quality and performance review visit west hertfordshire hospitals nhs trust thursday · pdf...

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Quality and Performance Review Visit

West Hertfordshire Hospitals NHS Trust Thursday 6th November 2014

Visit Report

Contents

Introduction .................................................................................................................................................... 2

Purpose of the Visit ............................................................................................................................................ 2

Teams ................................................................................................................................................................. 3

Visit Findings ....................................................................................................................................................... 4

Notable Practice ............................................................................................................................................. 4

Areas of Recognised Improvement ................................................................................................................ 4

Areas for Development ................................................................................................................................... 5

Areas of Immediate Concern .......................................................................................................................... 6

Areas of Significant Concern ........................................................................................................................... 6

Areas Requiring Further Investigation ............................................................................................................ 7

Conditions ....................................................................................................................................................... 9

Recommendations ....................................................................................................................................... 10

Decision of HEEoE Directorate of Education and Quality Review .................................................................... 11

Appendix 1: GMC Domains and Standards ....................................................................................................... 13

Appendix 2: Key Performance Indicators (KPIs)/Standards .............................................................................. 13

Appendix 3: Quality Matrix ............................................................................................................................... 14

Appendix 4: Existing Reference Documents Prior to and During Visit .......................................... 15

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Introduction 1.1 Health Education East of England (HEEoE) commissions and quality manages postgraduate medical,

dental and healthcare education on behalf of Health Education England. It does so within the

Corporate and Educational Governance systems of Health Education England and to the standards

and requirements of the General Medical Council (GMC), General Dental Council (GDC), the Nursing

and Midwifery Council (NMC) and other allied healthcare education regulators and requirements.

These processes are outlined in Health Education East of England’s Quality Improvement and

Performance Framework (QIPF).

1.2 As part of the development and implementation of the Quality Improvement and Performance

Framework, HEEoE seeks to ensure that, where possible, we align quality improvement processes to

ensure that the quality of our education and training within our employer organisations and our

education providers is continually improved. The HEEoE Quality and Performance Reviews are a key

part of this developing process.

1.3 Quality management uses information from many and varied sources that triangulate evidence

against standards of the quality of education and training within local education providers and across

the east of England. These sources include student, trainee and trainer surveys, the Quality

Improvement and Performance Framework (QIPF), panel feedback (e.g. ARCP panels), hospital and

public health data (e.g. HSMR), visits by specialty colleagues (“School Visits”) and Quality and

Performance Reviews (formerly known as Deanery Performance and Quality Reviews) that may be

planned or triggered by concerns or events.

1.4 Whilst Health Education East of England’s Quality Management processes incorporate information

from many sources, it is explicit that the primary purpose of the Quality and Performance Review is

the quality management of non-medical, medical and dental education and training. The visit is not

designed to, nor capable of, providing a thorough assessment of the quality care provision. Moreover,

if concerns are identified, these are passed on to those responsible and where appropriate shared

through Quality Surveillance Groups or with regulators.

1.5 This report is of a planned Quality and Performance Review assessing non-medical and medical

education and training in the provider, and is not a response to any concerns.

1.6 This report is based on sampling via surveys and visits and is not therefore exhaustive. The findings

are provided with the caveat that any further conclusions that are drawn and action taken in response

to those conclusions may require further assessment.

This report summarises the findings and recommendations of the “Quality and Performance Review” to West

Hertfordshire Hospitals NHS Trust on 6th

November 2014 in line with Health Education East of England’s Quality

Improvement and Performance Framework.

Purpose of the Visit 2.1 The purpose of the visit is the review of the Trust’s performance against the Learning and

Development Agreement including the GMC and Non-Medical Commissioned Programmes standards. Through the review and triangulation of the evidence gathered through Health Education East of England’s Quality Improvement and Performance Framework (QIPF), the visit will seek to explore key lines of enquiry where further assurance is needed and to celebrate good practice. The visit is multi-professional, reflecting the whole workforce and the clinical learning environments that the Trust provides for all professions and specialties.

