nlg(14)336 · the proposal or arrangements outlined in this paper support the achievement of the...

NLG(14)336

DATE 26 August 2014

REPORT FOR Trust Board of Directors – Public

REPORT FROM

Wendy Booth, Director of Performance Assurance & Tr ust Secretary

CONTACT OFFICER

As above

SUBJECT

Clinical Leadership: Report from KPMG on Trust Res ponse to Original Review Recommendations

BACKGROUND DOCUMENT (IF ANY)

None

REPORT PREVIOUSLY CONSIDERED BY & DATE(S)

N/A

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

The report provides the report from KPMG on their f ollow-up review on the Trust’s clinical leadership arrangements

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

NO

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

NO

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

YES

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

YES

THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

Ensures compliance with Monitor Enforcement Underta kings

ACTION REQUIRED BY THE BOARD The Board is asked to note the report

0© 2013 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.

Northern Lincolnshire and Goole NHS Foundation Trust

Capacity and Capability of Clinical Leadership Follow-Up Report

Final reportAugust 2014

Healthcare Advisory


Clinical Leadership Follow-Up Review Contents

Page

Clinical Leadership Follow-Up Review

■ Executive Summary 2

■ Detailed Findings 6

Appendices

1. Recommendations 21

2. Audit approach 24

The contacts at KPMG in connection with this report are:

Andrew Bostock

Partner

KPMG LLP (UK)

Tel: +44 (0) 121 232 3215Mob: +44 (0) 779 631 3249 [email protected]

Professor Hilary ThomasPartner

KPMG LLP

Tel: +44 (0)20 7311 4154 [email protected]

Sue Cordon

Senior Manager

KPMG LLP (UK)

Tel: +44 (0) 121 232 3215 Mob: +44 (0) 778 572 2316 [email protected]

Serena Stirling

Clinical Associate

KPMG LLP (UK)

Mob: +44 (0) 7979 700332 [email protected]

This Report has been prepared on the basis set out in our Engagement Letter dated 14 July 2014 and should be read in conjunction with the Engagement Letter. This Report is for the benefit of only Northern Lincolnshire and Goole NHS Foundation Trust (‘the Trust’) on the basis that it shall not be copied, referred to or disclosed, in whole or in part, without our prior written consent. Nothing in this report constitutes a valuation or legal advice. We have not verified the reliability or accuracy of any information obtained in the course of our work. This Report is not suitable to be relied on by any party wishing to acquire rights against KPMG LLP (other than the Beneficiaries) for any purpose or in any context. Any party other than the beneficiaries that obtains access to this Report or a copy (under the Freedom of Information Act 2000 or otherwise) and chooses to rely on this Report (or any part of it) does so at its own risk. To the fullest extent permitted by law, KPMG LLP does not assume any responsibility and will not accept any liability in respect of this Report to any party other than the Beneficiaries.

mailto:[email protected]





Clinical Leadership Follow-Up Review Executive Summary

ContextNorthern Lincolnshire and Goole NHS Foundation Trust provides acute hospital and community services to a population of more than 350,000 people across North and North East Lincolnshire and East Riding of Yorkshire. The Trust’s annual turnover is around £300 million, managing 850 beds across three hospital sites and is also one of the largest employers in the region, with a headcount of approximately 6500 staff.

The Trust has been under extensive local and national scrutiny with regards to Sir Bruce Keogh's Review of hospital trusts with a high standardised mortality ratio. This created significant anxiety for the local health community. The Trust was put in to ‘special measures’ as a result of the Keogh report. Since then, the Trust has been planning and implementing a ‘Keogh Action Plan’ to improve quality and patient safety across all sites and engaging with staff to ensure safe, effective and high quality services for patients.

This work included responding to the identification of a weak clinical leadership structure in the Trust by Monitor. As part of the organisation's response, KPMG completed a ‘Capacity and Capability Review of Clinical Leadership’ reporting in October 2013, proposing 29 recommendations to refresh clinical leadership, with varying timescales for implementation. Some significant developments have occurred since this time which have resulted in the appointment of a substantive Medical Director and Chief Operating Officer. As a sign of the positive direction of travel for the Trust, a review by the Chief Inspector of Hospitals in July 2014 assessed the Trust as ‘Requires Improvement’ rating, achieving amber for all domains, except ‘Caring’, where the Trust achieved green (‘Good’). This report also highlighted that mortality rates are improving for the Trust (summary hospital level mortality indicator (SHMI) now 109, within the ‘as expected’ range) and significant improvements have been made in clinical leadership.

This clinical leadership follow up report will review the Trust’s progress against each of the 29 original recommendations made in KPMG’s 2013 report, taking into account available evidence, including the action plans in place to ensure the delivery of these recommendations against the criteria identified by Monitor as stipulated in the scope of our review.

Our approachWe interviewed key staff to assess the Trust’s progression and completeness of actions according to the defined timescales set. In addition to this, we facilitated focus groups at each of the three main hospital sites to ascertain staff views regarding clinical leadership in the Trust and progress made in this area during the last year. We also reviewed the monitoring information provided to the Board and its sub-committees during the period of implementation.

Structure of this reportWe have provided an Executive Summary to highlight the key findings from this review. Our detailed findings are included in pages 6 to 20, followed by appendices.These include a listing of 16 new recommendations to further strengthen your clinical leadership and progress the 2 recommendations not implemented.

