© 2012 AQuA

Learning from the Mid Staffordshire Experience

Stephen Moss – Former Chairman

Mid Staffordshire NHS Foundation Trust

Outline of session

•Overview•Context•Background•Impact•Personal reflections•Thoughts to leave with you•Conclusion

Overview

•A Trust which lost its way!•Main impact on Frail Elderly

- Mortality

- Fundamentals of care

- Compassion•Focus – Emergency Care Pathway•Variations in quality of care

Context

• Acute Trust – two sites• Modern Facilities• 500 beds - £150m turnover 3,000 staff• Foundation Trust – February 2008

The background

• Didn’t happen overnight• Commission for Health Improvement (CHI) visit

2002• Deteriorating patient/staff surveys 2004 - 2007 • Whistleblower 2007• Mortality Rates 2007• Healthcare Commission investigation 2008 – 2009

Impact

• Patients and local community• Staff • Politicians • Regulators

Personal refections

The three factors, which together led to catastrophic failure:

Professionalism of front line clinical teams Ineffective governance Unhealthy culture and ineffective leadership

Personal refections on what can be learnt

• Public confidence/public service

• Profile of quality, safety and compassion

• Open and transparent

• The human impact

Personal reflections on what can be learnt

How do we know we are as good as we think we are? (assurance)

• Set up systems at every level• Triangulate the data• Outcomes v process

• Embrace challenge

Personal reflections on what can be learnt

Does our culture support safe, effective, compassionate care?

Role of the Board Support for front line clinical teams Values Leadership development Support for staff to speak out Human factors science

• Can you/your team describe what makes a culture which supports the delivery of safe, effective, compassionate care?

• How would you measure how closely you are meeting this?

• What action is your team taking to reduce variations in the quality of care and to systematically share good practice?

• What personal contribution are you making?

• Can you describe how your organisational values are impacting on the quality of care in your patch?

• How do you know?

• Can you identify the mechanisms which exist in your organisation for staff to speak out about poor care or inappropriate behaviour?

• How do you know that your team feel confident to do so?

• How do you use feedback from student health care professionals regarding clinical placements?

• Are students clear about what action they should take relating to inappropriate care/behaviour?

• How do you know they feel confident to speak out?

Conclusion

• Keep Mid Staffs on your radar!• Ensure the focus is firmly on supporting the ‘front line’ –

Embed Human Factors science• Ensure assurance systems get under the skin of what's

going on!• Don’t lose sight of ‘The Human Impact’• Avoid complacency like the plague