Improvement Programme 2014/15 Health Improvement Scotland Invited Review of Aberdeen Royal Infirmary Quality and Safety

Transcription

1 Improvement Programme 2014/15 Health Improvement Scotland Invited Review of Aberdeen Royal Infirmary Quality and Safety Immediate Action Plan (including unannounced visit to Care of Older People and Royal College of Surgeons (England) report) 1 December 2014

2 Contents Page Section 1: Introduction 3 Section 2: Patient Feedback and Outcomes 6 Section 3: Leadership and Governance 8 Section 4: Planning and Performance 9 Section 5: Workforce 10 Section 6: Clinical Engagement 12 Section 7: Actions arising from Royal College of Surgeons Report 13

3 Section 1: Introduction 1.1 NHS Grampian has the ambition to be a high performing organisation - safe, effective, caring, responsive and well led. 1.2 This summary overview sets out the immediate actions that we will be taking to address the findings from the invited review of Quality and Safety at Aberdeen Royal Infirmary, the Royal College of Surgeons (England) report and the findings and recommendations from the unannounced Older People in Acute Hospitals Inspection. We have developed a comprehensive NHS Grampian improvement programme which will be agreed with Scottish Government following consideration of any further expert support from Health Improvement Scotland. 1.3 The overall programme sets out the wide range of actions being implemented to ensure that our corporate, health and healthcare strategy is fit for the future, and that service delivery meets the requirements of the people of Grampian and Scottish Government policy. 1.4 The actions that we will taking immediately as set out in this summary and for the foreseeable future will demonstrate that we are committed to taking steps to deliver against high quality patient care based on: Executive and senior management leadership Engagement between the Board, staff and our patients in terms of planning for future services and the delivery of performance and quality outcomes Clarity around management structures and operational effectiveness Commitment to continuous improvement and learning from staff and patients Supporting staff and building capability, capacity and resilience across all services. 1.5 In this overview report we focus on the actions that are already being implemented or will commence within the next 30 days. The aim is not only to make improvements that will have an effect in the short term but also to have a long term impact in relation to the role of NHS Grampian as a partner in the north east of Scotland and north of Scotland health and care community Key findings from the HIS review 1.6 NHS Grampian has an ambition to be the best performing board in Scotland. Performance against this ambition is measured by clinical outcomes, patient experience and staff experience. Whilst we have some way to go to achieve this ambition we remain proud of the services provided at Aberdeen Royal Infirmary and the people that deliver our services. 1.7 We are grateful for the recognition that the report gives to the challenging environment in which we have been operating and of the hard work and dedication of many staff within Aberdeen Royal Infirmary. 1.8 The primary focus of the review was on the quality and safety of care within Aberdeen Royal Infirmary and the conclusions of the review team confirm that: The patient outcome data did not show consistent or widespread concerns about patient safety or the quality of patient care. Aberdeen Royal Infirmary is not significantly different from the Scottish average for a range of measures about the quality and safety of patient care 3

4 NHS Grampian, primarily Aberdeen Royal Infirmary, is on trajectory for all but two elements of the Scottish Patient Safety Programme. Being on trajectory means that sustained improvements have been made and that these are widespread throughout the Board. The detailed case note review confirmed many areas of good practice, including patients being seen by consultants and experienced trainees early in their admission, evidence of good communication with patient relatives and clear care plans. 96% of patients rated the service they received as being good, very good or excellent. The review concluded that on the whole patients and carers report positive experiences of the care they receive whilst in Aberdeen Royal Infirmary. 1.9 We do however acknowledge that there are areas for improvement and very much welcome all opportunities to enhance and improve our services. The reports highlight the challenges facing the organisation and the need for decisive and immediate action Extensive plans have already been drawn up to take forward all the recommendations and issues in relation to culture, behaviour and leadership. We take these reports extremely seriously and we accept the recommendations that the reports make 1.11 We will embrace the recommendations within the three reports as a valuable component of our journey of improvement and the Board will attend to these as a matter of priority Within this action plan we confirm the Board s commitment to the implementation of the necessary improvements and ensuring that we establish a robust and deliverable strategy to provide high quality, sustainable and resilient services to patients supported by a robust implementation plan. In developing our strategy the Board and senior leadership will engage with our staff, patients, partners and wider public and ensure that key decisions about future services and resources are undertaken in an open and transparent manner Our improvement plans will focus on delivery of the following outcomes: Patient Outcome and Experience We will ensure that we evidence and demonstrate our commitment to listening and responding to feedback from patients and that a culture of learning and continuous improvement is embedded across all services. Leadership and Culture We will agree, communicate and implement values and behaviours which will establish a positive and constructive culture of respect, dignity and innovation. We will robustly tackle personal and professional behaviour that is not consistent with these values. We will ensure that effective leadership is established within Aberdeen Royal Infirmary with clarity around the structure, roles and responsibilities and a sharp focus on the scrutiny of performance and risk mitigation. Nursing and medical staff and management will have equal responsibility and accountability for performance, patient safety and staff governance. 4

