Quality Governance in the NHS March 2011 - Redesign of the HSS Governance Model - Research - 1 Augus

Quality Governance in the NHS

A guide for provider boards

National Quality Board

Refresh Date: March 2011

Contents

Introduction 2

• Purpose of this guide

• Context: the transition and productivity challenge

• Context: the NQB's Review of Early Warning Systems in the NHS

Chapter 1: Quality in the NHS 6

• What is quality?

• What is quality governance?

• The Quality Governance Framework

Chapter 2: Strategy 10

• Does quality drive your trusts strategy?

• Are you aware of the potential risks to quality at your organisation?

Chapter 3: Capability and culture 14

• Do you the board, have the necessary leadership, skills and knowledge to ensure

delivery of the quality agenda?

• Do you promote a qualityfocused culture throughout your trust?

Chapter 4: Processes and structures 19

• Does your trust have clear roles and responsibilities in relation to quality governance?

• Do you have clearly defined, wellunderstood processes for identifying opportunities

for quality improvement, for identifying potential risks to quality, and for escalating

and resolving issues?

• Do you actively engage patients, staff and other key stakeholders on quality?

Chapter 5: Measurement 23

• Is appropriate quality information analysed and challenged at your organisation?

• Do you consistently assure the robustness of quality information?

• Do you work to ensure that quality information is used effectively?

Conclusion 27

Introduction

1. The primary purpose of the NHS, and everyone working within it, is to provide a high quality service, free at the point of delivery to everyone who needs it. This common goal unites all those working in the NHS, from hospital doctors, to nurses, to GPs, to dentists, to allied health professionals, to clinical managers and nonclinical staff.
2. The NHS has coalesced around the definition of quality set out by Lord Darzi in 2008[1]. Care provided by the NHS will be of a high quality if it is:

Safe;

Effective,

with positive Patient Experience.

3. Quality care is not achieved by focusing on one or two aspects of this definition; high quality care encompasses all three aspects with equal importance being placed on each.
4. This is not an easy task; quality is a moving target. Continuous improvement in quality means that what is considered of an acceptable quality today may not be acceptable this time next year. Wellpublicised failures in quality are testament to the complexities associated with a service as large and multifaceted as the NHS working to ensure that all care, every day, for every person, is of a high quality.
5. Individuals working in clinical teams providing NHS services are at the frontline of ensuring quality of care to patients. Many of these frontline staff work within a framework of professional regulation that makes them personally accountable for the quality and safety of care they provide to individual patients. However, ultimately, it must be the board and leaders of provider organisations[2] that take final and definitive responsibility for improvements, successful delivery, and equally failures, in the quality of care.
6. Evidence suggests there is significant correlation between the governance behaviours2 a board disseminates to its organisation and the level of performance achieved at that same organisation. A key finding in the article Hospital Governance and the Quality of Care supports this assumption, stating that, "The large difference in board activities between highperforming and lowperforming hospitals we found suggests that governing boards may be an important target for intervention for policy makers hoping to improve care in US hospitals"[3]. This finding emphasises the link between governance at board and leader level and the wider achievements of an organisation and highlights the importance of quality governance at board level to ensure quality care.

7. Therefore, the provider board is responsible for overseeing the quality of care being delivered across all services within the organisation and assuring itself that quality and good health outcomes are being achieved throughout the organisation[4]. Effective governance therefore requires that boards pay as much attention to quality of care as they do to management of finances.[5]

Purpose of this guide

8. Past service failures have illuminated gaps in knowledge amongst board members and a lack of clarity as to what good governance for quality looks like. This guide seeks to provide that clarity and acts as a route map to support provider boards as they navigate the system and lead their organisation in delivering improved quality and outcomes.
9. This guide considers how to govern for quality, both in terms of driving continuous improvement across the organisation and ensuring that the essential levels of quality and safety are met. It recognises that processes and structures are vital in governing for quality, but also that values and behaviours are essential to a culture that supports quality.