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Teams Visiting Team Dr Jonathan Waller, Deputy Postgraduate Dean

Dr Alys Burns, Deputy Postgraduate Dean Professor John Howard, Postgraduate GP Dean and Deputy Postgraduate Dean Chris Birbeck, Head of Quality Improvement Susan Agger, Senior Quality Improvement Manager Sally Judges, Professional Advisor – Allied Health Professions Dr Barbara Lloyd, Professional Advisor for Life Sciences, Cambridge University Hospitals Gareth George, Head of Beds & Herts Workforce Partnership Alan Makepeace, Education Lead, Beds & Herts Workforce Partnership Emma Heslin, Clinical Learning Environment Lead, Beds & Herts Workforce Partnership (observing) Dr Ian Barton, Head of School of Medicine Dr Timothy Howes, Director of Medical Education, Colchester Hospital Alan Randle, Associate Dean - Academic Quality Assurance, University of Hertfordshire Dr Barbara Burden, Lead Midwife for Education, University of Bedfordshire Heather Moulder, Director of Nursing and Quality, Herts & South Midlands Area Team Carol Kelsall, Lay Representative Liz Houghton, Lay Representative Dr Maria Cooke, Trainee Representative Verity Penner, Student Representative, University of Hertfordshire Agnès Donoughue, Quality Co-ordinator

Trust Team Samantha Jones, Chief Executive Lynn Hill, Deputy Chief Executive Dr Michael Van der Watt, Medical Director Mr Paul Da Gama, Director of Workforce Tracey Carter, Director of Nursing Tracy Moran, Deputy Director of Nursing Dr Ratna Makker, Clinical Tutor and Foundation Training Programme Director/Acting DME Dr Arla Ogilvie, Deputy Clinical Tutor Mrs Rhonda Fusco, Non-Medical Clinical Tutor/Education Lead Ms Ros Bund, Medical Personnel Manager Jane Barrett, Head of Training and Development Dr Zelma Hall, Foundation Training Programme Director (F1) Dr Jeremy Chase, Foundation Training Programme Director (F2) Dr Thomas Galliford, Undergraduate Tutor Dr Pauline Foreman, GPST Programme Director Dr Sachin Navarange, SAS Tutor Kim Hull, Medical Education Manager Mr Michael Menezes, RCOG College Tutor Dr Chantal Kong, RCP Tutor Dr Mamatha Kumar, RCOA Tutor Dr Pradnya Sheth, RCPCH Tutor Mr Jeremy Read, Consultant T&O (representing College Tutor) Ms Faye Barampouti, College Tutor – Ophthalmology - tbc Dr Prema Singh, College Tutor – Microbiology – tbc

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Domain/KPI/Standard Notable Practice GMC Domain 5

Delivery of approved curriculum including assessment 3.1 HEEoE considers that the year on year improvements across most

domains tested within the GMC NTS survey 2012 - 2014 represent a considerable achievement by the Trust’s Faculty of Medical Educators despite the many recognised challenges in the area of service provision which were also being addressed at the time.

3.2 There were good examples of supervision and role emergent

placements for students in Pharmacy and Physiotherapy. 3.3 Examples were given across all Allied Health Professions (AHP),

Health Care Sciences (HCS) and Pharmacy groups of good practice by mentors, tutors and practice educators in response to learners in difficulty. In addition, students were aware of the processes and confident about their implementation. Pharmacy and Physiotherapy placements were exceptionally well organised and managed.

GMC Domain 7/KPI 1 Management of education and training 3.4 HEEoE commends the Director of Medical Education, Clinical Tutor

and Postgraduate Centre staff for their engagement with HEEoE’s reporting requirements and quality management processes.

GMC Domain 8 HEEoE funded investment/Educational Resources and Capacity 3.5 The Trust is making good use of non-medical tariff to support

nursing and midwifery Practice Education Facilitator (PEF) roles and to assist with the monitoring of the nursing and midwifery mentor database.

KPI 6 Employment of students 3.6 Radiography third year students are offered honorary contracts as

supernumerary staff when placements finish and the students start their first jobs within the Trust or elsewhere. This has helped embed their practice before taking up their first posts as registered professionals.

Domain/KPI/Standard Areas of Recognised Improvement GMC Domain 1/KPI 3

Patient Safety

4.1 The implementation of the Onion project is a very welcome initiative with demonstrable patient safety gains which promotes the engagement of all staff including trainees and students in the process. It was noted however that, due to service pressures, all staff groups experienced difficulty in attending. Whist this includes

Visit Findings

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the development of a junior doctor Onion within this process to allow direct trainee feedback on any areas of concern about Trust issues, the student nurses and midwives also expressed a wish for this opportunity to be extended to other staff groups to provide the opportunity for multi-professional engagement.

