Learning from the Mid Staffordshire ExperienceStephen Moss – Forman Chairman

Outline of Session

• Overview• Context• Background• Warning signs• Themes • Impact• Personal reflections

Mid Staffs could never happen here!

• How do you know ?

• “Mid Staffs could happen here• How do we safe guard against it ?”

Overview

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

- Mortality- Fundamentals of care- Lack of compassion

• Focus – Emergency Care Pathway• Huge variations in quality of care• Could it happen again?

• Acute – two sites• 500 beds• Turnover – £150 million• Over 3,000 – staff• Foundation Trust since February 2008

The Background

Poor HSMR

Complaints(Cure the NHS)

Healthcare Commission Investigation(Mar 2008)

Healthcare Commission Report

(Mar 2009)

Professor Alberti Report

(May 2009)

Dr Colin Thome Report

(May 2009)

Independent Inquiry(2009-2010)

Public Inquiry(2011-2012)

Public Inquiry Report (est May 2012)

Awarded FT status(Feb 2008)

• Loss of ‘star rating’ 2004• Peer Reviews 2005/6• HCC Reviews 2006• Audit Reports• Patient and Staff Surveys 2007• Whistleblowing 2007• Royal College of Surgeons Report 2007• Financial Recovery Plan• FT Application• HCC Investigation

The Warning Signs

• Distorted priorities• Poor operational systems• Low staffing levels• Culture• Lack of clinical engagement• Ineffective leadership• Ineffective governance systems

The Themes

• Patients and the local community• Our staff• The Board• Governors• Commissioners• Media• Politicians• Regulators

The Impact

The three key factors, which together led to catastrophic failure

• Professionalism of front line clinical teams

• Weak governance throughout but particularly at board level

• Unhealthy culture and ineffective leadership

Personal Reflections

Our starting point

• Public confidence/Public service• Profile of quality, patient safety and compassion• Open and transparent style • Strategy/operational balance • The human impact

Personal Reflections

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

• Set up systems at every level• Triangulate the data/intelligence• Regular testing of systems and their application• Outcomes versus process• Embrace challenge

Personal Reflections

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

Personal Reflections

Actively seek feedback

• Patients and support groups

• Staff

• GP’s and Commissioners

Personal Reflections

More views on the Board

• Pace and energy!• Roles/relationships/scope of Medical & Nurse Directors• Visibility• NED’s – understanding the business and knowing the questions to ask

Personal Reflections

1  "If there is one lesson to be learnt, I suggest that people must always come before numbers " ( Robert Francis QC)          How are you ensuring that your Board makes this a reality ?  2  How do you proactively seek the views of your local community and how does the Board use this intelligence?     For FT's what measures have you introduced to ensure that Governors are equipped to seek out intelligence from their constituencies?  3  What mechanisms has your Board introduced to regularly receive feedback on issues of concern from staff ?  4  As Chair, how do you ensure the right strategy/operational balance in Board meetings, and how do you ensure that operational feedback relating to patient safety and experience feeds strategic intentions ?

• The buck stops with the Board!• Maintain a strong focus on operational issues• Focus on what matters to patients• Ensure front line clinical teams have the tools for the job – hold to account for delivering• Ensure assurance systems allow you to ‘get under the skin’ of the Trust• Celebrate what you do well – but avoid complacency like the plague

Conclusion