1. Clinical Governance From Strategy to Action – Making a Difference in NHS Tayside

2. Griffiths Report Financial Assurance Financial Probity Clinical Assurance Clinical Probity E X T E R N A L S C R U T I N Y

3. Clinical Governance in NHS Tayside Anticipate and Prevent Harm – clinical risk, patient safety, “near miss” Understand and Minimise Unnecessary Variation – data, measurement, improvement Demonstrate Learning and Sustainable Change – adverse events management when they occur Ensure Multi-professional, Multi-disciplinary Reflective Practice Ensure Appropriate Patient and Carer Involvement

4. Setting the Scene  1 in 10 hospital admissions result in an adverse event (DoH, 2000)  Average cost of adverse events in healthcare is £6 billion in the UK (Boslin, 2007)  Only 15% of doctors surveyed in the UK were willing to report an adverse incident (Boslin, 2007)  Medical error is the 3 rd most frequent cause of death in Britain after cancer and heart disease…..kills four more times people than die from all other types of accident (DoH, 2000)

5. The shifting landscape of the past 12 months… The Francis Report February 2013 – Examined the commissioning, supervisory and regulatory organisations and other agencies, including the culture and systems of those organisations, in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009 and why problems were not identified sooner, and appropriate action taken. The Keogh Review July 2013 – Review into the quality of care and treatment provided by 14 hospital trusts in England. The Berwick Report August 2013 – A promise to learn – a commitment to act: Improving the safety of patients in England. Awaiting the Vale of Leven Report

6. What Keogh looked at… He was asked to review quality of care and treatment in Trusts with persistently high Hospital Standardised Mortality Ratios. He looked at information and data relating to: Patient Experience Safety Workforce Clinical and Operational Effectiveness Leadership and Governance

7. The Keogh findings No one indicator gave all the assurances. The review emphasised the importance of Boards making better use of data to identify potential problems. For example, high mortality rates must be treated with caution but they are an important warning sign. However, it is just as important to look at other indicators, especially feedback from patients and staff. Need to look at all the data in the round – TRIANGULATION – to build up a picture of clinically effective, quality and safe care

8. So, how can we put the learning from The Keogh Review into practice? Need an essential shift away from looking at individual bits of data to overall organisational intelligence This requires a fundamental change to how we’ve operated before Medical and Nurse Director developed the Tayside Care Assurance Framework based on Keogh’s five domains

9. The new Tayside Care Assurance Framework - What it is and what it will do A whole system measurement and monitoring framework to support clinicians and managers use information collected to identify variation, monitor performance and support improvement. It will provide assurance to the Board and the public about the services they provide ‘From the Point of Care to the Board’ in the form of an easily accessible report.

10. How does the report show TRIANGULATION?

11. GMC Survey Complaints Re-admission Rate After 3 months Poor Staff Survey After 6 months Litigation Costs Staff Sickness Absence After 12 months Nurse Capacity Grievance NMC Referrals Clinical Indicator After 18 months Treatment Time Guarantee

12. The NHS Tayside Clinical Governance Strategy Person-centred, safe and effective clinical care – Clinical Governance Strategy “Our ambition is that every day every one of us delivers, sees and experiences standards of care that we would want for our own loved ones. This can only happen by putting the patient at the centre of everything we do, working as a team and making sure we have the information and data we need to deliver excellent treatment”

13. The focus of the strategy is to: Promote and encourage appropriate patient and carer involvement in everything we do Deliver high-quality, evidence-based care Encourage and enable our staff to work in multi- disciplinary and multi-professional (ie joined-up) teams and use reflective practice Anticipate and prevent harm through robust systems for clinical risk, patient safety and investigation of ‘near misses’ Understand and minimise unnecessary variation by the intelligent use of data, measurement and improvement Demonstrate learning and sustainable change from adverse events

14. The scope of Clinical Governance Clinical Risk Management Clinical Effectiveness Person-Centredness Continuous Improvement Staff Focus The strategy describes the systems, escalation processes and triggers used to coordinate all of these elements which inform improvement, quality of care and risk management at all levels throughout the organisation. This system gives assurances ‘From the Patient to the Board’.