4.2 The Trust has made progress in several areas with regard to addressing and developing mechanisms to deal with undermining whenever and wherever it arises.

GMC Domain 5

Delivery of approved curriculum including assessment

4.3 The training programmes in Paediatrics, Ophthalmology and General Practice have shown consistent improvement in the delivery of the requirements of their associated curricula.

GMC Domain 6/KPI 4

Support and development of trainees, trainers and local faculty

4.4 The Trust has ensured that trainees and students have been empowered through structured opportunities to raise issues of concern, to be involved in developing solutions and to receive feedback – “the trainee/student voice”.

4.5 The work of the SAS Tutor to support the development of SAS trainees through the commissioning of courses and the delivery of training in the clinical setting is welcomed.

GMC Domain 7/KPI 1 Management of education and training

4.6 Student nurses who had returned to the Trust following placements on other sites and in other trusts reported that the Trust was much better organised and that patient care had improved.

Domain/KPI/Standard Areas for Development GMC Domain 1/KPI 3

Patient Safety

5.1 Whilst the Trust has developed and implemented a commendable process for the reporting, analysis and utilisation of the learning from Serious Incidents (SIs) and from its morbidity and mortality process, which has been recognised nationally, the full and effective implementation of the dissemination of learning from SIs requires further development.

5.2 Whilst Trust and departmental induction is delivered, concerns were identified with regard to the quality, content and effectiveness of induction, particularly at departmental level for all professions. Concerns were also expressed that significant time within the PfPP programme is devoted to the delivery of mandatory training thereby reducing significantly the proportion of trainee time spent shadowing in the clinical environment.

GMC Domain 5


5.3 The trainees met reported that access to study leave opportunities was impeded by service needs, in particular the requirements of the rota.

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5.4 It was reported that the proposed PEF role is not yet in place to

support the new HCS practitioner and scientist training programme placements within the department.

GMC Domain 6/KPI 4

Support and development of trainees, trainers and local faculty 5.5 HEEoE is encouraged by the evidence of the development of

functional faculty groups particularly in paediatrics. However, this was not so apparent in other specialties.

5.6 It was reported that nurse mentors did not have sufficient capacity

for their role and that the adequate provision of training necessitated mentors fulfilling their educational role in their own time with no recognition. There were also reports of students having to use their own time including days off and annual leave to ensure assessment and sign off documents were completed.

5.7 There is good access for AHP, HCS and Pharmacy Educators to the

WHHT Leadership Academy Programme run by the University of Hertfordshire. Current arrangements for access to CPD outside of the University of Hertfordshire are poor.

5.8 The nurse mentors confirmed that there is a co-mentoring system

in place but that the model is not consistent across wards. It is suggested that clarity is provided for the co-mentoring model.

5.9 It was reported that there is variation in nurse mentor updates and

the approach taken across services, with some mentors receiving payment and others receiving time in lieu.

5.10 The Trust is encouraged to maximise student/trainee feedback and

embed this into Trust processes.

GMC Domain 7/KPI 1 Management of education and training 5.11 The supernumerary status of commissioned nursing students is an

area that requires clarity. It was reported that they can feel that they are expected to be part of ward numbers and therefore effectively expected to work as Health Care Assistants (HCAs) to meet service requirements.

Domain/KPI/Standard Areas of Immediate Concern There were no areas of immediate concern.

Domain/KPI/Standard Areas of Significant Concern GMC Domain 1/KPI 3

Patient Safety 6.1 No formal consultant-led face to face handover process could be

identified other than Friday evening in Medicine. This is

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considered to be a significant patient safety concern. The ‘e-handover’ system as currently delivered also does not address the immediate patient safety concerns regarding handover.

6.2 Whilst considerable progress has been made with the introduction

of ‘e-handover’, this process is yet to be fully embedded and realised across all sectors to which it applies. It is therefore strongly recommended that this system continues to be given the highest priority for full implementation.

6.3 The inappropriate transfer from the Acute Admissions Unit (AAU)

to the wards with no handover and bed managers apparently ignoring the RAG rating continues to be an area of significant concern.

