19/01/2010 by Patrick Keady.

HSJs Fundamentals of Governance took place in London, late last year.

Click here to see my review of the Conference. For a .pdf, contact me via www.betteroutcomes.org

About Patrick Keady

Patrick helps NHS organisations make better decisions. A former NHS Director of Governance and Strategy, he received awards from the BMA and IOSH. Patrick is a Company Director, a Trustee at a Chartered professional body and Editorial Board member at a peer-reviewed Journal. For more information, click www.betteroutcomes.org

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31/03/2009 by Patrick Keady.

The NHS Institute has been an exciting place to work. During my 18 months with them, I led the development of their intranet-based risk register and board assurance framework, standing orders, standing financial instructions and scheme of delegation.

As well as being a key link between the Institute and the Department of Health, I was actively involved in developing their balanced scorecard; sustainable development; reviewing the security of their people, buildings and information; the procurement of health and safety training and risk assessment services and lots more besides.

Working with the NHS Institute meant a lot me. Over the 18 months, it has transformed into an outward looking, customer-focussed organisation. Whenever I hear about NHS Live, Knowledge Management, World Class Commissioning, the Management Training Schemes, the Productives, Safer Care series … I’ll think of them.

And I’m looking forward to my next assignment at NHS Stoke on Trent.

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12/02/2009 by Patrick Keady.

‘Without a national study, politicians and health professionals go into denial ….. we don’t have a problem’. This was one of the comments for Sir Liam Donaldson when he opened the Patient Safety Research Portfolio Conference this morning at the Royal College of Physicians

Speaking to a selection of the researchers that participated in the 36 patient safety research projects undertaken over seven years, at a cost of about 70p per NHS England employee per annum. He outlined his vision of the ten contributions that patient safety research offers to improving healthcare, as follows:

•    increasing awareness of patient safety - with clinicians, provider organisations and commissioners
•    understanding the causes of patient (un)safe-ty – and in relation to sleep deprivation, Sir Liam reminded us of the importance of the 48 hour week - clinicians are more likely to kill patients when they are tired.
•    more research in the young discipline of patient safety will enhance safety and improve productivity
•    establishing conceptual concepts - to enhance the ‘poverty of concepts in patient safety’
•    developing solutions – including improved design in healthcare, a recurring theme throughout the day
•    setting standards for information – before and after studies, randomised control trials etc
•    informing evidence based care
•    evaluating progress including checklists - twice as effective as education
•    nurturing researchers
•    and promoting leaders in patient safety

Professor Richard Lilford oversaw the Patient Safety Research Portfolio from its inception and this morning, he highlighted some of the successes of the programme. These included Professor Nick Barber’s discovery that nursing homes openly welcomed the prospect of his team observing medication errors and recommending improvements – their willingness could be related to the significant amount of time that care home staff spend in medication-related activities.

The day was chaired by Professor Paul Barach, one of the best Chairs that I’ve seen at a healthcare seminar/conference. He has has a very rare ability. He keeps the audience interested, even during the ‘graveyard shift’.  And he ensured that all 17 leaders in patient safety research, delivered their presentations in less than 4 hours. Now that is a rare achievement.

Citing an (unnamed) study elsewhere in the world, we heard that 9% of clinicians wash their hands before they touch a patient in the operating room and 17% do so after they touch the patient. Enter Professor Sheldon Stone summarising the successes of the Clean Your Hands campaign – and reminding us of the rationale for the campaign - 8% of patients acquire healthcare associated infections and their mortality is six times higher. Direct contact by hand is the main route of infection and Sheldon delivered this very serious message, in an entertaining way.

Chris Fuller described HHOT – the hand hygiene observation tool and Professor George Hanna told us about the checking procedures developed by his team for naso-gastric tubes. Dr Rebecca Lawton highlighted the success and lessons learned in evaluating non-luer spinal connectors.

While risk metrices represent risk and are almost universal in healthcare, Professor John Clarkson highlighted their limitations - they lack a systematic approach. And this is why he and his team are developing a toolbox for healthcare, that will include risk assessment models and tools and a process for escalating the higher risks.