Context: the transition and productivity challenge

10. The Government's July 2010 White Paper, Equity and Excellence: Liberating the NHS, set out an ambitious and far reaching programme of change for the NHS aimed at:

• Putting patients at the heart of all NHS care;

• Delivering improved healthcare outcomes; and

• Empowering local organisations and professionals to improve quality

11. Over the next four years, the NHS will make the transition to the new system architecture described in the White Paper resulting in major structural changes to how the NHS is organised and run. Subject to the passage of legislation, by April 2014:

• An independent NHS Commissioning Board will have been established, taking over responsibility from the Department of Health for overseeing the commissioning of NHS services and the allocation of the NHS budget (April 2012)

• Strategic Health Authorities will have been abolished (March 2012)

• Primary Care Trusts will have been replaced by new GP Consortia, who will be responsible for the commissioning of local health services for their populations

• Monitor will have become the new Economic Regulator for the NHS (April 2013)

• All Trusts will have become Foundation Trusts, free from central direction or control but subject to a new system of economic regulation

• A new champion for patient voice will have been created with the establishment of HealthWatch

• A number of arms length bodies will have been abolished, including the National Patient Safety Agency and the NHS Institute for Innovation and Improvement, with their roles and functions transferring elsewhere

12. In addition to these structural changes, despite the strong financial settlement afforded by the spending review, rising demand, demographic changes and the cost of new drugs and technologies mean the NHS will need to offer efficiency savings of up to £20 billion over the next four years to improve the quality of the comprehensive service on offer to patients.
13. However, despite the significant changes and reforms ahead, the role of provider organisations and their boards will remain relatively constant. It is therefore critical that we capitalise on this stability, with the leadership of provider organisations truly becoming champions of quality.

Context: the NQB's Review of Early Warning Systems in the NHS

14. This guide will support provider boards in navigating this journey providing a framework for governing for quality with the necessary definitions, advice and information on where to find useful tools which board members can draw on. It has been developed by the National Quality Board (NQB) as part of its role in supporting the NHS around quality. It follows on from the NQB's Review of Early Warning Systems in the NHS (February 2010), a report that looked to describe how the NHS should be preventing and taking action in relation to serious failures in quality.[6]
15. The report recommended that provider boards be given further guidance on how best to govern for quality. This follows recommendations that came out of the reviews of the serious failings at Mid Staffordshire NHS Foundation Trust, which found that there had been a breakdown in the structures and governance of the board resulting in an overall lack of focus on quality at the organisation[7].
16. Following the Shipman Inquiry and the problems in the paediatric cardiology service at Bristol Royal Infirmary, the concept of clinical governance emerged as a support to clinicians and individual providers in ensuring the care delivered and commissioned is of a high quality. Since its first articulation in 1998, the concept of clinical governance has been widely accepted within the NHS, bringing together the culture and structures and processes which healthcare organisations, clinical teams, and individual clinicians, need to assure and improve the quality of care they deliver.

17. This guide looks to bring together the concept of quality governance with the already familiar doctrine of clinical governance under a single banner. Clinical governance has traditionally been the realm of clinicians and clinical managers within NHS trusts. Given that the primary focus of all NHS funded care is to be the delivering of improving quality and outcomes, the distinction between quality governance and clinical governance is less relevant as clinicians and managers are working towards the same ends – the delivery of the highest quality services.
18. This guide aims to do three things:

Firstly, it looks to define quality governance and give shape to

what it means to govern for quality across an organisation

Secondly, it seeks to provide support to provider boards in

achieving and delivering this quality governance

Thirdly, it looks to identify and provide links to further

publications, documents and concepts that provide detail on supporting aspects of quality governance

Chapter 1

Quality in the NHS

What is Quality?

