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Ratings – A key part of the new CQC hospital inspection programme

Professor Sir Mike Richards

Chief Inspector of Hospitals

November 2013

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Our purpose and role

Our purpose

We make sure health and social care services

provide people with safe, effective,

compassionate, high-quality care and we

encourage care services to improve

Our role

We monitor, inspect and regulate services to

make sure they meet fundamental standards

of quality and safety and we publish what we

find, including performance ratings to help

people choose care

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Asking the right questions about quality and safety

Safe

Effective

Caring

Responsive to

people’s needs

Well-led

Ratings in the new hospital inspection programme

• Rationale for ratings

• The task

• Proposed approach

• Making judgements

• Some examples to ask for your views

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Rationale for ratings

• The public want information about the quality of services presented in a way which is easy to understand

• The approach taken by Ofsted is seen as a model, though we recognise that hospitals are more complex than schools. Patients/public may, for example, be interested in a particular service (e.g. maternity or frail elderly care) rather than a single global rating

• Ratings of services and of Trusts should hopefully be a driver for improvement

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Ratings: Proposed approach (1)

• A four point scale will be used for all ratings

• Outstanding

• Good

• Requires Improvement

• Inadequate

• Ratings will always take account of all sources of information

• Intelligent monitoring tool

• Information provided by Trust

• Other data sources

• Findings from site visits

• Direct observations

• Staff focus groups

• Patient and public listening events

• Interviews with key people

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Ratings: Proposed approach (2)

• Bottom up approach: Rate each of the 8 core services on each of the five key questions (safe, effective, caring, responsive, well led).

• Then rate the Trust as a whole on the five key questions, including an overall assessment of well led at Trust level.

• Derive a final overall rating.

• Note: Where Trusts provide separate services (e.g. A+E or maternity) on different sites we will attempt to rate these separately

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RATINGS TEMPLATE

Safety

Data/Surveillance Direct observation

• Never events • Safe environment

• Serious incidents • Safe equipment

• Infections • Safe medicines

• Safety thermometer • Safe staffing*

• Staff survey (selected items) • Safe processes

• Safe handovers

• Safe information/records

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Effectiveness

Data/Surveillance Direct observation

• HSMR • Management of the deteriorating patient

• SHMI • Care bundles

• Mortality alerts • Pathways of care

• National clinical audits

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Caring

Data/Surveillance Direct observation

• Inpatient survey • Staff/patient interactions

• Cancer patient survey • Comfort rounds

• Friends and Family Test • Patient stories

• Response to buzzers

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Responsive

Data/Surveillance Direct observation

• Waiting time standards • Patient reports

• Cancelled operations • Translation facilities

• Ambulance stays • ‘Comfort factors’

• Analyses of complaints (e.g. TVs, seating areas, rooms

for parents)

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Well-led

Data/Surveillance Direct observation

• Staff survey (7 items) • Interviews (CEO, MD, DoN etc.)

• Staffing levels • Focus groups

• Sickness rates • Board/ward interactions

• Flu vaccination rates • Staff reports (e.g. of bullying)

• Board minutes

• Quality governance minutes

• Mortality reviews

• Handling/learning from complaints

• Risk register

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Service: Maternity

Positive findings Negative Findings Rating

Safe •

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Effective •

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Caring •

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Responsive •

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Well led •

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RATINGS TEMPLATE

Trust X: Ratings

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Safe Effective Caring Responsive Well Led Overall Accident & Emergency

RI RI G G G RI

Medicine

G RI G G G RI

Surgery

G RI RI RI RI RI

Critical Care RI G G G G G

Maternity

RI G O G I RI

Peadatrics

RI G G G G G

End of Life

G RI G RI RI RI

Outpatients

G G G RI RI RI

Overall

RI RI G RI RI RI

Key

O Outstanding

G Good

RI Requires Improvement

I Inadequate

UA Unassessable

Judgement 1: Medical Care, Trust A

• Medical care was found to be good on almost all wards, with audit data showing good clinical outcomes

• However, one ward for frail elderly was understaffed and had a high incidence of pressure ulcers and falls

How would you rate this service?

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Judgement 2: Surgical care, Trust B

• Trust B had 5 ‘never events’ over the past year (somewhat above average for a Trust of this size). All related to retained swabs.

• The inspection team reported that the Trust has taken this very seriously. The WHO surgical checklist has now been fully implemented and an open, learning culture in theatres is now evident.

• Surgical outcomes are otherwise good and patients report that staff are very caring.

How would you rate this service?

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Judgement 3: Caring, Trust C

• The inspection team observed multiple staff/patient interactions indicating high levels of caring. Several patients at the listening event also reported positively on the caring behaviour of staff.

• However, results from the inpatient survey indicate that this trust is in the lower quartile in terms of patients’ experience of care.

Howe would you rate this service?

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Judgement 4: Paediatric A+E services, Trust D

• Adult A+E services at Trust D were judged to be good on all domains (safe, effective, caring, responsive, well led).

• Trust D has no consultants in A+E trained in paediatrics and very few nursing staff are trained in paediatric resuscitation.

• Care for children once admitted was judged to be good/outstanding.

How would you rate (1) The A+E service

(2) The paediatric service?

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Judgement 5: Non clinical services, Trust E

• Trust E has good or outstanding ratings for all 8 core services.

• The Trust was recently found to have poor hygiene in its kitchens by environmental health inspectors.

• The Trust management was horrified that they had not spotted this for themselves and had immediately rectified the situation. They were very open about this at the time of the CQC inspection and appear to have learnt from this experience.

Q: Should this incident affect the Trust’s rating?

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Trust X: Ratings

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Safe Effective Caring Responsive Well Led Overall Accident & Emergency

RI RI G G G RI

Medicine

G RI G G G RI

Surgery

G RI RI RI RI RI

Critical Care RI G G G G G

Maternity

RI G O G I RI

Peadatrics

RI G G G G G

End of Life

G RI G RI RI RI

Outpatients

G G G RI RI RI

Overall

RI RI G RI RI RI

Key

O Outstanding

G Good

RI Requires Improvement

I Inadequate

UA Unassessable