Dr Karin Lowson’s insight into single hospital rooms, was topical and revealing. Patients in single rooms are more satisfied. They are less likely to acquire infection experience medication errors during their hospital stay. That said, some patient in single rooms are more likely to die and experience depression. And the risk of an adverse event and length of stay are about the same for patients in wards and in single rooms.

Much has been said about enhancing the patient safety agenda on the curricula of healthcare professionals. And recommendations as to this an be achieved, were provided by Dr Pauline Pearson and Professor Amanda Howe.

Professor Ian Watt gave an overview of how patients can ensire that clinicians deliver safe patient care – by making sure that the treatment is appropriate for them, that the treatment is as planned and in accordance with the appropriate protocol, and identifying how the health system can be made safer.

Dr Ken Catchpole shared his line of enquiry in operating theatres and elsewhere in healthcare. And he has four key questions. Is the healthcare team’s approach consistent with achieving high standards of care. Is what they are doing acceptable for Ken and his family. Does what the team are doing have to be like this. Is this the best it can be? Simple questions, revealing answers.

And Professor Mary Dixon-Woods outlined six rules for governance in operating theatres. The organisation is geared to promote patient safety. Protocols are deployed appropriately and everyone serves their spirit. Optimum communication. Minimal distraction and interruption. Effective authority and accountability. Reporting patient safety incidents.

Professor Justin Waring is in the process of summarising the outputs from the PSRP under the broad headings of the nature of patient safety, sources of risk and safety, and identifying the future direction for research.

And Martin Fletcher was the final speaker, talking about the science of safety. The NPSA Chief Executive sees the patient safety research agenda developing by networking the researchers, funding more PhD students and running another UK patient safety research conference.
Some of the many highlights for me were hearing about the science of safety, Ken Catchpole’s approach to enquiry in patient safety, how patients can be more assertive, updating the curricula, design of hospitals and non-luer spinal connectors, prospective analysis, competency based training in naso-gastric tubes and handwashing, observing hand hygiene, the benefits and weaknesses of focusing on improving culture and CHUMS.

With many thanks to Sir Liam Donaldson, Professor Lilford, the PSRP team and all of the researchers for making this fantastic conference a reality.

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21/11/2008 by Patrick Keady.

While it seems obvious now, I’d never thought about equality and diversity like this before. Today I learned that equality and diversity affects all of us. Whether its because of gender, race, sexual orientation, bullying, home circumstances, nationality, disability, harassment, age, sickness absence etc.

Run by the Garnett Foundation, today’s session was all about exploring equality and diversity in relation to recruitment and selection. Using a range of interactive approaches, we practised and developed our interviewing skills. While professional actors played a number of diverse parts.

During lively interactive workshops, we explored staff retention and working cultures that foster inclusion and diversity. The training event provided a safe learning environment to highlight areas for improvement in our knowledge and understanding and also to share learning.
While I had heard a lot about the Garnett Foundation,  today’s training session met my expectations, and more.

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15/10/2008 by Patrick Keady.

I chaired NHS Risk Management today. Organised by the Health Service Journal, NHS Risk Management was their first conference that focussed exclusively on risk management.

Birmingham’s Centennial Centre was oozing with energy and attendees including clinical governance managers (10%), safety and health practitioners (15%), risk managers (35%) and directors (40%). And the delegates came from the full spectrum of healthcare organisations: SHA/other (5%), Foundation Trusts (10%), Independent Healthcare (20%), Trusts (30%) and PCTs (35%).

While I’ve been practicing in risk management for 20 years, I had mixed expectations of the conference …… and thankfully it was an enjoyable and informative conference. Here were some of the highlights for me.

Mark Burns, the Safety and Security Adviser at Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust reminded us of how risk management is now directly linked with Corporate Objectives. Trusts are more aware of their risk appetite - the level of risk that they are happy with. And he reflected on how reactions to incidents have improved – senior managers today ask ‘what happened?’ In the past, they would have asked ‘who did it?’

