A ‘new wave’ of CQC inspections In response to the Francis report, the Care Quality Commission (CQC) is changing the way it inspects hospitals. Since September 2013, under the leadership of Sir Mike Richards, a new approach has been trialled with 37 acute trusts in England. DJ Brown, one of the many specialist clinical advisors recently recruited by the CQC, discusses what nurses can expect from this new model of inspections
596
few weeks, the trust has provided over 3000 documents, which have been distilled into a 200-page summary. We have also had the opportunity to listen to a presentation from the trust executive team and question them on the substance of the data they presented. Armed with this background of both the views of the leadership and patients, and carrying a sheaf of recording sheets, we are charged with visiting the trust to look and listen, and to record the evidence that demonstrates the workings of our specialist areas. After two full working days filled with observation, formal interviews, focus groups and cross-referencing between teams, we come to an agreed view on what we have found, both by area team and across the entire trust. As inspectors, our remit is to answer five questions about the service we are inspecting: ■■ Is is safe? We want evidence that the trust is taking all reasonable steps to keep patients from harm: to predict, react to and learn from patient safety incidents in order to reduce avoidable harm ■■ Is it effective? We are looking for evidence that patients are being treated correctly and that their outcomes are what we would expect for the service being provided ■■ Is it caring? We want to see that the individual members of staff treat their patients with kindness, empathy and concern, and that there is clear evidence that they are treated with dignity and respect and are given the emotional support they need ■■ Is it responsive? We want to know that the trust’s systems and processes are managed effectively to deal with variations in patient needs and demand. We want to determine if the pathways work as intended and change with changing circumstances ■■ Is it well led? We want the trust to show that its staff is satisfied with its leaders, and that the organisation has a clear vision, mission, values and that leaders’ behaviour reflects these. Each of these five domains are then split further into ‘Key Lines of Enquiry’ (KLOEs) (Box 1). We are not seeking fault or in any way
attempting to ‘trip up’ the organisation. We have been given standards for each of these KLOEs which identify what ‘good’ looks like. Our remit is to determine, primarily, ‘is this service good?’. If the answer is yes, then we have one other question. Is it, in fact, so good, so impressive, that we would encourage our peers to travel to this site and see for themselves how well it is performing. If so, we can dub the service ‘Outstanding’. On the other hand, if we do find it falls below the standard of ‘Good’, then we must determine if it merely ‘requires improvement’ or whether it is putting patients at risk, in which case it is ‘Inadequate’. In this extreme case, CQC regulations can be used to impose restrictions and improvement notices. These four ratings—Oustanding, Good, Requires Improvement and Inadequate— which the CQC shares with OFSTED are given to each of the five domains, for each of the services. These are summarised for each service, for each location (if there is more than one), and then the entire matrix summarised into one overall rating for the trust. So, what can you, as a member of staff, expect from a CQC visit to your trust? Let us divide this into four stages:
Preparation The fact that the CQC is ‘looking for good’ does not diminish the fear that an inspection tends to inspire in a trust’s management— and not without reason. The regulator has the power to close the entire hospital and, ultimately, post Francis, to impose criminal sanctions on trust leaders.You can expect to be given plenty of direction on how to improve your area for the visit. The lingering smell of wet paint is not uncommon. If you work in the trust offices or, woe betide you, in the information department, you will be at the receiving end of a request for documentary evidence of the trust’s performance, systems and processes. Even if you’re on the shop floor, these requests will likely come your way: staffing levels, skill mix, recruiting strategies, performance against targets, governance structures, meeting minutes... the list may be long.
