quality and performance review visit the queen elizabeth hospital king’s … · ·...

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Quality and Performance Review Visit

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Thursday 1 May 2014

Visit Report

Contents

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

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

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

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

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

Areas of Immediate Concern .......................................................................................................................... 4

Areas of Significant Concern ........................................................................................................................... 4

Areas of Recognised Improvement/Strengths ............................................................................................... 6

Areas for Development ................................................................................................................................... 6

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

Conditions ........................................................................................................................................................... 7

Recommendations .............................................................................................................................................. 8

Decision of HEEoE Directorate of Education and Quality Review ...................................................................... 9

Appendix 1: GMC Domains and Standards ....................................................................................................... 10

Appendix 2: Key Performance Indicators (KPIs)/Standards .............................................................................. 10

Appendix 3: Quality Matrix ............................................................................................................................... 11

Appendix 4: Existing Reference Documents Prior to and During Visit ............................................................. 12

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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 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust on 1

st May 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 Professor Simon Gregory: Director of Education & Quality and Postgraduate Dean Dr Jonathan Waller: Head of Education & Quality and Deputy Postgraduate Dean (Quality Improvement) Dr Alys Burns (Lead 2): Head of Education & Quality and Deputy Postgraduate Dean Professor John Howard: Head of Education & Quality and Deputy Postgraduate Dean Chris Birbeck (Lead 3): Head of Quality Improvement Susan Agger (Lead 1): Senior Quality Improvement Manager Sally Judges: Professional Advisor – Allied Health Professions (AHPs) Judy Croot (Lead 5): Professional Advisor – Health Sciences Dr Jane McDougall: Head of School of O & G Dr Johnson Samuel: Clinical Tutor, Basildon & Thurrock University Hospitals NHS Foundation Trust Rosie Doy: Associate Dean for Learning, Teaching and Employability, University of East Anglia Prof Richard Holland: Medical School Representative, Norwich Medical School (observing) Dr Barbara Lloyd: Professional Advisor for Life Sciences, CUHFT (observing) Chris Sykes (Lead 4): Education Development Manager, Norfolk & Suffolk Workforce Partnership Gabi Trojan: Quality and Performance Lead, Norfolk & Suffolk Workforce Partnership Mavis Spencer: Deputy Director of Nursing, East Anglia Area Team Brenda Purkiss: Lay Representative Liz Houghton: Lay Representative Dr Maria Cooke: Trainee Representative Beth Purser: Student Representative Agnès Donoughue: Quality Coordinator

Trust Team Manjit Obhrai: Chief Executive Dr Mark Blunt: Medical Director Mark Vaughan: HR Director Jeannette Richardson: Medical Staffing Manager Catherine Morgan: Director of Nursing, Quality and Patient Safety Dr Andrew Douds: Clinical Director for Medical Education Adele Abbott: Non-Medical Clinical Tutor / Educational Lead Val Newton: Deputy Director of Nursing Lorraine Wellard: Workforce Development and Education Manager Mr Harald Bausbacher: Foundation Training Programme Director Dr Pradip Sarda: Specialty College Tutor – Medicine Mr Nam Tong: Specialty College Tutor – Emergency Medicine Ms Anna Arya: Specialty College Tutor – O&G Dr Glynis Rewitzky: Specialty College Tutor – Paediatrics Mr Anil Chakrabarti: Specialty College Tutor – Orthopaedics Mr Jonathan Easterbrook: Specialty College Tutor – Surgery Dr Sudarshana Gururajarao: Specialty College Tutor – Anaesthetics Dr Sue Wilde: Specialty College Tutor – Radiology Dr Richard Musson: GPST Programme Director Dr Leena Deol: GPST Programme Director Dr Sharon Richardson: SAS Tutor Heather Slater: Medical Education Administrator

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Visit Findings

Domain/KPI/Standard Notable Practice

GMC Domain 6 Support and development of trainees, trainers and local faculty 3.1 Trainee Engagement. The Trust has engaged trainees in the

development of, and participation in, the new Trust governance structures. Trainee representatives are invited to be members of the appropriate Trust Committees within this structure.

AHP Learning 3.2 There were examples of excellent practice in AHP learning identified, such as in Radiography.

Domain/KPI/Standard Areas of Immediate Concern

GMC Domain 1 Patient Safety 4.1 Patient tracking. There was a trainee report of a significant incident in

this area. This issue has been reported to the GMC as a possible “Cause for “Concern”.