AcknowledgementsWe would like to thank the Trust for the assistance and co-operation which was provided throughout the review period.



Areas of good progressStructure The new clinical leadership structure is in place and this has positively driven clinical change. All positions are now appointed to, with a recent change to the

Associate Medical Director (AMD) in the Medicine Group. Clinical Leads (CLs) have been appointed to specialities across the Trust, however further work is required in this area to fully establish roles and responsibilities.

Trust Management Board has been established. Staff we interviewed reported that in addition to being productive and supportive, these meetings provide an opportunity to integrate relationships across the Groups.

Governance There are regular Governance meetings within the Groups attended by AMDs and General Managers (GMs).

Organisational reporting of Serious Untoward Incidents (SUIs) has improved. The Trust has recently reviewed its arrangements for the management of SUIs in response to the updated NHS England Serious Incident Framework. The Trust has strengthened the mechanisms for ensuring that the wider learning from SUIs is disseminated throughout the organisation and this was confirmed at our staff focus groups.

Visibility The visibility of the Board has been sustained at a high level. Amongst other activities there is a well developed programme of Director Visits, announced and

unannounced, to clinical areas and departments and staff in our focus groups were positive regarding these. Visits are used as an opportunity for Directors to check with staff if they are receiving the appropriate level of information and communication regarding Trust issues that affect them or their areas.

Process Appraisal rates for all staff groups is at the Trust’s target level and the quality of these events and emergent performance plans is audited.

Doctor Revalidation is up to date and the Medical Director is appointing a Revalidation Assistant to support the administration of this process.

Mandatory training is at target levels and staff report greater access opportunities across the Trust’s areas. There is a blend of face to face and e-learning which is reported by staff to work well.

The Trust has made good progress and has closely monitored the actions from the recommendations made in the Keogh review. The sustainability of the progress made during the last year is important and the Quality Development Plan has evolved from that process. This will continue to be actively monitored to ensure further actions required are implemented and embedded to increase sustainability.



Areas for further development The Medical Director was appointed in January 2014 and has had some unavoidable absence and time away from the Trust on a leadership programme. To some

extent, this has slowed the anticipated pace and progression with some of the recommendations made in our initial Clinical Leadership Review. However, he has now returned and is in the process of progressing many of the areas we list below.

It is essential at this stage that the recommendations made in this review are progressed as soon as possible.

Triggers to drive change Recent staff changes in the Medicine Group Senior Management Team were necessary which has caused a period of instability. However interim staff are in place in

the AMD and GM role and this has resulted in significant traction in terms of development and pace of change required to drive forward the required agenda. The Medicine AMD is required to support the Therapeutics and Diagnostics Group as they do not have a AMD post in the structure, however, due to the size of the Medicine Group and the challenges that it currently faces, this arrangement is probably not feasible. The Board should reconsider this position and seek more sustainable options (Recommendation 3).

External stakeholders The outcome of the Sustainable Services Review is not as yet known and this impacts on future plans. Relationships with Commissioners have been fragile at times

and although all parties are working together to strengthen relationships this may continue to be problematic and affect engagement with external stakeholders (Recommendations 6 &11).

Clinical engagement in decision making The role of Clinical Leads requires development to ensure a future common approach and role in quality of services and outcomes (Recommendation 8).

Visibility of the Board The Trust is improving the way it engages with junior doctors to ensure this group can propose valuable contributions to patient safety and quality agendas. However,

although recent forums have been established, these need to be better publicised to ensure junior doctors have opportunities to attend. (Recommendation 10).

Clinical accountability There is an agreed job planning process in the Trust and job plan reviews have commenced. However, although progress is being made with the development of a

resource pack and a detailed plan in place, reviews of many consultant’s job plans are yet to be completed. Changes of senior personnel in the managerial structure of some Groups has added delays into the process. The Medical Director needs to ensure the process is robust and improves compliance and monitoring arrangements. There are plans to address the allocation of SPAs reducing from a default position of 2.5 to 1.5, with additional sessions allocated as appropriate. (Recommendation 13)

There is no mechanism in the job planning or appraisal process whereby internal secondments/ skills/ interests are recorded on a central register and annually updated (Recommendation 16).



ScopeThis review followed up the progress made with implementation of the recommendations detailed in our initial review, this considered:

1. The capacity and capability of the Directors and their direct reports to deliver the following:

Drive the clinical change needed to deliver the Keogh review recommendations in a timely manner;

Develop and implement clinical strategies and the quality agenda;

Engage and lead clinical bodies/groups in the organisation to deliver clinical change;

Engage with key stakeholders both internally and externally to provide assurance on the changes being implemented and embedded

Scrutinise and challenge clinical practices to ensure that sub-optimal care is not being delivered/tolerated;

Provide leadership to deliver the improvements necessary to ensure high quality, safe services are sustained across the organisation.

2. The appropriateness of the clinical leadership team’s skill mix, experience and division of responsibilities.

3. The effectiveness of the mechanisms being put in place by clinical leadership to lead and embed transformational change consistently across the clinical bodies and organisation.

4. The ability of clinical leadership in place to deliver the required reorganisation of stroke services across the Trust.

Status of recommendations from our initial reviewThe table below demonstrates the status of recommendations from our initial clinical leadership review in 2013.

