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Once again an NHS trust is highlighted as having poor, if not dangerous, care. See this item in the London Telegraph.

Tacoma Narrows Bridge collapsing, captured in ...

Catastrophic System Failure [Tacoma Narrows Bridge collapsing, captured in 16 mm Kodachrome motion picture film. The view looks west. (Photo credit: Wikipedia)]

Are the problems a result of design flaws in the way the NHS organises itself to deliver care? Some basic elements of the UK’s NHS that are relevant to the argument I’m going to make:

  1. consultants/specialists have contracts of employment and clinical duties are agreed annually in “job plans” in use since 1991
  2. doctors, once qualified, and registed with the GMC, the professional regulator, are immediately employable in the NHS; their authority to act rests on this
  3. performance improvement and clinical professional development is still work in progress in the NHS despite GMC efforts over the years
  4. junior doctors in training rarely fail and marginal clinical performance is not recognised as such
  5. the Royal Colleges act on behalf of the interests of doctors, not in the public interest as that is the job of the General Medical Council, though they no doubt would argue otherwise.

One starting point is that CQC (Care Quality Commission) inspection may identify the problems, but hospital doctors, other clinicians (nurses, OT, etc.), managers and the board have a collective duty to clinical quality. CQC is not a system of accreditation, and so failing hospitals continue to be protected from the consequences of their actions. The only options are bureaucratic and invariably political (merge the hospital with another, shut the hospital), but this does not solve the problem of failed oversight and management. There is good evidence that hospital quality control systems are weak and rigourous quantitative methods are still needed. I have separately argued that hospitals need in-house operations management capabilites to model clinical care systems, for instance — exemplary hospitals providing high quality care use data-driven analytics in improving clinical work flow and patient outcomes. The Francis report is what I would say is a ‘team hug’ approach recognising individual and cultural factors. I’ll also take a starting point that job plans are not working to uphold standards of care. Putting all this together, we might conclude that we have either the failure of hospital management systems, or the absence of the right type of control system.

My suggested solution is that the NHS should introduce a system called “privileges”, by which appointments/employment and clinical work are subject to prior agreement and degrees of supervisory quality control and oversight. This is an evidence-informed quality control system:

  1. The responsibility of clinical quality rests primarily with the hospital, not the NHS as such, and hospitals need to put in place quality systems that check the quality of clinical work. The quality of clinical work is the responsibility of the hospital Board, as advised by the Medical Director
  2. Medical job plans of NHS employment should include explicit use of privileges or contracts should include privilege as the fundamental determinant with respect to the scope of practice in these job plans.
  3. Appointments to a hospital’s medical staff would require a review of credentials, training, fellowships, previous work undertaken by a medical committee with a recommendation to the Medical Director (and then to the Board, which would be the body granting privileges).
  4. The privileges system would introduce a system of control over what clinical work the individual doctor is recognised as qualified to do (say knee surgery but not hand surgery)
  5. Changes in what a doctor has privileges to do would require the doctor to produce evidence of specific training to establish their ability in the required area.
  6. All new medical appointments, regardless of their total time practising since being licensed, would be supervised in their first 6 months to a year, by a senior colleague acting on behalf of the hospital. At the end of this probationary period, privileges would be confirmed.
  7. Privileges are not forever, but are reviewed for substantive changes on an ongoing basis, and fundamentally reviewed every so many years.

I like the idea because I’ve worked in a system that used privileges, where I’ve seen how it acted to improve clinical quality and worked to the benefit of the doctors themselves. It brings order and structure to clincal work within the hospital by better aligning case mix with skill mix. New hospital appointments would be supervised, while monthly notices kept all clinical staff, importantly nurses on the wards and in the operating theatres, up to date to changes in privileges (who had an area added, or dropped).

Interestingly, the private hospitals in the UK use a system akin to privileges to decide whom to appoint to their medical staff, but it lacks substantive quality criteria or credentialling apart from the requirement of having an NHS appointment!

Some additional potential benefits:

  1. It would create a level clinical playing field between the public and private systems, now that the private or independent sector is becoming more important and perhaps better integrated into the care system in the UK;
  2. Thinking of the future, the privileges system would decouple to some extent doctors’ employment and the work they do. This might increase the likelihood that new ways of organising clinical services in the community, for instance, might become more common.
  3. Patients would have clear evidence that quality and clinical work are connected.

