Getting hospital inspections right for children and young people Professor Alan Glasper assesses an independent report prepared for the Care Quality Commission on the care of children and young people in hospital. The report suggests major changes to the way inspections of children’s services are conducted
Getting inspections right Dr Shribman led a team consisting of clinical experts and CQC staff with the key objective of ensuring that future inspections of children’s services accurately measure the efficacy of care delivered to children, young people and their families. To achieve this, Dr Shribman and her team consulted widely with key stakeholders and she submitted her comprehensive 89page report to the CQC entitled ‘Getting it right for children and young people (including those transitioning into adult services): a report on CQC’s new approach to inspection’ at the end of March 2014 (Shribman, 2014) and on 4 August 2014 the regulator published its response to this report (CQC, 2014a). Dr Shribman believes that there has been a commonly held view among previous inspectors that children’s services in hospitals function well and as a result have been consistently rated as meeting regulatory requirements. This may not actually reflect the full picture and this is why her report contains no fewer than 73 recommendations designed to improve CQC inspections of children’s services in England.
1000
The CQC has carefully considered this report and as a response has accepted in full or in part 70 of these recommendations. The CQC recognises the multi-faceted aspects of inspecting hospital services for children, young people and their families.The new and improved system of inspecting children’s services has already been piloted during the recent CQC inspections of the Alder Hey Children’s Hospital in Liverpool and the Children’s Hospital in Sheffield where Heidi Smoult, who is one of eight Heads of Hospital Inspections, and herself a member of Dr Shribman’s team, was present. She believes that Shribman’s recommendations have played a major part in helping the CQC more fully understand and assess the care that is delivered to children, young people and their families in hospital. Furthermore, this report has highlighted the need for appropriate care for children of all age groups, and the careful management of their transition, where necessary, from children’s to adult services. These new processes put forward by Shribman will ensure that future CQC inspections of hospital services for children and young people are fit for purpose. Importantly, these processes need to be seen by the staff who work in these areas to be proportional, legitimate and conducted by people with the authority and confidence to do so.
Background Children and young people make up about 20% of the population of England and Wales but use medical services proportionally higher than other groups, as seen, for example, in a study by Lattimer et al, 1998. Dr Shribman believes that the needs of sick children are often ignored in the adult-centric focused orientation of many general hospitals. She cites the Report of the Children’s and Young People’s Health Outcomes (Lewis and Lenehan, 2012) which has shown that there are variations in child ill health in different parts of the country. Inequalities in child health, especially infant mortality, obesity, accidents and teenage pregnancy, are more common in those from disadvantaged backgrounds.
Children, young people and their families find it challenging to make their voices heard and to be involved in decisions about their health. Worryingly, multidisciplinary team members are not adequately prepared to cope with the complexities of caring for sick children and some staff have limited experience of working with them, especially in areas such as disability and mental health (Glasper, 2012).
Recommendations for future CQC inspections The CQC’s new approach to inspection will be used to enhance the standards of care delivered to sick children and their families in hospital and reduce unacceptable variations in care delivery. One of Dr Shribman’s initial comments in her report is aimed at destroying the myth that children and young people are simply little adults who eat less food and require smaller beds. She also highlights the importance of care staff acknowledging the vulnerability of the sick child and in recognising the signs of the deteriorating child. This is exemplified by, and perhaps reflective of, Florence Nightingale’s famous quotation that children ‘are affected by the same things as adults but much more quickly and seriously’ (Nightingale, 1859:72). It is beyond the scope of this paper to consider all 73 of Dr Shribman’s recommendations but a summary of the main aspects will be discussed and implications for practice considered. Dr Shribman suggests that the CQC inspect hospital services for children, young people and their families in three domains: general hospital issues, general and emergency services issues, and specialist children and young people service issues. General hospital issues—these inspection components are pertinent to any CQC hospital inspection but have particular relevance for children and young people, be they receiving care in an acute NHS Trust or a stand-alone specialist children’s hospital. Crucially, the CQC will investigate staffing in its widest context ranging from overall numbers through
© 2014 MA Healthcare Ltd
I
n late 2013 the Care Quality Commission (CQC) invited Dr Shribman, an expert in children’s and young people’s care, to lead a small team with a mandate to design an appropriate methodology for the CQC’s revised inspection programme. The focus of this work was to plan how the CQC inspects specialist children’s services, including stand-alone hospitals under the new processes of inspection developed by the Chief Inspector of Hospitals, Professor Sir Mike Richards, in the wake of the Francis Inquiry. The CQC is committed to ensuring that children and young people using specialist hospital services receive optimal care and health outcomes through the new approach to hospital inspection. Dr Shribman’s work for the CQC highlights the importance of specialist hospital services for children and young people, and that the new hospital inspection processes should recognise the complexities of these services for children and their families.