6.4 There are significant information governance issues. In particular,

Foundation trainees reported not receiving password access on induction. Problems were also encountered regarding utilisation of Arterial Blood Gas analysers (ABGs), PAC and Radiology systems. There were reports of the use of other people’s passwords to gain access to systems. This is clearly a patient safety issue and a serious breach of information governance.

6.5 The students met reported that, when transferring patients to the

wards, they were sometimes unable to access areas due to a lack of door passes, which constitutes a risk to patient safety.

GMC Domain 6/KPI 4

Support and development of trainees, trainers and local faculty 6.6 The Trust does not currently have in place a system that provides

for the appropriate selection, training and appraisal of its educational supervisors and named clinical supervisors (e.g. for GP trainees in secondary care) to the AoME standards required by the GMC. There is a lack of clarity of supervision roles, no formal processes for the appraisal of educational supervisors and a failure to identify sessional commitment for educational supervision in job plans.

GMC Domain 7/KPI 1 Management of education and training 6.7 Whilst HEEoE recognises the considerable amount of effort that

has gone into redefining the Trust’s governance structures, we are concerned by the lack of explicit reference to education and training within the Trust “Temple” and what we perceive as a tortuous linkage between the Education Committees and the Trust Board, and from the Board back to all operational levels.

Domain/KPI/Standard Areas Requiring Further Investigation GMC Domain 1/KPI 3

Patient Safety 7.1 It was reported that, on regular occasions, patients had to be

placed overnight in the gym and/or the cardiac catheter laboratory. The Trust is required to investigate this matter and, if corroborated, take urgent action to eliminate this practice because of the inherent patient safety and dignity issues attached to this.

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7.2 Medical trainees expressed concern that at night there were

currently one registrar and two junior trainees looking after 200/300 patients overnight with the Registrar also covering resuscitation calls and other areas which in itself represents a considerable workload. They were therefore particularly troubled by reports that the Princess Michael of Kent (PMOK) Registrar may be removed. The Trust is required to investigate and urgently reassure HEEoE that this is not the case, otherwise this represents a major patient safety concern.

7.3 The trainees met reported a clustering of nights on call on the core

medical rota, three or four in a row and up to four sets in 4/5 weeks. This is a potential patient safety issue which would also impinge on the delivery of their curriculum. The Trust is asked to investigate and take action if this is corroborated.

7.4 It was reported that there is a high level of agency midwives within

Women’s Health which, if found to be the case, has significant implications for the training and continuity of mentorship of students. The Trust is required to urgently investigate this matter and to respond formally.

7.5 There were discrepancies reported between the Radiography

students and educators. HEEoE’s AHP Professional Advisor will investigate further with the Trust.

7.6 It was reported that some nursing students felt that at times they

are being left unsupervised when caring for patients. The Trust is required to investigate these reports and respond appropriately.

GMC Domain 3

Equality, Diversity and Opportunity 7.7 It was reported that there was a confidentiality breach concerning

the visibility of patient details on whiteboards in the AAU. The Trust is reminded of the need to ensure confidentiality and dignity in accordance with the Caldicott Guardian guidelines and is requested to investigate this breach.

GMC Domain 5

Delivery of approved curriculum including assessment 7.8 The reported Operating Department Practitioner (ODP)

arrangements for first year students on the St Albans site were very positive but it would appear that there are issues with the arrangements for the second year students on the Watford site. No ODP mentors attended the session with the visiting team so it was not possible to explore this matter fully. WHHT are requested to investigate this matter and provide assurance of the quality of student learning.

GMC Domain 7/KPI 1 Management of education and training 7.9 Discussion with the nursing mentors would appear to indicate that

there is a misalignment between the funded establishment and the resources made available to support student learning. Examples were given where posts have been removed, which has compromised the mentors’ ability to support students. The Trust is asked to investigate and provide evidence that the funding is being

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appropriately utilised to meet resource requirements.

Domain/KPI/Standard Conditions

GMC Domain 1/KPI 3

Patient Safety 8.1 The handover processes must be reviewed and concerns with

regard to patient safety addressed. These include the shortcomings of e-handover as currently delivered, the lack of a formal face to face handover process as reported by the trainees in Medicine other than on Friday evening, and the lack of consultant input into handover in Medicine. HEEoE will continue to closely monitor the situation and requests a copy of the latest e-handover audit that was reported to us verbally within the Trust presentations.