1. Over the last three years, the NHS has coalesced around a shared definition of quality. This was set out by Lord Darzi in the NHS Next Stage Review Leading Local Change[8] as comprising three elements:

• effectiveness of the treatment and care provided to patients – measured by both clinical outcomes and patientrelated outcomes. There is much evidence of wide variation in the clinical effectiveness of care delivered across the country;

• the safety of treatment and care provided to patients – safety is of paramount importance to patients and is the bottom line when it comes to what NHS services must be delivering. It has risen up the agenda over the last ten years following the publication of An Organisation with a Memory[9] and Safety First: a report for patients, clinicians and healthcare managers[10]. High profile failures in more recent years, such as at Mid Staffordshire and Basildon and Thurrock, have brought further, and considerable, media attention to the agenda; and

• the experience patients have of the treatment and care they receive – how positive an experience people have on their journey through the NHS can be even more important to the individual than how clinically effective care has been.

2. Whilst it is important to identify and deliver against the three separate elements that comprise quality, it is critical to recognise that, though different, they are all aspects of the same thing: high quality care. Quality is only achieved if all three of these domains are present equally and simultaneously in care – delivering on just one or two in isolation is not enough.

What is Quality Governance?

3. Ultimately, the board of a provider organisation is responsible for the quality of care delivered across all services that the organisation provides.
4. As with other aspects of activity, for instance, financial management, this is achieved through governance arrangements, which delegate responsibility down to the operating levels in the organisation. In the case of quality, this means that although individuals and clinical teams are at the frontline and responsible for delivering quality care, it is the responsibility of the board to create a culture within the organisation that enables clinicians and clinical teams to work at their best, and to have in place arrangements for measuring and monitoring quality and for escalating issues, including, where needed, to the board. Boards should encourage a culture where services are improved by learning from mistakes, and staff and patients are encouraged to identify areas for improvement, and not afraid to speak out.
5. In this document, we use the term quality governance to refer to the values and behaviours and the structures and processes that need to be in place to enable the board to discharge its responsibilities for quality. The board's responsibilities for quality are threefold:

• to ensure that the essential standards of quality and safety (as determined by CQC's registration requirements) are at a minimum being met by every service that the organisation delivers

• to ensure that the organisation is striving for continuous quality improvement and outcomes in every service; and

• to ensure that every member of staff that has contact with patients, or whose actions directly impact on patient care, is motivated and enabled to deliver effective, safe and personcentred care

6. The arrangements for quality governance should complement, and be fully integrated with, the governance arrangements for other aspects of the board's responsibilities, for example, finance governance and research governance.
7. As part of its assessment process for new applicants for FT status, Monitor developed and consulted on a definition of quality governance, and a supporting framework and good practice structure. This breaks down into manageable chunks the structures and processes that relate to quality and that can act as levers to ensure good governance for quality within a trust.
8. This guide will use both Monitor's definition of quality governance and its quality governance framework as the basis of its guidance on how to govern for quality.
9. Monitor defines quality governance as: "the combination of structures and processes at and below board level to lead on trustwide quality performance including:

• ensuring required standards are achieved

• investigating and taking action on substandard performance

• planning and driving continuous improvement

• identifying, sharing and ensuring delivery of bestpractice

• identifying and managing risks to quality of care"

10. This definition looks to pinpoint the key components of quality governance and how provider boards can assure their organisation against them. It breaks down quality to encompass the practicalities of how a board can go about using its expertise and building up a governance structure and culture that inspires quality from board to ward.

The Quality Governance Framework:

11. Drawing on Monitor's Quality Governance Framework[11], Figure 1 below sets out the definition of quality governance in terms of its four component parts:

• Strategy;

• Capabilities and culture;

• Processes and structures; and

• Measurement

Figure 1: The Quality Governance Framework

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• The Board should promote a quality focused culture throughout the trust

Strategy Capabilities and Culture

Quality Governance Framework

Processes and Structures Measurement

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•There should be clearly defined, well •The Board schhoaullldenbgeeadssured of the understood processes for escalating and robustness of the quality

resolving issues and managing quality information performance •Quality information must be used

