Post on 04-Feb-2016
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Education Quality Standards Education Quality Standards and Standards for Quality and Standards for Quality
Patient Care-are they Patient Care-are they synonymous?synonymous?
Dr E A HughesDr E A Hughes
Regional Postgraduate DeanRegional Postgraduate Dean
West MidlandsWest Midlands
NHS Trusts with the West NHS Trusts with the West MidlandsMidlands
Quality of EducationQuality of Education
Assurance of quality in higher education is Assurance of quality in higher education is the collections of policies, procedures, the collections of policies, procedures, systems and practices internal or external systems and practices internal or external to the organisation designed to achieve, to the organisation designed to achieve, maintain and enhance qualitymaintain and enhance quality
Quality in healthcare
Effective
GoodExperience
Safe
Bring clarityto quality
Measure quality
Publish quality performance
Recognise & reward quality
Raise standards
Safeguard quality
Stay ahead
Making quality the organising principle of the Making quality the organising principle of the NHSNHS
QUALITY OF QUALITY OF EDUCATIONEDUCATION
Royal CollegesRoyal Colleges
Deanery visitsDeanery visits
RegulatorsRegulators
Quality AssuranceQuality Assurance
Royal CollegesRoyal Colleges Deanery Deanery PMETBPMETB GMCGMC
QAAQAA EQUIPEQUIP EQCEQC NMCNMC QABMEQABME
Maintaining Quality of Care Maintaining Quality of Care Standards Standards
Maintaining Quality of Care Standards Maintaining Quality of Care Standards
Healthcare CommissionHealthcare Commission CQCCQC NHSLANHSLA SHASHA MonitorMonitor
Impact model applied to Healthcare Impact model applied to Healthcare (adapted from Mackinnon Partnership 2000, SfH 2007)(adapted from Mackinnon Partnership 2000, SfH 2007)
1313
How can we ensure such systems work together to How can we ensure such systems work together to achieve high quality care?achieve high quality care?
Educational changeEducational change
2005 PMETB established –substantial 2005 PMETB established –substantial change to roles of Colleges and Deanerieschange to roles of Colleges and Deaneries
PMETB –risk based approach PMETB –risk based approach 2007 MMC commenced. 2007 MMC commenced.
PMETB PMETB Quality Framework Autumn 2007Quality Framework Autumn 2007
QM Visits -DeaneryQM Visits -Deanery ‘‘All such visits will be targeted and proportionate to All such visits will be targeted and proportionate to
the concerns identified prior to the visitthe concerns identified prior to the visit Wherever possible, autonomy should be given to Wherever possible, autonomy should be given to
the Trusts, Health Boards and other LEPs to monitor the Trusts, Health Boards and other LEPs to monitor their own performance against PMETB standrards their own performance against PMETB standrards and requirements.and requirements.
Visits should have a very clear and articulated Visits should have a very clear and articulated purpose and should be kept to the minumum needed purpose and should be kept to the minumum needed to ensure that PMETB’s standards are metto ensure that PMETB’s standards are met
Stafford HospitalStafford Hospital
Visited by Deanery for Foundation training 2005 Visited by Deanery for Foundation training 2005 –some issues found around induction. Visited by –some issues found around induction. Visited by Head of Foundation and revisited 2006 –Head of Foundation and revisited 2006 –satisfactorysatisfactory
RCP reviewed medical training 2006 on behalf RCP reviewed medical training 2006 on behalf of PMETB –satisfactoryof PMETB –satisfactory
PMETB survey 2006 –all green triangles PMETB survey 2006 –all green triangles PMETB survey 2007-5 green triangles and 2 red PMETB survey 2007-5 green triangles and 2 red
triangles –triangles –clinical supervision clinical supervision noted to be high noted to be high satisfactionsatisfaction
Stafford HospitalStafford Hospital
Foundation visit in May 2008 with intervening Foundation visit in May 2008 with intervening informal visit from Associate Dean for informal visit from Associate Dean for Foundation SchoolFoundation School
Foundation visitors highly experienced – Foundation visitors highly experienced – Associate Dean, Senior Clinical tutor (A and E Associate Dean, Senior Clinical tutor (A and E consultant) and Dean of Keele Medical Schoolconsultant) and Dean of Keele Medical School
Report notes ‘review well attended by trainees Report notes ‘review well attended by trainees with strong engagement and people prepared to with strong engagement and people prepared to speak out’speak out’
Stafford HospitalStafford Hospital
A and E noted to have high level of work although it is a A and E noted to have high level of work although it is a very challenging and a good learning environment. very challenging and a good learning environment. Hours in A and E noted to be good Hours in A and E noted to be good
One consultant only but good use made of Associate One consultant only but good use made of Associate specialists and practitioners in supervising FY2 doctorsspecialists and practitioners in supervising FY2 doctors
Well prepared for appraisal in A and EWell prepared for appraisal in A and E All consultants considered approachableAll consultants considered approachable PMETB survey results indicated that some very good PMETB survey results indicated that some very good
training was occurring with no evidence of an endemic training was occurring with no evidence of an endemic problem with all trainingproblem with all training
Stafford HospitalStafford Hospital
SpR in A and E raised concerns regarding training with SpR in A and E raised concerns regarding training with regard to lack of supervision, training and lack of cover regard to lack of supervision, training and lack of cover out of hoursout of hours
Would not discuss this with the Dean so completed Would not discuss this with the Dean so completed JEST survey – suggested that patient safety was low in JEST survey – suggested that patient safety was low in Trust’s priorityTrust’s priority
Disparity between his views and those of FY2 doctors –Disparity between his views and those of FY2 doctors –why?why?
