1. Francis, Keogh and Berwick – the implications for clinical audit
Presentation for NAGG, 18th September 2013

2. The Francis Report 2010
The Mid Staffordshire NHS Foundation Trust Inquiry Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009 Chaired by Robert Francis QC
Independent Inquiry covered January 2005 to March 2009 and was set up to enable those affected by poor care an opportunity to tell their stories.
Terms of reference also allowed for the views and experiences of staff to be gathered, and for the inquiry to seek explanations from management and directors.
Reported in 2010

3. The Francis Report 2010 Key findings
Serious deficiency in the performance and resourcing of clinical audit in at least some areas of activity. The impression given is that practice and attitudes in relation to this are considerably out of date.
Lack of leadership – “ the trust generally performed poorly on clinical audit. There was no one taking the lead for clinical audit for a year and the trust-wide group did not meet at all during this period”
Lack of clinical engagement – for example - a surgeon stated that the medical lead and head of surgery had no interest in clinical audit and reviews because of lack of time.
Clinical audit not carried out accordance with national standards in each area of activity.

4. The Francis Report 2010 Key findings cont.
Limited participation in national clinical audits – the trust did not participate in many of the national audits run by the specialist societies
Inconsistency across trust – perception was that in some clinical areas there were good clinical audit programmes whilst in others performance was very poor in comparison with the same speciality in other trusts
Confusion over role of clinical audit staff and support
Re-audits not carried out

5. The Francis Report 2010 Recommendation 5:
The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis.
Midstaffs Public Inquiry Website
Kings Fund Presentation by Robert Francis Lessons from Stafford

6. The Francis Report 2013
To examine the operation of 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 to examine why problems at the Trust were not identified sooner, and appropriate action taken.
February 2013

7. Clinical audit?
‘It seems quite extraordinary that the general acceptance of the importance of clinical governance, and in particular clinical audit, which had been recognised nationally from the time of the Bristol Royal Infirmary Public Inquiry report in 2000, if not before, had failed to permeate sufficiently into Stafford to result in a functioning, effective system by 2009’
Francis Inquiry Report 2013 section 2.352
When audits were carried out, there was no robust mechanism to ensure that changes were implemented.
When re-audits were required, they were often not undertaken.
The trust did not participate in many of the national audits

8. The Keogh Review
Review into the quality of care and treatment provided by 14 hospital trusts in England
Professor Sir Bruce Keogh KBE
Selected as mortality outliers
Intensive review by experienced teams making extensive use of available data
‘Although all 14 trusts face a different set of circumstances, pressures and challenges ahead, this review has also been able to identify some common themes or barriers to delivering high quality care which I believe are highly relevant to wider NHS.’
Keogh review final report (16 July 2013)

9. The Keogh Review Key themes include
The capability of hospital boards and leadership to use data to drive quality improvement. More clearly needs to be done to equip boards with the necessary skills to grip the quality agenda.
Some boards use data simply for reassurance, rather than the forensic, sometimes uncomfortable, pursuit of improvement
The fact that some hospital trusts are operating in geographical, professional or academic isolation

10. The Keogh Review Ambition 1
We will have made demonstrable progress towards reducing avoidable deaths in our hospitals, rather than debating what mortality statistics can and can’t tell us about the quality of care hospitals are providing.
Professor Nick Black has been commissioned to study mortality data, which will lead to the introduction of a new a new national indicator on avoidable deaths in hospitals, measured through the introduction of systematic and externally audited case note reviews.

11. The Keogh Review Ambition 2
The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level.
All those who helped pull together the data packs produced for this review must continue this collaboration to produce a common, streamlined and easily accessible data set on quality which can then be used by providers, commissioners, regulators and members of the public in their respective roles. The National Quality Board would be well placed to oversee this work.

