Item 7.1 for 30 Sep 2013 Ambition for Excellence

Board Meeting 30 09 13 Open Session Item 7.1 NHS GRAMPIAN

Ambition for Excellence – Person-centred care in Grampian: lessons from the Francis, Keogh, and Berwick reports

1. To outline the key themes from Volume 2 of the Francis Report, the Keogh Report, and the Berwick Report. 2. To provide assurance that NHS Grampian has examined the Francis, Keogh and Berwick Reports and identified relevant areas. 3. To seek Board support for our ongoing work to ensure that the Board’s values of Caring, Listening, Improving are embedded across NHS Grampian.

Strategic Context

The strategic context is the national Quality Strategy and its three ambitions of providing person-centred, safe and effective care.

Discussion

The Reports

Concerns about mortality and the standard of care provided at the Mid Staffordshire NHS Foundation Trust resulted in an investigation by the Healthcare Commission which published a highly critical report in March 2009.

Subsequently, an Independent Inquiry was set up, chaired by Robert Francis QC primarily to give those most affected by poor care an opportunity to tell their stories and to ensure that the lessons to be learned from those experiences were fully taken into account in the rebuilding of confidence in the Trust.

Volume 2 of the Francis Report was published on 6 February 2013. Many of the report’s 290 recommendations do not apply directly to Scotland, but Boards across NHS Scotland are expected to consider the relevant recommendations, in particular those relating to ensuring safe, effective and dignified patient care. The report identifies shocking examples of lack of basic care in a culture where statistics were preferred to patient experience data. Francis lists a large number of warning signs over a period of almost a decade, which should have sparked professional staff, clinical and managerial, in to urgent action. However, the Board was pre-occupied with the desire to achieve Foundation Trust status, and the medical staff had dissociated itself from management. He refers to a cycle of defensiveness, concealment, and lessons not being learnt. In response to the dreadful events that took place over the years, Francis calls for all NHS organisations to put the patient first at all times (to “look for the people behind the statistics”) and to empower the frontline staff in a culture of openness, transparency and candour.

1 Board Meeting 30 09 13 Open Session Item 7.1 The Keogh Report, published in July 2013, reviewed the quality and treatment provided in 14 Hospitals in England that were considered outliers in relation to standardised mortality. They were reviewed across the three dimensions of quality: clinical effectiveness, patient experience, and safety. The report also looked at failures in professionalism, leadership and governance.

It identified 8 ambitions related to culture and safety, to show significant progress towards being achieved within 2 years:

1. Reduction in avoidable deaths 2. Rapid access for NHS organisations, patients and public to accurate, insightful, and easy to use data about quality at service line level 3. Treatment of patients, carers, and members of the public as vital partners in the design and assessment of their local NHS 4. Patients and clinicians participate actively in Government inspections 5. No hospital should be an island unto itself: an end to professional and institutional isolation 6. Nurse staffing levels to appropriately reflect the case load and the severity of illness of the patients being cared for 7. Junior doctors in specialist training should not just be seen as the clinical leaders of tomorrow, but clinical leaders of today 8. All NHS organisations need to understand the positive impact that happy and engaged staff have on patient outcomes and need to make this a key part of their quality improvement strategy.

The Berwick Review followed in August 2013. The remit of the Berwick Advisory Group was to study the accounts of Mid Staffordshire, as well as the recommendations of Francis, in order to distil lessons learned and to specify changes required for the (UK) government and the NHS in England. The report lists a range of identified “problems” and then “solutions”. The body of the report is concerned with recommendations in nine categories covering:

 the overarching goal  leadership  patient and public involvement  staff  training and capacity building  measurement and transparency  structures  enforcement  moving forward.

Translation of the key findings to the NHS Grampian Board

In Scotland, the Quality Strategy (May 2010) continues to underpin the approach to healthcare with its three ambitions of providing person-centred, safe and effective care.

In NHS Grampian, we aim to embed a culture of “Caring, Listening, Improving” throughout the organisation.

2 Board Meeting 30 09 13 Open Session Item 7.1 The Executive Team sought to ensure that the relevant recommendations of the three reports were taken forward within the existing work around “Caring, Listening, Improving”, and established a short-life working group. Many of the areas of work discussed in this paper were formulated by this group.