HCC had identified concerns with high HSMR and care HCC had identified concerns with high HSMR and care issues and were undertaking an Inquiryissues and were undertaking an Inquiry
Stafford HospitalStafford Hospital
Intensive action plan with weekly Intensive action plan with weekly monitoring, SHA involvement, A and E monitoring, SHA involvement, A and E task force , recruitment of middle grades task force , recruitment of middle grades and 4 new consultants with immediate and 4 new consultants with immediate locum input at both levelslocum input at both levels
External visits confirmed improvementExternal visits confirmed improvement Multiple visits by Deanery, CQC and SHA Multiple visits by Deanery, CQC and SHA
over last 3 yearsover last 3 years
Can poor educational quality be Can poor educational quality be used in isolation as evidence of a used in isolation as evidence of a poor standard of clinical care?poor standard of clinical care?
Is good educational quality an Is good educational quality an indicator of high quality care?indicator of high quality care?
GMC Survey 2010 Total Red Outliers by LEP – Mid Staffs is 6th in league table(Taken from GMC survey online tool – total outlier summary matrix)
GMC Survey 2008-09 Total Red Outliers by LEP – Mid Staffs 10th in league table(Taken from GMC survey online tool – total outlier summary matrix)
Surviving the StormSurviving the Storm
‘‘How did we let it happen?’How did we let it happen?’ ‘‘It is sobering to realise how one can get It is sobering to realise how one can get
used to such poor standardsused to such poor standards In retrospect more of us should have In retrospect more of us should have
made it clear that there were unacceptable made it clear that there were unacceptable staffing levels and practices in emergency staffing levels and practices in emergency care’care’
Paul Woodmansey Clinical Medicine 2011Paul Woodmansey Clinical Medicine 2011
What lessons have we learned from Mid What lessons have we learned from Mid Staffs?Staffs?
How are we bringing education and quality How are we bringing education and quality together to identify areas of potential together to identify areas of potential concern and also of good practice?concern and also of good practice?
Quality Review Visit Framework:Quality Review Visit Framework:Checking our Evidence BaseChecking our Evidence Base
Level 2: Exceptional Review Visit by School
Level 1: Exceptional Paper-Based Review
Level 4: Exceptional Regulatory Body Trigger Visit (i.e. GMC)
Scheduled Review
Planned Programme Review
Level 3: Exceptional Trigger Visit by Deanery with Externality
Deanery Review Regulatory Body Deanery Visit (GMC)
Programme Review
Exceptional LEP Review
Scheduled LEP Review
Head of School and School Quality Lead
Head of School and School Quality Lead
Postgraduate Dean
Head of School and School Quality Lead
Associate Dean for Quality / Head of School
Associate Dean for Quality
Postgraduate Dean
Framework Description Responsible
Quality Assurance Visit Reviews:Quality Assurance Visit Reviews:Reviews 2010/11 – Approx 60-80 reviews per Reviews 2010/11 – Approx 60-80 reviews per
yearyear
Visit Database:Visit Database:Monitoring and Closing the LoopMonitoring and Closing the Loop
All process All process points points documenteddocumented
Flags up if Flags up if monitoring not monitoring not completedcompleted
Allows Allows performance performance managementmanagement
Questionnaires:Questionnaires:GMC SurveyGMC Survey
Shared with all levels of Deanery (Strategic, School, Programme, LEP)
Analyse red outliers similar to JEST to allow comparison
Questionnaires:Questionnaires:JEST (Local tool)JEST (Local tool)
Local survey for Local survey for TraineesTrainees
ElectronicElectronic Accessible by Accessible by
LEPs and LEPs and DeaneryDeanery
Analysed for Analysed for themes and QA themes and QA evidence baseevidence base Significant work
undertaken in thematic analysis
Patient Safety Concerns during Postgraduate Patient Safety Concerns during Postgraduate MedicalMedical
Quality Review VisitsQuality Review Visits
During Deanery monitoring visits to Local During Deanery monitoring visits to Local Education Providers and their training Education Providers and their training units, trainees and consultants are units, trainees and consultants are routinely asked by the visiting team if they routinely asked by the visiting team if they perceive any risk to patient safety in the perceive any risk to patient safety in the clinical service at the Trust.clinical service at the Trust.
