Clinical Governance Annual Report 2005-06

National standards audit infection prevention plan complaints and incidents major incident E-learning modules stakeholders clinical guidelines root cause analysis retraining risk reduction contingency plan expectation guidelines work collaboratively clinical classification system Clinical Governance Annual Report 2005-06

Introduction Each year, NHS Professionals places more than 2 million flexible workers in assignments in over 4,500 clinical areas in the NHS. Like NHS bodies, NHS Professionals has a duty to provide clinically effective, high quality services, to protect patients and the public. Since our inception as a Special Health Authority in April 2004, one of our key objectives has been to develop clinical governance arrangements that are specifically tailored to the supply of flexible workers, helping Trusts manage risk in an area that has been highlighted as being particularly challenging. In order to achieve this we have introduced clinical governance arrangements for the flexible workforce that are as rigorous as in any other NHS organisation. We receive consistent feedback from our partner Trusts that they value this aspect of our work. Through our clinical governance arrangements, NHS Professionals reduces risks to patients over and above that can be achieved by commercial agencies. We do this by making use of NHS intelligence and best practice to ensure that only suitable flexible workers are recruited. Where problems do arise these are not only fully investigated but also followed through to ensure similar problems do not re-occur in the same, or another, partner Trust. In this way, NHS Professionals reduces the risk further across the NHS with every new Trust it takes on. 2 Clinical Governance Annual Report 2005-06

However, meeting the expectations and requirements of the NHS to provide high quality, competent flexible workers incurs overheads to the Authority over and above those that may be faced by commercial agencies. Significant savings have been achieved in this area year on year, but it is an ongoing challenge to get other health bodies to recognise these additional costs. In our first year we put in place arrangements to ensure that in bringing together the existing services we had inherited, we built on best practice in those regions and spread that across the whole country. The clinical governance infrastructure was only in place for the latter half of the year so there was rapid development of the clinical governance framework for the organisation, characterised by the introduction of a number national initiatives and systems. These were described in last year s Clinical Governance Annual Report. This new report describes the developments in our second year, 2005-6. During this period, great progress was made both strategically and operationally and we made considerable efforts to ensure we shared our work with our partner Trusts. This report has been written to inform the SpHA Board, our partner Trusts and other interested bodies such as the Healthcare Commission about the progress that has been made in providing good quality flexible workers to the NHS and reducing the risks to patients and the public. Richard McMahon PhD, Director of Clinical Governance. Clinical Governance Annual Report 2005-06 3

Clinical Governance Strategy The most significant development for clinical governance in NHS Professionals in 2005-6 was the publication of our Clinical Governance Strategy. This document for the first time set out the direction and priorities for improving the quality and reducing the risk from flexible workers at a national level. The Strategy was launched to a national audience by the Chief Nursing Officer, Christine Beasley, in September 2005 and has been extremely well received by our partner Trusts. The Strategy identifies the key principles that underpin clinical governance in the Authority as being that: Clinical governance is integral to, and integrated in all our activities The organisation must have an open culture and become a learning organisation NHS professionals will work collaboratively with its partners to protect patients and improve their care. Four aims are described in the Strategy: 1. To apply the highest standards of recruitment practice in order to ensure patient safety 2. The ensure we place flexible workers in Trusts and PCTs who are competent and in whom managers and clinical staff can have confidence 3. To assist Trusts and PCTs in the meeting of their clinical governance objectives and achievement of national clinical priorities 4. To improve the quality of temporary clinical staff supplied to the NHS as a whole. The next section of this report describes the progress that has been made in meeting these strategic aims. (A full copy of the Strategy may be downloaded from our website: www.nhsprofessionals.nhs.uk.) 4 Clinical Governance Annual Report 2005-06