5 Performance and Planning We will ensure that robust and sustainable plans are developed and implemented to meet the performance standards in relation to patient flow and Emergency Department waiting times and that monitoring of performance is demonstrated with appropriate analysis and challenge. Workforce We will continue to ensure that the workforce challenges around recruitment, retention and sustainability are assessed and that appropriate mitigating actions are being implemented to ensure quality care for patients and support sustainable and resilient services. We will ensure that all staff, including professional trainees, can develop their skills and experience in a positive and supportive environment. Staff Engagement We will ensure that there is enhanced visibility and engagement of the Board with staff resulting in a closer connection, enhanced trust and confidence in the Board s strategic direction and accountability for person centred, safe and effective care We will ensure that the advisory structure and Board are connected with a common purpose and agenda and that the remit and membership is representative of health professions and professional staff. Accountability 1.14 The actions that we have set out in this summary and the wider improvement plan will deliver the outcomes noted above and confirm the actions that have already been progressed by the Board In terms of oversight over the implementation of the Improvement Plan a Scrutiny Group will be established, comprising four non-executive members of the Board, the Chair of the Area Clinical Forum and Employee Director. The Scrutiny Group will provide assurance to the Board and Scottish Government that steps are being taken to implement the agreed actions and secure the desired outcomes that will provide confidence that we are consistently delivering person-centred, safe and effective care In terms of accountability the Chief Executive will be directly responsible to the Board for implementation of the agreed actions within the improvement plan. The Chief Executive will delegate lead responsibility for each element of the plan to members of the Executive and Senior Management Team. 5

6 Section 2: Patient Feedback and Outcomes Outcome We will ensure that we evidence and demonstrate our commitment to listening and responding to feedback from patients and that a culture of learning and continuous improvement is embedded across all services We are proud of the staff that we employ across Aberdeen Royal Infirmary and for their commitment and dedication to the delivery of high quality safe and effective care. Aberdeen Royal Infirmary is, and will continue to be, one of Scotland s leading teaching and research hospitals. We have highly trained and experienced staff. During 2013/14 and 2014/15, the Board approved 10m of additional investment in 210 medical and nursing staff across a range of services and in support of our commitment to ensure that we have safe and sustainable levels of staffing across our services. The Board have also committed continued significant investment in our world class infrastructure; the purpose built Emergency Care Centre (which incorporates our Emergency Department and Unscheduled Care services in a co-located facility), the commitment to the replacement of the maternity hospital and commissioning of a new Cancer Centre, a complete refurbishment of all inpatient clinical areas within Aberdeen Royal Infirmary and completion of three new operating theatres and planning for the implementation of the first non-invasive robotic surgery service in Scotland. The quality of our staff and the infrastructure in which we operate was recognised in the patient experience data reviewed by Health Improvement Scotland. We do however acknowledge that there are further areas where we could improve the gathering of, and responding to, feedback from patients. Patient feedback forms a critical element of our commitment to being a learning organisation and ensuring that we continuously review and improve services. We will ensure that we improve the way we investigate, respond to and learn from complaints and build on collecting real-time patient experience. By the end of December, we will ensure that patient feedback is consistently acknowledged within 3 working days and that we significantly improve our performance against the 20 day standard to respond in full to feedback. We commit to upper quartile performance in terms of responding to feedback from the end of January. In addition to responding in writing, we will be making contact with a sample of complainants to discuss their feedback and to ensure that they are clear on the actions that we will be taking and that we have demonstrated that we have listened and responded to the matters raised. 6