Recommendations which we consider as not implemented are listed below:

Management should ensure responsibility for clinical staff performance through effective job planning and appraisal, is incorporated as a defined job role within the clinical leadership structure.

Management should incorporate a process into the job planning or appraisal process whereby internal secondments/ skills/ interests are recorded on a central register.

We have made further recommendations in these areas and other areas and these (16 in total) are detailed in Appendix 1.

Fully implemented Partially implemented – work ongoing Not implemented

15 12 2


Clinical Leadership Follow-Up Review Detailed Findings

1. The capacity and capability to lead and drive clinical body and stakeholder engagement to scrutinise practice and deliver sustainable safe, effective and high quality person centred care across the organisation.

Theme KPMG Recommendation NLAG Position KPMG Comments

Active development of clinical changes and strategies

Recommendation 1

Compliance with the Web V system should be a point of focus during clinical leadership ward visits to ensure the full benefits of the system are being realised consistently throughout the Trust. This approach should be instigated when all new clinical initiatives are implemented to monitor how well they are embedded within the organisation.

The Trust compliance is being monitored by the Chief Nurse and Medical Director walkabouts and Executive and Non-Executive Director visits. Web V is now live across the Trust and has resulted in improved quality and patient outcomes.

Recommendation achieved

Web V is being led by a project board which meets periodically to review operational, sustainability and resilience issues of the system. The risks associated with any potential failure or interruption to the system have been assessed and feature on the Trust’s Risk Register.

Web V is now fully rolled out across the Trust. However, staff in focus groups reported that there are areas which are not using the full potential of the system. Compliance is being monitored by the Executive team on Executive visits.

Web V is currently used in weekly ward rounds and the Medical Director and Chief Nurse are currently discussing the development of ‘safety huddles’ to enhance patient safety and embed it in everyday practice. The system has been instrumental in triggering key patient assessments e.g. dementia assessment within 72 hours of admission and this has led to improved compliance with these assessments being undertaken. The Trust is seeking to develop ‘Web V Champions’ to provide real time staff support in the clinical environment. The capabilities of the system are being reviewed and areas for further development being explored e.g. DNAR documentation.

Capability to drive clinical change

Recommendation 2

The Quality and Patient Experience Committee (QPEC) should review the proposed membership of the SHINE (Quality Network) Group to ensure all areas of the Trust are represented.

This has been completed and agreed at QPEC. This can be evidenced by the minutes of QPEC, SHINE Terms of Reference and all staff e mails. This action has resulted in increased staff representation and engagement with the quality agenda


QPEC reports directly to the Board and SHINE is now a sub group of QPEC. The terms of reference for QPEC and SHINE have been refreshed to reflect this new relationship. The SHINE group has representatives from a variety of staff groups in the Trust.

To highlight the quality agenda in the Trust, ‘Quality Mentors’ from SHINE can be distinguished by orange lanyards. SHINE holds regular ‘Dragons Den’ events. Any member of staff can present quality improvement ideas to secure a mentor who supports the delivery of the work. From our focus groups, it was felt that this arena can be very nursing focused and other professional groups may need encouragement to engage. (Recommendation 1)

The following pages set out our detailed findings against the recommendations made in our original review:




Triggers to drive change

Recommendation 3

Management should ensure that the new clinical leadership arrangementsoperate effectively as an early warning system to proactively drive improvement.

Completed. The Trust held aninternal consultation on the new clinical leadership structure, which ended on 30 September 2013. The response to consultation and the final structure was issued November 2013 and implemented January 2014, coinciding with the new Medical Director appointment. This has resulted in improvedclinical leadership & challenge and increased engagement of medical staff and pace of change.

Recommendation in progress, work ongoing

The Trust now has five Groups, represented by triumvirates comprising of: Associate Medical Director (AMD), General Manager (GM) and Head of Nursing (or Head of Midwifery). Within the groups there is medical leadership through the Clinical Leads (CLs) and nursing leadership from Matrons. Three AMDs are consultants and one is an Allied Health Professional (AHP - Speech and Language Therapist). The Chief Operating Officer (COO) is recruiting a Deputy COO to provide operational support to GMs, with whom she regularly meets. The AMDs are supporting the CLs in their new role in leading quality services through a series of formal and informal meetings. From the focus groups, some staff felt that the CLs lacked empowerment to make managerial decisions and lead services. However, this role is recognised as being new relatively new and therefore not well embedded in all areas. (Recommendation 2)

The Medicine Group has undergone extensive clinical and managerial change. The Group currently has an interim AMD and interim GM (on secondment from Community and Therapies). Due to the size of this Group, there is currently work underway to reorganise the services in to more manageable portfolios e.g. planned and unplanned care. The Therapeutics and Diagnostics Group is of a comparable size and budget to other Groups and is currently without an AMD. This Group is under the care and support of the AMD for Medicine, however Medicine has a large span of responsibility and associated challenges and the AMD arrangements to support Therapeutics and Diagnostics Group should be reconsidered. (Recommendation 3)

Staff reported that the new structure is an improvement and is still embedding, with AMDs and CLs evolving in their new roles. Some staff were concerned at the lack of stability in the Medicine Group structure with two key roles being interim. It was reported to us that Nursing and AHPs are very well led in the Trust, with AHPs led under the Medical Directorate via the AMD for Community and Therapies. However, there are AHPs within the Therapeutics and Diagnostics Group who are not led by the AMD for Community and Therapies. AHPs in our focus groups reported that they do not have a Matron but instead, quality is led through ‘Professional Advisors’ who do not attend the Matrons Forum. (Recommendation 4)

Focus groups also reported that the new structure needs to ensure that the Trust is being brought together ‘as one’, given the extensive geography. Staff reported inconsistencies in the services approach to cross site working. (Recommendation 5)

Clinical Leadership Follow-Up Review Detailed Findings (cont.)