© 2014 MA Healthcare Ltd
H
is eyes blinked in the half-light of the hotel bar. His face, lined by years of industry, leaned towards me in conspiracy, ‘I’ve been a patient at th’ospital more than once. And I need tell you—I have strong views’. We are at one of several listening events held the evening before the on-site visit as part of the new-wave, post-Francis, CQC hospital inspections. To ensure his audience was listening, the man’s gaze arched over the other people at the table, where my colleague, Jonathan, sat with eyebrows raised and pen poised, struggling to look nonchalant as he awaited what the man would report. ‘They’re brilliant,’ he said finally. ‘I can’t fault them. I have nothing but th’ultimate praise for everyone who works there—doctors, nurses, all of them. I’ve come ‘ere th’evening to make sure you know that.’ In our small venue, there are more than two dozen local people here to tell their stories. Not all of these accounts are positive but, encouragingly, the ones that are significantly outnumber the complaints. The CQC has said they will put the people that use the service at the centre of the new inspection process. These listening events are proof of this intention. The fact that the 30-strong CQC team includes representatives from the Patients’ Association and ‘experts by experience’ who represent patients’ views is further testament. The remainder of the inspectors consist largely of clinical experts, recruited for their capacity for peer review. This is also evidence that the CQC is holding true to its second commitment to make inspections robust and reliable. Consultant surgeons, obstetricians, paediatricians, medics, pharmacists and senior nurses, as well as staff nurses, student nurses, end-of-life specialists and senior managers have all been recruited to assist the team of analysts and full-time CQC inspectors with coming to a fair and balanced view of a hospital’s performance. The CQC has also committed to making its inspections evidence-based. To that end, we— the inspection team—have been plied with information gleaned from public sources and from the trust we are inspecting. Over the last
British Journal of Nursing, 2014, Vol 23, No 11
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
COMMENT Site visits When the CQC is in town, you may be asked to attend a focus group for your level or type of work: junior doctors, allied health professionals, non-clinical staff and so on. If you are in a senior leadership position, as a department head for instance, you will need to set aside some time for a both a group and a one-to-one interview. If you’re at work on the shop floor, you should expect to see inspectors wandering around your department. (Yes, they will be carrying clipboards). A word of advice: tell them what you really think. This is important to patient care. ‘Spin’ is easily sniffed out, and will only raise suspicions, ultimately causing more harm than good. Trust leaders should take note: any patina with which you try to gloss your organisation won’t survive such a large team of inspectors. One trust’s document explaining to staff ‘What to say to the CQC’ did them no favours at all. Staff should also be prepared for unannounced inspections within a week or two of the main event. These allow follow-up on areas where inspectors need more information or want to see out-of-hours working.
The report These ‘new wave’ inspections have all been part of a national pilot designed to improve the inspection process itself. The trusts have been given ‘shadow’ ratings and are not required to publish the findings, although the trust leadership teams have been encouraged to publish their reports. The system is being improved and, after further consultation, the new process is expected to become part of the CQC’s regulatory framework. Clearly, if a trust’s rating is good overall— and for most trusts we expect it to be—then the results will probably be published by the trust. So you should perhaps expect, after all that preparation, that an unpublished report suggests something unpalatable. It’s true that an ‘inadequate’ rating is a cause for serious concern, but there should be no shame in receiving a ‘needs improvement’ rating. It is an opportunity to learn what we should be doing to provide better care for our patients. ‘Outstanding’ is reserved for only the truly exceptional, so a large proportion of services are likely to be rated ‘Good’, even if there are areas identified for improvement within specific KLOEs.