•The Board should actively engage effectively

with patients, staff and other key

stakeholders on quality

12. These are the key areas provider boards need to look at when wanting to redesign their governance structures and outputs around quality. Ensuring that there is good governance for quality within an organisation is not a tick box exercise and these four components of the Quality Governance Framework are not separate categories of process. Rather they are elements of a continuous cycle or journey which boards will need to use to assure themselves that their organisation is both compliant with the essential levels of quality and safety and striving for continuous quality improvement.
13. In the next few chapters, we outline the framework, posing a series of questions provider boards can use to assess the adequacy of the procedures and processes within their organisation and to suggest possible improvements. We also reference supporting documents and guidance that will support boards in developing comprehensive governance arrangements under each of the framework headings. At the end of every chapter is a Further Reading' section that will provide links and further information to references made within the text. This guide is not intended to be prescriptive and not all elements will be applicable to all providers. The guide is structured so that boards can find further information on the specific development needs appropriate to their own organisation.

Chapter 2 Strategy

1. Does quality drive your trust's strategy?

Do you look to identify on a regular basis how quality drives your overall trust strategy? Do you have in place systematic processes to create a strategy that the whole trust, from CEO to receptionist and from medical/nursing director to care assistant can sign up to? Once identified, are these processes working? This might include processes such as:

• Dialogue with commissioners on possible changes to patient pathways and on the ways in which providers can contribute, e.g. developing outreach services to bring care closer to patients (1)

• More generally, the full involvement of patients, the local community, commissioners and staff to help identify the major strategic choices facing the organisation and to determine the way forward (2)

• An analysis of the organisation's performance on key quality indicators, benchmarked against national/international comparisons and against the

organisation's improvement performance over time, leading to the identification of possible priorities for quality improvement (2)

• Ongoing review of clinical developments, (e.g. NICE guidance (3)), and national guidance, (e.g. guidance from Royal Colleges), in order to determine which to adopt and how quickly

• Assessing the implications for workforce of the strategy and building this into detailed workforce planning

• Clear processes and clearly defined responsibilities for putting strategy into action, including devising indicators to monitor progress in implementation

Is your strategy clear, periodically reviewed and refreshed as opportunities/challenges change and seen as a living document that is continuously monitored by the board?

Do you work to ensure that your quality goals are consistently consulted on and are effectively communicated across your trust and community? For example, boards must:

• Utilise and engage with Quality Accounts (4)

• Actively communicate specific board decisions

• Actively disseminate quality goals (5)

Do you track your ongoing quality performance and work to drive up improvement relative to your quality goals where necessary? This can be achieved by:

• Designing a quality dashboard for your board which picks up the main aspects of quality relevant to your strategy

• Ensuring there are more detailed sets of ward to board quality indicators at lower levels with clear procedures for escalating to the board

2. Are you aware of the potential risks to quality at your organisation?

Do you look to monitor and understand current and future risks to quality and take steps to address these? This should involve:

• Maintaining oversight of risks to compliance with essential standards of quality and safety (as set out in CQC's guidance about compliance) (7)

• Regular review of risk estimates contained in CQC Quality and Risk Profiles and taking further action to pinpoint underlying issues (8)

• Reviewing ongoing performance in national clinical audits, clinical registries, clinical services accreditation schemes and related national quality improvement initiatives that provide data that permit comparison with other providers

• Assuring yourself against these so that minimum common standards will not be compromised

• Reviewing incidents from within the trust and wider NHS, including safety alert notices and other publications from the NPSA,(9) to identify similarities

or areas for organisation learning

• Reviewing the learning from complaints (upheld and nonupheld) following a Health Service Ombudsman investigation where recommendations have been made for systemic improvements

• Act on learning from HM Coroner's Inquest and specifically on Rule 43 decision

Do you use appropriate risk assessment tools and engage in appropriate formal processes to assess potential impacts on quality and safety? An example of a risk template can be found below. (11)

Do you look to monitor the impact of financial and operational initiatives at your organisation? This should involve using quality indicators as an early warning indicator or temperature check' for your organisation. More information on temperature checking can be found in Maintaining and Improving Quality during the Transition (paragraph 3.24) which has been published alongside this report.