Recommendation 4

All new clinical strategies should include consideration of a ‘patient pathway walkthrough’ during the development phase. This would encourage consideration of a all departments impacted by the clinical change, allow appropriate consultation to be made and avoid delays to implementation.

The Trust agreed with this recommendation and is currently waiting on the outcome of the Sustainable Services Review to inform future plans.


This work is ongoing and the Trust is currently awaiting the outcome of the Sustainable Services Review which will inform its future plans. There are many proposed and potential clinical changes throughout the Trust’s services.Engagement of all departments is recognised as being central to these proposals and the successful implementation of any future working arrangements. Forums where these discussions are usually held include:

• The Trust Management Board;• Planning and Strategy Group; and• Business meetings with the COO and Groups.(Recommendation 6)

Use of relevantdata to inform change

Recommendation 5

Management should ensure CDs (or the new AMDs) attend Group Governance Meetings and data assurance findings are appropriately cascaded to ward level to ensure data validity concerns do not impact on the pace of clinical change.

This will be reinforced as part of the implementation of the new clinical leadership structure. Associate Medical Directors have been appointed and are in post. All but one Clinical Lead post has been appointed to. ‘Time Out’ was held to outline expectations of role and ways of working and the new Medical Director attended this event. These developments can be evidenced by the revised organisational structure, job descriptions and Group governance meeting minutes. The new structure has resulted in improved clinical leadership & challenge, increased engagement of medical staff and pace of change.


There are regular Governance meetings within the Groups attended by AMDs and GMs. There is inconsistency across the sites as to who attends and the location of these meetings. Information from these meetings is cascaded to service level using a variety of methods.

From the focus groups, some staff reported that they would like to see the Board represented at their Governance meetings, perhaps on a biannual basis, to reinforce the importance of this business. (Recommendation 7)




Clinicalengagement in decision making

Recommendation 6

The Trust should ensure the new clinical leadership structure has clearly defined two way communication channels to allow clinical engagement. This should include a process whereby a specific clinical lead is nominated for every change programme to act as a clear conduit for the clinical voice. Management should consider consulting with staff in areas such as Diagnostics and Therapeutics where governance and clinical engagement were praised in the Keogh report and spoken about positively during our review to understand the drivers of success.

The Trust has implemented a Trust Management Board (TMB) to include Clinical Leads and has coincided with the implementation of the revised clinical leadership structure. This can be evidenced by the TMB minutes, scheme of delegation and revised organisation structure. This development has resulted in improved clinical leadership, challenge and increased engagement of medical staff.


The organisation has established a Trust Management Board which has complemented the implementation of the new structure. The clinical voice is represented in this arena by the AMDs attendance.

The Medical Advisory Committee meets regularly and is attended by the Medical Director. We were informed that the remit of this group is being reviewed to ascertain how best the clinical voice can inform organisational development and decision making.

The Medical Director aims to further develop the role of CLs to significantly focus on quality. The Medical Directorate will be embedding improvement methodology in day to day business to impact on patient safety and empower staff to improve practices. (Recommendation 8)

Recommendation 7

The Trust should should perform a ‘temperature check’ staff survey within 6-9 months of implementing the new clinical leadership structure to gauge the success of the engagement mechanisms.

The Trust has implemented a ‘Morale Barometer’ hosted on the intranet and is accessible by all groups of staff. This has demonstrated that there is increased staff morale and engagement.


A morale barometer is reported quarterly. The Executive team reported that this is showing an improvement in staff feelings towards the recent pace and scale of organisational change. However, our focus groups reported that there is not always the time to complete the online survey and feel that the questions are not achieving a true picture of staff morale.

Themes relating to morale are going to be explored further by way of exit interviews and semi structured interviews in August 2014 for medical staff. (Recommendation 9)





Clinical desire to engage in medical management

Recommendation 8

The Director of Operations and Medical Director, supported by the Director of OD and Workforce, should develop an exit strategy for AMDs to clearly define the route back into full time clinical activity after a post in medical management.

The Trust agreed with this recommendation and reference to the agreed exit strategy approachwill be included within the Trust's response to the consultation.


All AMDs in post have retained clinical sessions. This is not only important for their credibility with their peers and staff groups, it also allows their continuation of clinical practice should they relinquish the role at some point in the future.

Visibility of the Board

Recommendation 9

The Trust should consider developing a regular Junior Doctor Forum which is attended by the Chief Executive and Medical Director in line with the Keogh Report findings of effective junior doctor engagement as a marker of quality and clinical engagement.

There is currently junior doctor input into a number of initiatives and groups. However, the Medical Director is will be developing this further to improve clinical leadership, challenge and engagement of medical staff.


The Trust engages junior doctors through a variety of forums, but this is inconsistent throughout the organisation.

In some Groups, junior doctors attend the Mortality Performance Committee (chaired by the Trust’s Chairman). A Junior Doctors Taskforce has been established to support this area of practice.

