education quality standards and standards for quality patient care-are they synonymous?

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


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’


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


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


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


Postgraduate Dean


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.


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’).


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.


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

education quality standards and standards for quality patient care-are they synonymous?

Documents

high quality care

quality patient care

education quality standards

good training

pmetb quality framework

foundation training

green triangles pmetb

care issues