party shadow health spokesman, says the solution for providers feeling the squeeze has to be quality, and the measures to align the system have to be outcomes.

He contends that open publication of provider performance [based on outcomes] “would put the pride back into services, push clinicians and managers to innovate and give patients a real choice as institutions compete.”

His ”three wishes” for improving the quality of healthcare are:

1. to universally collate independent user satisfaction scores to assess the responsiveness, accessibility and quality of healthcare delivered;

2. to create a quality and outcome performance system for secondary care to measure the outputs of that care, such as readmission or 30-day survival; and

3. to roll out a system of patient-reported outcome measures for all elective procedures and many chronic conditions.

Read the full text of Dr Jones’ HSJ opinion column on health outcomes here.

US report on transforming hospitals into high reliability organisations

High reliability concepts are tools that a growing number of hospitals use to help achieve their safety, quality, and efficiency goals. Creating a culture and processes that radically reduce system failures, and effectively respond when failures do occur is the goal of high reliability thinking.

This report – Becoming a High Reliability Organization Operational Advice for Hospital Leaders – is written for hospital leaders interested in providing patients safer and higher quality care. It presents the thoughts, successes, and failures of hospital leaders who have used concepts of high reliability to make patient care better

The full report can be downloaded here.