© 2014 MA Healthcare Ltd
Quality summit Finally, you—and indeed your patients—may be invited to attend a 1-day event, co-hosted by the CQC, in which the final report is presented and the trust’s plans for improvement discussed in detail. The CQC will only do the
British Journal of Nursing, 2014, Vol 23, No 11
Box 1. The CQC’s Key Lines of Enquiry (KLOEs) Is it SAFE? ■ How safe has care been in the past (based on records and data)? ■ Has the organisation learned when things go wrong and improved safety standards as a result? ■ Are there reliable systems, processes and practices in place to keep people safe? ■ How does the organisation monitor safety in real-time and react appropriately to changes in risk level, including at an individual patient level? ■ How well are problems anticipated and planned for in advance? Is it EFFECTIVE? ■ Are care and treatment delivered in line with current legislation, standards and nationally/ internationally recognised evidence-based guidance? ■ How do the outcomes for this organisation compare with those of similar providers? ■ How well are they being monitored and improved? ■ How does the provider make sure that staff (including skill mix), equipment and facilities enable the effective delivery of care and treatment, which does not affect quality? ■ How does the provider support and enable multidisciplinary working within and between services across the organisation and with external organisations? Is it CARING? ■ Are patients made to feel safe and comfortable, and treated with compassion, dignity and empathy, while they receive treatment and personal care? ■ How are patients and those close to them involved as ‘partners’ in their care, taking part in informed decisions about their care, with support where needed? ■ Do staff develop trusting relationships and communicate respectfully with patients and those close to them, throughout their hospital stay? ■ Do patients and those close to them receive the support they need to cope emotionally with their treatment and hospital visit/stay? Is it RESPONSIVE? ■ How does the provider plan its services to meet the needs of the different types of people it serves? ■ How does the provider ensure its service meets the needs of patients in vulnerable circumstances or who lack the capacity to communicate their needs? ■ How does the provider make sure that people from all of its communities can access its services in a timely fashion? ■ How does the provider take account of patients’ needs and wishes, so they are ready to leave hospital at the right time, when they are well enough and with the right support in place? ■ How does the provider routinely learn from people’s experiences, concerns and complaints to improve the quality of care? Is it WELL-LED? ■ Is there a clear vision and a credible strategy to deliver high-quality care to patients and are the risks to achieving this understood? ■ Do the governance arrangements ensure that responsibilities are clear, quality and performance are regularly considered, and problems are detected, understood and addresed? ■ How do the leadership and culture within the organisation reflect its vision and values, encourage openness and transparency and promote delivery of high-quality care across teams and pathways? ■ How does the organisation ensure that patients’ views and experiences are the key driver for how services are provided, and that staff are involved and engaged? ■ How does the organisation strive continuously to learn and improve, support safe innovation, and ensure the future sustainability of high-quality care?
first of these, since the question ‘how do we improve’ is not one that the CQC is permitted, in its role as regulator, to answer. If you are due for a ‘new wave’ CQC inspection, there will be substantial amounts of preparation for you and your colleagues. But be reassured, you will be visited by peers who know what it’s like to work in your area, and do the job you do. You will not be judged harshly or unfairly, nor in
a spirit of negative inquiry—but simply on your capacity to provide a good service to the people that matter most: your patients. BJN For more information about the new CQC inspections, visit http://tinyurl.com/psrr3ec DJ Brown
Senior Clinical Fellow, Emergency Medicine Maidstone and Tunbridge Wells NHS Trust
597
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
596
few weeks, the trust has provided over 3000 documents, which have been distilled into a 200-page summary. We have also had the opportunity to listen to a presentation from the trust executive team and question them on the substance of the data they presented. Armed with this background of both the views of the leadership and patients, and carrying a sheaf of recording sheets, we are charged with visiting the trust to look and listen, and to record the evidence that demonstrates the workings of our specialist areas. After two full working days filled with observation, formal interviews, focus groups and cross-referencing between teams, we come to an agreed view on what we have found, both by area team and across the entire trust. As inspectors, our remit is to answer five questions about the service we are inspecting: ■■ Is is safe? We want evidence that the trust is taking all reasonable steps to keep patients from harm: to predict, react to and learn from patient safety incidents in order to reduce avoidable harm ■■ Is it effective? We are looking for evidence that patients are being treated correctly and that their outcomes are what we would expect for the service being provided ■■ Is it caring? We want to see that the individual members of staff treat their patients with kindness, empathy and concern, and that there is clear evidence that they are treated with dignity and respect and are given the emotional support they need ■■ Is it responsive? We want to know that the trust’s systems and processes are managed effectively to deal with variations in patient needs and demand. We want to determine if the pathways work as intended and change with changing circumstances ■■ Is it well led? We want the trust to show that its staff is satisfied with its leaders, and that the organisation has a clear vision, mission, values and that leaders’ behaviour reflects these. Each of these five domains are then split further into ‘Key Lines of Enquiry’ (KLOEs) (Box 1). We are not seeking fault or in any way