Patient Safety Concerns during Postgraduate Patient Safety Concerns during Postgraduate MedicalMedical
Quality Review VisitsQuality Review Visits Organisational HazardsOrganisational Hazards 1. Inadequate facilities (e.g. A&E units without ready 1. Inadequate facilities (e.g. A&E units without ready
access to urgent imaging and lab services).access to urgent imaging and lab services). 2. Departmental rules preventing ready access to 2. Departmental rules preventing ready access to
required services by junior doctors.required services by junior doctors. 3. Protocols which impede timely medical care (e.g. 3. Protocols which impede timely medical care (e.g.
care before patient transfer to suitable wards /care before patient transfer to suitable wards / internal referral systems allow for patients to get ‘lost in internal referral systems allow for patients to get ‘lost in
the system’).the system’).
Patient Safety Concerns during Postgraduate Patient Safety Concerns during Postgraduate MedicalMedical
Quality Review VisitsQuality Review Visits 4. Protocols / facilities which regularly lead to patient care 4. Protocols / facilities which regularly lead to patient care
within inadequately / unsuitably staffed areaswithin inadequately / unsuitably staffed areas (e.g. acute medical patients moved to T/O or rehab wards).(e.g. acute medical patients moved to T/O or rehab wards). 5. Rotas which do not provide enough doctors for the work to 5. Rotas which do not provide enough doctors for the work to
be done (e.g. covering excess numbers ofbe done (e.g. covering excess numbers of ward patients over the weekend).ward patients over the weekend). 6. Doctors routinely expected to perform tasks for which they 6. Doctors routinely expected to perform tasks for which they
are untrained (e.g. take consent for surgeryare untrained (e.g. take consent for surgery / insert central lines / lead paediatric resuscitation without relevant / insert central lines / lead paediatric resuscitation without relevant
training - NLS, PLS)training - NLS, PLS) 7. A pattern of poor clinical work by other, non medical, 7. A pattern of poor clinical work by other, non medical,
professional workers.professional workers.
Patient Safety Concerns during Postgraduate Patient Safety Concerns during Postgraduate MedicalMedical
Quality Review VisitsQuality Review Visits
Supervision and Senior CoverSupervision and Senior Cover 1 1 If any junior doctor cannot access the immediate support (by If any junior doctor cannot access the immediate support (by
phone, followed, if necessary, immediately by personal presence) of phone, followed, if necessary, immediately by personal presence) of a more senior doctor to deal with a clinically dangerous situation, a more senior doctor to deal with a clinically dangerous situation, then this is a patient safety risk. The senior does not need to be then this is a patient safety risk. The senior does not need to be from the junior’s own firm or subspecialty, but must be of the same “ from the junior’s own firm or subspecialty, but must be of the same “ branch” (medicine, surgery, T/O, paediatrics etc)branch” (medicine, surgery, T/O, paediatrics etc)
2 Senior doctors with acute care responsibility should be on the 2 Senior doctors with acute care responsibility should be on the hospital site, within daytime hours, and without other responsibilities hospital site, within daytime hours, and without other responsibilities
for the relevant periodfor the relevant period..