4.2 There was a trainee report regarding a possible incident of

unprofessional behaviour on the Cardiology / Care of the Elderly Ward.

KPI 2 Learning Environment 4.3 Information governance. Issues were reported around information

governance and nursing students having to use other people’s password access details to log in.

All of the above were raised with the Chief Executive and Medical Director as concerns requiring immediate attention on the day of the visit.

Domain/KPI/Standard Areas of Significant Concern

GMC Domain 1/KPI 3 Patient Safety 5.1 Patient Tracking 5.1.0 Despite the reported introduction of a new electronic patient tracking

system, trainees continued to report issues in its delivery, particularly in Medicine. Educators also reported that they had reservations about the new system.

5.1.1 The student nurses reported that they were mostly unaware of patient tracking processes.

5.2 Supervision 5.2.0 Within some medical specialties, concern was expressed by trainees

that junior trainees (often at F1 level) were managing large numbers of complex patients with inadequate numbers of middle grade support.

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5.2.1 Middle grade trainees in O&G reported variable availability of consultant supervision on the delivery unit.

5.2.2 The Trust’s reliance on external support to maintain adequate

provision of mentorship for student nurses continues. However, there is concern that should this support be removed the Trust doesn’t have capacity to sustain the improvements.

5.3 Induction 5.3.0 Trust induction. Issues were reported with ensuring that trainees

starting out of phase had timely access to the IT resources needed for patient care.

5.3.1 It was reported that there is not a consistent approach with regard to

the delivery and content of departmental induction across all units. 5.4 Staffing 5.4.0 Staffing gaps are difficult to fill, leaving trainees unsupported on some

wards, especially in medicine.

GMC Domain 3 Equality, Diversity and Opportunity 5.5 The Trust has not achieved the target of 100% compliance with

Equality & Diversity, and Safeguarding Vulnerable Adults and Children Training for Supervisors.

GMC Domain 6/KPI 4 Support and development of trainees, trainers and local faculty 5.6 It was reported that no educational supervisor training had been

provided in the past year. 5.7 It was noted that current workload pressures are impinging to such an

extent that “Sign off Mentors” are not able to meet the NMC requirements of one hour a week dedicated time with their students and often have to use their own time to undertake the formal assessments of their students.

5.8 The administration of the medical rota remains a problem. However, it

is understood that a new Rota Coordinator has recently been appointed to address this area of concern.

5.9 It was reported by the Mentors that there is a lack of funding for, and

access to, study days / development opportunities; in particular, attendance at good quality external / independent courses / programmes is difficult.

5.10 It was reported by Trainers that the job planning process does not lead

to adequate recognition of SPA time for the role of educational supervision. Likewise, the process does not recognise time spent for clinical supervision. In addition, service pressures are also making identification of time for training increasingly difficult for consultants.

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GMC Domain 7/KPI 1 Management of Education and Training 5.11 The recent introduction of new Governance structures for education

and training needs time to embed and appropriate monitoring systems need to be in place to check sustainability. The proposals for Board level engagement and assurance processes need clarity.

5.12 A consistent approach to formal engagement with UEA regarding

clinical placements of nursing and midwifery should be sought.

KPI 3 Quality of Care 5.13 Breaches of confidentiality in nursing handovers were reported. Some

are carried out at the end of the bays where, potentially, all patients in the bay can hear what is being said.

Domain/KPI/Standard Areas of Recognised Improvement/Strengths

GMC Domain 1 6.1 Trainees reported that handover is good and well organised, usually held in separate rooms away from clinical practice

6.2 The trainees felt that consultants are approachable and that

educational supervision is in place and working well. They are able to get their workplace-based assessments completed.

6.3 The clinical teaching environment in the MAU has significantly

improved including feedback to the individual trainee when they have been involved in an SI and there is good consultant cover until 10pm.

GMC Domain 6 6.4 Trainees felt that overall their experience was good across most specialties, with GP ITU, Paediatrics and Surgery particularly highlighted.

KPI 2 6.5 The Trust has recognised the need to map all of the learners in order to develop a clear strategy for managing the demands of a wide range of learners against their registered and capable practitioners.

6.6 Several students commended their clinical learning environments on

the support and quality of experience they received (in particular midwifery, day surgery).

GMC Domain 8 6.7 Trainees felt that the postgraduate centre staff are supportive.

