PICU service DRAFT
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METHODOLOGY The method for working with the CQC report data consisted of six key stages:
1.
identify the numbers of general practices in the south-west of England that had been reported on by the CQC, and the number in each overall rating category
2.
determine the best method for extracting useful information and examples from the reports
3.
extract and summarise report data
Identifying the number of general practices in the south-west that had been reported on by the Care Quality Commission
The CQC has publicly accessible data on its website (see www.cqc.org.uk/content/how-get-and-
re-use-cqc-information-and-data#directory
).
The steps followed to identify general practices are detailed in Appendix 15
. This process produced a list of all the general practices within the ReGROUP catchment area that had been reported on by the CQC (see Table 38
). The ReGROUP catchment area includes the City of Bristol, Cornwall, Devon, the Isles of Scilly, North Somerset, Plymouth, Somerset, South Gloucestershire and Torbay.
TABLE 38
South-west England general practices with overall ‘outstanding’ CQC rating (
n
= 16)
Sampling took place in January 2016 using the CQC data set that had been completed up to 1 December 2015. There were 442 active location practices in the ReGROUP catchment area, of which 227 (51.4%) had been inspected and rated and had had their inspection results made publicly available (see Table 11
).
Obtaining Care Quality Commission report data
Each rated practice has a dedicated web page on the CQC website (e.g. .) with the following data
publicly available:
1.
an Overview tab that contains:
o
inspector’s description of the practice
o
overall rating
o
rating for each of the five key questions
o
rating for each of the key services/population groups
o
link to a portable document format (PDF) of the CQC inspection report.
2.
an Inspection Summary tab
3.
a Reports tab
4.
a Registration Info tab
5.
a Contact tab.
For each practice included in this analysis, we extracted:
overall rating
location ID
location name
postcode
publication date
copy of the inspector’s description text pasted onto the template.
A copy of the full CQC inspection report PDF was also downloaded, saved, and printed.
Determining the best method for extracting useful information and examples from
the Care Quality Commission reports
An iterative approach was used to determine the best method for extracting useful information and examples from the CQC report secondary data. All approaches were discussed and reflected on by the workstream 3 team, until a final decision about the methodology was reached.
Initially a standard thematic analysis was attempted: all report data were uploaded to NVivo version 10, a coding frame was jointly agreed by the workstream 3 team, and three complete reports were individually coded. However, it quickly became apparent that the amount of detail and repetition within the CQC reports meant that a content analysideters approach was time-
consuming and resulted in extraneous coding that did not meet with the aims and time frame of this aspect of the qualitative work.
The second approach was to apply a typology analysis to the report data, this time reviewing the responses to each of the five key questions across the reports, sampled from all of the four rating categories. This was completed for one question using a sample of 10 reports. However, it was recognised that this output did not provide any useful findings over and above the question prompt list provided by CQC for each of the KLOEs.
The final approach was to categorise themes from the CQC’s own identified examples of good practice (see www.cqc.org.uk/content/examples-outstanding-practice-gps
; accessed 25 April
2016) along with examples extracted from the sampled reports. These themes and examples were
used to identify key interview prompts for GP interviews, and to provide illustrated examples from practice.
FINDINGS Is the service safe?
Inspectors identified ligature anchor points and environmental risks on all inpatient wards. There had been two patient deaths on the acute wards in 2022 - both had involved the use of a ligature. One of these had involved the use of a fixed ligature point. Individual patient risk management plans were mostly generic, did not refer to environmental risks, and were not updated according to identified risks.
The trust and ward staff had not ensured that mixed sex wards were laid out, utilised, and monitored to mitigate associated risks and prevent sexual safety incidents. Staff did not sufficiently monitor and observe single sex spaces. Male and female corridors were unlocked and accessible to any patient or staff. In the last 12 months there had been 111 incidents involving 'sexual abuse' or 'sexually inappropriate
behaviour' across the 9 acute inpatient wards. 2 of these were categorised as serious incidents. Inspectors also noted blind spots in the ward environments on Elizabeth Casson House, Oakwood, Juniper and Cherry wards, without mirrors or CCTV to mitigate the associated risks.
A patient on Oakwood ward had informed staff that they did not feel safe around some other patients
in communal areas. The patient was involved in a physical altercation with 2 patients and it was later found that they had acted to protect themselves as staff had not been available to support them. On Elizabeth Casson House we observed a patient becoming distressed in a communal area. Staff were
not within the communal area and did not respond to the patient until an inspector brought this to their attention.
Is the service well-led?
