Agenda item

Eileen Walsh (Chief Assurance Officer, Oxford University Hospitals NHS Foundation Trust) has been invited to present a report with an update on the John Radcliffe Hospital’s CQC Improvement Journey.

The Committee is invited to consider the report, raise any questions and AGREE any recommendations arising it may wish to make.

Eileen Walsh (Chief Assurance Officer, Oxford University Hospitals NHS Foundation Trust); Andrew Grant (Chief Medical Officer, Oxford University Hospitals NHS Foundation Trust); and Lisa Glynn (Director of Clinical Services, Oxford University Hospitals NHS Foundation Trust) had been invited to present a report with an update on the John Radcliffe Hospital CQC Improvement Journey.

The Chief Assurance Officer informed the Committee that the report provided an insight into how the organisation addressed the specific areas of improvements listed in the CQC report and placed them in the context of the wider strategic and operational developments that had been made.

The Committee enquired as to the level of staff and patient involvement in the development of the Trust strategy. The Chief Medical Officer informed the Committee that the strategy was developed with extensive staff and patient engagement. Staff engagement continued beyond the point of publication and adoption of the strategy in the form of regular staff listening events that included members of the leadership team, and were an opportunity to hear staff concerns.

Patient engagement had contributed to service development work in the form of patient partners and experts by experience, and individual work streams had involved patient recommendations where possible.

The Chief Assurance Officer added that the patient’s voice was kept at the heart of the strategy, and that Listening Events were held involving patients and stakeholders that had influenced the development of the strategy, as co-creation was the key platform for developing future strategies.

The Chair queried what opportunities there were for the strategic ambition of the Trust to integrate with the wider prevention agenda. The Director of Clinical Services explained that one of the Trust’s key priorities was the part that key acute providers could play in prevention. The Trust was heavily involved with early detection of cancer through the Targeted Lung Health Check Programme, that would be initiating in April 2024. The Trust worked closely with the community and partners in relation to Wantage Community hospital, and were looking to expand additional services that would meet the needs of local populations and support the demand seen in local hospitals for acute services. In order to address the demand on urgent care services, the Trust had been involved with the Integrated Neighbourhood Teams as well as the Primary Care Strategy. The Trust had also been looking at admission and attendance avoidance, and the development of same day emergency care services.

The BOB ICB Place Director for Oxfordshire explained that the Trust was trying to strike a balance between treatment and prevention. Oxford University Hospitals NHS Foundation Trust (OUH) was involved in many prevention projects, such as co-location of maternity services within ‘Flos in the Park’, the Early Lives Project, and the Hospital at Home service to support acutely sick people at home. The BOB ICB Place Director emphasised that the greatest long-term impact on prevention was to focus on children and young people, and the Community Paediatrics service was fundamental to this.

The Chief Medical Officer also highlighted the Oxfordshire Rapid Intervention for Palliative and End of Life Care (RIPEL) service for palliative care at home, and that the service had made a fundamental difference to the patients it had served.

The Committee queried whether resources would be increased for the Hospital at Home Service to ensure coverage in rural areas, and whether RIPEL would include Primary Care Networks (PCNs). The Director of Clinical Services informed the Committee that OUH were looking at what services were having the most effect to reduce attendance to acute hospitals, including the Hospital at Home service, which was a key programme to manage demand and to support patients to be at home. RIPEL was a service that the Trust was committed to and wanted to evolve further and would build into PCNs and integrated neighbourhood teams. The challenge would lie in the reorganisation of resources and the allocation of funding, and the Trust was assessing this for next year to determine how resources could be used to the best effect.

The Committee enquired about how technology was being used to improve patient safety. The Chief Medical Officer informed the Committee that a lot had happened in the last five years to develop the Trust digitally. The Trust invested in the electronic incident reporting service Ulysses that provided a digital architecture for a greatly strengthened patient safety response framework. Electronic patient records provided electronic observations so that teams could view vital signs on patients remotely. Another important change was the introduction of daily Patient Safety Response meetings where senior leaders from across the organisation reviewed every incident from the last 24 hours with moderate harm or above, which allowed close oversight of patient safety in the organisation, and ensured the Trust was responsive to incidents and had the right learning response. The new national framework for responses (PSIRF) focused on changing the culture from one of blame to one of learning and improvement, and offered a range of different incident learning responses such as After-Action Review, Multi-Disciplinary Team Learning Reponses and Patient Safety Incident Responses (PSIIs).The framework introduced thematic responses, so that when incidents occurred, they fed into the broader longer term improvement plan rather than being taken independently. The work was supported by patient safety partners, service users who were part of the safety response framework and contributed to reviews of cases, and some committees that oversee these workstreams. Alongside this, there had been significant safety retraining for all staff, from basic training for all staff to more detailed levels for patient safety experts.