British Journal of Nursing, 2014, Vol 23, No 18
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY to skill mix and measures of dependency. The Royal College of Nursing (RCN), for example, has produced very sophisticated nurse staffing models for different departments within children’s services which was updated in 2013 (RCN, 2013). The RCN believes that these staffing standards are the minimal essential requirement for all providers of services to babies, children and young people. Measures of sick child acuity linked to objective and measurable standards of staffing are strongly recommended. In Scotland, this is already mandatory, and a toolkit has been designed to help ward mangers deploy staff more effectively in relation to patient acuity (NHS Education for Scotland (NES), 2013). In addition to staffing issues, Dr Shribman’s recommendations also include an inspection of the care environment, such as cleanliness and infection control, and how organisations learn from mistakes through serious incidence reporting. General and emergency services issues pertinent to children—Dr Shribman recommends that inspectors investigate the availability of paediatric-specific equipment, especially in operating theatres. Specialist children and young people service issues—these are aspects of care delivery that are applicable to the large standalone children’s specialist NHS Trusts, and large tertiary children’s services hosted by some NHS Trusts. Inspectors in these scenarios are asked to measure compliance to national specialised specifications.
© 2014 MA Healthcare Ltd
Developing the intelligent monitoring tool Much of the work that goes into an inspection of a children’s service occurs before the CQC inspectors visit the physical premises. This relies on the gathering of data, but as Dr Shribman points out, hard factual data rarely give the full picture and she recommends that CQC inspectors take due regard of qualitative data from key stakeholders such as parents or parents’ organisations before they conduct an inspection. The CQC system of intelligent monitoring of acute and specialist NHS Trusts examines 150 sets of data or indicators, which shape inspections. The data examined by the CQC include information from sources such as: staff, patient surveys, mortality rates and hospital performance information such as waiting times and infection rates. Intelligent monitoring is one of the four key aspects of how the CQC regulates services. The other three aspects are: registraion, expert inspection and judgement (CQC, 2014b)
British Journal of Nursing, 2014, Vol 23, No 18
It is Dr Shribman’s assertion that there has been a lack of pertinent data about children’s services, which has been available in past inspections, and she advises that the current intelligent monitoring tool be made more robust for gathering data about these services. By improving the range of data that are available to CQC inspectors, this will make the whole process of inspection more objective. In particular, the decision by the CQC to fund the development of inpatient surveys for children and their families will go some way to bridge the current inequity between patient experience data from adults when compared with children. There are to be three survey instruments developed for children’s services. The first will be aimed at 0–7 year olds and will be completed by family carers; the second will be designed for 8–12 year olds and this will have two sections, the first for children and the second for carers to complete. The third survey instrument will be designed for 13–17 year olds to complete, with a section for carers. It is anticipated that the results of these surveys, which will be rolled out during autumn 2014, will help in the further development of the CQC intelligent monitoring tool. In addition, the report suggests that the CQC should consider using mobile phone technology to solicit feedback data from children and young people. In her report, Dr Shribman cites the work undertaken by Northampton hospital with ‘Fabio the frog’, an electronic patient-experience tracker, which is part of the National Paeditric Toolkit™ especially designed to capture data from young children using animated methodology (Northampton General Hospital, 2010) (http://tinyurl.com/l3rqr2g). A further key recommendation from Dr Shribman is that CQC inspectors should obtain a summary of formal complaints and Patient Advocacy and Liaison (PALS) data from NHS Trusts being inspected. Additionally, she recommends that feedback about individual Trusts be obtained from the RCN and the Royal College of Paediatrics and Child Health.