8.2 The Trust must ensure the transfer of patients from the AAU to the

wards includes appropriate handover. The RAG ratings applied must be adhered to by bed managers without challenges.

8.3 The use by AHPs, student nurses and foundation trainees of other

people’s password access details to log in to the computer system was reported. This is a serious breach of information governance which must cease with immediate effect.

8.4 The situation regarding the lack of door passes for students needs

to be immediately addressed to minimise the risk to patients and also to students.

8.5 The Trust must address the poor quality of its IT systems which is

having a negative impact on the delivery of education and training and is affecting patient safety via the implementation of its proposed substantial investment into IT in 2015.

GMC Domain 6/KPI 4

Support and development of trainees, trainers and local faculty 8.6 The Trust is required to provide clarity of supervisor roles and to

deliver to the GMC and AoME standards for the selection, training, appraisal and job planning of educational supervisors and named clinical supervisors (e.g. for GP trainees in secondary care) in line with the timetable for implementation set by the GMC (completion of selection, training and job planning by July 2015 in order that completion of the process through educational appraisal is delivered by July 2016). In addition, the presence of education and development needs to be more explicit in the appraisal process for Mentors.

GMC Domain 7/KPI 1 Management of education and training 8.7 The Trust must ensure that the required outcomes within the

Education Outcomes Framework and the GMC Quality Improvement Framework are fully delivered. Namely, that education and training is a routine agenda item for consideration by the Board although we were pleased to note that there is a named Non-Executive Director with meaningful responsibility for

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the governance of multi-professional education and training.

Domain/KPI/Standard Recommendations

GMC Domain 1/KPI 3

Patient Safety

9.1 Whilst there is a process for induction, the Trust must significantly

improve its delivery of universal and relevant Trust and

departmental induction. This should include a review of the PfPP

programme to maximise the opportunity for clinical shadowing and

to reduce the excessive use of this time for mandatory training.

The Trust must also improve its monitoring of AHP induction

arrangements.

GMC Domain 5


9.2 The evidence of developing functional Faculty groups is welcomed

but the Trust is urged to extend this process to cover all specialties

of a relevant size and to ensure trainee representation within all

faculty groups.

9.3 The Trust should review the rota design to maximise the training

opportunities available to junior doctors, in particular access to

study leave.

9.4 The Trust must implement the proposed PEF role in order to

support the new HCS practitioner and scientist training programme

placements within the department.

GMC Domain 6/KPI 4

Support and development of trainees, trainers and local faculty

9.5 The Trust needs to adopt the 0.25 PAs per trainee for educational

supervisors in line with the recognised national standard and in

accordance with postgraduate medical tariff.

9.6 The Trust is asked to explore the negative impact that service

pressures are having for both nursing students and mentors being

able to complete the necessary assessment and sign off

documentation. The Trust is reminded of the Nursing and

Midwifery Council (NMC) requirement that “Sign off Mentors”

must have one hour protected time per week with their students

and that this must be applied.

9.7 The Trust must improve processes for AHP, HCS and Pharmacy

educators to access CPD outside of the University of Hertfordshire.

9.8 The variation in mentor updates across the services should be re-

assessed in line with the work being undertaken across the Beds &

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Herts area by the Workforce Partnership.

9.9 The Trust is encouraged to maximise the student/trainee feedback

including surveys, and these should be embedded into Trust

processes.

GMC Domain 7/KPI 1 Management of education and training

9.10 The Trust should clarify the supernumerary status of commissioned

nursing students and ensure that they are not treated as Health

Care Assistants (HCAs).

With regard to the provision of postgraduate medical education and training, West Hertfordshire Hospitals NHS Trust has: Met with conditions the requirements of Health Education East of England under the Quality Improvement Framework (QIF) of the General Medical Council, and therefore conditional approval is given for three years subject to demonstrable, sufficient and sustained fulfilment of the requirements of the QIF and of the conditions set above. Failure to fulfil the requirements of the GMC’s QIF and its published domains and standards within the required timeframe would result in removal of trainees and could result in loss of GMC approval of the educational environment.