Linda Handley-Wright, the Risk Manager at Derby City PCT expanded on the theme of culture. The key is to make risk management interesting, using LEAN principles and engaging the right people. Linda added that organisations need to address different learning styles – including scenarios, what if’s and linking risk management with other initiatives via training needs analysis. In Derby, they’ve taken Standards for Better Health as the basis of something much better - they’ve produced the Healthy Derby 10-year plan aimed at improving health, commissioning and engagement.

And engagement was a key message from Dr Anne Dyas, a Consultant Microbiologist at Worcestershire Acute Hospitals NHS Trust. Dr Dyas urged that ‘we (people involved in managing risks) must get out there and teach. To be prepared to defend changes in practice with robust evidence’. She warned that changes introduced simply for public relations reasons will not be sustainable. Jobs done in haste will probably be done badly. Dr Dyas added that data is only as good as those that gather it – she warned against multiple data sources. Most extra tasks need extra hands and extra equipment. New initiatives must support the task (of infection prevention and control) and not add to it. And do Dr Dyas’s views work in practice? Definately. Dr Dyas’s team oversaw a significant reduction in MRSA and CDiff at their Trust and this helped them win the 2008 Oxoid Infection Control Team Award.

Anne Cleminson (Trust Secretary) and Steve Bradbury (Risk Manager) from Mersey Care NHS Trust described the key elements of Assurance at their Trust - getting buy-in from key stakeholders, Committees that are fit-for-purpose, an effective Assurance Framework and good communication. And the Trust’s biggest champions are the Non-Executive Directors because of their creativity and innovation.

Ian Strudley, Head of the Health and Social Care Services, Health and Safety Executive, reminded delegates that HSE is all about reducing the real risks – upto 250 people die every year at work in the UK and many more have serious injuries and ill health. HSE reduces the real risks, by balancing risks and benefits. He gave examples of how HSE is working in partnership with organisations such as the Healthcare Commission – agreeing the Concordat for joint working between regulatory and inspecting bodies. HSE works with the NHS Litigation Authority – workshops on stress management standards. And with respect to managing violence and aggression, it works with the NHS Counter Fraud and Security Management Service.

Stephen Williamson, the Corporate Health, Safety and Risk Adviser at University Hospital of South Manchester NHS Foundation Trust reminded us of what the ideal health and safety management system looks like - setting the policy, organizing, planning for action, measuring performance, auditing compliance and review. Steve reflected the views of many delegates with respect to NHS Patient Safety First – that it will succeed with Executive ownership, and clear commitment from clinicians, managers, corporate and support functions.

Gary Hay and David Firth, partners at Capsticks, gave an overview of key legal compliance and regulation. They described the risk-related legislation in place, CNST claims, the NHSLA risk management standards, employment legislation and stress at work. No real surprises there. And then they introduced a case-study about a patient scalded in a bath – and delegates faces lit up. The case study renewed the energy of the audience. The case study felt real and it gave the delegates and opportunity to contribute.

And then the controversial (and most thought-provoking) presentation – on World Class Commissioning. Controversial because it was close to home for many of the delegates. Roger Hymas from Humana, had recently completed a secondment as Director of Commissioning with Hampshire PCT. And he reminded us that on 4th July, the Financial Times proposed that the PCTs be turned into one giant health insurer. Roger highlighted eight ‘tests’ for insurers – and PCTs meet three of the tests, don’t meet another three and possibly meet the remaining two.

Roger identified his top-10 risks facing the NHS. And in reverse order they were:

10. The NHS will run out of money in the longterm, and not before the next general election (possibly June 2010). 2008 is the year when demand is running ahead of budgets and at the same time, PCTs are spending just 15% of what the private sector spends on managing Commissioning – the suggestion here is that PCT Commissioning functions need to be better funded and by implication, they need a greater range of skills in their teams.

9. Practice-based commissioning will not gain traction. While it is estimated that only a third of GPs will be willing and able to make practice-based commissioning deliver in the way that PBC advocates suggest, by increasing PBC activity, the NHS has the potential to redistribute significant amounts of money – with GPs switching patients from one Acute Trust to another.