7 The unannounced Older People in Acute Hospitals Inspection ARI and Woodend The report into the care of older people in acute hospitals highlights examples where care did not meet the standard required. We will address the areas for improvement following the unannounced inspection of the care for older people in acute hospitals at Aberdeen Royal Infirmary and Woodend Hospital We take examples where care did not meet our standards extremely seriously and we will ensure that we implement the necessary improvements in leadership, training and ward operational standards to consistently deliver high quality patient centred care. We have approved a detailed improvement action plan to address all the recommendations made. Implementation of the actions will be monitored by the Board. A copy of the detailed improvement action plan is available as a separate document. 7

8 Section 3: Leadership and Governance Outcome We will agree, communicate and implement values and behaviours which will establish a positive and constructive culture of respect, dignity and innovation. We will robustly tackle personal and professional behaviour that is not consistent with these values. We will ensure that effective leadership is established within Aberdeen Royal Infirmary with clarity around the structure, roles and responsibilities and a sharp focus on the scrutiny of performance and risk mitigation. Nursing and medical staff and management will have equal responsibility and accountability for performance, patient safety and staff governance. Whilst quality and safety are good at Aberdeen Royal Infirmary the review team highlighted the need for the Board to strengthen the management structure and processes of accountability to provide assurance that quality and safety standards are maintained and improved; and develop an organisational development (OD) plan which will enhance the Board and senior management leadership, improve clinical engagement, rigorously apply the values and behaviours, and support the enhancement of effective management within Aberdeen Royal Infirmary. This will be taken forward during December. The Board accepts its responsibility around establishing and enforcing the implementation of standards of conduct and behaviour and takes its responsibilities in this respect extremely seriously. A number of actions have already been taken by the Board including commissioning of the Royal College of Surgeons England to undertake a review of the general surgery service within Aberdeen Royal Infirmary. We are committed to establishing a culture of respect, trust and openness. The Board will reconfirm the values and standards of conduct expected of staff and ensure that there is a robust and consistent approach taken to address instances where staff behaviour or action is not consistent with the values set for the organisation. We will undertake a fundamental review of leadership in Aberdeen Royal Infirmary and ensure that there is strong and effective governance with emphasis on clinical, operational and managerial responsibility. We will ensure that there is appropriate senior management and professional leadership across the sector in support of the General Manager, with clarity over roles and devolved responsibilities and a commitment to joint accountability for services and performance. 8

9 Section 4: Planning and Performance Outcome We will ensure that robust and sustainable plans are developed and implemented to meet the performance standards in relation to patient flow and Emergency Department waiting times and that monitoring of performance is demonstrated with appropriate analysis and challenge. The Board are responsible for the delivery of performance across a number of agreed outcomes. Whilst we face challenges in meeting national standards in relation to access times and delayed discharges, our performance in overall terms against HEAT measures and outcomes is in line with performance across NHS Scotland; and would highlight the following: 4 hour A&E Waiting Times Standard - since April 2013 the 95% target has been met in 8 out of 12 months, in line with the performance of boards across Scotland. Reduction in attendance rate at A&E - NHS Grampian s attendance rate at A&E has fallen substantially in recent years and is low in Scottish terms. Infection control - Clostridium difficile infections per month per 1000 occupied bed days (patients aged 65 plus) are ahead of target. Health improvement measures - Performance across most health improvement measures is consistently ahead of national targets; including number of completed Alcohol Brief Interventions and Child Healthy Weight Interventions, number of Successful Smoking Cessation Quit attempts, number of Inequalities Targeted Cardiovascular Health Checks, referral to treatment within 3 weeks for alcohol and drugs and early access to antenatal care booked at 12 weeks. The review however highlighted the need for the Board to review its overall unscheduled care plan and to ensure that there is a sustainable and resilient staffing model within the Emergency Department. The actions we are taking are noted below. We will review the model of care in relation to unscheduled activity and the management of patient flow. We are undertaking a planned evaluation of the Board approved unscheduled care plan in the context of Health and Social Care Integration. We will ensure that actions taken are effective and efficient in managing the flow of patients to the most appropriate point of care within the hospital. This includes working with key partners and agencies across Grampian. We will develop a plan to secure a sustainable emergency department service. We will continue to work with the National Unscheduled Care Expert Leads to ensure that we develop a sustainable workforce model which provides leadership, direction and engagement for our multi-disciplinary staff. We are committed to being in the upper half of performance within NHS Scotland in delivering the 4 hour arrival to treatment standard. 9