Domain/KPI/Standard Areas for Development

GMC Domain 1/KPI 3 Patient Safety 7.1 There was a cultural issue in one particular area regarding Health Care

Assistants (HCAs) reportedly behaving inappropriately at times towards nursing students. HCAs were using students to support their workload without cognisance of their particular learning needs or student status. There were also examples where the NHS values were not being modelled by these HCAs.

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7.2 Workload pressures, especially in the MAU at night, could be alleviated by the provision of the AHPs/Physician’s Assistants model adopted in the Surgery Assessment Unit (SAU) and by the better use of non-medical staff undertaking routine jobs, for example, taking blood samples.

GMC Domain 3 Equality, diversity and opportunity 7.3 It is felt that the integration of Values and Behaviours in the Trust

needs further work, particularly for non-medical staff, most notably HCAs.

GMC Domain 5/KPI 4 Delivery of approved curriculum including assessment 7.4 It was reported that access to, and delivery of, the protected local

teaching programme for Foundation trainees was haphazard, with the sessions often being cancelled without any clear explanation as to why.

7.5 It was reported that 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.

GMC Domain 6/KPI 4 Support and development of trainees, trainers and local faculty 7.6 The majority of trainees met were not aware that there was a

consultant with the designated role of Careers Advisor within the Trust.

GMC Domain 8 Educational Resources and Capacity 8.1 IT systems were reported to be of poor quality and that there was

limited access to rooms for teaching purposes within the Trust generally.

8.2 Accommodation issues for AHPs, nurses and medical students and FY

students.

Domain/KPI/Standard Areas Requiring Further Investigation

GMC Domains 6/7 9.1 HEEoE would like evidence of the process for the escalation of SIs to HEEoE’s Responsible Officer.

Healthcare Scientist Learning

9.2 The Trust is asked to investigate the reported service workload issue on Trainee Pharmacists.

Domain/KPI/Standard Conditions

GMC Domain 1/KPI 3 10.1 The implementation of the electronic patient tracking system continues to cause concern. The Trust must investigate the reported lapses of patient tracking and provide an update demonstrating that the system is working effectively by 30 September 2014. In view of the longevity of this concern, consideration would need to be given in withdrawal of trainees and/or students if this is not achieved. [domain

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1/KPI 3] (4 months). 10.2 Within some medical specialties, concern was expressed by trainees

that junior trainees (often at F1 level) were managing large numbers of complex patients with inadequate numbers of middle grade support. [domain 1] (4 months).

10.3 Breaches of patient confidentiality were reported including examples

of nursing handovers undertaken at the end of bays. This is a serious matter and must cease with immediate effect. Written assurance is required from the Chief Executive to confirm that this condition has been met. [KPI 3] (immediate concern).

GMC Domain 3 10.4 The current levels of E&D training for Education Supervisors and Clinical Supervisors remain below the required level. This should be 100%. [domain 3] (3 months).

GMC Domain 6/KPI 4 10.5 It was reported that there had been lack of educational supervisor training for the last 12 months. The Trust is required to demonstrate that all current educational supervisors have been trained to meet the requirements of the GMC for recognition of educational supervisors according to the Academy of Medical Educators [AoME] standards [domain 6/KPI 4] (3 months).

10.6 The Nursing and Midwifery Council (NMC) requirement that “Sign off

Mentors” have one hour protected time per week with their students must be applied. [domain 6/ KPI 4] (3 months).

GMC Domain 7/KPI 1 10.7 Evidence is required that full implementation of the new Governance structures for education and training have been embedded and Board engagement has been achieved [domain 7/ KPI 1] (6 months).

GMC Domain 8/KPI 2 10.8 The accessibility to the IT systems was found to be of poor quality. In particular, the use by student nurses of other people’s password access details to log in to the computer system was reported. This is a serious breach information governance and must cease with immediate effect. Written assurance is required from the Chief Executive to confirm that this condition has been met. [domain 8/ KPI 2] (immediate concern).

Domain/KPI/Standard Recommendations

GMC Domain 6 11.1 The Trust is advised to adopt the 0.25 PAs for educational supervisors in line with the recognised national standard.

KPI 2 11.2 It is proposed that the funding and access to study days/development for Mentors (Practice Educators) is reviewed.

11.3 The Trust is encouraged to develop a formal approach to clinical

placements of nursing and midwifery students with UEA.

