The Francis report and its aftermath. Conor Davidson. Compassion. Candour. Culture. Training. Leadership. Assurance. 2001. First Annual Dr Foster guide shows that Stafford Hospital had a higher than expected HSMR at 108. 2006.
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The Francis report and its aftermath
First Annual Dr Foster guide shows that Stafford Hospital had a higher than expected HSMR at 108.
Reports in the local press that hospital is in a ‘squalid state’ (after visit by Terence Deighton)
CHAOS KILLS UP TO 1200 IN ONE HOSPITAL
"an atmosphere of fear of adverse repercussions"
"forceful style of management"
"pressure to meet targets"
"systemic failure of the provision of good care"
"too few staff, or staff not sufficiently qualified to cope"
"incontinent patients left in degrading conditions"
"injury and loss of dignity, often in the final days of their lives"
"constant strain of financial difficulties"
"isolation from the wider NHS community"
"lacked effective clinical governance"
Core values and fundamental standards**Aptitude test* Nurse training include 'at least 3 months' hands on care**Named nurses for patients**Regulation of Healthcare Support WorkersConsider creating role of registered older people's nurse*NICE to recommend staffing levels** (but note Keogh on reported vs actual staffing levels)
Financial problems since 2003/04 Bullying management cultureBoard focused on achieving foundation trust statusIll thought-through staff cuts and service reconfigurationsDysfunctional consultant body
'Fit & Proper' person test for directors**Leadership college*System of accreditation/training for leadership posts*DoH should do impact assessments before any structural change of the healthcare system*
whether a complaint has been made or a question asked about it.
Disregarded criticismIneffectual complaints systemIsolated from wider NHSNo support for whistleblowersHigh HSMR blamed on coding errorFalsified records in A&E
More effective NHS complaints system**Statutory 'duty of candour' - to patients, public and regulators*Gagging clauses should be banned**Regulators should share information**Common information practices**Real time effective accessible data**
At Mid Staffs:
Poorly developed audit/clinical governance systemsBoard unaware of situation on the groundIgnoring indicators of poor performanceFailure of regulatory system
Fundamental/enhanced standards*Clear metrics on quality** (Note Keogh on mortality ratios)
Fundamental standards should be rigorously enforced and to cause death or serious harm to a patient by noncompliance should be criminal offence**Single regulatorBeefed up commissioners*Note role of medical training in assurance
Early warning signs - shabby & dirty environment, unsmiling staff who were distracted by mobile phones, didn't answer buzzers promptly, didn't pick up litterIsolated 'timewarp'Toleration of mediocrity'Keep your head down'BullyingIsolated 'Systems business' put over patients business
All of them!Focus on 'culture of caring''Cultural barometer'Vague points about values, teamwork, post discharge careFrustration at political interference in NHSSchwarz roundsCan cultural change be achieved through top down recommendations?
“In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.”
Placing the quality of patient care, especially patient safety, above all other aims.
Engaging, empowering, and hearing patients and carers throughout the entire system and at all times.
Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.
Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.