attempting to ‘trip up’ the organisation. We have been given standards for each of these KLOEs which identify what ‘good’ looks like. Our remit is to determine, primarily, ‘is this service good?’. If the answer is yes, then we have one other question. Is it, in fact, so good, so impressive, that we would encourage our peers to travel to this site and see for themselves how well it is performing. If so, we can dub the service ‘Outstanding’. On the other hand, if we do find it falls below the standard of ‘Good’, then we must determine if it merely ‘requires improvement’ or whether it is putting patients at risk, in which case it is ‘Inadequate’. In this extreme case, CQC regulations can be used to impose restrictions and improvement notices. These four ratings—Oustanding, Good, Requires Improvement and Inadequate— which the CQC shares with OFSTED are given to each of the five domains, for each of the services. These are summarised for each service, for each location (if there is more than one), and then the entire matrix summarised into one overall rating for the trust. So, what can you, as a member of staff, expect from a CQC visit to your trust? Let us divide this into four stages:
Preparation The fact that the CQC is ‘looking for good’ does not diminish the fear that an inspection tends to inspire in a trust’s management— and not without reason. The regulator has the power to close the entire hospital and, ultimately, post Francis, to impose criminal sanctions on trust leaders.You can expect to be given plenty of direction on how to improve your area for the visit. The lingering smell of wet paint is not uncommon. If you work in the trust offices or, woe betide you, in the information department, you will be at the receiving end of a request for documentary evidence of the trust’s performance, systems and processes. Even if you’re on the shop floor, these requests will likely come your way: staffing levels, skill mix, recruiting strategies, performance against targets, governance structures, meeting minutes... the list may be long.
© 2014 MA Healthcare Ltd
H
is eyes blinked in the half-light of the hotel bar. His face, lined by years of industry, leaned towards me in conspiracy, ‘I’ve been a patient at th’ospital more than once. And I need tell you—I have strong views’. We are at one of several listening events held the evening before the on-site visit as part of the new-wave, post-Francis, CQC hospital inspections. To ensure his audience was listening, the man’s gaze arched over the other people at the table, where my colleague, Jonathan, sat with eyebrows raised and pen poised, struggling to look nonchalant as he awaited what the man would report. ‘They’re brilliant,’ he said finally. ‘I can’t fault them. I have nothing but th’ultimate praise for everyone who works there—doctors, nurses, all of them. I’ve come ‘ere th’evening to make sure you know that.’ In our small venue, there are more than two dozen local people here to tell their stories. Not all of these accounts are positive but, encouragingly, the ones that are significantly outnumber the complaints. The CQC has said they will put the people that use the service at the centre of the new inspection process. These listening events are proof of this intention. The fact that the 30-strong CQC team includes representatives from the Patients’ Association and ‘experts by experience’ who represent patients’ views is further testament. The remainder of the inspectors consist largely of clinical experts, recruited for their capacity for peer review. This is also evidence that the CQC is holding true to its second commitment to make inspections robust and reliable. Consultant surgeons, obstetricians, paediatricians, medics, pharmacists and senior nurses, as well as staff nurses, student nurses, end-of-life specialists and senior managers have all been recruited to assist the team of analysts and full-time CQC inspectors with coming to a fair and balanced view of a hospital’s performance. The CQC has also committed to making its inspections evidence-based. To that end, we— the inspection team—have been plied with information gleaned from public sources and from the trust we are inspecting. Over the last
British Journal of Nursing, 2014, Vol 23, No 11
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
COMMENT Site visits When the CQC is in town, you may be asked to attend a focus group for your level or type of work: junior doctors, allied health professionals, non-clinical staff and so on. If you are in a senior leadership position, as a department head for instance, you will need to set aside some time for a both a group and a one-to-one interview. If you’re at work on the shop floor, you should expect to see inspectors wandering around your department. (Yes, they will be carrying clipboards). A word of advice: tell them what you really think. This is important to patient care. ‘Spin’ is easily sniffed out, and will only raise suspicions, ultimately causing more harm than good. Trust leaders should take note: any patina with which you try to gloss your organisation won’t survive such a large team of inspectors. One trust’s document explaining to staff ‘What to say to the CQC’ did them no favours at all. Staff should also be prepared for unannounced inspections within a week or two of the main event. These allow follow-up on areas where inspectors need more information or want to see out-of-hours working.
