Quality During Transition

1. Quality During Transition Ian Cumming National Director for Quality During Transition National Quality Board

2. TIME OF GREAT CHANGE • A patient led NHS Putting patients at the heart of everything we do - “Nothing about me without me” • Delivering better health Focus on outcomes - e.g. 1 yr cancer survival • Autonomy and Accountability Empowering physicians and improving efficiency • The Public’s health Prioritise prevention

3. CHANGE IS NOT JUST DRIVEN BY THE BILL • In addition to the challenges of reform, the NHS is having to adjust to much slower growth in recurrent funding: • In 2010/11 we had +5.5% growth. In 2011/12 – 2014/15 we will have basically “flat real”. This is unprecedented in the history of NHS • This will create a financial challenge for the NHS of £15-20 billion over 4 years (20%) – the QIPP challenge. £2.5 billion of this will be in growth in prescribing costs.

4. Savings Examples Classified timescale for saving to be realised long term medium term short term negative neutral positive impact on health

5. NOT JUST £ : GLOBAL DRIVERS OF CHANGE

6. THE CREATION OF A NATIONAL QUALITY TEAM MAINTAIN QUALITY DURING TRANSITION Implement phase 1 of NQB report, including an assurance process for Quality Legacy Documents from PCTs & SHAs. IDENTIFY NEW QUALITY ARCHITECTURE Lead phase 2 of the NQB report, clarifying where accountabilities for quality will sit at system level April 13+ SINGLE OPERATING MODEL FOR Q&S IN SHA CLUSTERS Identify best practice and devise a single quality operating model STANDARD SET OF QUALITY METRICS Produce a ‘good enough’ set of indicators to aid monitoring and management during transition Ensure rapid dissemination and implementation of recommendations MID STAFFS PUBLIC INQUIRY

7. Quality During Transition

8. NHS HISTORY TEACHES US... LESSONS FROM ELSEWHERE Body of evidence exists for mitigating actions to reduce risk in clinical handovers, including: • Face-to-face verbal updates between incoming/outgoing teams • Outgoing team writes summary • Incoming team assesses current status and review historical data • Outgoing team shares knowledge from previous handover and declares stance toward planned changes • Unambiguous transfer of responsibility • Private sector practice of due diligence • NASA formal state of ‘heightened alert’. • One of the key risk factors for serious failure is a recent history of mergers or major structural change (CHI, Lessons from CHI Investigations 2000-2003) • Mergers have a negative effect on delivery of services because of a loss of managerial focus on services (Fulop et al 2002, study of London Trusts) • NHS has a clear line of accountability for finance and robust hand over processes between finance professionals • NHS does not have the same clarity or robustness for quality handovers • NHS is a people-based organisation with a strong tradition of verbal culture • The scale of the anticipated change and the amount of knowledge it will take out of the system cannot be dealt with in traditional ways – NHS needs to raise its game to manage the risk EVIDENCE SHOWS THAT QUALITY IS AT RISK DURING ANY CHANGE Learning the lessons from the past and elsewhere

9. First full version of cluster wide handover document produced by 30th June 2011 SHA to produce regional handover document by 3rd October 2011 Cluster handover document to inform face to face handover between cluster and Clinical Commissioning Groups before March 2013 SHA handover document to inform face to face handover between SHA and NHS Commissioning Board Each PCT within a cluster to produce handover document PCT NHSCB PCT CLUSTER SHA CLUSTER CCG PCT SHA ACTIONS TO REDUCE RISK: HANDOVER PROCESS FOR PCT AND SHA CLUSTER PCT NTDA CQC and Monitor to feed into the production of SHA document SHA Legacy document to inform face to face handover between SHA and NHS Trust Development Authority Board discussion of the document(s) should take place at PCT or Cluster level 2012/13

10. New System Quality Architecture

11. 2 2 Who’s responsible for maintaining the bar? Who’s responsible for maintaining the bar? Who sets the bar on quality? 1 Who sets the bar on quality? 1 Who’s responsible for driving continuous quality improvement? 3 Who’s responsible for driving continuous quality improvement? 3 How do we response to a specific service failure? 5 How do we response to a specific service failure? 5 How do we respond to a serious /systemic failure? 6 How do we respond to a serious /systemic failure? 6 How do we spot and tackle pre-failure? 4 How do we spot and tackle pre-failure? 4 Proportion of services Proportion of services Unsafe Substandard Adequate Good Excellent Unsafe Substandard Adequate Good Excellent As the quality curve shows, the quality of care will vary between and within providers of NHS care, from unsafe to excellent As the quality curve shows, the quality of care will vary between and within providers of NHS care, from unsafe to excellent The NHS defines quality as good patient experience, high levels of patient safety and care that is effective. The challenge for the whole system is to move services and organisations along the curve to the right

12. Christopher Mellor Acting Chair, Monitor and National Quality Board member Dame Jo Williams DBE Acting Chair, Care Quality Commission and National Quality Board member Sir David Nicholson KCB CBE NHS Chief Executive and Chair, National Quality Board

13. The NHS early warning system ( ) ( ) ( ) ( ) ( )

14. Revised EWS: • Board retains prime responsibility for quality, but in the event of a serious failure, the Risk Summit model should be built upon, drawing upon experiences of Child Safety • When triggered, it would provide a framework for bringing everyone together, sharing and aligning action plans, reviewing progress and actions etc. • The commissioner should chair the discussion and coordinate any action, as they hold the NHS pound and geographical population, not replacing accountability of individual orgs • Relationships and knowledge built through pro-active Quality Surveillance and Assurance Group, meeting regularly to share comparative data on quality across the local and regional Sector. National Quality Board

15. Proposed Quality Surveillance and Assurance Model (proactive part)

16. Single Quality Dashboard

18. Never events reported Jan 11- Dec 11 Rolling Year

19. If you listen for the whispers you won’t have to hear the screams – Cherokee Indian saying Thousands of patients suffer avoidable harm across the NHS in England every year........

20. Public Inquiry Mid Staffordshire Foundation Trust

21. Mid Staffordshire Public Inquiry 139 days of oral evidence 181 witnesses nearly 2 million pieces of written evidence 7 expert seminars looking to the future Robert Francis, QC visits to exemplar practice within the NHS Final report expected… National Quality Board

22. Mid Staffs Public Inquiry cont..“The Inquiry has conducted the most intricate examination of the working of the NHS and its regulatory and supervisory bodies since the inception of the NHS”“…it is not logical to assume that there cannot be other Trusts failing in a similar way across the country” “…proper regulation should be able to deliver what patients and carers want:- - a good standard of care - a degree of compassion - to be kept safe” Tom Kark, QC Counsel to the Inquiry National Quality Board

23. Mid Staffs.... • Roles and Responsibilities • Communications and use of information • Assurance, monitoring and oversight • People and Culture • Patient and Carer Voice • Statutory Changes and Guidance • Workforce Planning and Information • Finance • Governance

24. Consistently emerging issues…. • Serious Untoward Incidents • Complaints • NPSA Alerts • Staff and Patient Surveys • Workforce Surveys • Cost Improvement Plans • HSMR • Annual Reports and Board Papers • Whistleblowers • Media Analysis