(6) Bradford Teaching Hospitals NHS Foundation Trust http://www.bradfordhospitals.nhs.uk/aboutus/annual report/Bradford%20Teaching%20Hospitals%20Quality%20Report.pdf

8. CQC. Essential Standards of quality and safety http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and _safety_March_2010_FINAL.pdf
9. CQC: How to use your Quality and Risk Profiles http://www.cqc.org.uk/_db/_documents/20100921_QRP_v1_NHS_How_to_U se_Guidance_FINAL.pdf
10. NPSA: Safety Alerts http://www.nrls.npsa.nhs.uk/resources/type/alerts/
11. Example of a risk template www.uhcw.nhs.uk/clientfiles/File/CIP_Quality_Assessment.pdf

Chapter 3

Capabilities and culture

1. Do you the board have the necessary leadership, skills, and knowledge to maintain and improve the quality of all clinical services?

Do you know whether you are seeing the full quality picture at your organisation? Are the indicators presented comprehensive or are there gaps? Do you know what should be included and reported on as a minimum data set?

Do you understand your quality data? How do you use the data to ensure that quality performance is subject to rigorous board challenge on a consistent basis? This might include:

• Regularly challenging any unexpected trends or outliers in the main "dashboard" indicators and Quality and Risk Profiles

• Undertaking a regular cycle of review of more detailed indicators in specific clinical areas

• Requiring exception reporting of lowerlevel indicators where they give rise to concern, with clear cut principles for escalation

• On occasion, closely investigating particular clinical areas

• Carrying out leadership/patient survey visits to clinical areas

Does your board comprise the appropriate mix of skills and capabilities in relation to delivering good quality governance? Do you have skills among your nonexecutive directors in the following areas:

• Clinical skills

• Public health skills

• Health economics

• Systems analysis

• Risk management

• Education, financial management, human resources and workforce, organisational change and research

• Stakeholder engagement

• Continuous quality improvement

• Skills across the health and social care continuum, creating a link between the NHS, Public Health and Social Care.

Do you have a systematic process to assess the training needs of new and existing board members and provide access to training as needed? You should consider:

• Availability and relevance of short courses and training needs

• Induction and support for new board members

• Appropriate support and materials in accessible formats for nonexecutive directors (1)

2. Do you promote a qualityfocused culture throughout your trust?

Do you take an active leadership role on quality? This might include:

• An organisational vision and set of values

• Structured walk rounds by board members

• Visible board leadership of specific quality initiatives

• Positive feedback to staff

• The integration of a range of patient feedback into key performance indicators

• Building quality objectives and impact statements into all business development plans (2)

• Taking a structured approach across the organisation to raising awareness of what is required to achieve compliance with essential standards of safety and quality and to embed this with staff

Does your organisation take proactive steps to listen to patients and involve them in all aspects of service monitoring and design? This might include:

• Regularly reviewing the results of patient and staff feedback

• Ensuring that an item on patient feedback, including a patient story (complaints and commendations), is taken at an early stage in each board meeting

• Giving specific responsibility to one nonexecutive director for overseeing the operation of the complaints system and ensuring that all board members review a sample of complaints each year

• Ensuring that all patients who give detailed feedback on their experience receive a summary of the actions made as a result

• Referring back all proposals for service redesign which do not have evidence of patient involvement

• Ensuring a mixed methodology approach to patient engagement (3)

• Ensuring patients are told when things go wrong, and receive an apology and proper redress, if applicable (4)

Is there a strong culture of reporting and learning from evidence at your organisation using both quantitative and qualitative methods evidenced by an increase in incident reporting and learning? This might include:

• Well signposted systems for staff concerns/patient complaints (5)

• Selfcompletion postal surveys, e.g. national patient (and staff) surveys

• Interview – administered telephone surveys

• Online ratings sites

• Online surveys (web or email)