Conclusion The most important aspect of future inspection of children’s services is—who should be on an inspection team and what should they actually inspect? Dr Shribman has considered involving children and young people and their families in the inspection process but, after due consideration, has advised the CQC not to take children out of school to participate in hospital inspections. However, she has asked the CQC to consider using parents as experts by experience and young adults post-19 years old. In addition to these service users, she advises a team made up of a consultant paediatrician, a paediatric intensivist, a children’s nurse and a specialist children’s nurse, among others. Dr Shribman recommends that all pertinent areas of children’s services be inspected using key lines of enquiry, but she highlights paediatric emergency admission/short stay units, the hospital play service, facilities for parents and transition services as being worthy of special attention. Undoubtedly, the new inspection processes will help to drive up standards of care for children and young people in hospital. BJN Care Quality Commission (2014a) CQC’s response to Dr Shribman’s recommendations. http://tinyurl.com/kjy9rjr (accessed 30 September 2014) Care Quality Commission (2014b) Hospital Intelligent Monitoring. http://tinyurl.com/nayu9ju (accessed 30 September 2014) Glasper A (2012) A strategy to improve the health of children and young people .BJN 21(17):1040–1 Lattimer V, George S, Thompson F et al (1998) General Practice. Safety and effectiveness of nurse telephone consultation in out of hour’s primary care: randomised controlled trial. BMJ 317(7165): 1054–9 Lewis I, Lenehan C Report of the Children’s and Young People’s Health Outcomes Forum. (2012) http://tinyurl.com/o4vj3pq (accessed 30 September 2014) NHS Education for Scotland (NES) (2013) Nursing and Midwifery Workload and Workforce Planning. Learning toolkit.. 2nd edn. NES, Edinburgh Nightingale F (1859) Notes on nursing: what it is, and what it is not. Edn 1970. Duckworth and company, London Northampton General Hospital (2010) Fabio helps young NGH patients to have their say. Royal College of Nursing (2013) Defining staffing levels for children and young people’s services. RCN, London. http://tinyurl.com/bwlfutg (accessed 30 September 2014) Shribman S (2014) Getting it right for children & young people (including those transitioning into adult services): a report on CQC’s new approach to inspection. http://tinyurl.com/k53ofsr (accessed 30 September 2014)
KEY POINTS n A new report has been published which suggests major changes in the way that the Care Quality Commission (CQC) conducts its inspections of children’s services in hospitals n The report recommendations are designed to ensure that the new hospital inspection processes recognise the complexities of service delivery for children and their families n There are variations in child ill health in differing parts of the country, and the CQC is determined to help minimise these n The report advises that the current CQC Intelligent Monitoring Tool be made more robust for gathering data about children’s services
1001
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
Getting inspections right Dr Shribman led a team consisting of clinical experts and CQC staff with the key objective of ensuring that future inspections of children’s services accurately measure the efficacy of care delivered to children, young people and their families. To achieve this, Dr Shribman and her team consulted widely with key stakeholders and she submitted her comprehensive 89page report to the CQC entitled ‘Getting it right for children and young people (including those transitioning into adult services): a report on CQC’s new approach to inspection’ at the end of March 2014 (Shribman, 2014) and on 4 August 2014 the regulator published its response to this report (CQC, 2014a). Dr Shribman believes that there has been a commonly held view among previous inspectors that children’s services in hospitals function well and as a result have been consistently rated as meeting regulatory requirements. This may not actually reflect the full picture and this is why her report contains no fewer than 73 recommendations designed to improve CQC inspections of children’s services in England.
1000
The CQC has carefully considered this report and as a response has accepted in full or in part 70 of these recommendations. The CQC recognises the multi-faceted aspects of inspecting hospital services for children, young people and their families.The new and improved system of inspecting children’s services has already been piloted during the recent CQC inspections of the Alder Hey Children’s Hospital in Liverpool and the Children’s Hospital in Sheffield where Heidi Smoult, who is one of eight Heads of Hospital Inspections, and herself a member of Dr Shribman’s team, was present. She believes that Shribman’s recommendations have played a major part in helping the CQC more fully understand and assess the care that is delivered to children, young people and their families in hospital. Furthermore, this report has highlighted the need for appropriate care for children of all age groups, and the careful management of their transition, where necessary, from children’s to adult services. These new processes put forward by Shribman will ensure that future CQC inspections of hospital services for children and young people are fit for purpose. Importantly, these processes need to be seen by the staff who work in these areas to be proportional, legitimate and conducted by people with the authority and confidence to do so.
Background Children and young people make up about 20% of the population of England and Wales but use medical services proportionally higher than other groups, as seen, for example, in a study by Lattimer et al, 1998. Dr Shribman believes that the needs of sick children are often ignored in the adult-centric focused orientation of many general hospitals. She cites the Report of the Children’s and Young People’s Health Outcomes (Lewis and Lenehan, 2012) which has shown that there are variations in child ill health in different parts of the country. Inequalities in child health, especially infant mortality, obesity, accidents and teenage pregnancy, are more common in those from disadvantaged backgrounds.