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Decision of HEEoE Directorate of Education and Quality Review

With regard to the provision of postgraduate medical education and training, The Queen Elizabeth Hospital King’s Lynn NHS Foundation 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:

An action (improvement) plan is required by 30 June 2014 including confirmation of completion of actions on the immediate conditions. A formal update on the action (improvement) plan is required by 30 September 2014 unless otherwise stated under the conditions section above.

Next QPR Visit:

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

Professor Simon Gregory Director of Education and Quality and Postgraduate Dean

Date: 29th

May 2014

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Appendix 1: GMC Domains and Standards

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.

Appendix 2: Key Performance Indicators (KPIs)/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.

KPI Four – Student Support / Education / Assessment

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

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KPI Five – MPET Investment

Provider organisations demonstrate effective utilisation of the Multi-Professional Education and Training Levy (MPET) investment.

Date: April 2014

Group Category Metric Measure Data Source Goal (3) Amber (2) Red (0/1)

Green Amber Red

Induction Hospital Induction % of trainees participating LEP records 100%

Departmental Induction % of trainees participating LEP records 95%

Induction content covers all key areas % of inductions judged satisfactory (1) LEP records 100%

Working Patterns EWTR Compliance of rotas as published % of rotas compliant LEP report 100%

EWTR Compliance of rotas as monitored % of rotas compliant LEP report 100%

Rota supports delivery of curriculum % of rotas educationally satisfactory (2) LEP records 100%

Handover well organised and supervised % of trainees reporting positively Trainee survey

Feedback Trainee survey response rate % of all trainees responding HEEoE 100%

Outcome Unsatisfactory ARCP outcomes % ARCP 5 HEEoE

Educational Supervisors

Appropriately prepared % trained

LEP records 95%

Appropriately selected % selected against defined criteria LEP records 92%

Appropriately approved/reviewed % reviewed/appraised

LEP records

Appropriately prepared % trained LEP records 95%

Trained in equality and diversity % trained

LEP records 88%

Trained in workplace based assessments % trained LEP report 95%

Trained to appropriate level in safeguarding children and

vulnerable adults

% trained

LEP records 70%

Clinical Supervisors Appropriately prepared % trained LEP records 89%

Appropriately selected % selected LEP records

Appropriately reviewed % reviewed/appraised LEP records

Appropriately prepared % trained LEP records 89%

Trained in equality and diversity % trained LEP records 86%

Trained in workplace based assessments % trained LEP report 87%

Trained to appropriate level in safeguarding children and

vulnerable adults

% trained LEP records 62%

Governance Board member with responsibility for PGMET Identifiable LEP records Yes

Evidence of Board discussion of PGMET (3) Minuted discussion every meeting/identifiable LEP records Yes

Supervision Sufficient time allocated for educational supervision

* 0.125 PA/trainee/week/ consultant %

LEP records Yes

Curriculum Delivery Mapped service provision against curriculum Completed LEP report Yes

Teaching Protected teaching time provided % Yes Trainee survey

Protected teaching time accessible % Yes Trainee survey

How many hours/week on average protected time Number of hours (4) Trainee survey

Trai

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Trust:Queen Elizabeth Hospital Kings Lynn

Quality Metrics Dashboard Against LDA Requirements

Self assessment RAG Status

Trai

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Appendix 3: Quality Matrix

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Appendix 4: Existing Reference Documents Prior to and During Visit

Learning and Development Agreement 2013/14 HEEoE Trust Quality Report 2013 HEEoE Quality Summary Report 2014 PQAF Action Plan 2014 PQAF Pre- and Post-Registration Surveys 2013/14 Healthcare Scientists, Pharmacy and AHPs Documentation Visit Reports and Trust Action Plans relating to: Deanery Performance and Quality Review 2011 School of Anaesthesia Visit 2014 School of Dentistry Visit 2010 School of Emergency Medicine 2014 and 2011 Foundation School Visit 2013 School of General Practice Visit 2013 School of Medicine Visits 2014 and 2013 School of Obstetrics and Gynaecology Visit 2012 and 2014 School of Paediatrics Visit 2011 School of Surgery Visit 2013 GMC Survey: GMC Survey Results 2009/2013 GMC Patient Safety Concerns 2013 and Trust Responses GMC Free Text Comments 2013 and Trust Responses QM3 Clinical Tutor/DME’s Report 2014 Quality Metrics Dashboard 2014 Public Trust Board Minutes 2013/2014 CQC Reports 2013/14 List of SIs 2013/14