15. Harm and Near Misses Defined Harm is defined as ‘injury’ (physical or psychological), suffering, disability or death which was unexpected e.g. medication incident – missed dose, needle-stick injury Quite simply, harm is something you would not wish to happen to yourself or your family A Near Miss describes an incident where there was no harm, loss or damage but this was possible e.g. avoidance of wrong site surgery

16. Who should report an adverse event / incident? All staff, regardless of role, have a responsibility to report any incidents or near misses to ensure action can be taken to improve the system and keep patients safe “Everybody’s Responsibility!”

17. Mid Staffordshire Inquiry Recommendations A common culture to be shared throughout the system, three characteristics are required: Openness: enabling concerns to be raised and disclosed freely without fear, and for questions to be answered; Transparency: allowing true information about performance and outcomes to be shared with staff, patients and the public; Candour: ensuring that patients harmed by a healthcare service are informed of the fact that an appropriate remedy if offered, whether or not a complaint has been made or a question asked about it Mid Staffordshire Report, p75 Feb 2013

18. Top 5 Incidents 1. Slips trips falls 2. Violence and aggression 3. Other 4. Medication 5. Documentation/administration Common Themes for Incidents & SCEAs Themes from SCEAs Failure to escalate to senior personnel in a timely manner Incomplete/ inadequate record keeping Communication in the interface between and across disciplines and services and external agencies Communication and supporting documentation/IT infrastructure. The need for more robust and consistent support mechanisms for staff when an incident occurs Failure to recognise the deteriorating patient and take appropriate action

19. Significant Clinical Event Analysis or Significant Standard Event Analysis/Local Review Staff must consider if the incident features on the list for a Significant Clinical Event Analysis (SCEA). Significant Clinical Event Analysis (SCEA) focus on significant clinical incidents which have an impact of permanent psychological and/or physical harm or death of one or many patient (s). SCEAs are usually held when there has been a systems failure that can occur anywhere, and not just the area/s where the incident occurred, thus addressing organisational issues

20. Back to Basics – Juran Triangle Quality Planning – our Strategy and Care Governance Framework Quality Improvement – our actions to get the work done Quality Control – our checks and balances that give assurance,tells us what we say we are doing has been done

21. Implementation Plan Communication Plan Links with Vision, Aims, Values and Behaviours Does every member of staff know their responsibility? Improvements in structures from Local Clinical Governance meetings to Improvement & Quality Committee Reporting data and information from Care Assurance Framework that provides assurance

22. Structures to Deliver LOCAL CLINICAL GOVERNANCE GROUPS AT WARD/DEPARTMENT LEVEL PATIENT WARDS, DEPARTMENTS & COMMUNITIES LOCAL CLINICAL GOVERNANCE GROUPS AT WARD/DEPARTMENT LEVEL PATIENT WARDS, DEPARTMENTS & COMMUNITIES Tayside NHS Board ORGANISATIONAL SUPPORT FOR CLINICAL GOVERNANCE Professional and Clinical Leadership, The Nursing & Midwifery Directorate, Clinical Governance & Risk Management Team, The Centre for Organisational Effectiveness (TCOE), The Patient Safety Team, The Business Unit and Business Intelligent Hubs. GOVERNANCE COMMITTEES STRATEGIC/MANAGEMENT GROUPS AND COMMITTEES DIRECTORATE/CHP SAFETY, GOVERNANCE AND RISK GROUPS NEW CARE GOVERNANCE MEASUREMENT AND MONITORING FRAMEWORK PATIENT FAMILY CARERS

23. Micro system and front line Engaged staff – clinical risk, safety and improvement are priorities Permission to improve care and patient experience Leading Better Care Releasing Time to Care MDT reflection and action

24. How will we know what improvement looks like? Patient Carer Experience Data Patient Safety Data Workforce Experience Data Visible and Accountable Leadership Clinical Effectiveness/Clinical Strategy

25. Key Milestones…. Setting Priorities – NOT boiling the ocean MDT Reviews crucial Failure to rescue deteriorating patient Medication issues Clinical Engagement Learning Loops

26. “If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented.” Robert Francis QC