12. The Keogh Review Ambition 2 (continued...)
Boards of provider organisations - executives and non-executives - must take collective responsibility for quality within their organisation and across each and every service line they provide. They should ensure that they have people with the specific expertise to know what data to look at, and how to scrutinise it and then use it to drive tangible improvements. Over the last decade, many hospitals in the United States have recognised the importance of this by creating board level Chief Quality Officers. Creating a new board role is not essential, but having someone with the breadth of skills required is.
The skills deficit amongst commissioners must be addressed
The requirements for Quality Accounts will be reviewed for

13. The Keogh Review Ambition 3
Patients, carers and members of the public will increasingly feel like they are being treated as vital and equal partners in the design and assessment of their local NHS. They should also be confident that their feedback is being listened to and see how this is impacting on their own care and the care of others.
Involving patients and staff was the single most powerful aspect of the review process.
All NHS organisations should seek to harness the leadership potential of patients and members of the public.

14. The Keogh Review Key areas for improvement In patient safety
poor quality root cause analysis of incidents and limited dissemination of learning from when things go wrong
Understanding and use of data
the complexity of the data and the difficulties this presents for professionals, patients and the public who want to understand and use it;
the shortage of key skills in data analysis and interpretation available to trust boards and management teams; and
consistency of metrics and information to be used to monitor quality on an ongoing basis.

15. The Berwick Report A promise to learn– a commitment to act
Improving the Safety of Patients in England
National Advisory Group on the Safety of Patients in England
‘Our job has been to study the various accounts of Mid Staffordshire, as well as the recommendations of Robert Francis and others, to distil for Government and the NHS the lessons learned, and to specify the changes that are needed.’
Advisory group chaired by Don Berwick, President Emeritus and Senior Fellow of the Institute for Healthcare Improvement
The Berwick Report (August 2013)

16. The Berwick Report
The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.
Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.
Rules, standards, regulations and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.

17. The Berwick Report
All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities
Recognise that the most valuable information is about risks and things that have gone wrong
Give help to learn, master and apply modern improvement methods
Use data accurately, even where uncomfortable, to support healthcare and continual improvement

18. The Berwick Report
Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
Patients and their carers should be represented throughout the governance structures of NHS-funded healthcare providers, for example by sitting on and actively participating in safety and quality committees.
The recommendations of the Keogh Review were endorsed

19. The Berwick Report
Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.
Collaborative learning through safety and quality improvement networks can be extremely effective and should be encouraged across the NHS. The best networks are those that are owned by their members, who determine priorities for their own learning.
Every NHS organisation should participate in one or more collaborative improvement networks as the norm.

20. The Berwick Report
Most health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly, and should be closed.
Commissioners should increase funding for NHS organisations to analyse and effectively use safety and quality information.
The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified.
An in-depth, independent review of structures and the regulatory system should be completed by the end of 2017, once current proposed changes have been operational for three years

21. The Berwick Report Key actions include:
Government and NHS England Leaders must support investment in the improvement capability of the NHS
NHS Organisation Leaders and Boards must:
Monitor the quality and safety of care constantly, including variation within the organisation.
Embrace complete transparency
Join multi-organisational collaboratives – networks
System Regulators must simplify, clarify, and align their requests and demands from the care system

22. The Berwick Report Key actions (continued):
Professional Regulators and Educators must assure the capacity and involvement of professionals as participants, teammates, and leaders in the continual improvement of the systems of care in which they work.
NHS Staff and Clinicians must:
Participate actively in the improvement of systems of care.
Acquire the skills to do so.

23. The way forward?
Clinical audit must take it’s place in an integrated view of healthcare quality management and service improvement
How can we help to develop the skills:
For commissioners
For trust boards and the senior leaders in other healthcare providers
For clinicians, of all grades and from all specialties
For healthcare managers
For clinical audit staff

24. The way forward?
‘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
HQIP has an established Service User Network
HQIP Service User Network web page
We have produced a range of guidance on patient and public engagement in clinical audit
HQIP PPI Guidance

25. Contact us Healthcare Quality Improvement Partnership
  Website:
Promoting quality improvement for better healthcare