“Caring Listening Improving”

The purpose of NHS Grampian is to improve the health of the people in Grampian and the North East of Scotland, to provide high quality services to patients, and to help people choose the best ways to look after their health. We care to treat each individual with dignity and respect, and we aim to behave with integrity, consistency and compassion, in an open honest and fair environment.

Grampian has a strong history of partnership working, with 5 full-time partnership representatives released to support all staff. The partnership approach in NHS Scotland is the longest established and most extensive set of partnership arrangements in the public sector in the UK, proven to have contributed to improved service delivery1. The partnership approach allows managers to identify issues early and allow staff to become engaged in the running and the assessment of the organisation.

Staff experience is recognised as fundamentally important to improved outcomes for patients. Keogh noted that happy staff make a difference to the patient experience. Through the Board’s person-centred work, the Nurse Consultant for Patient Safety and Experience and the Deputy Director of Workforce have combined their respective efforts to develop a person-centred – patient and staff – approach.

For staff, this is linked to demonstrable achievement of the Staff Governance Standards and the emerging Staff experience work. Modules are developed in Datix (the NHS Grampian incident reporting system) for capturing this. The approach is linked to the Dignified Workplaces initiative that will include a range of tools including conversations, workshops, and diagnostics, including a stress management survey and action planning.

The membership of CHAIN (Contact, Help, Advice, and Information Network) is growing. It is anticipated that raising awareness of relevant quality improvement activities will inspire and motivate individuals to undertake improvement themselves.

The Berwick report states:

“In the end culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.”

The Dignified Workplace approach which aims to embed the values of “Caring, Listening, Improving” across Grampian and provide support for cultural change where behaviours do not appear to adhere to these values was approved by the Board in January 2013. A People Centred Care Action Plan is currently being developed which looks to draw on evidence from both patient and staff experience in order to change culture.

1 Bacon N & Samuel P (2012) “Partnership in NHS Scotland” January 2012, ESRC

3 Board Meeting 30 09 13 Open Session Item 7.1 We have a wide range of tools available to enable us to engage with patients. As well as our Feedback service we use surveys, questionnaires, patient interviews, patient diaries, recordings and patients stories. Each of these tools is used in different ways. For example, patient stories are recorded and used for education and learning in undergraduate and postgraduate programmes as well as local educational events and meetings. Patient stories are presented to every Board meeting and it is the intention to augment these with staff stories. We receive daily feedback via our website. More recently social media has provided another form of interaction and we respond to comments on Twitter and Facebook.

Patients are involved in the design, running and assessment of services in Mental Health, Health Care Associated Infection, and Managed Clinical Networks in cancer and chronic disease management.

However, the majority of these tools provide feedback on an experience or an event in the past. They require the staff member to take action, possibly some time after concerns first surfaced, which we then investigate and respond to. Increasingly we want to move to a situation where we listen in real time – where patients and staff can tell us what is concerning them and we can address the issue at the time.

The Executive Team has recently agreed that real time patient and staff experience feedback will be a priority. The elements required to establish this are being tested and developed. Further work will be required to move from testing to spreading throughout the organisation.

NHS Grampian has an established record in public involvement relating to service redesign. In 2012, the Maternity Services Review received widespread acclaim for its involvement of the public across the Grampian region. In 2013, the Grampian Child Health strategy is developed with similar involvement of the public.

Equality and Diversity training is well established in NHS Grampian with large numbers of medical, nursing, allied health professional and non-clinical staff undergoing the training programme.

As part of our aim to establish a caring and compassionate culture, we are currently developing the concept of ‘values based interviewing’ (VBI) as part of the recruitment process in NHS Grampian. Values based interviewing is similar to traditional interviewing but with a focus on identifying candidates’ personal values rather than simply assessing their competencies and previous experience. Marcus Erooga, in ‘Towards Safer Organisations’ (2009), suggested that VBI ‘has the potential to make a worthwhile contribution to the recruitment process as it focuses on behaviours within the context of organisational values, probing the extent to which potential new recruits are likely to respect and adhere to these.’ The Department of Health recently confirmed that being mindful of ‘values’ while recruiting would be one of its key responses to the Francis Report, the investigation into failings at Mid Staffs NHS Trust.