The report These ‘new wave’ inspections have all been part of a national pilot designed to improve the inspection process itself. The trusts have been given ‘shadow’ ratings and are not required to publish the findings, although the trust leadership teams have been encouraged to publish their reports. The system is being improved and, after further consultation, the new process is expected to become part of the CQC’s regulatory framework. Clearly, if a trust’s rating is good overall— and for most trusts we expect it to be—then the results will probably be published by the trust. So you should perhaps expect, after all that preparation, that an unpublished report suggests something unpalatable. It’s true that an ‘inadequate’ rating is a cause for serious concern, but there should be no shame in receiving a ‘needs improvement’ rating. It is an opportunity to learn what we should be doing to provide better care for our patients. ‘Outstanding’ is reserved for only the truly exceptional, so a large proportion of services are likely to be rated ‘Good’, even if there are areas identified for improvement within specific KLOEs.
© 2014 MA Healthcare Ltd
Quality summit Finally, you—and indeed your patients—may be invited to attend a 1-day event, co-hosted by the CQC, in which the final report is presented and the trust’s plans for improvement discussed in detail. The CQC will only do the
British Journal of Nursing, 2014, Vol 23, No 11
Box 1. The CQC’s Key Lines of Enquiry (KLOEs) Is it SAFE? ■ How safe has care been in the past (based on records and data)? ■ Has the organisation learned when things go wrong and improved safety standards as a result? ■ Are there reliable systems, processes and practices in place to keep people safe? ■ How does the organisation monitor safety in real-time and react appropriately to changes in risk level, including at an individual patient level? ■ How well are problems anticipated and planned for in advance? Is it EFFECTIVE? ■ Are care and treatment delivered in line with current legislation, standards and nationally/ internationally recognised evidence-based guidance? ■ How do the outcomes for this organisation compare with those of similar providers? ■ How well are they being monitored and improved? ■ How does the provider make sure that staff (including skill mix), equipment and facilities enable the effective delivery of care and treatment, which does not affect quality? ■ How does the provider support and enable multidisciplinary working within and between services across the organisation and with external organisations? Is it CARING? ■ Are patients made to feel safe and comfortable, and treated with compassion, dignity and empathy, while they receive treatment and personal care? ■ How are patients and those close to them involved as ‘partners’ in their care, taking part in informed decisions about their care, with support where needed? ■ Do staff develop trusting relationships and communicate respectfully with patients and those close to them, throughout their hospital stay? ■ Do patients and those close to them receive the support they need to cope emotionally with their treatment and hospital visit/stay? Is it RESPONSIVE? ■ How does the provider plan its services to meet the needs of the different types of people it serves? ■ How does the provider ensure its service meets the needs of patients in vulnerable circumstances or who lack the capacity to communicate their needs? ■ How does the provider make sure that people from all of its communities can access its services in a timely fashion? ■ How does the provider take account of patients’ needs and wishes, so they are ready to leave hospital at the right time, when they are well enough and with the right support in place? ■ How does the provider routinely learn from people’s experiences, concerns and complaints to improve the quality of care? Is it WELL-LED? ■ Is there a clear vision and a credible strategy to deliver high-quality care to patients and are the risks to achieving this understood? ■ Do the governance arrangements ensure that responsibilities are clear, quality and performance are regularly considered, and problems are detected, understood and addresed? ■ How do the leadership and culture within the organisation reflect its vision and values, encourage openness and transparency and promote delivery of high-quality care across teams and pathways? ■ How does the organisation ensure that patients’ views and experiences are the key driver for how services are provided, and that staff are involved and engaged? ■ How does the organisation strive continuously to learn and improve, support safe innovation, and ensure the future sustainability of high-quality care?
first of these, since the question ‘how do we improve’ is not one that the CQC is permitted, in its role as regulator, to answer. If you are due for a ‘new wave’ CQC inspection, there will be substantial amounts of preparation for you and your colleagues. But be reassured, you will be visited by peers who know what it’s like to work in your area, and do the job you do. You will not be judged harshly or unfairly, nor in
a spirit of negative inquiry—but simply on your capacity to provide a good service to the people that matter most: your patients. BJN For more information about the new CQC inspections, visit http://tinyurl.com/psrr3ec DJ Brown
Senior Clinical Fellow, Emergency Medicine Maidstone and Tunbridge Wells NHS Trust
597
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