Patient Safety Reporting Process:Patient Safety Reporting Process:Lead Visitor ResponsibilitiesLead Visitor Responsibilities
Quality Governance:Quality Governance:Joining the QA Framework Joining the QA Framework
Together Together
LEP quality review, report and action plan
PMDE Quality Committee
PMDE Quality Committee
PMDE BoardPMDE Board
SHA Governance / Patient Safety
Group
LEP Local Education Meetings
LEP Local Education Meetings
Governance Groups
Organisational Levels
Quality Review Processes
School Boards (i.e. PMDE and FPMB)
School Boards (i.e. PMDE and FPMB)
Programme quality review, report and action
plan
Deanery quality review, report and action plan
Regulatory Body (i.e. GMC)
Regulatory Body (i.e. GMC)
Regulator(i.e. GMC, formerly
PMETB)
Deanery
School
LEP
Annual Deanery Report
School Annual Report
LEP Annual Report
Royal Colleges
Royal Colleges
Patient Safety Oversight GroupPatient Safety Oversight Group
Formal subcommittee of the SHA BoardFormal subcommittee of the SHA Board Medical Directors, DoN Postgraduate Medical Directors, DoN Postgraduate
Dean and deputyDean and deputy Director of Patient Safety, Regional CQC Director of Patient Safety, Regional CQC
Director, Performance Director, HCAI Director, Performance Director, HCAI specialists and mental healthspecialists and mental health
Others as appropriate are co-optedOthers as appropriate are co-opted
Escalating ConcernsEscalating Concerns
NHS West Midlands Postgraduate Medical Trainees are encouraged to raise NHS West Midlands Postgraduate Medical Trainees are encouraged to raise concerns when appropriate regarding their training programme via a number of concerns when appropriate regarding their training programme via a number of mechanisms such as the GMC Survey, Job Evaluation Survey Tool (JEST), mechanisms such as the GMC Survey, Job Evaluation Survey Tool (JEST), Reviews/Visits Reviews/Visits to Local Education Providers (LEPs), Annual Review of Competency to Local Education Providers (LEPs), Annual Review of Competency Progression (ARCP), Appraisals, and Incident Reporting etc.Progression (ARCP), Appraisals, and Incident Reporting etc.
When issues arise that are not appropriate or out of sequence When issues arise that are not appropriate or out of sequence with these processes, Trainees may raise concerns by using the with these processes, Trainees may raise concerns by using the following pathways as appropriate to their concern. Concerns following pathways as appropriate to their concern. Concerns may cover any issue including patient safety and quality of may cover any issue including patient safety and quality of education and training. Trainees should invoke pathways education and training. Trainees should invoke pathways appropriately and in order of priority.appropriately and in order of priority.
http://www.westmidlandsdeanery.nhs.uk/Home/EscalatingConcerns.aspxhttp://www.westmidlandsdeanery.nhs.uk/Home/EscalatingConcerns.aspx
Lay AdvisorsLay Advisors
Currently have pool of 35 Lay AdvisorsCurrently have pool of 35 Lay Advisors
Activity Organiser / Activity Lead Guidance Activity Organiser / Activity Lead Guidance has been developed.has been developed.
April 2010/March 2011 – 71 Activities Attended April 2010/March 2011 – 71 Activities Attended which included QA Reviews, Programme which included QA Reviews, Programme Reviews, ARCP/RITA, Assessment, Recruitment Reviews, ARCP/RITA, Assessment, Recruitment etc.etc.
Feedback from both Lay Advisors and Activity Feedback from both Lay Advisors and Activity Leads has been extremely positiveLeads has been extremely positive
““Utilisation of Lay Advisors has been valuable due Utilisation of Lay Advisors has been valuable due to their independency and professional knowledge to their independency and professional knowledge and skills from business and other non-health and skills from business and other non-health
sectors”sectors”
Was Mid Staffs an Isolated Case?Was Mid Staffs an Isolated Case?
An NHS hospital is to face a lawsuit launched by more than 20 families who An NHS hospital is to face a lawsuit launched by more than 20 families who claim their loved ones were subjected to "appalling and humiliating" claim their loved ones were subjected to "appalling and humiliating" treatment. treatment.
Law firm Leigh Day & Co intends to argue that the standard of care offered Law firm Leigh Day & Co intends to argue that the standard of care offered at Redditch's Alexandra Hospital was so bad that it breached the human at Redditch's Alexandra Hospital was so bad that it breached the human rights of several patients, including a 73-year-old man whose ribs are rights of several patients, including a 73-year-old man whose ribs are alleged to have been "broken open" by the use of a hoist after heart surgery. alleged to have been "broken open" by the use of a hoist after heart surgery.
The action includes allegations of neglect such as dehydrated patients not The action includes allegations of neglect such as dehydrated patients not
being given water or not being fedbeing given water or not being fed. .
DO GMC SURVEYS GIVE US INDICATORS OF POOR QUALITY OF DO GMC SURVEYS GIVE US INDICATORS OF POOR QUALITY OF CARE?CARE?
