Dr. Philip Crowley, HSE National Director Quality and Patient Safety looks at the lessons for the Irish healthcare system of The Francis Report on the Mid Staffordshire Trust.
The Francis Report into care provided in the Mid Staffordshire Trust has rocked the NHS.
It follows an initial report of care at the Trust that uncovered appalling standards of care:
- Basic care was neglected
- Patients left in soiled bed linen
- Calls to use the bathroom ignored
- Patients left sitting on commodes
- Patients unwashed for long periods
- Food and drink left out of reach
- Pain relief late or not provided
- Very poor hygiene
- Families cleaned toilets for fear of infection
Concerns were raised following an analysis of mortality data that demonstrated that the hospital had significantly higher mortality rates than other trusts.
Francis concluded that similar poor care could exist in other care settings.
Findings at a Trust and Trust Board Level
There was a negative culture with a tolerance of poor standards, a focus on finance and targets, and a denial of concerns and isolation from practice elsewhere. Consultants were not at the forefront of promoting change and patients not heard. The Board did not have a grip on its accountability and there was a lack of focus on standards of service due to an obsession with targets. There were poor nursing and midwifery standards as a result of poor leadership and staffing policies. The report concludes that the economies imposed by the Trust Board, year after year, had a profound effect on the organisation’s ability to deliver a safe and effective service.
Findings at a system level
Francis concluded that similar poor care could exist in other care settings, that numerous warning signs were ignored and that standards did not focus on the effect of a service on patients. There was a failure of communication between the many agencies in place to monitor the provision of safe, quality services. This was also a product of the regulator’s “fierce independence”. There was a failure to appreciate the risk of disruptive loss of corporate memory resulting from repeated, multi-level reorganisation.
Since the publication of the Francis Report the Medical Director of the NHS Professor Sir Bruce Keogh has published a further review into care quality in 14 trusts with persistent high mortality rates. This again found deficiencies in care, problems with the retention of quality staff, a lack of engagement with patients and staff and poor safety outcomes.
What must the Irish health service learn from this report?
We have no evidence that such a poor standard of care as highlighted by the Mid Staffordshire Report is in existence within Irish hospitals. However, we do not currently measure in-hospital mortality rates, patient experience or staff culture (although we have started to measure the latter) and our current indicator set remains weak in the area of measuring quality. Allied to that, many of the conditions that gave rise to the environment in which the Mid Staffs Trust so comprehensively failed their patients currently pertain in Ireland.
- We have lost large numbers of staff from all parts of the service in early retirement schemes.
- The services have been constrained in replacing staff due to significant cost containment pressures.
- We have (very reasonably) had a major focus on a small number of key access targets that may lead to tunnel vision and a lack of attention on other measures of care quality and patient safety.
There was a failure to appreciate the risk of disruptive loss of corporate memory resulting from repeated, multi-level reorganisation.
Therefore we certainly cannot be complacent. It is imperative that we learn from this report and work to ensure such a fall in the expected standards of care is not allowed to happen in any of our hospitals or anywhere else in our health system.
We are working to develop more comprehensive quality information including hospital standardised mortality rates. We will deliver a quality dashboard to become part of the performance measurement process which will bring together measures of patient outcomes, patient safety, adverse incidents, complaints, and staff and patient experience. The measurement of patient experience in real time will be promoted in all health care settings alongside our initiative to involve patients in hospital and community delivery settings.
We are working to promote a culture of engaged leadership where managers have the ability to know what is happening ‘on the ground’ and are fully engaged with front line service delivery. Service planning and cost containment are assessed for their impact on patient care. We will be auditing the regional service planning risk assessment process. We have piloted a patient safety culture survey in five hospitals and are now rolling this out across all hospitals. We will promote mechanisms to listen to front line staff concerns and ideas for improvement in all health care settings and this will include professionals in training positions.
We have developed the Clinical Director role to complement the role of the Director of Nursing to ensure clinical understanding is placed at the centre of decision making at all levels of the service. We are analysing our clinical audit reports, complaints and incident investigations to ensure that we extract and share learning across our system.
We are working to promote a culture of engaged leadership where managers have the ability to know what is happening ‘on the ground’ and are fully engaged with front line service delivery.
The development of hospital groupings and the appointment of Hospital Boards have the potential to have a profound impact on the quality and safety of acute care and we will be supporting them to ensure that quality and safety is a standing item on every meeting agenda, that they have a mechanism to hear directly from patients and front line staff, that they agree a quality and safety strategy for the hospital/group and that they ensure that quality information reported to the Board is treated with the same importance as financial information
Since 2011, the HSE has provided funding to develop and deliver, in partnership with the RCPI, the Diploma in Leadership and Quality in Healthcare which provides training for senior healthcare professionals and managers in the fundamentals of leadership, patient safety, improving patient experience and quality improvement. The Clinical Director programme, part of the Quality and Patient Safety Directorate represents an unprecedented opportunity for change and improvement in the way health services are delivered through clinical leadership.
We are working to ensure clear nurse leadership exists for all ward areas. We need to urgently address areas where recruitment is proving problematic, especially NCHDs and consultant grades to ensure we can attract the best candidates to work in our system.
The real challenge today is for our managers to adopt the leadership that really focuses on the quality of care they provide, ensures that all management discussion is informed by clear measurements of patient related outcome measures, demonstrably values front line staff, listens to patients, promotes an expert, well trained workforce and models the desired behaviours to create a culture of care, kindness and excellence.