Leaders had a good understanding of the services they managed and the current challenges they faced. Ward managers and matrons took action to respond to challenges for their wards but did not always feel that timely or effective action was taken when concerns were escalated to more senior managers or other divisions within the trust. Staff did not always feel respected, supported and valued.
Concerns were varied across wards but included; permanent staff being rude and unsupportive to agency staff, bed managers and duty managers overruling ward staff clinical decisions to refuse admissions, and a lack of understanding or response to the challenges and stress faced by ward staff.
Staff and leaders on all wards told us that repairs and improvements to the ward environments were delayed or difficult to arrange due to a lack of funds. Ward staff told us that there were financial pressures within the trust that compromised quality of care.
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There was a trust sexual safety improvement project underway but this was in its infancy and staff had a limited understanding of the project and their role in it. Some staff and managers were unaware of the serious sexual safety incidents that had occurred elsewhere in the trust and the initial
learning from these.
Discussion
Measuring quality In its strategy for 2016 to 2021, CQC articulates its aim to move to a more intelligence-driven model of regulation and inspection across all health and social care sectors, and it has replaced IM with a new system, CQC Insight (Care Quality Commission 2016a). In that light, it is worth considering what lessons can be drawn for CQC Insight from our research. Proportionate or risk-based regulation requires the regulator to be able to monitor performance and adjust its regulatory response accordingly. We would therefore expect CQC’s quality monitoring systems to have some predictive value. We do not think that the system of IM has been able to support such prioritisation and targeting of regulatory resources. The predictive value of quality-monitoring datasets might be improved by using more up-to-date data; using time series data to take into account changes in provider performance over time; and using a wider range of data sources. However, our research suggests that there are limits to how much regulators such as CQC can design and implement risk-based or responsive regulatory models that target regulatory interventions to providers based on available performance metrics. We welcome CQC’s efforts to develop a more insightful monitoring system, which draws together both hard and soft intelligence from a wide range of sources, and takes into consideration providers’ own ability to accurately and honestly selfevaluate. However, the difficulty of doing this in practice should not be underestimated. This challenging work must engage patients, users, providers and commissioners in the development of a multifaceted monitoring tool. Impact of the Care Quality Commission on provider perform
The role of inspection in systemic transformation In order for CQC to have impact at a system level, there is a presumption that stakeholders in the system agree on the diagnosis, and have the capacity, capability and will to unite and take action. If CQC is reliant on wider stakeholder groups to support providers towards compliance, this support must be available on a more consistent basis across sectors, and stakeholders need to be aware of their role. CQC
needs to work more closely with stakeholders (particularly commissioners and other regulators) to support providers to improve, and, when appropriate, manage the consequences of a closure. This includes further alignment of the regulatory processes of the different regulators to ensure they complement, and do not conflict with, one other. NHS England and NHS Improvement have recently announced their intention to work in closer partnership in overseeing the health sector (NHS England and NHS Improvement 2018). CQC could play a significant role in this partnership, through aligning regulatory processes and maximising the potential systemic impact; building on work already under way to agree a consistent approach to defining and measuring quality with other arm’s length bodies (Care Quality Commission 2016a). In order to have a sustainable impact on local systems, CQC needs to join up
its assessments with NHS Improvement and NHS England, as well as commissioners, professional networks and other key actors in local systems; something that has been found to be difficult in the past.
CHANGE MANGEMENT PLAN
To develop innovative strategies that improve quality of healthcare services: it will be
crucial in improving the healthcare services
provided by the hospital in terms of
excellence by using tools as well as methods fostering patient’s outcome alongside
healthcare quality.
To develop innovative strategies that improve quality of healthcare services: it will be
crucial in improving the healthcare services
provided by the hospital in terms of
excellence by using tools as well as methods fostering patient’s outcome alongside
healthcare quality.
To develop innovative strategies that improve quality of healthcare services: it will be
crucial in improving the healthcare services provided by the hospital in terms of
excellence by using tools as well as methods fostering patient’s outcome alongside
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healthcare quality.
It is up to those in leadership positions to engage employees in having
a say in what is happening within their workplace (Porter-O’Grady, & Malloch, 2015). That will have a positive effect on the organization and
lead to sustainable changes and is necessary for improved outcomes. By improving the teletracking system so that it functions the way it was
intended to, the organization will be able to ensure that the right patient will be in the right place at the right time. This improvement will
also allow staff to make sure they are using the right resources necessary to bring about system changes while keeping within their allowable charge reimbursements .