Trust May 2010 May 2011
Green Outliers Red Outliers Green Outliers Red Outliers
HEFT Heartlands – 25GHH – 2Combined = 27
Heartlands – 29GHH – 22Combined = 51
19 16
Mid Staffs 4 16 6 11
Walsall 11 12 9 16
Worcs Alex – 10 Alex – 8 Alex – 10 Alex – 10
UHB - QE 7 20 12 30
All trainees by post specialty by local education provider
Dawn of a New EraDawn of a New Era
NHS OUTCOMES FRAMEWORKDomain 1
Preventing people from
dying prematurely
Domain 2
Enhancing the quality of life for
people with LTCs
Domain 3
Recovery from
episodes of ill health /
injury
Domain 4
Ensuring a positive patient
experience
Domain 5
Safe environment
free from avoidable
harm
NICE Quality Standards (Building a library of approx 150 over 5 years)
Commissioning Outcomes Framework
Commissioning Guidance
Provider payment mechanisms
Commissioning / ContractingNHS Commissioning Board – certain specialist services and primary care
GP Consortia – all other services
Duty of quality
Du
ty of q
ua
lityD
uty
of
qu
alit
y
tariffstandard contract
CQUIN QOF
Domain 1
Preventing people from
dying prematurely
Domain 2
Enhancing the quality of life for
people with LTCs
Domain 3
Recovery from
episodes of ill health /
injury
Domain 4
Ensuring a positive patient
experience
Domain 5
Safe environment
free from avoidable
harm
NICE Quality Standards
Commissioning Outcomes Framework
Commissioning Guidance
Provider payment mechanisms
Commissioning / Contracting– certain specialist services and primary care
– all other services
Duty of quality
Du
ty of q
ua
lityD
uty
of
qu
alit
y
tariffstandard contract
CQUIN QOF
NHS Outcomes FrameworkNHS Outcomes Framework
46
Excellent quality care in training environments
Competent and capable staff
Fitness for purpose & leadership
Promote health and wellbeing and health
inequalities
Support the NHS constitution
Promoteresearch and
innovation
Promoteeffective team and
interdisciplinary working
Respondto changing service
demands
Excellence of education
training &development
Educational Outcomes FrameworkArchitecture ver 3 dated 26 Aug
Individuals & professional
groups aligned with workforce
demandMeets strategic
local workforce & commissioning
plans
SoS/DH HEE46
Meet standards set by independent
regulatory/statutory bodies
Excellent experience
for students and trainees
Safety
Effectiveness
Specific Indicators
(using where
possible already
established metrics)
Specific Indicators
(using where
possible already
established metrics)
LETB/HEIsHealthcare
Org
Plan, develop
and secure supply of a
capable patient –centered
workforce
47
Outcomes Outcomes
Excellent quality care in training environments
Competent and capable staff Fitness for purpose and leadership Excellence of education training and
development Individuals and professional groups aligned
with workforce demand
Relationship between health care education Relationship between health care education and quality of careand quality of care
4848
Quality healthcare education and training can Quality healthcare education and training can directly and substantially benefit care.directly and substantially benefit care.
The EOF will provide a framework to make The EOF will provide a framework to make these benefits explicit and enable further these benefits explicit and enable further
research to directly link education and learning research to directly link education and learning to improvements in patient care outcomes.to improvements in patient care outcomes.
ProfessionalismProfessionalism
Origins of “Professionalism”
from Latin by way of Middle English, professiō, the taking of vows of a religious order
Just what is Professionalism?
“... I know it when I see it ....”
Supreme Court Justice
Potter Stewart 1964
Professionalism in Action
We are what we repeatedly do. Excellence then, is not an act, but a habit.”
Aristotle
The futureThe future
However well designed the systems for However well designed the systems for regulating performance and managing services regulating performance and managing services might be, the quality and safety of patient care might be, the quality and safety of patient care depend first and foremost on the skills of the depend first and foremost on the skills of the clinical teams delivering that care –clinical teams delivering that care –professionalism will return to centre stage – professionalism will return to centre stage – those with responsibility for high standards of those with responsibility for high standards of clinical practice will find themselves under clinical practice will find themselves under scrutiny scrutiny
Chris Ham BMJ 2011Chris Ham BMJ 2011
Although your job is not easy…Although your job is not easy…
Making a difference….Making a difference….
“In this moment, in this place, you have a valuable opportunity. You can make something happen,
and you can make a difference ”
Ralph Marston
“Change will not come it we wait for some other person or some other time. We are the ones we’ve
been waiting for. We are the change that we seek”
Barak Obama