The Committee enquired as to who monitored the databases created by the collection of data. The Chief Medical Officer explained that there was a Governance team that overlooked the databases and provided monthly reports with breakdowns of all incidents by harm level and type of incident. For example, there had been an increase in incidents of violence and aggression against staff over the last year that had been tracked, and which the Trust had provided staff support for. The database allowed the Trust to track specific incidents such as hospital-acquired pressure ulcers and this had been the focus of integrated quality improvement work, the result of which there had been a third reduction in these incidents. The data was important in helping the Trust to understand what the incident risk profile was, and to target learning and improvement responses accordingly.

The Committee queried whether the Trust had programmes for staff wellbeing, such as self-harm diversions built into search engines. The Chief Medical Officer informed the Committee that there were numerous internal and external supports for staff clearly signposted on their intranet, and a staff support service had been created, although he was not aware of wellbeing programmes built into the Trust’s search engines. The Chief Assurance Officer added that there was an employee assistance programme available 24/7 to provide counselling to staff for both personal and professional issues.

The Chair queried whether significant learning was communicated to patients and families affected, and whether they were involved in the learning journey. The Chief Medical Officer informed the Committee that communication with families was essential and would always occur after these incidents under the Trust’s duty of candour. Patients were always invited to share their questions after serious incidents, and outcome reports were shared with them. The Trust had sought to triangulate the learning from complaints, so if a complaint had been received it would be examined to see whether an incident needed to be created to learn from it, and a weekly meeting aimed to derive learning from this.

The Chief Assurance Officer highlighted that the Trust board and non-executive members took a strong interest in patient safety, and the Chief Executive implemented a direct feedback mechanism with clinical teams who were involved with serious incidents to present their reflections to the executive team. Several key committees had been introduced; including the Risk Committee to discuss proactive risks and thematic risks; the Productivity Committee to focus how to progress performance in the organisation; and the Delivery Committee to ensure large programmes of work had been implemented. The Trust had ensured that patients had been involved in the aftermath of incidents, and had been provided with both clear explanations to understand what went wrong as well as a swift apology when the Trust was at fault.

The Committee queried how the values of kindness and caring were taught in the organisation and how this was evaluated. The Chief Medical Officer responded that the organisation prioritised kindness, and kindness interaction training was provided to all senior leaders. The success of this was measured by examining metrics produced from staff surveys and by looking at sickness and turnover rates.

The Committee asked if data could be provided to show how improvements had been made. The Chief Assurance Officer informed the Committee that the Trust could provide metrics that demonstrated the improvement trajectory over the last few years. This data could be supplemented by staff and patient surveys that provided anecdotal and human experiences. The Chief Medical Officer added that the board adopted a nationally recommended approach of presenting data, using Statistical Process Control (SPC) charts that helped focused discussions and identified improvement areas.

The Committee enquired as to how strong the internal audit function was and how the sharing of patient stories was imbedded in the organisation. The Chief Medical Officer explained that not all incidents generated patient stories that go to the board, but the patient experience team supported stories that generated different learning to help the board gain insight into the range of issues faced by the organisation.

The Chief Assurance Officer added that although patient stories were not heard at every committee, stories were sometimes made into videos that could be shown before conferences. The Trust had a very strong internal audit function that developed a comprehensive audit plan every year, which was formed with cooperation from all the executive directors and the areas of examination were stress-tested. The audit committee, chaired by non-executives, received this plan, and examined it with auditors to determine key risk and concerns.

The Committee AGREED to submit further questions to OUH around the specific service areas of gynaecology, Surgery, Maternity, and urgent & emergency care, and to request written responses to these questions subsequent to the meeting.

The Committee AGREED to issue the following recommendations to OUH:

1. For the Trust to continue to take improved measures to improve patient safety at the John Radcliffe. It is recommended that staff are sufficiently supported and trained in being able to maximise patient safety.

2. For ongoing stakeholder engagement and coproduction to be at the heart of the John Radcliffe Hospital’s efforts to address the concerns identified by the CQC, and for there to be clear transparency around this, with further evidence of this to be provided.

3. For clear transparency around the Trust’s efforts to address the CQCs concerns around the John Radcliffe. It is recommended that there are clear indicators that could help determine how improvements in the John Radcliffe are being driven overall as well as in the specific service areas of Gynaecology, Maternity, Surgery, and Urgent & Emergency Care.

4. For sufficient resources to be secured for the purposes of delivering and potentially expanding the Hospital at Home Service.

5. For a site visit to be orchestrated for the purposes of providing the Committee with insights into the measures taken by the Trust to improve patient safety at the John Radcliffe.