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Factors that contribute to organisational failures:

“ The limited understanding of how important and how simple it can be to genuinely listen to the views of patients and staff and engage them in how to improve services.” Sir Bruce Keogh 16/7/2013

Staff at all levels of the organisation are engaged in the discussions around the Francis and related reports as regards how the key findings apply to their areas of work.

Members of the Clinical Governance Committee have undertaken a development session to develop a deeper understanding of incidents and complaints. A similar development session for the Staff Governance Committee is planned for November 2013.

The clinical advisory structure has considered the three reports and debated the relevance to its function and role. The Medical Director has taken the reports to the Area Medical Committee and the Consultant Sub-Committee. These committees are collating responses from their specialty sub-committees to be amalgamated in a response to the Area Clinical Forum. Similarly, the nursing and pharmacy sub-committees are taking responses from their constituents to be amalgamated at Area Clinical Forum level.

At a development session of the NHS Grampian Board and Executive Team, it was agreed that the Board will enhance its links to the clinical advisory structure by making representation available at the sub committees of the Area Clinical Forum. Representation is already present in the Consultant Sub Committee by the Non Executive for Acute Services.

The Medical Director and the Director of Workforce are working with the Clinical Director for Postgraduate Education to use feedback from junior staff collated by the General Medical Council (GMC) to start a dialogue with clinical departments about culture, professional standards and rules of behaviour and respect. A series of such meeting have taken place between December 2012 and July 2013, in a department where such standards were not being adhered to.

The Director of Nursing and Quality and the Director of Workforce have established a series of conversations with Senior Charge Nurses across the organisation to understand what the culture feels like and how we could improve. Through these conversations we have identified that the focus on flow and targets is not always conducive to person-centred and safe patient care and we have committed to look at how we deploy our resource and also what we expect from our clinical leaders and how people approach their work.

Through their management teams, the Acute Sector and Aberdeenshire have conducted workshops with their staff to consider the recommendations of the Francis Report. The Quality Governance and Risk Unit undertook a workshop to consider the recommendations in relation its improvement plan and priorities.

The experience of staff and patients is one of the key indicators of the health of an organisation. In Grampian, we have recognised the importance of listening to people –

5 Board Meeting 30 09 13 Open Session Item 7.1 whether it is people who use our services or their families, carers and friends or whether it is listening to our staff. It is through listening that we learn and improve.

Many of these techniques are based on listening to patients but equally we have a range of techniques through which we can listen to staff: face-to-face meetings with senior managers, the line management structure or our well-developed staff side and partnership arrangements.

A range of engagement approaches therefore exist already. However, ways to refresh dialogues are being explored and developed. The fundamental principle is that we intend to weave communication strands through existing staff meetings to engage with staff from all sectors in their own environments, which will hopefully encourage more natural real time feedback. A mixture of approaches, both formal and informal, is required to take this forward with staff throughout the organisation. A Communication and Involvement Framework and a Staff Engagement Plan are being developed by the Director of Corporate Communications and a Senior Communications Officer.

The NHS Grampian Quality plan was approved by the Board in April 2013 when it was agreed to report progress regarding elements of the plan. The driver diagram of the elements within the plan is shown below. Progress against some of the elements has been outlined above.

The Quality Dashboard was presented to the Board for the first time in June 2013. The Dashboard is being presented to the Board for a second time with this paper with the timing linked to the release of the national Hospital Standardised Mortality Data. The dashboard contains high level data around mortality, incidents, falls, infection and patient experience. It includes commentary on improvement activity that is taking place in relation to these areas of work. Further work is required to link the dashboard to organisational and service quality objectives.

The ‘Intelligent Board’ business cycle has been approved in principle by the Board, with implementation scheduled for autumn 2013. This will help to ensure a good balance for Board discussion between strategic business and operational pressures. The intelligence needed by the Executive Team and the Board will, in the future, be structured around the organisation’s strategic goals. It will highlight trends, forecasts and enable an external focus. It will help the Board and other strategic committees to consider the following issues:

 Our performance in relation to our strategy  The impact of trends and external influences  Patient and staff feedback and experiences  Variability across Grampian, Scotland, Europe. A monthly Executive level review takes place of all high and very high incidents and serious complaints to ensure an appropriate overview response and facilitate organisational improvement and learning.