Timeframes:

Action Plan to be received by: A report on the areas requiring further investigation is required by 20/12/14.

An action (improvement) plan to address the conditions and recommendations highlighted in the report is required by 06/02/15.

A formal update on the action (improvement) plan is required by 06/05/15.

Next QPR Visit:

Subject to a satisfactory action plan, and unless otherwise triggered, the next full Quality Performance Review [QPR] will be in 2017.

Dr Jonathan Waller Deputy Postgraduate Dean: Date: 27

th November 2014

Decision of HEEoE Directorate of Education and Quality Review

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Domain 1 – Patient Safety

The duties, working hours and supervision of trainees must be consistent with the delivery of high-quality, safe patient care. There must be clear procedures to address immediately any concerns about patient safety arising from the training of doctors.

Domain 2 – Quality Management, review and evaluation

Specialty including GP training must be quality managed, reviewed and evaluated.

Domain 3 – Equality, diversity and opportunity

Specialty including GP training must be fair and based on principles of equality.

Domain 5 – Delivery of approved curriculum including assessment

The requirements set out in the approved curriculum must be delivered and assessed. The approved assessment system must be fit for purpose.

Domain 6 – Support and development of trainees, trainers and local faculty

Trainees must be supported to acquire the necessary skills and experience through induction, effective educational supervision, an appropriate workload, personal support and time to learn. Standards for trainers:

Trainers must provide a level of supervision appropriate to the competence and experience of the trainee.

Trainers must be involved in, and contribute to, the learning culture in with the patient care occurs.

Trainers must be supported in their role by a postgraduate medical education team and have a suitable job plan with an appropriate workload and time to develop trainees.

Trainers must understand the structure and purpose of, and their role in, the training programme of their designated trainees.

Domain 7 – Management of education and training

Education and training must be planned and maintained through transparent processes which show who is responsible at each stage.

Domain 8 – Educational resources and capacity

The educational facilities, infrastructure and leadership must be adequate to deliver the curriculum.

Domain 9 - Outcomes

The impact of the standards must be tracked against trainee outcomes and clear linkages should be reflected in developing standards.

KPI One – Education Governance

The organisation is assured that they have robust education governance in place

KPI Two – Learning Environment

The organisation provides high quality learning environments for students

KPI Three – Quality of Care

Students are adequately prepared by the provider organisation to deliver high quality care.

Appendix 1: GMC Domains and Standards

Appendix 2: Key Performance Indicators (KPIs)/Standards

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KPI Four – Student Support / Education / Assessment

Students are effectively supported, educated and assessed by the provider organisation.

KPI Five – Investment of HEEoE Commissioned Funding

Provider organisations demonstrate effective utilisation of the HEEoE commissioned funding investment.

Appendix 3: Quality Matrix

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Appendix 4: Existing Reference Documents Prior to and During Visit Learning Development Agreement – 2014/15 CQC Reports – December and October 2013; January 2012 List of SIs Trust Quality Report – August 2014 Notes of Pre-Visit Meeting with Trust – September 2014 Deanery Performance and Quality Visit Reports – October 2011 and April 2012 Action Plan Updates and Correspondence with Trust 2011/14 QIPF Self-Assessment for Employers 2014/15 QIPF Education Provider Review of Employer Organisations – October 2014 QIPF Joint Medical and Non-Medical Action Plan 2014 PQAF Surveys of Pre-Registration and Post-Registration Students – 2013/14 Healthcare Science, Pharmacy and Allied Health Professionals Documentation 2014 Quarterly Mentor Monitoring Return 2014 HEEoE Monthly Quality Summary Report – August 2014 Director of Medical Education’s Report – September 2014 Quality Metrics Dashboard – September 2014 GMC Training Survey: Training Survey Outliers 2009-14 Patient Safety Concerns 2013/14 Free Text Comments 2013/14 Visit Reports and Trust Action Plans relating to: School of Anaesthesia 2014 School of Emergency Medicine 2014 Foundation School 2014 School of General Practice 2014 School of Medicine 2013/14 School of O & G 2012/14 School of Ophthalmology 2010/14 School of Paediatrics 2013 School of Surgery 2013/14 Additional Documents Provided by the Trust: Trust Board and Committee Organisational Chart 2014 Trust Board Minutes and Agenda 2014