Key Achievements In order to deliver the aims of the Clinical Governance Strategy an operational plan is developed each year. The plan for 2005-6 is attached as Appendix 2, however the key developments are described in detail below under the headings of the clinical governance aims set out in the Strategy. 1. Ensuring the Highest Standards of Recruitment Practice. The first step in ensuring that the flexible workers we supply to Trusts are safe and competent practitioners is by making sure that we only take on temporary workers about whom we have good evidence that they are fit and proper people to offer contracts of engagement to. The regional services we took on when we became the Special Health Authority were each working to differing standards and processes. In addition there were a number of sets of national guidance that applied to the recruitment of flexible workers, some of which differed from the others. During 2005-6 we agreed national standards for the recruitment of our flexible workers that were applied to all our regional recruitment services. These standards addressed key issues such as ensuring a consistent approach to the nature and checking of references for flexible workers we recruited. However, it is not good enough to set standards if they are not monitored. So, during the year a system of auditing the standards was introduced. This involved members of the clinical governance team auditing the recruitment practices in a different region from their own. Compliance with the new national standards was at 91% by the final audit of the year, with areas of non-compliance mainly centering on the lesser standards, for example having separate photographs of the applicant on file, in addition to those from their passport or other document used to confirm identity. As well as the introduction of the new standards, systems were reviewed and the advantages of being a national organisation began to be realised. For example, before the Special Health Authority it was possible for a flexible worker dismissed in one region to be recruited to the NHS Professionals service in the next. Following the setting up of the SpHA this is no longer possible, with systems put in place during 2005-2006 that ensured any NHS Professionals flexible worker dismissed from us would be identified if they re-applied anywhere in the country. A flexible worker was dismissed from NHS Professionals in London when it emerged that she had withheld vital information at the time of her initial application. A year later she tried to join NHS Professionals again and she was immediately identified through the internal alert system. This level of risk reduction cannot be provided through either commercial agencies, or Trust in-house nursing banks. Clinical Governance Annual Report 2005-06 5

2. Ensuring that the flexible workers placed in Trusts and PCTs are competent and in whom managers can have confidence. There are many aspects to trying to make sure that NHS Professionals flexible workers are good practitioners. One of the critical aspects is developing systems that assist in the matching of flexible workers to assignments available. During 2005-6 much development work went into constructing the Clinical Classification System which not only provided the basis for future matching of workers to assignments but also formed the basis of the introduction of the NHS s new pay system, Agenda for Change. Another key aspect of assuring the quality of NHS Professionals flexible workers is effectively managing complaints and concerns raised about them. NHS Professionals ensures that all complaints are not only fully investigated, but followed through and brought to a conclusion. The framework for this process was put in place during 2005-6 when the national Complaints and Incidents Policy was approved by the Board and rolled out across the organisation. The Policy mirrors the national processes and standards that NHS Trusts are required to follow, and is also innovative in incorporating the management of incidents under the same policy. This not only allows better monitoring of all adverse events involving A series of complaints about a Care Support Worker s attitude and poor communication with patients were tracked in the North. A performance management process was undertaken with the flexible worker and an action plan put in place. The Care Support Worker completed the plan with the support of NHS Professionals staff and continues to work for us with no further incidents having occurred. individual NHS Professionals practitioners, but also addresses the uniqueness of NHS Professionals position whereby most incidents involving our flexible workers are reported to us as complaints. In order to effectively manage the complaints and incidents, NHS Professionals purchased a proprietary complaints and incidents management system designed for use in NHS Trusts and PCTs called Safeguard. 6 Clinical Governance Annual Report 2005-06