8. Block contracts remain impenetrable to PCT scrutiny and validation, including mental health block contracts - see Risk 10 above about PCT Commissioning functions.

7. PCTs need to invest more in management systems. In other words if PCTS don’t put aside money to invest in management systems, they’re unlikely to get control of their PCT finances – links with Risk 10 !

6. The supply side will shrink - reducing competition and choice. This will be a consequence of Trust mergers and some of the private sector providers (including ISTCs) retreating from NHS provison

5. Patients need more encouragement to play their role in re-shaping the market. Consumer surveys consistently show that consumers want choice. Patient Choice has much more to do, if it is to achieve its potential.

4,3 and 2 - Is Monitor encouraging Foundation Trusts to be too aggressive in developing their financial strategies (?) through:
- the pursuit of earnings before interest, tax, depreciation and amortisation as a key measure of success.
- the building of significant capital reserves on FT balance sheets
- service line analysis which could lead to huge distortions in provision

PCTs that transfer money to their local FT and other providers are transferring the financial risk to themselves! They are also in danger of losing control of Commissioning. Armed with the management tools developed by Monitor, FTs may choose to cherry-pick the more financially profitable specialties and procedures. And FTs could choose to unilaterally decommission services, putting patients at risk.

1. WCC will not move fast enough - or fail.

What a thought-provoking presentation to end the day. And it suggests that provided PCTs implement robust risk management processes and they invest in management systems, then World Class Commissioning is likely to become a reality.

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06/04/2008 by Patrick Keady.

To download this article, click Summary of the Act

Here you will find a summary of the Act of Parliament that came into force today, 6th April 2008. Those who disregard the safety of patients, workers, visitors and others with fatal consequences, are more vulnerable to serious criminal charges: Corporate Manslaughter (in England, Wales and Northern Ireland) and Corporate Homicide (in Scotland). Examples are given of some of the actions that NHS organisations can take, to protect themselves from unlimited fines, publicity orders, remedial orders. Taking these actions will also help you to reduce the risk of making career-limiting decisions.

The lack of convictions resulting from these 276 deaths, contributed to the introduction of The Corporate Manslaughter and Corporate Homicide Act 2007: Herald of Free Enterprise (1987), 193 deaths. The Sheen Report criticised the P&O attitude to safety, asserting that ‘….from top to bottom the body corporate was infected with the disease of sloppiness….’. Kings Cross Fire (1987), 31 deaths. Southall train crash (1997), 7 deaths. Ladbroke Grove rail crash (1999), 31 deaths. Hatfield rail crash (2000), 4 deaths.

It applies to all NHS organisations, Arms Length Bodies, Independent Healthcare organisations and a wide range of other organisations including partnership employers (trade unions and employers’ associations), Government Departments and Police Forces.

The Act sets out a new offence for convicting organisations where there was a gross failure in how activities were managed or organised. Organisations will be guilty of the new offence if the way in which their activities are managed or organised:
• cause death and
• amount to a gross breach of a duty of care owed to the deceased.

This will arise where the organisation’s conduct falls far below what could have been reasonably expected. While ‘far below’ has yet to be defined in the Courts, Juries are likely to take into account, breaches of legislation and guidance: Health and Safety at Work etc Act 1974, Management of Health and Safety at Work Regulations 1999 and HS(G)65: Successful Health and Safety Management. They will also take into the following into account: how serious and dangerous the failures were, the risk of death posed; admissible expert evidence; patient and occupational safety & health guidance relevant to the breach; those attitudes, policies and systems demonstrating the acceptable practices in the organisation that were likely to encourage a lack of compliance with the above.

A duty of care exists for example, in respect to the systems of work and equipment used by employees, the condition of workplaces, other premises and in relation to products or services supplied to patients. The Corporate Manslaugher/Homicide offence is based on existing duties, already owed in the civil law of negligence.