The Medical Director is currently reviewing how the Trust engages with junior doctors to ensure that this group can propose valuable contributions to patient safety and quality agendas. It is important to ensure that any forums are widely publicised throughout all areas of the Trust to allow the opportunity for junior doctors to attend. (Recommendation 10)






Visibility of the Board

Recommendation 10

Specific queries should be included as part of ward visits and department meetings after Trust wide cascades, to ensure all messages have been effectively communicated.

A relatively new initiative is the CEO monthly cascade. Senior staff attending these cascades are asked to cascade key information. Queries regarding the sharing of key information/ communication is included in Director visits. It is hoped that this will improve clinical leadership, medical staff engagement, communication and staff morale.


There have been a range of ongoing activities to increase the visibility of the Board and reinforce communication to and from the Board: Executive and Non Executive team visits, in the form of

announced and unannounced programmes have been occurring regularly.

Ward reviews will now be based on the five CQC domains and amalgamated with the programme of mock CQC inspections.

Regular staff briefings with the CEO and Directors Regular all staff e mails Informal Director visits to clinical areas

Focus groups reported that the Board are very visible in clinical areas and that the CEO is approachable and receptive. They feel the challenge remains to ensure that this presence is felt on all Trust sites.

Staff reported that during the last 18 months, they felt better informed and communication came in a range of forms. However, the focus groups highlighted a reliance on e-mail to communicate key messages, which could be a challenge to some frontline staff who have limited opportunities to check e mails.





External

stakeholders

Recommendation 11

A nominated member of the Executive Team should continue to proactively seek engagement from external Primary Care stakeholders regarding the Action Plan. All regulators must be informed of any issues encountered which may impact on the timeliness of delivery of the plan.

The Trust agreed with this recommendation. The Keogh Action Plan is discussed at the Commissioner Quality Contract Board and Community Mortality Group. As part of the Keogh Action Plan Assurance Process, regular meetings between the CEO of NLAG and the Chief Officers of the CCGs and the LAT have been arranged. It is hoped that this will improve the quality of the patient experience.


This is an area of ongoing work for the Trust. The CCGs have been largely supportive thus far in the Trust’s journey and efforts continue to ensure that these relationships continue to develop.

The Trust is awaiting the outcome of the Sustainable Services Review, to which the CCG hopes to have a plan by September 2014.

(Recommendation 11)

Recommendation 12

Management should ensure regular forums are scheduled to bring together GPs, CCGs, LATs and Trust staff (including both clinical and managerial representation) to discuss integrated care opportunities and pathway changes being proposed within the Trust.

The Trust agreed with this recommendation and is being addressed as part of the Sustainable Services Review. Both clinical and managerial staff are involved in integrated care and pathway discussions.


As the Trust is awaiting the outcome of the Sustainable Services Review, there are currently limited forums bringing these stakeholders together to discuss patient pathways. Collaboration has however occurred on a ‘needs must’ basis in unplanned care for example, where GPs were engaged and committed to the partnership. There has also been collaboration across the Trust whereby clinicians from primary and secondary care meet regularly to participate in improvement initiatives facilitated by the NHS Improving Quality group.

Recommendation 13

The Trust should look to CCGs for additional support where difficulties are encountered in engaging GPs and other Primary Care bodies within the community.

Interdependencies have been agreed as part of the Keogh Action Plan although in some instances further detail is required from Commissioners. Joint Trust clinician and GP mortality review meetings have commenced. Regular meetings between the Chief Executive of NLAG and the Chief Officers of the CCGs and the LAT have been arranged. These meetings will be used to ensure engagement and address any difficulties encountered. This work requires ongoing commitment from the CCGs.


This is an ongoing area of development for the Trust. (see Recommendation 11)




Theme KPMG Recommendation

NLAG Position KPMG Comments

Clinical accountability

Recommendation 14

Management should ensure responsibility for clinical staff performance - through effective job planning and appraisal -is incorporated as a specific defined job role within the clinical leadership structure.

A revised Job Planning Framework has been agreed further to a recent internal audit. The Medical Director will work in support of the Chief Operating Officer and General Managers in implementing and enforcing these requirements. This should result in improved quality outcomes, improved clinical leadership and increased medical staff engagement.

Recommendation incomplete, action required

Job planning is a major theme in the Trust’s approach to workforce planning. This is an area of continual development and is currently being embedded in the new structure. Recent progress has included: Development of a job planning resource pack; Team Job Planning in progress; AMDs and Clinical Leads supported with job plan training; Work commenced with PWC to look at consultant productivity; Job Planning Governance Group established; and Job Planning KPIs have been developed

These activities have highlighted capacity challenges. The Medical Director is currently considering the appointment of an administrative assistant to support team and individual job planning processes.

This area remains a priority for the Trust. (Recommendation 12)

Recommendation 15

Rigid accountability mechanisms must be implemented to ensure members of the clinical leadership team are consistently enforcing disciplinary measures where policy breaches are identified.

A Zero Tolerance Framework is in place and is being reinforced in both the managerial and clinical leadership structures.


Executive members reported that a Zero Tolerance Framework is embedded in the organisation and is at the point where it can be devolved to Groups to mandate, monitor and review. There have been some delays in the decision making processes due to capacity and a suitable IT system is being sourced to support the this framework.