An NHS Professionals nurse was involved in a very serious drug administration error whilst working in a different Trust from that with which she held a substantive contract. A full investigation took place in partnership with all the key stakeholders. Root Cause Analysis was used to inform the investigation, and consequently a number of contributory factors relating to the nurse, colleagues on the same shift, Trust policies and NHS Professionals own procedures were identified and acted on. This system was configured for NHS Professionals particular needs during the year and was ready by the end of March to be rolled out across the whole country, on the completion of the NHS Professionals national IT network. It is not just IT resources that lead to an effective management of complaints and incidents. The handling of such occurrences by managers is critical, therefore in line with the objective of becoming a learning organisation, all the managers in the clinical governance teams underwent training with the National Patient Safety Agency in Root Cause Analysis. This methodology was applied where serious incidents occurred. Table 1 (below) shows the number and nature of complaints received during the year. This is a complaint rate per placement of 0.14%, with by far the most common cause for complaint being the reliability (attendance and punctuality) of flexible workers. For comparison purposes, the complaint statistics for flexible workers from commercial agencies placed through NHS Professionals are also shown. However as the contract for such workers is between the Trust and the agency, NHS Professionals frequently is not made aware of these complaints. Even so, it is of note that even with this perceived under-reporting, the complaint rate for flexible workers from commercial agencies is higher than for those supplied from NHS Professionals. One of the ways in which we can support our flexible workers is by providing educational opportunities for them. Some of these are offered locally, however NHS Professionals recognises the value of providing a central resource for our workers. We also recognise that by the nature of their working patterns flexible workers find it hard to access traditional, classroom based education. Therefore during the year we developed a specification tendered for a provider of ten e-learning based educational modules. The tendering process was completed successfully and Doctors.Net was awarded the contract to deliver the modules during 2006-7. Another way of supporting our flexible workers, and the Trusts to which they are assigned, is through the development of clinical guidelines. These provide a baseline for knowledge and practice that Trusts can expect of our flexible workers. Four clinical guidelines were published on the NHS Professionals website during the year on topics such as blood administration, record keeping and the prevention and control of infection. These subjects are also topics for the e-learning modules mentioned above, thus ensuring that flexible workers have consistent resources to support their practice. Table 1. Number and Percentage of Complaints Received 2005-6. Complaint NHS Professionals Commercial Agencies Number Percentage Number Percentage Clinical: Professional Conduct 402 18% 150 17% Competence 350 16% 233 27% Clinical Incident 175 8% 80 9% Non-clinical: Reliability 896 40% 233 27% Attitude 269 12% 103 12% Other 14 6% 65 8% Total 2235 100% 864 100% Number of Assignments: 1,653,069 409,497 Complaint rate: 0.14% 0.21% Clinical Governance Annual Report 2005-06 7

3. Assisting Trusts with their Clinical Governance and Service Priorities. NHS Professionals recognises that it has a wider responsibility than simply filling assignments for its partner Trusts. As an NHS body, NHS Professionals can contribute to wider priorities. For example, during the year we ensured that each of our regions had robust emergency preparedness arrangements. In London, the NHS Professionals Major Incident Plan was put to the test with the bombings on 7th July. Despite serious problems in manning the London contact centres as a result of the disruption to transport in the city, NHS Professionals was able to respond effectively to the situation supplying nurses and doctors to many London hospitals. Following this incident a review of arrangements took place to see what could be learned from the experience and the regional Major Incident Plans modified further. Another priority across the NHS during the year was for organisations to consider their contingency plans, should there be a pandemic outbreak of influenza. In such a situation NHS Professionals would face the two challenges of supporting an upsurge in demand from our partner Trusts, whilst at the same time possibly facing a reduced availability of call handlers in the contact centres. An initial plan was developed and implemented during the year, with ongoing work clearly required as the organisation changes. In developing many of these policies and the clinical guidelines described in the previous section, we recognised the importance of ensuring our work fitted in with Trust policies and practices. Therefore, we set up the Clinical Reference Group. This is a virtual group that conducts its business electronically. All partner Trusts may nominate a representative to the group who is responsible for consulting on NHS clinical developments within their own organisations and coordinating feedback to the Authority. During the year, NHS Professionals also developed and implemented a 10 point plan to reduce the potential risk of infection associated with flexible workers. This included the appointment of an infection control advisor to the Authority, the development of clinical guidelines and association with the NPSA Clean Your Hands Campaign. NHS Professionals Clean Your Hands materials for Flexible Workers 8 Clinical Governance Annual Report 2005-06

4. Improving the quality of clinical flexible workers supplied to the NHS as a whole. As a Special Health Authority, NHS Professionals has responsibilities beyond those relating to supplying flexible workers to partner Trusts. During 2005-6 we worked closely with the NHS Litigation Authority s Clinical Negligence Scheme for Trusts review of their risk management standards in order to ensure that risks posed by the supply of flexible workers were adequately considered. The Authority also made a significant contribution in relation to locum doctors to the Chief Medical Officer s post Shipman Call for ideas, with a number of our proposals subsequently appearing in the final report. Similarly, NHS Professionals was invited to join the working party examining how poorly performing doctors can be supported and brought back into safe and effective practice. Demonstrating the effectiveness of clinical governance activities can be challenging, however one indicator can be the incidence of serious incidents. A register of the most serious clinical incidents involving NHS Professionals flexible workers has been kept from October 2004. The graph below shows the decline in these most serious incidents since the introduction of the national clinical governance arrangements by the Special Health Authority. Whilst it is not possible to demonstrate a definite causal link between the two, it would seem logical that improved standards of recruitment and of handling all complaints and incidents would reduce the likelihood of such incidents occurring. Incidents entered on NHS Professionals serious incidents register 20 18 16 14 12 No. 10 8 6 4 2 0 OCT - DEC 04 JAN - MAR 05 APR - JUN 05 JUL - SEP 05 OCT - DEC 05 JAN - MAR 06 Clinical Governance Annual Report 2005-06 9