Children, young people and their families find it challenging to make their voices heard and to be involved in decisions about their health. Worryingly, multidisciplinary team members are not adequately prepared to cope with the complexities of caring for sick children and some staff have limited experience of working with them, especially in areas such as disability and mental health (Glasper, 2012).
Recommendations for future CQC inspections The CQC’s new approach to inspection will be used to enhance the standards of care delivered to sick children and their families in hospital and reduce unacceptable variations in care delivery. One of Dr Shribman’s initial comments in her report is aimed at destroying the myth that children and young people are simply little adults who eat less food and require smaller beds. She also highlights the importance of care staff acknowledging the vulnerability of the sick child and in recognising the signs of the deteriorating child. This is exemplified by, and perhaps reflective of, Florence Nightingale’s famous quotation that children ‘are affected by the same things as adults but much more quickly and seriously’ (Nightingale, 1859:72). It is beyond the scope of this paper to consider all 73 of Dr Shribman’s recommendations but a summary of the main aspects will be discussed and implications for practice considered. Dr Shribman suggests that the CQC inspect hospital services for children, young people and their families in three domains: general hospital issues, general and emergency services issues, and specialist children and young people service issues. General hospital issues—these inspection components are pertinent to any CQC hospital inspection but have particular relevance for children and young people, be they receiving care in an acute NHS Trust or a stand-alone specialist children’s hospital. Crucially, the CQC will investigate staffing in its widest context ranging from overall numbers through
© 2014 MA Healthcare Ltd
I
n late 2013 the Care Quality Commission (CQC) invited Dr Shribman, an expert in children’s and young people’s care, to lead a small team with a mandate to design an appropriate methodology for the CQC’s revised inspection programme. The focus of this work was to plan how the CQC inspects specialist children’s services, including stand-alone hospitals under the new processes of inspection developed by the Chief Inspector of Hospitals, Professor Sir Mike Richards, in the wake of the Francis Inquiry. The CQC is committed to ensuring that children and young people using specialist hospital services receive optimal care and health outcomes through the new approach to hospital inspection. Dr Shribman’s work for the CQC highlights the importance of specialist hospital services for children and young people, and that the new hospital inspection processes should recognise the complexities of these services for children and their families.
British Journal of Nursing, 2014, Vol 23, No 18
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY to skill mix and measures of dependency. The Royal College of Nursing (RCN), for example, has produced very sophisticated nurse staffing models for different departments within children’s services which was updated in 2013 (RCN, 2013). The RCN believes that these staffing standards are the minimal essential requirement for all providers of services to babies, children and young people. Measures of sick child acuity linked to objective and measurable standards of staffing are strongly recommended. In Scotland, this is already mandatory, and a toolkit has been designed to help ward mangers deploy staff more effectively in relation to patient acuity (NHS Education for Scotland (NES), 2013). In addition to staffing issues, Dr Shribman’s recommendations also include an inspection of the care environment, such as cleanliness and infection control, and how organisations learn from mistakes through serious incidence reporting. General and emergency services issues pertinent to children—Dr Shribman recommends that inspectors investigate the availability of paediatric-specific equipment, especially in operating theatres. Specialist children and young people service issues—these are aspects of care delivery that are applicable to the large standalone children’s specialist NHS Trusts, and large tertiary children’s services hosted by some NHS Trusts. Inspectors in these scenarios are asked to measure compliance to national specialised specifications.