10 Section 5: Workforce Outcome We will continue to ensure that the workforce challenges around recruitment, retention and sustainability are assessed and that appropriate mitigating actions are being implemented to ensure quality care for patients and support sustainable and resilient services. We will ensure that all staff, including professional trainees, can develop their skills and experience in a positive and supportive environment. We believe that our staff are amongst the best working in NHS Scotland and as a Board we are committed to doing all that we can to support them. We take our role as a teaching hospital seriously and we will ensure that this support is extended to all staff and to trainees in all disciplines. Investment in additional clinical staffing has been a priority for the Board and a number of planned investments have been approved over the last two financial years to support service developments and/or address known pressures arising as a result of increased activity. The key investments approved by the Board in relation to clinical staffing are noted below: Service Source of investment FTE 000 New theatre investment LDP Prioritised investment ,348 Cancer action plan LDP Prioritised investment ITU nursing Additional NRAC funding Endoscopy Additional NRAC funding OMFS Head and Neck consultant Additional NRAC funding New nurse posts Additional NRAC funding ,100 Trauma Theatre nursing Additional NRAC funding Unscheduled care Additional NRAC funding ,000 Total ,905 The Board has continually prioritised staff recruitment and actions are being taken to address the impact of external factors. These actions included workforce 2020, the establishment of the nursing resource utilisation group, enhancing availability of affordable housing, dignified workplaces and innovative approaches to unscheduled care. We will implement plans to ensure that there are sufficient numbers of nurses and an appropriate mix of skills in all wards We have already increased the number of nurses by 200 full time equivalents in the last two years and plan to recruit an additional 30/40 new nurses during 2015/16. We will engage with Robert Gordon University to maximise the conversion of graduates into new and vacant posts and appoint a nurse consultant to provide leadership and professional development support to the care for the elderly service. We will also continue to focus on recruiting to the posts already approved and ensure that staffing levels are further improved. 10

11 We will develop and implement a robust medical workforce plan. We are reviewing the medical staffing within each clinical specialty to develop plans to ensure that we have resilient and sustainable clinical services, anticipating any gaps in training numbers, matching staff coming to the end of their training with vacant posts and planning for staff retirements. We will ensure that the training of medical staff is considered a priority. We are committed to improving the training of doctors in conjunction with the training programme directors, clinical supervisors, post graduate dean and medical staff, including trainees. This commitment will be underlined with the appointment of an Associate Medical Director Education and Training who will report on our training performance directly to the Board, under the responsibility of the Medical Director. Royal College of Surgeons (England) report In response to the findings within this report and the HIS report into Quality and Safety we have committed to improving leadership, management and engagement between clinicians and managers. We will establish a system of management within the General Surgery division and across all divisions at Aberdeen Royal Infirmary with clinicians and managers working together at the heart of the care that we provide with clear roles and responsibilities, ensuring that all staff understand what is expected of them and all consultants have job plans. Where poor or unprofessional behaviour is encountered it will be robustly addressed through established policies and procedures. We will ensure that the recommendations made by the Royal College of Surgeons (England) are implemented in full. We have agreed and approved a detailed action plan to address all the recommendations made. Implementation of the actions will be monitored by the Board. A copy of the Board s action plan is available as a separate document. 11