I acknowledge that much is done to create a quality environment within the publicly-funded NHS, and this is not ignored in my comments, which in no way need undermine efforts at team working, or cost control. Job Plans in NHS contracts do not discuss clinical focus in detail and actually spend more space on dealing with private practice and academic appointments than on direct patient care; in essence, they are only workload management plans. However, as employment contracts, they focus on the dimensions of employment (e.g. car allowances, maternity leave and employer responsibilities such as providing the necessary tools for the work to be done).

In my view, the problems have a genesis in these aspects of the system that taken together do not produce the desired outcomes when there are problems, and may actually mask poor quality care. Considering a system like privileges may serve to focus attention on what is really important.

Additional Notes

There are types of privileges: admitting, surgical, courtesy.

Hospitals can add conditions to privileges such as living nearby so the doctor can get to the hospital quickly in an emergency.

Hospitals would revoke or suspend privileges where there is evidence of danger to patients, unethical conduct, and disruptive of hospital operations (that last one’s tricky).

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Régulation de la machine à vapeur Merlin

If only it were that easy. (Photo credit: zigazou76)

There have been quite a few cases of late of regulatory failure by the Care Quality Commission [CQC] in the UK.  How can regulatory performance be monitored and improved?

The first thing to realise is that regulators are monopoly suppliers of regulation; that means, that if they don’t do a good job, the regulated don’t have a choice.

Regulators often find reasons to expand their remit (regulatory creep) and because they are prima facie trusted to do their work, regulatory overseers’ consent. Tight performance expectations coupled with effective oversight helps, as does conducting regulatory benchmarking exercises to assess comparative performance with other regulators. This helps keep regulators focused and not get drawn into expanding, like a gas, from what they need to do essentially.

The people who work as regulators invariably derived there expertise from the industry area being regulated. In the case of the CQC, people who had worked in hospitals. This creates an obvious risk in terms of ‘regulatory capture’ by the regulated. The NHS used to speak of being a ‘family’, all cosy, and as we all know, in families it is important to support each other and suppress dissent — paternal/maternal models of behaviour dominate.

But, regulators need to learn how to adopt new behaviours from what got them the job in the first place; much organisational failure arises from failure of people alter their behaviour as roles change. The relationship between regulatory and regulated cannot be chummy; it must be built on evidence that the regulator knows what they are doing and are not going to be compromised by past relationships or a need to be ‘liked’ by the regulated. The selection of the ‘great and the good’ to act as chairpersons and chief executives risks individuals putting their own reputation ahead of the need to regulate with vigour. Sometimes, as the NHS is learning, regulators have to have the teeth to do what needs to be done.

Perhaps more relevant is how regulatory inspectors use their knowledge when inspecting a hospital. While one hopes they use their knowledge well, they are not immune from making assumptions that something is happening (because in their experience seeing ‘A’ means ‘B’ is happening, when in fact it may not). I recall doing some performance work in a UK NHS hospital, and as I was walking through A and E and noticed that guideline posters were both out of date and not dated.  I was told they would change that immediately. Well, mundane stuff making sure guidelines are current, and dated as such, but pretty sloppy. Perhaps a regulator might assume that staff would know what to do. A risky assumption.

Regulatory inspectors need to be able to test all the systems to ensure the are working together. This means, for instance, taking a patient chart at random from the records and tracking the patient care through to discharge, and perhaps follow up at home.  I did a review of discharge on an NHS hospital and was looking at the charts and asked the ward staff about discharge plans for various patients. I was told for some of them that they didn’t have target dates, but that they made up dates for patients to keep them quiet. I asked what the patients thought of this and they said they usually forgot anyway. Needless to say, this sort of dishonesty is easy to catch (the staff thought I was ‘like them’ and would understand the need; I wasn’t and I didn’t); doing good chart audits of this sort are part of a detailed hospital regulatory inspection. Are the staff still dishonest, though? Let’s just say they didn’t do very good care planning as they had no target dates for discharge against which to calibrate resource use and then review when things didn’t happen as planned. Easy to pick up. With better care planning, it is easier to be honest with the patients.

I take a leaf from the nuclear industry regulatory inspection process. A basic assumption is that the regulated have good reasons to conceal, mislead and hide relevant information.  Since the stakes are high that poor inspection leads to system problems (think Japanese report on Fukushima nuclear site), starting from a position of doubt about the veracity of information enables a more robust approach to regulation.

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