Supporting Clinical Governance In order to deliver the initiatives already described, the Authority has an established clinical governance structure. The Clinical Governance Committee was convened in November 2004 under the Chairmanship of Sue Hobbs, Non-Executive Director. The Committee is a sub-committee of the Special Health Authority Board and provides assurance to the Board that the Authority is discharging its responsibilities with regard to clinical governance. This is achieved by ensuring that clinical governance strategy and plans are developed, implemented and monitored. The Committee is made up of national directors including the CEO, non executive directors, and representatives from service users (see appendix 1). The Committee has a number of members with a clinical background from both nursing and medicine. Each of the NHS Professionals regions (including the Doctors service) has a Head of Clinical Governance to lead on clinical governance issues in that area. The Heads of Clinical Governance come together to form the Clinical Governance Operational Group that is responsible for implementing and developing clinical governance across the Authority, and is accountable to the Clinical Governance Committee. The Clinical Governance Operational Group developed the clinical governance plan and implemented it during the year. 10 Clinical Governance Annual Report 2005-06

Non-Clinical Risk NHS Professionals clinical governance function also takes responsibility for the aspects of non-clinical risk associated with its facilities, such as health and safety and security. NHS Professionals has a Head of Risk Management who oversees the risk register and the Authority s arrangements to handle risk. Each of the regions has its own Risk Management Committee to address issues that occur locally. The Authority has a risk management strategy and develops an annual implementation plan During the year, policies for health and safety, fire safety and security management were produced and adopted by the Authority Board, replacing the policies from former sponsor organisations. A process of half yearly risk assessment was introduced and implemented at each NHS Professionals site. Sixty five incidents were reported during 2005-6 involving corporate staff, consisting mainly of minor slips or trips. In addition, fifty two incidents affecting NHS Professionals flexible workers were reported (see Table 2, right), which were then followed up with the Trust or PCT in which they occurred. Table 2: Incidents reported that affected NHS Professionals flexible workers. Nature of Incident Number Percentage Moving or handling injury 2 4% Violence/aggression 8 15% Needlestick injury 6 12% Feeling bullied/ 10 19% discriminated against Unhappy at reception in 26 50% clinical area Total: 52 100% Following risk assessments and analysis of a critical incident that involved the theft of Authority property from one of our London offices, the security processes when corporate staff leave the organisation (retrieval of badges, key fobs etc.) were reviewed and new control systems put in place. Clinical Governance Annual Report 2005-06 11

The Future Having put in place robust clinical governance arrangements it is important that NHS Professionals consolidates these and continues to build for the future with the resources it has available. The Trusts and PCTs with which we work in partnership need to be assured that NHS Professionals not only reduces the cost of flexible staffing, but also the potential risks associated with such staff. From April 2006 NHS Professionals has a new service level agreement that for the first time clearly sets out the clinical governance arrangements for our customers and clarifies the roles and responsibilities of both parties. Other developments for the next year include the publishing of a national Code of Behaviour for our flexible workers, the introduction of an Attendance Policy and the establishment of a group to ensure that good practice and lessons learned in one part of the organisation are spread across the whole service. Also in 2006-7, it is expected that the Chief Medical Officer s response to the reports into the Shipman Inquiry will be published. This may well provide an opportunity for NHS Professionals Doctors service to expand its role to one with a wider remit for locum doctors across the NHS as a whole. In addition the Doctors Service will work closely with the GMC to run a pilot scheme on locum appraisal which will commence in the winter of 2006. These developments will provide a firm basis from which NHS Professionals will continue to supply competent and safe flexible workers to the NHS. 12 Clinical Governance Annual Report 2005-06