• Surveys using handheld devices (onsite)

• Exit cards and discharge surveys

• Routine administrative data, e.g. the Secondary Users Survey (SUS) and Mental Health Minimum Dataset

• Complaints handled in line with the Ombudsman's Principles (6)

• Remedies for justified complaints e.g. acknowledgements, apologies, explanations, financial remedies and system improvements (7)

• Letters and compliments

• Face to face interviews

• Focus groups

• Comments cards and suggestion boxes (on site)

• Mystery shopping and observation

• Patient stories and diaries

• Customer journey mapping (8)

Do you effectively communicate your quality success, (and failures), across your organisation? This might include:

• The publication of high level indicators of performance against your organisation's strategy

• Systematic publication of lower level indicators at clinical team/ward level(9)

• Regular publication of reports to the board on the results of internal clinical audits (10), and analysis of patients safety incidents (11) and the action taken

• Regular publication of reports to the Board on the number/type of complaints, including detailed analyses of any areas where a rise or particularly high rate of complaints has been experienced, the number referred to the Ombudsman, the number that were upheld and any individual and systemic remedies provided

• Using the learning from complaints in staff induction and training, including the importance of good complaints handling in all staff inductions

9. DH. Essence of Care. DH. 2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en /@ps/documents/digitalasset/dh_119978.pdf
10. HQIP. Clinical Audit. A simple guide for NHS Boards and partners. 2010. http://www.hqip.org.uk/assets/DevTeamandNJRUploads/HQIPNHS BoardsClinicalAuditSimpleGuideonline1.pdf
11. NPSA. Root Cause Analysis (RCA) Investigation tools and guidance. 2010. http://www.nelm.nhs.uk/en/NeLMArea/News/2010August/23/NPSA RootCauseAnalysisRCAinvestigationtoolsandguidance/

Chapter 4

Processes and structures

1. Does your trust have clear roles and responsibilities in relation to quality governance?

Do your board members understand and acknowledge their ultimate accountability for quality and the responsibility for delivering quality performance that must be cascaded from board to ward'? Are you satisfied that:

• The responsibilities of different levels of management are clearly defined

• Relevant processes and structures to support this are in place

• Reward systems are aligned with the recognised accountabilities

• Quality receives effective coverage both in board meetings and in relevant committees/subcommittees below and at board level.

• All board members recognise that they are accountable jointly and severally for all aspects of governance

2. Do you have clearly defined, wellunderstood processes for identifying opportunities for quality improvement, for identifying potential risks to quality, and for escalating and resolving issues?

Does your organisation make effective use of the following processes to identify opportunities for quality improvement? Can you point to examples in which these processes have resulted in demonstrable improvements?

• Clinical audits, including participation in relevant national audits and registries (1)

• Clinical services accreditation schemes and other professionally led national quality improvement programmes

• Annual professional appraisals and CPD (2)

• Analysis of quality indicators, in particular outlier analysis

• Regular reviews of compliance with essential standards supported by Quality Risk Profiles (QRPs)

• Risk assessment and proactive risk management (3)

• Use of information from errors and nearmisses including root cause analysis (4)

• Use of information from complaints and concerns (5) , (6), (7)

• Other ways of capturing proposals for quality improvement from staff or from patients (8)

• Management of poor performance including reskilling, remediation and rehabilitation (9)

Does your organisation also make effective use of continuous improvement approaches? Can you point to examples? This might include the use of:

• Business process reengineering

• Collaboratives

• Lean methodology(10)

• Plan, Do, Study, Act cycles (PDSA)

• Six Sigma (11)

• Statistical process control

• Total Quality Management (TQM) (12)

It is important to remember that a coherent narrative around why you are launching a project and what became of a previous one is vital. Boards should look to encourage quality improvement approaches but ensure staff are not overwhelmed. It is important to see through and complete on ongoing projects and to explain to staff the value and linkage between projects and the overall strategy.