© 2014 MA Healthcare Ltd
Developing the intelligent monitoring tool Much of the work that goes into an inspection of a children’s service occurs before the CQC inspectors visit the physical premises. This relies on the gathering of data, but as Dr Shribman points out, hard factual data rarely give the full picture and she recommends that CQC inspectors take due regard of qualitative data from key stakeholders such as parents or parents’ organisations before they conduct an inspection. The CQC system of intelligent monitoring of acute and specialist NHS Trusts examines 150 sets of data or indicators, which shape inspections. The data examined by the CQC include information from sources such as: staff, patient surveys, mortality rates and hospital performance information such as waiting times and infection rates. Intelligent monitoring is one of the four key aspects of how the CQC regulates services. The other three aspects are: registraion, expert inspection and judgement (CQC, 2014b)
British Journal of Nursing, 2014, Vol 23, No 18
It is Dr Shribman’s assertion that there has been a lack of pertinent data about children’s services, which has been available in past inspections, and she advises that the current intelligent monitoring tool be made more robust for gathering data about these services. By improving the range of data that are available to CQC inspectors, this will make the whole process of inspection more objective. In particular, the decision by the CQC to fund the development of inpatient surveys for children and their families will go some way to bridge the current inequity between patient experience data from adults when compared with children. There are to be three survey instruments developed for children’s services. The first will be aimed at 0–7 year olds and will be completed by family carers; the second will be designed for 8–12 year olds and this will have two sections, the first for children and the second for carers to complete. The third survey instrument will be designed for 13–17 year olds to complete, with a section for carers. It is anticipated that the results of these surveys, which will be rolled out during autumn 2014, will help in the further development of the CQC intelligent monitoring tool. In addition, the report suggests that the CQC should consider using mobile phone technology to solicit feedback data from children and young people. In her report, Dr Shribman cites the work undertaken by Northampton hospital with ‘Fabio the frog’, an electronic patient-experience tracker, which is part of the National Paeditric Toolkit™ especially designed to capture data from young children using animated methodology (Northampton General Hospital, 2010) (http://tinyurl.com/l3rqr2g). A further key recommendation from Dr Shribman is that CQC inspectors should obtain a summary of formal complaints and Patient Advocacy and Liaison (PALS) data from NHS Trusts being inspected. Additionally, she recommends that feedback about individual Trusts be obtained from the RCN and the Royal College of Paediatrics and Child Health.
Conclusion The most important aspect of future inspection of children’s services is—who should be on an inspection team and what should they actually inspect? Dr Shribman has considered involving children and young people and their families in the inspection process but, after due consideration, has advised the CQC not to take children out of school to participate in hospital inspections. However, she has asked the CQC to consider using parents as experts by experience and young adults post-19 years old. In addition to these service users, she advises a team made up of a consultant paediatrician, a paediatric intensivist, a children’s nurse and a specialist children’s nurse, among others. Dr Shribman recommends that all pertinent areas of children’s services be inspected using key lines of enquiry, but she highlights paediatric emergency admission/short stay units, the hospital play service, facilities for parents and transition services as being worthy of special attention. Undoubtedly, the new inspection processes will help to drive up standards of care for children and young people in hospital. BJN Care Quality Commission (2014a) CQC’s response to Dr Shribman’s recommendations. http://tinyurl.com/kjy9rjr (accessed 30 September 2014) Care Quality Commission (2014b) Hospital Intelligent Monitoring. http://tinyurl.com/nayu9ju (accessed 30 September 2014) Glasper A (2012) A strategy to improve the health of children and young people .BJN 21(17):1040–1 Lattimer V, George S, Thompson F et al (1998) General Practice. Safety and effectiveness of nurse telephone consultation in out of hour’s primary care: randomised controlled trial. BMJ 317(7165): 1054–9 Lewis I, Lenehan C Report of the Children’s and Young People’s Health Outcomes Forum. (2012) http://tinyurl.com/o4vj3pq (accessed 30 September 2014) NHS Education for Scotland (NES) (2013) Nursing and Midwifery Workload and Workforce Planning. Learning toolkit.. 2nd edn. NES, Edinburgh Nightingale F (1859) Notes on nursing: what it is, and what it is not. Edn 1970. Duckworth and company, London Northampton General Hospital (2010) Fabio helps young NGH patients to have their say. Royal College of Nursing (2013) Defining staffing levels for children and young people’s services. RCN, London. http://tinyurl.com/bwlfutg (accessed 30 September 2014) Shribman S (2014) Getting it right for children & young people (including those transitioning into adult services): a report on CQC’s new approach to inspection. http://tinyurl.com/k53ofsr (accessed 30 September 2014)
KEY POINTS n A new report has been published which suggests major changes in the way that the Care Quality Commission (CQC) conducts its inspections of children’s services in hospitals n The report recommendations are designed to ensure that the new hospital inspection processes recognise the complexities of service delivery for children and their families n There are variations in child ill health in differing parts of the country, and the CQC is determined to help minimise these n The report advises that the current CQC Intelligent Monitoring Tool be made more robust for gathering data about children’s services
1001
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 25, 2015. For personal use only. No other uses without permission. . All rights reserved.