The Trust appears to have the vision and values embedded at every opportunity e.g. during recruitment, induction, personal development reviews and various levels of training. Focus groups reported that staff are very clear on the levels of professional behaviour expected from them and feel more confident to highlight poor practice and escalate concerns appropriately. Focus groups reported that the next step is to engender the confidence in staff to challenge each other on poor practice/inappropriate behaviours.






Recommendation 16

Specific communication to staff regarding the need for an annual appraisal - as a requirement for revalidation - should be made by the Chief Executive, Medical Director and Director of Organisational Development and Workforce. Disciplinary measures incorporated within the Zero Tolerance Framework should be consistently applied where individuals have not complied with this requirement.

Requirements in respect of appraisal have been reinforced with all staff and a Zero Tolerance Framework is in place.


Appraisal and revalidation in the organisation is up to date and the Board are continuing to monitor this, having met the target of 75% in December 2013 and is on target to achieve 95% by December 2014.

Staff in the focus groups reported being up to date with their appraisals. One doctor stated that an electronic alert would be helpful to remind them of this activity and stay on track with timescales, although we believe this is in place.

Recommendation 17

A detailed mechanism should be completed to assess the quality of appraisal data and specific actions developed where improvement areas are identified.

The Trust agreed with this recommendation and as a result the Trust appraisal target of 75% has been met and ongoing monitoring continues.


This is an area of ongoing activity for the Trust. A system is currently being sourced to capture common themes emerging from staff appraisals at all levels to inform personal, team and service development e.g. communication skills.





Recommendation 18

The Trust should ensure that adequate support is given to all staff members to complete mandatory training modules alongside clinical duties, including both time allocation and a review of the hardware available to staff.

The Trust agreed with this recommendation and set the following targets for mandatory training: 75% by the end of December 2013 and 95% by the end of December 2014. There is ongoing reinforcement and reminders regarding the need for the timely completion of mandatory training. Compliance is monitored via the Executive Team and relevant Trust Board Sub-Committee.


The Trust has made significant progress in this area. There is continued effort within the Trust to increase capacity and the organisation has utilised resources from neighbouring organisations to provide ‘on the job’ training opportunities.

Focus groups reported that mandatory training completion has generally improved. However, some areas remain challenged due to lack of time away from clinical activities, IT access and slow internet connections. Medical staff reported that having the time to do mandatory training is challenging and often complete it in personal time rather than cancelling clinical activities.


Recommendation 19

Management should look to address the findings from the internal audit job planning review on a timely basis.

A revised Job Planning Framework has been agreed further to an internal audit. The Medical Director will work in support of the Director of Operations and General Managers in implementing and enforcing this development to deliver quality outcomes and improved clinical leadership.


There is an agreed job planning process in the Trust. Job plans are currently being undertaken, however these are not complete in all areas. This is an area of ongoing activity for the Trust. Changes of senior personnel in the managerial structure some Groups has added delays into the process.

The Medical Director aims to make the process more robust and improve compliance and monitoring arrangements. Changes to the allocation of SPAs will take place, reducing from a default position of 2.5 to 1.5, with additional sessions allocated as appropriate to function and role. (Recommendation 13)




Theme KPMG Recommendations NLAG Position KPMG Comments

Reporting SUIs Recommendation 20

The process for investigating SUIs should be updated to include the specific requirement to provide feedback to the individual who reported the SUI.

The Trust has recently reviewed its arrangements for the management of SUIs in response to the updated NHS England Serious Incident Framework. An action plan has been agreed which includes issues such as strengthening the mechanisms for ensuring that the wider learning from SUIs is disseminated throughout the organisation. 'Safety/Quality Governance Days‘ have been initiated to develop a more robust mechanism for sharing and learning lessons.


SUIs from across the Trust are reviewed and lessons learnt disseminated in a variety of forums including senior nurse meetings and Safety and Quality Days within the Groups.

Under the new policy, the member of staff who reported an SUI has to sign to evidence that they have received and read the feedback from the investigation. This point was highlighted in the recent CQC inspection report as an area of good practice.

The new Clinical Leadership proposed structure

Recommendation 21

Management should develop a detailed TOR for the proposed Hospital Management Board (HMB) on a timely basis. HMB findings should be a standing agenda point at the Board, with all AMDs given the opportunity to present to the Board on a regular basis.

The Trust agreed with this recommendation and a Trust Management Board has been developed. This has coincided with the implementation of the revised clinical leadership structure. Regular meetings have now commenced.


A Trust Management Board has now been established and is chaired by the Chief Operating Officer and attended by the CEO and Medical Director. AMDs, GMs and senior nurses also attend. Staff reported that in addition to being productive and supportive, these meetings provide an opportunity to integrate relationships across the Groups.

Recommendation 22

Management should consider devising a portfolio of KPI targets relating to Trust wide issues, e.g. infection control, nutrition, etc for each AMD, which link to those KPIs monitored at a Board Level. Responsibility for these should be incorporated into the AMD job description.

Appointment to Clinical Lead posts has now been completed.


Activity in this area has commenced to bring together KPIs to evidence clinical leadership and requires further time to embed and develop.