Appendix 1 Membership of the Clinical Governance Committee 2005-6. Non Executive Directors Susan Hobbs (Chair) Carol Varlaam Fiona Eldridge Nilesh Goswami Director of Clinical Governance Director of Operations Head of Medical Services, NHS Professionals (Doctors) Director of Finance Director of Human Resources Richard McMahon Paul Roche Russ Powell Mike Pack Jeff Lynch Service Users (NHS Trusts) Sheffield Teaching Hospitals NHS Trust Whipps Cross University Hospital NHS Trust Worcestershire Acute Hospitals NHS Trust Chief Executive Officer (ex officio) Sylvia Grayson Lyn Hinton Rachel Overfield Carmel Flatley Co-opted member Sheffield Teaching Hospitals NHS Trust Chris Welsh Clinical Governance Annual Report 2005-06 13

Appendix 2 Summary of Clinical Governance Plan for 2005-6. Objective Date completed Outcome 1 Develop Clinical Governance strategy. Sept 05 Strategy approved by SpHA Board. Launched by Chief Nursing Officer for England at national meeting. 2 Introduce national standards for the recruitment of flexible workers. 3 All regional recruitment departments audited against new national standards. 4 Develop and implement a healthcare associated infection prevention plan for NHS Professionals. 5 Develop and implement the national Complaints and Incidents Policy. 6 Introduction of national complaints and incidents management system. Sept 05 Mar 06 Dec 05 Dec 05 Mar 06 Approved by the Clinical Governance Committee and implemented at all NHS Professionals recruitment centres nationally. Two national audits completed, with 91% compliance with standards achieved. A ten point plan was developed and all actions implemented including the appointment of an Infection Control Advisor, materials developed in conjunction with the National Clean Your Hands campaign and the publication of Infection Prevention and Control Guidelines. The Policy was approved by the Clinical Governance Committee, and implemented in all regions, including NHS Professionals for doctors. The system was configured for NHS Professionals services and rolled out to all regions on the national IT network. 7 Review Major Incident Plans across all regions. 8 Commissioning of E-learning modules for flexible workers. Jun 05 Mar 06 The contingency plans for NHS Professionals response to a major incident were reviewed, and subsequently examined again following the London bombings. A specification was developed and put out to tender. Three responses were received and the order subsequently placed with Doctors.Net 9 Introduce internal alert mechanism of ex-members who should be prevented from re-entering NHS Professionals. 10 Develop mechanism for engaging stakeholders in clinical and clinical governance developments. Jun 05 Jun 05 Policy agreed by Clinical Governance Committee, and system put in place. Clinical reference Group set up, with more than 20 Trusts signed up. 14 Clinical Governance Annual Report 2005-06

11 Develop clinical guidelines for flexible workers. 12 Train all Head of Clinical Governance in Root cause Analysis. Mar 06 Jun 05 Clinical guidelines developed and published on; Record Keeping Infection Prevention and Control Drug Administration Blood Transfusion. Training undertaken with National Patient Safety Agency. 13 To support the retraining of poorly performing locum doctors. Mar 06 NHS Professionals represented on National Clinical Assessment Service s Back on Track working party. 14 To assist in the further reduction of risk posed by locum doctors. 15 Develop contingency plan in preparation for an influenza pandemic. 16 Develop national placement and member expectation guidelines. Dec 05 Jun 05 Dec 05 NHS Professionals formal response submitted to CMO s Call for Ideas following the publication of reports into Shipman Inquiry. Plan approved by Clinical Governance Committee, and all items implemented. Guidelines completed and introduced to Trusts nationally during remainder of the year. 17 Review the Clinical Governance aspects of the Service Level Agreement with Trusts. 18 Work collaboratively with NHS Litigation Authority on revision of CNST risk management standards. 19 Development of Clinical Classification System. Dec 05 Mar 06 Mar 06 Clinical Governance section of SLA extensively reviewed and incorporated into new SLA for 06-07. Extensive work undertaken with CNST. Risks associated with flexible workers incorporated into new standard matrices. System developed and used as basis for Agenda for Change implementation. 20 Improve communication with Flexible Workers. Mar 06 Clinical items regularly included in newsletters, and Clinical Governance information published on website. Clinical Governance Annual Report 2005-06 15

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