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We recognise that in Grampian we have work to do to ensure that the way we deploy our staff, particularly nursing staff, is as effective as it might be. We have committed to review the overall nursing resource to ensure that there is the most appropriate workforce available and an improved balance, where possible, between substantive and bank and agency staff. This work will utilise the available workforce and workload planning tools and also consider the ratios between registered and unregistered nurses as well as how we can more effectively utilise administrative staff to support the clinical teams. There are a number of specific issues that we are addressing including the impact of 12 hour shifts on staff and staff safety, health and safety audits and an audit against Health and Safety Executive (HSE) stress management standards.

Measurement work has progressed with all clinical areas now linked into Lanqip. Work is now focusing on the use of the information within the system. The tiered intelligence model is to improve the availability of information to all, whilst packaging it appropriately and intelligently. This is achieved via monthly management information and cross system intelligence.

The implementation of the adverse event reporting module in Datix for general practice is continuing and the number of practices who participate is growing. The events are discussed at the regular practice Mortality and Morbidity (M&M) meetings and the learning is used by general practitioners to support their appraisal and revalidation. There is also sharing of learning between practices being developed.

7 Board Meeting 30 09 13 Open Session Item 7.1 Similarly, in the hospital sector regular M&M meetings are developed for each department and, increasingly, Datix is used to support these. In General Surgery, a list of Datix reportable complications has been drawn up, and a meeting takes place every Wednesday between the four surgical teams to present the latest incidents and formulate ways to improve practice.

The Medical Director is working with the Appraisal Leads for Primary and Secondary Care to develop the large pool of appraisers (200) in terms of leadership skills and skills in supporting doctors in difficulty. Regular quarterly meeting of appraisers in primary care have been taking place for a number of years and recently two of such meetings have been organised for appraisers in primary and secondary care together, with presentations relating to equality and diversity, role of occupational health, GMC Good Medical Practice and leadership skills. The next quarterly joint development meeting for appraisers is scheduled for November2013. Each appraiser sees between 5 and 10 medical practitioners per year as part of the appraisal process and appraisers are considered a powerful potential for cultural change. The development model for appraiser was explored in September at the yearly meeting for appraisers organised by NHS Education Scotland with 200 appraisers from across the country.

The General Manager of the Acute Sector has built on the existing “Back to the floor” programme initiated by the Director of Nursing, to develop the concept of the “Exemplar Ward”. To achieve Exemplar Ward status from bronze to gold, a ward will demonstrate excellence in a portfolio of standards amalgamated from Scottish Patient Safety Programme measures, Healthcare Environment Inspectorate (HEI) standards, Older People in Acute Care standards, Leading Better Care standards, and Staff Governance standards. Staff and patients participate in the regular ward visits, which aim to build a positive culture through quality conversations, problem solving, and reinforcement of core values with strong, visible leadership.

The NHS Scotland national programmes include patient safety (adult acute, mental health, paediatrics, maternity, primary care and neonatology), person centred health and care, early years, and older people in acute care.

The Scottish Patient Safety Programme has recently refreshed its priorities and approach.

There is particular focus on the deteriorating patient. This includes how we plan care with patients taking account of their stage of illness, how we identify unwell patients, escalation plans for such patients involving team responses, and resuscitation. The deteriorating patient approach has incorporated the sepsis and venous thrombolysis part of the previous Patient Safety Programme.

The Clinical Operational Management Team meeting considered the topic of deteriorating patients at its July 2013 meeting. A number of professionals presented on the relevance of their professional practice and care in relation to deteriorating patients. Following this workshop the working group membership was widened to take account of other stakeholders.

All Boards have been asked to carry out a review of case notes and care practices relating to mortality. NHS Grampian has submitted the two required responses and the Medical

8 Board Meeting 30 09 13 Open Session Item 7.1 Director is organising the process for conducting case note reviews. This work is being overseen by the Patient Safety Executive Group and the Acute Sector Quality Group.