The Quality Development Plan (previously Keogh Action Plan) has a Trust wide scope and the Medical Director aims to include these monitoring actions to the AMD portfolios to formalise monthly Group performance reviews. (Recommendation 14)






The new Clinical Leadership structure

Recommendation 23

The PAs allocation proposed for Clinical Leads should be reviewed to ensure they have appropriate capacity to dedicate to leadership duties. Consideration should also be given to the option of having site specific CLs reporting to Trust wide AMDs to address potential capacity issues.

Appointment to Clinical Lead posts completed. The new structure has appointed CLs across sites and this is appropriate to encourage collaboration across sites and to increase clinical engagement and team working within specialties.


The Trust has mandated that CLs should have 1 PA allocated as a minimum to undertake their role. There is however scope to flex the allocation of PAs according to the specific role, extent of the service and also to consider any impact of cross site working.

Medical staff in focus groups reported that where CLs work across sites, much of their current PA allocation to the CL role can be lost in travelling if not utilising VTC. The Trust should ensure that workload and the impact of cross site working of CLs is considered when allocating PAs. (Recommendation 15)

Recommendation 24

Job descriptions for GMs and Heads of Nursing should be reviewed to ensure they compliment the new structure, and management should communicate with these individuals to ensure they are aware of their role in the new structure.

This was agreed and is now in place.


The Director of Nursing has completed a review in this area. The Trust had staff groups with many different remuneration structures and work was undertaken to ensure equity and parity between roles.

The final phase of the work is underway with job titles being determined. In addition the Director of Nursing and Medical Director are currently reviewing the interplay and impact which the medical and nursing relationships have on patient safety within the Trust.

Recommendation 25

Management should develop a comprehensive and concise leadership and development course to equip AMDs and CLs with the tools and knowledge to effectively fulfil their roles.

A leadership programme for nursing leaders is already in place and ongoing.


Band 6/7/8 nursing staff have completed a 6 month leadership programme. AMDs and CLs will commence a leadership programme in September 2014 developed in partnership with Sheffield Teaching Hospitals NHS FT.


2. The appropriateness of the clinical leadership team’s skill mix, experience and division of responsibilities


Balance of skills and suitable experience at the Board Sub-Committees

Recommendation 26

The Trust should consider including the newly appointed NED as a member of QPEC to add additional clinical challenge to quality issues.

This is now in place and can be evidenced by the Revised QPEC Terms of Reference and has increased the element of clinical challenge in this forum.


The latest appointed NED with a clinical background has been attending QPEC since appointed. This individual will now take over the chairing of QPEC from August 2014.

External support to address skill gaps

Recommendation 27

Management should incorporate a process into the job planning or appraisal process whereby internal secondments/ skills/ interests are recorded on a central register and updated on an annual basis.

This Trust agreed with this recommendation and a central register is in development. A baseline of existing arrangements is to be established and a mechanism for recording and reporting to be agreed.

Recommendation incomplete, action required

Currently there is no common mechanism in place to capture this information. The Medical Director’s vision is that following job planning and appraisal events any relevant information should be included in the personal development plans of the individual clinician. This will assist in identification of any common themes or interdependencies. (Recommendation 16)



3. The effectiveness of the mechanisms being put in place by clinical leadership to lead and embed transformational change consistently across the clinical bodies and organisation.


Consistency

Recommendation 28

The Trust should develop a detailed Integration Plan to promote cross organisational working and raise the profile of community services, which should include specific measurable KPIs. This must be monitored on a regular basis by a dedicated group (such as the Vision and Values Group) and progress reports should be presented to the Board on a quarterly basis. In developing the Integration Plan management should look to areas of the Trust where integration is currently occurring to learn from internal successes.

The Trust agreed with this recommendation. The organisational name was changed to reflect the integration of community services and work is ongoing to increase the profile of the Community and Therapies Group.


The Trust has made positive progress in this area and seconding a Community and Therapies GM in to the Medicine Group has demonstrated the organisation's commitment to integration. This has been further developed by hosting an integrated care facility on the Grimsby site, staffed and managed by the community.

Lessons learnt across the Trust

Recommendation 29

Management should ensure a standard agenda point is added to an appropriate forum within each Group where all relevant SUIs from all locations are discussed and specific actions are noted and followed up on a timely basis.

This is already a Trust requirement. There are standard Terms of Reference for the Group Governance meetings. This requirement will be reinforced and audited as part of the annual Internal Audit review of the Trust's governance arrangements. Performance in respect of the management of SUIs, including the completion of agreed actions, is monitored via the Executive Team and the Trust Governance and Assurance Committee.


The management of SUIs is closely monitored within the Trust and reviewed at various forums:

Governance Meetings within the Groups are now well established and attended by AMD, GM and senior nurses.

Quality and Safety days within Groups focus on important themes for learning e.g. ophthalmology never events.

Learning Lessons Review Group extract and communicate learning points applicable for staff as a result of SUIs

A weekly SUI Review Group is to be chaired by the Director of Performance Assurance to review processes and challenge the RCA quality. This will include the staff involved in the SUI and commence August 2014.


Appendices

1. Recommendations

2. Audit approach


Priority rating for recommendations raised

High risk: issues that are fundamental and material to your system of internal control. We believe that these issues might mean that you do not meet a system objective or reduce (mitigate) a risk.

Medium risk: issues that have an important effect on internal controls but do not need immediate action. You may still meet a system objective in full or in part or reduce (mitigate) a risk adequately but the weakness remains in the system.