T he leader needs to review the current situation and look for waste and inefficiency (Leming-Lee, Terri, & Betsy, 2017). Any process that does not add value should be removed. It is important for staff to see willingness from the leader plus ample amounts of courage, passion, energy, discipline, and trust (Porter-O'Grady & Malloch, 2015). Having these inner qualities while following the planned steps to improve the system can allow for the work to progress smoothly and create hopefulness among the employees. It will also give staff a willingness to work on improving the organization.
Stakeholders
A long list of stakeholders had to be considered to move forward the project. These ranged from patients and their families to healthcare professionals and policy makers.
Communication Approaches for A Change Management Plan
Every organization should be embracing change as well as transformation towards beingflexible and adapting in the market. Methods of effective communication should be used towardsensuring the success of the program whenever embracing change. Efficient as well as effectivecommunication is crucial in healthcare as it is guaranteeing easy acquisition and recording ofpatient’s data and information for safe removal. It is also assisting in coordinating departments,employees as well as agencies in providing the needed care (Ballantyne, 2017, p. 59).Clinicians use an integrated approach to communication and change management forpassing crucial information in the change management plan. An integrated approach allows healthcare management to gather future information alongside adopting the information to therequired recipient. Clinicians can ensure that all messages for communication are connectedtogether towards giving approach that is a holistic regarding provision of healthcare servicesthrough an integrated communication approach. The method is addressing prevention as well asresponsiveness within a poorly managed healthcare organization. The approach has ensured thathealthcare programs are
connected towards satisfying advancement operationally andtechnologically
SMART ACTION PLAN
A multidisciplinary, collaborative formulation of SMART
seclusion ending indicators has potential to reduce total episodes and time
spent in seclusion. However, for individuals with ongoing risk of harm
to
others as a constant feature of their
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presentation this may increase time
nursed under seclusion policy in a less restrictive
environment. Reasons
for this may include setting unrealistic and unattainable targets for this
subset of patients.
A multidisciplinary, collaborative formulation of SMART
seclusion ending indicators has potential
to reduce total episodes and time
spent in seclusion. However, for individuals with ongoing risk of harm
to
others as a constant feature of their presentation this may increase time
nursed under seclusion policy in a less restrictive
environment. Reasons
for this may include setting unrealistic and
unattainable targets for this
subset of patients.
A multidisciplinary, collaborative formulation of SMART seclusion ending indicators has potential to reduce total episodes and time spent in seclusion. Seclusion is a controversial, highly restrictive method of managing risk displayed by acutely disturbed patients. My aim is to investigate the effect on rate and duration of seclusion episodes when Specific, Measurable, Achievable, Reproducible, Time bound (SMART) targets are agreed with patients and health professionals for ending a period of seclusion.
CONCLUSIONS
Overall, PICUs appear to be meeting standards relating to ward orientation, privacy and dignity and patients being able to talk to staff. Carers are able to express their views and are offered information about the unit. Findings for qualified nursing staff were particularly positive, with all but one standard answered positively by over 70% of respondents. However, areas for improvement are also highlighted. For patients, this concerns having access to information and involvement in care planning, therapy and activities, medication management and complaints. Carers rarely receive an assessment of their needs or are involved in risk management plans. Finally, PICUs are not rehearsing responses to alarm calls regularly.
Overall, there appear to be no significant differences in the key standards relating to quality of care that have been measured between PICU and acute wards. For staff, the only significant difference regarded more opportunity for one-to-one time with patients on a PICU. This might be expected as PICU provide higher levels of staff input (Beer et al. Reference Beer, Pereira and Paton
2001
).
Qualified nurses gave a more favourable opinion than did patients of
all but one of the standards that they both rated. Reasons for this are unclear and warrant further exploration, but highlight the importance of obtaining a diverse representation of people who
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experience life on a PICU. One possibility is that the nurses are referring to their standard practice with patients as a whole and patients to their individual experiences.
Implications Our findings have implications for both clinical services and future research. If we seek to reduce coercive interventions in mental health services, it is important to determine which patients are at greatest risk for such interventions using accurate, unbiased clinical data and multivariable models. In the current study, we show that whilst recent behaviour is clearly an important determinant of PICU and seclusion use,
patient age, sex, admission status and time since admission also contribute to risk of receiving these measures. Alternative, less coercive strategies must meet the needs of patients with these characteristics. From a research perspective, given that randomised controlled trials evaluating the effectiveness of seclusion and PICU are likely to pose ethical and logistical issues, it is essential to identify factors that distinguish cases and controls as such factors (if not accounted for by randomisation) will need to be appropriately dealt with in statistical models.