Within the context of the national person centred work, Grampian has established a local aim: “By the end of 2014 NHS Grampian will be recognised as a caring, listening and improving organisation as evidenced by an increase in the capture and use of patient, carer and staff experience information for improvement. Co-production will be a key feature of improvement plans”. Looking back on his review, Keogh stated that “the use of patient and staff focus groups was probably the single most powerful aspect of the review process and ensured that a cultural assessment, not just a technical assessment, could be made.” The importance of the voices of staff and patients reverberates with Berwick who says, “The patient voice should be heard and heeded at all times.” He also recommends that, “feedback should be collected as far as possible, in real time”.

With the above in mind, a range of activities is underway by teams that attended the NHS Scotland learning events in order to commence a programme of improvement work. This includes the real time collection of patient, carer and staff experience information, which is collated and combined with Better Together results and formal feedback information to create a person-centred portfolio for participating clinical areas. To this end, we have purchased a module of Datix, which has been adapted to provide a platform for real time staff experience data collection. The module is already being used to record real time patient experience, whilst there is a plan to test the real time staff experience component at the earliest opportunity. This will contribute to fulfilling Berwick’s recommendation that, “Staff should be free to state openly their concerns about patient safety without reprisal”.

Moving forward towards 2020, staff and patient experience information will be key to ensuring the delivery of person-centred, safe and effective care.

Key Risks

The relevant strategic risks are: 853 – Patient Safety and 1134 – Sustainable Workforce

 In his letter to the Health Secretary Sir Bruce Keogh refers to themes, which could demonstrate learning across the system. One of these is formulated as: “the imbalance that exists around the use of transparency for the purpose of accountability and blame, rather than support and improvement”. Such a dysfunctional use of transparency may befall members of staff, their managers, the general public and the press. It would drive an open and transparent reporting culture underground and stand in the way of developing person centred safe and effective services. The experience with NHS Scotland inspection regimes shows how external inspections in a societal culture of blame and recrimination can undermine staff engagement and morale.  The development of “an industry” out of person centred and patient safety initiatives has the potential to become an additional burden to already very busy staff, reducing patient facing time.  The complexity of using and interpreting aggregate measures of mortality, including HSMR, and the dearth of alternative good quality indicators for safe and effective service delivery may provide false reassurance or unnecessary loss of confidence when analysing the Quality Dashboard by the Board.

9 Board Meeting 30 09 13 Open Session Item 7.1 Conclusions

NHS Grampian is consulting its staff on the key findings of the Francis, Keogh and Berwick reports.

The implementation of the recommendations is approached by building on work already in place relating to person centred, safe and effective care as a result of existing local and national initiatives.

The organisation is amalgamating standards from the various national programmes with the recommendations of the three reports to formulate a quality portfolio that is customised to specific clinical areas. It intends to involve staff and patients in the assessment of these portfolios.

All the actions are carried out under the “Caring Listening Improving” banner to ensure that a culture of support and improvement is established as opposed to one of accountability and blame.

Recommendations

The Board is asked: 1. To consider the NHS Grampian approach to the key findings of the Francis, Keogh and Berwick Reports 2. To advise the Executive Team on any improvements that can be made to this approach 3. To further consider the role that Non Executive Board members may have in the implementation of the recommendations.

Background Papers

1. The Francis Report www.midstaffspublicinquiry.com 2. Independent Inquiry into Care Provided by Mid Staffordshire NHS Trust – Grampian NHS Board Meeting 3 August 2010 3. Quality Strategy Update – Grampian NHS Board Meeting 6 December 2012 4. Mid Staffordshire Trust Inquiry - Internal Audit Report 2011/2012 5. The Keogh report http://www.nhs.uk/NHSEngland/bruce-keogh- review/Documents/outcomes/keogh-review-final-report.pdf 6. The Berwick Report - A Promise to learn – a commitment to act: Improving the safety of patients in England www.gov.uk/government/publications/berwick-review-into- patient-safety

Executive Leads

Elinor Smith Dr Roelf Dijkhuizen Dr Annie Ingram Director of Nursing & Quality Medical Director Director of Workforce

Elinor Smith, Director of Nursing & Quality Helen Robbins, Head of Quality, Governance and Risk September 2013