12 Section 6: Clinical Engagement Outcome We will ensure that there is enhanced visibility and engagement of the Board with staff resulting in a closer connection, enhanced trust and confidence in the Board s strategic direction and accountability for person centred, safe and effective care. We will ensure that the advisory structure and Board are connected with a common purpose and agenda and that the remit and membership is representative of health professions and professional staff. The development of a new clinical services plan will provide an important opportunity for sector wide clinical engagement linked to the 2015/16 Local Delivery Plan and Property and Asset Management Plan. We have committed to improving leadership, management and engagement between clinicians and managers at Aberdeen Royal Infirmary and across the organisation. The Board will also play an active part in enhancing the level of clinical engagement and have committed to refocusing the patient safety walkround programme and to reviewing the effectiveness of the clinical advisory structure and its links to the business of the Board. This review process commenced at the recent Board seminar in November. At the seminar there was an open and constructive discussion involving senior clinical managers, the advisory structure, staff partnership representatives and senior management on the key issues and priorities for the Board. We will also build on the Grampian Recognition Awards programme to ensure that recognition of the individual and collective contributions of staff are given increased prominence and acknowledgement. We will take urgent action to engage fully with clinical and non clinical staff. We will build on recent and positive discussions with staff to ensure that open and constructive staff engagement is embedded within the culture from the Board to the ward. We will establish a strong medical management structure with medical staff in leadership roles. At every level of the organisation medical leaders will work alongside nurse leaders and managers and together they will have collective responsibility for improving patient care, working in partnership with all staff and involving patients. We will ensure that there are robust medical appraisal and revalidation processes implemented across all specialties, with job plans agreed with every consultant. We will complete the review of the advisory structure to ensure that the multi-professional representation is able to engage with, advise and escalate matters for management and Board attention. 12

13 Section 7: Royal College of Surgeons of England - Invited Review Mechanism NHS Grampian s Improvement Action Plan Tasks Further Investigations Patient Outcomes We will identify and conduct a formal review of the clinical cases brought to the attention of the RCSE team. The findings will be presented at the General Surgery department quality improvement meeting. If any issues concerning a surgeon s professional practice are established, these will be taken forward using NHS Grampian s professional performance management system in conjunction with the GMC. (Source: RCSE Recommendations and 19) We will ensure that the 16 cases already fully reviewed by the RCSE have appropriate follow up in place. (Source: RCSE Recommendation 4) Responsible person Further Investigations Values, Behaviour and Culture We will investigate allegations of discrimination based on the grounds of protected characteristics using an external expert. Findings will be taken forward in accordance with NHS Grampian s conduct policy and in conjunction with the GMC (Source: RCSE Recommendation 16,18 and 19) We will investigate allegations of misconduct with respect to previous appointment processes in the General Surgical Department. Findings will be taken forward in accordance with NHS Grampian s conduct policy and in conjunction with the GMC (Source: RCSE Recommendation 16,18 and 19) Divisional Clinical Director for Surgery Clinical Lead for General Surgery Medical Director Director of Workforce 13

14 Communication with Regulatory Bodies We will share the RCSE report with the chairman of the Health Improvement Scotland review team appointed to review the Quality and Safety of the Aberdeen Royal Infirmary. (Source: RCSE Recommendation 15) We will share with the General Medical Council the RCSE report and any subsequent findings relating to professional behaviour or performance that come out of further investigation (Source: RCSE Recommendation 18 and 19) Medical Director Medical Director Educational + Training We will review and improve the programme of education, support and supervision for Surgical Trainees in conjunction with NHS Education for Scotland. (Source: Recommendation 9) Director for Medical Education Addressing Values, Culture and Behaviour We will engage the General Surgery consultants in a programme of setting behavioural standards, professional reflection, mediation and team building. (Source: RCSE Recommendations 7, 8, 9, 16-18, 27-28) We will review each individual surgeon s professional portfolio and activity to ensure they all have an up to date job plan, clear annual objectives, a recent multi source feedback report, a recent patient feedback questionnaire and a professional development plan. (Source: RCSE Recommendations 8, 9, 16 and 22) Clinical Lead for General Surgery Head of Organisational Development Divisional Clinical Director for Surgery Deputy Responsible Officer Restructuring of General Surgery - Organisation We will review and restructure the General Surgical Department with respect to emergency and elective teams and elective case sub-specialisation (Source: RCSE Recommendations 5, 10, 20, 21, 28 and 29) Clinical Lead for General Surgery 14

15 Restructuring of General Surgery Quality Performance, Improvement and Learning We will review, improve and enhance the systems of quality review, governance and performance management that operate within the General Surgery Department. (Source: RCSE Recommendations 8, 10-12, 16, 23-26, 28, 29) Restructuring of General Surgery Clinical Practice We will review and agree a standard approach to routine General Surgical clinical practice in line with best guidance on safe, effective, and person centred care within a multi-professional team environment. (Source: RCSE Recommendations 6, 7, 8, 10, 13, 14, 16, 20, 21 and 27-29) General Surgical Lead for Quality and Safety Clinical Lead for General Surgery 15