Low risk: issues that would, if corrected, improve the internal control in general but are not vital to the overall system. These are generally issues of best practice that we feel would benefit you if you introduced them.

No. Risk Recommendation

1 (Med)

Capability to drive the Quality Agenda

The Trust should ensure that the ‘Dragons Den ‘ forum encourages staff from all clinical and non clinical groups to propose innovative ideas to support the pace and scale of quality improvement in the Trust.

2 (Med)


The Medical Director should ensure that the recently implemented clinical leadership arrangements encourage role development and autonomy at all levels and allow this structure further time to embed into the organisation.

3 (Med)


The Medical Director and Board should review the current arrangements in place, and consider future requirements, for AMD support to Therapeutics and Diagnostics Group. These arrangements will require formalising.

4 (Med)


The Trust should ensure that the leadership and management structure in place for allied health professionals is formalised and complementary of the new nursing and medical structures. Fostering a leadership culture of clear accountability and inclusivity in the clinical groups will strengthen the Trust’s progression of the Quality Development Plan.

The following 16 recommendations have been raised to provide our view on the options open to the Trust for further improvement within clinical leadership and thetimescales within which these options could be executed. We have RAG rated our recommendations based on the urgency and anticipated impact on the Trust.

Appendix OneRecommendations




5

(Med)


The Trust should consider reviewing the extent to which cross site working occurs within services. Visibility of the new clinical leadership structure on all sites is important to ensure inclusive engagement of the clinical body and will also strengthen the embedment of clinical leads within the organisation.

6

(Med)


All new clinical strategies should include consideration of a ‘patient pathway walkthrough’ during the development phase. This would encourage consideration of a all departments impacted by the clinical change, allow appropriate consultation to be made and avoid delays to implementation.

7

(Low)

Use of relevant data to support change

The Trust should consider regular Board representation at Group governance meetings to affirm the role of the triumvirates in the new leadership structure and oversee data robustness from ‘Ward to Board’.

8 (Med)

Clinical engagement in decision making

The Medical Director should ensure that the Clinical Lead job description, job plan and appraisal encourages and acknowledges the contribution which this role has in developing, leading and delivering clinical engagement with the Quality Development Plan and Quality Strategy.

9 (Low)

Clinical engagement in decision making

The Trust should consider regular ‘deep dives’ into morale themes as a result of the barometer responses, to ‘temperature check’ staff resilience and well being during times of rapid pace and scale of change. Management should ensure that information and themes captured from the morale barometer and qualitative interviews is used to inform the Trust of where further cultural change work could be further developed.

10 (Med)

Junior doctor engagement

The Medical Director should ensure that the Trust wide forum for the engagement of junior doctors is a regular event and that they are made aware of the timetable of meetings and have the opportunity to attend. This will encourage and strengthen the clinical voice within the new leadership structure and support cultural change efforts.




11 (Med)

External Stakeholders

Management should seek opportunities to strengthen commissioner relationships at all levels and ensure that they continue to develop at this important time in the Trust’s development.

12

(Med)


The Medical Director should seek to appoint an administrative assistant to support and strengthen the robustness of the current job planning, appraisal and revalidation processes.

13

(High)


The Trust should ensure that job planning for all consultant staff is completed as soon as possible and the monitoring of compliance and progress should be reported regularly to Board.

14

(Med)


The Trust should seek to develop a portfolio of KPIs for each AMD linked to Trust wide issues as soon as possible. These should be included in the AMDs performance reviews , to ensure regular monitoring and responsive management of issues arising within Groups, engaging CLs where appropriate.

15

(Med)


The Medical Director should ensure that once the AMDs have formally discussed PA arrangements with CLs, that a formal agreement is put in place regarding the expectations of the roles and responsibilities of each individual CL.

16

(Low)

External support to address skills gaps

The Trust should ensure that there is a logical and common approach to the data capture of internal secondments/ skills/ interests to inform service development ,education and training investment and staff engagement with personal and professional development.


Appendix TwoAudit approach

We interviewed the following individuals during the course of this review:

Dr Jim Whittingham Chairman

Karen Jackson Chief Executive Officer

Karen Griffiths Chief Operating Officer

Dr Karen Dunderdale Chief Nurse

Dr Mark Withers Medical Director

Neil Pease Director of Organisational Development & Workforce

Wendy Booth Director of Performance Assurance & Trust Secretary

Bryony Simpson Associate Medical Director - Community & Therapy Services

Dr Oltunde Ashaolu Interim Associate Medical Director - Medicine

Professor Carrock Sewell Associate Medical Director - Path Links

Mr Lawrence Roberts Associate Medical Director - Women & Children’s

Karen Fanthorpe Interim General Manager - Medicine

We also held focus groups across the three main hospital sites:

Focus Group at Scunthorpe General Hospital

Focus Group at Goole and District Hospital

Focus Group at Diana Princess of Wales Hospital


Appendix TwoAudit approach (continued)

We reviewed the following documents during the course of our work:

NLAG Keogh Action Plan and KPIs for June 2014 and Buddying Arrangements Update

Keogh Action Plan Measures April 2014

Keogh Action Plan Performance Measures May14

Mapped Keogh Action Plan June 2014

CQC Northern Lincolnshire and Goole NHS Foundation Trust Quality Report July 2014

CQC Action Plan

Zero Tolerance Framework

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