• 84,000 – the number of patient safety incidents reported to the National Patient Safety Agency, resulting in some degree of harm to NHS England inpatients in 2006/07
• 2,000 – The National Audit Office reported that 2,000 patient deaths a year are attributable to negligence. It is unclear if any of these deaths result from gross failure in the management and organisation of care and other activities

It has been suggested that had the following four events occurred after 6th April 2008, that the relevant NHS organisation could have been charged with Corporate Manslaughter:
• NHS Trust (a) - 90 patients died from Clostridium Difficile.
• NHS Trust (b) – 1 patient died from an air embolism
• NHS Trust (c) – 1 patient tore a ligament and was treated successfully, then contracted MRSA and died.
• Window Restrictors – between April 2002 and March 2004, seven people died following a fall from, or jumping from the windows of NHS buildings. The Window restrictors were missing in all seven cases.

Courts will look at management systems and practices across the organisation, with a view to finding an effective means of prosecuting the worst corporate failures in managing patient and occupational safety & health. This introduction of this Act of Parliament, is an opportunity for employers to reconsider how risks are managed. Organisations are advised to ensure that they are taking proper steps to meet the legal duties referred to above in ‘Gross failure’.

Juries will consider how the fatal activity was managed or organised, including the systems and processes for managing safety and how these were operated in practice. A substantial part of the failure within the organisation will have been at a senior level. Senior level refers to those who make significant decisions about the organisation or substantial parts of it. These include headquarters functions and operational management roles. Consultant Doctors and GP Practices (but not individual GPs) might also be considered senior level.

Prior to 6th April 2008, health & safety investigations were usually lead by the Health and Safety Executive. However, all Corporate Manslaughter investigations will be lead by the Police. While NHS benchmarking successes (including the Annual Health Check) are essential in today’s NHS, it is unlikely that they will be relevant in the event of a Corporate Manslaughter investigation. For an overview of what will be relevant, check out ‘Gross failure?’ above.

An organisation guilty of the offence will be liable to an unlimited fine. The Act provides for the Courts to impose a publicity order, requiring the organisation to publicise details of its conviction and fine. This will be commenced at a later date, when sentencing guidelines are available in autumn 2008. Courts may also require an organisation to take steps to address failures behind the death (a remedial order).

Not under this Act - it is the organisation itself that will face prosecution. However, please note that since 1975, individuals can be prosecuted for gross negligence manslaughter/culpable homicide and for health and safety offences – under the Health and Safety at Work etc Act 1974. Prosecutions against individuals will continue to be taken where there is sufficient evidence and it is in the public interest to do so. As patient safety and occupational safety & health continue to move up the Corporate agenda, these prosecutions will probably be career-limiting too.

Failures by senior managers to successfully manage patient safety and occupational safety & health, will leave organisations vulnerable to charges of corporate manslaughter. Senior managers are advised to ensure that they and their organisation comply with current patient safety and occupational safety & health requirements. The Institute of Directors and the Health and Safety Commission has produced guidance entitled “Leading health and safety at work – Leadership Actions for Directors and Board Members” http://www.hse.gov.uk/pubns/indg417.pdf

Employers have a legal duty (RIDDOR) to report certain incidents at work, including work-related deaths. Where a criminal offence is suspected, the police will lead the investigation and work in partnership with the Health and Safety Executive, local authorities and other regulatory authorities.

While the Government expects that cases of corporate manslaughter/homicide following deaths, will be rare, here are examples of questions that NHS Organisations might want to reconsider today, to ensure that their patient and occupational safety & health culture continues to perform well in the future, and under increased scrutiny. Objective and subjective evidence will be crucial.

Who is responsible, from the Board through to Specialities? Which individuals are in the ‘senior level’? Do they understand their responsibilities? Are policies practical, audited and reviewed? Risk assessments are up-to-date? How do you notify staff of changes in policy? How are near-misses reviewed? Do you implement recommendations from SUI reviews, root cause analyses, investigations and Inquiries? Breaches, how does the organisation respond? Are minutes from these meetings actioned - Board and Committees, including Governance, Risk Management, Occupational Safety and Health, Patient Safety, Workforce, Clinical Effectiveness? Are emails and other correspondence reviewed? Are staff supervised effectively? 100% of staff are appraised regularly? How are underperforming staff managed? Are staff trained about policies and associated record-keeping?

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