Answer

Quality Improvement in Health and Social Care

Introduction

Liverpool Community Hospital NHS Trust was formed with a new Board and senior employees and got insufficient inspection since it was perceived as low-risk, partly because of the nature of the services offered. The outcome was avoidable harm to patients over several years and preventable stress for employees who were, in some instances, bullied and distraught when they attempted to raise concerns regarding worsening inpatient services. These failures were recurrent in the health services LCH offered to HMP Liverpool and added partly to the more significant challenges facing the prison. This paper analyzes the aspect of patient harm as service failure from this case study. This paper also provides recommendations and improvement plans on how LCH can correct the patient harm challenges.

Task 1

In the recent past, substantial investment has been channeled to healthcare service restructuring methods in dealing with the rising problems confronted by the sector, such as the aging population, limited funding, and medical inflation.  Appleby (2015) highlights that as the Health and Social Care Act began in 2012, the UK government spent averagely £1.5 billion in launching prevalent performance development changes to NHS services. Initiatives like process remodel, and health data structures implementation is always pursued togrow the productivity and quality of healthcare supplied while concurrently decreasing waiting times. Pickles et al. (2008, p.5) assert that health service restructuring programs have conventionally concentrated on two areas; performance improvement and supervisory limitations, patient encounter, and less consideration. A competent and conforming procedure does not certainly imply an extraordinary experience will be conveyed (Bate & Robert,2006, p.308). For example, a patient might get an appointment fast, but their broad experience will be miserable if, for instance, the waiting room is congested. The patient encounter should be the primary objective, together with delivering performance enhancement and meeting limitations. 

From the outset, LCH was a dysfunctional organisation that acted inaptly in pursuit of Foundation Trust (FT) status, planning infeasible financial targets that dented patient services. LCH provided services that were ill-equipped to handle mainly prison healthcare in HMP Liverpool. The Board and Senor leadership of LCH failed to acknowledge that LCH was beyond its depth and never considered the outcomes. Employees were overburdened, demotivated, and in some situations, bullied. External NHS bodies failed to realize the challenges for four years as the management team as inexperienced and new (Kirkup, 2018, p.3). LCH Board’s main goal was to become an FT, although frontline employees never shared this viewpoint. This goal dominated the management team’s time and focus, and they and the Board became blind to the real concerns that started arising in the company. 

LCH has enough contract revenue to continue with the previous service level when it started. LCH was asked by its commissioners to attain a very substantial cost-saving over the next four years. It seems to have provided no challenges to the viability of achieving this while sustaining current service levels. CCGs and NHSE commissioned LCH services, and it is not apparent that any had a general view on the cumulative effect. This naivety on the LCH part tipped it into a situation of massive cost pressures. Coupled with their acknowledgment of an unsustainable revenue position, LCH undertook to produce an enormous cash surplus in the same period (Kirkup, 2018, p.4). This seems to have been triggered by the desire to show a strong financial position to get the FT application. However, the cumulative effect of this with the revenue reduction was not sufficiently deliberated. To tackle the external and self-imposed cost pressures, the management team began on various radical cost-improvement measures. The suggested cost improvement primarily entailed decreasing staff numbers given the community services nature. Suggestions were subject to quality impact assessment (QIA). This procedure should have recognized the adverse impacts on services and whether they could alleviate. If adverse impacts were deemedinsurmountable, the suggestion would have been abandoned. However, these evaluations were deficient in LCH and failed to recognize the visible adverse impacts of the proposals that were executed. When QIAs are done, they were not actively handled nor thoroughly reviewed. 

The adverse effects of such an ambitious cost improvement program were firstly a demotivated staff. The staff were not involved in the staff reductions plan and felt they were not listened to. Hence sick leave amongst staff rose, which worsened staffing levels further. Secondly, though it was apparent that most staff endeared to compensate for employee reductions, it is equally evident that services started to suffer irrespective of their efforts (Kirkup, 2018, p.4). The frequency of patient harm cases subject to compulsory reporting nationally grew, comprising pressure ulcers and falls. Other occurrences, some grave, should have been reported and investigated. But staff highlighted that reporting was dejected, the investigation was inadequate, events were continually downgraded in significance, andaction planning for improvement was lacking or invisible.

At Liverpool Community Health NHS Trust (LCH), patient experience was not considered in their healthcare delivery.  Prevention of patient harm is foremost to health services quality, comprising their safety, and relies on some vital elements. Firstly, clinical care must be offered based on evidence-based criteria, by adequately experienced and skilled staff working collaboratively. Secondly, there must be an organizational culture that fosters openness and learning through operative professional and managerial leadership and administration (Harrison, 2004, p.20). Thirdly, clinical governance must be useful, to allow timely identification of any deviation from the necessary standards, so that the causes are highlighted, and corrective measures executed speedily. According to the CQC’s report, staff who were confronted with substantial and always overwhelming challenges from the situations they were operating in, reacted to the problems by putting in more time, not taking days off, and training to manage excessive caseloads. Employees were doing their best to uphold patient safety and guarantee that they were treated with empathy and dignity regardless of the problems. Irrespective of these efforts, CQC’s report discovered that the care provided amid the review period was unsafe in noteworthy areas, that employees should not have been put in this situation, and that avoidable harm came to patients (Kirkup, 2018, p.15). The most affected services were community dentistry, intermediate care, and healthcare in HMP Liverpool. LCH staff operated in a reactive environment, and prevention work was not established promptly. LCH lacked appropriate reporting and care planning, which were severe patient safety indicators that should have provoked immediate action and an evaluation of the reporting culture in the Trust.

The process mapping tool below illustrate the barriers the patients experienced when accessing LCH services at the emergency department, and how these barriers were severe patient safety signs that should have triggered prompt action to prevent patient harm.

Task 2

Recommendations

LCH should embrace caring for patients as a team activity. Competent patient care depends on individual staff in a department working in effective collaboration. During complex care management, precise objectives should be written and agreed with patients, which all team members should know and communicate (Langley et al., 2009, p30). As a team, the staff should know their roles in enhancing the patient outcome and for the optimum delivery of care. Hence this calls for constant evaluations, reviews, handovers, briefings, and feedback amongst team members to foster professional relationships and Trust. Also, it encourages seamless care delivery and a transparent environment, mostly to avert care delays. LCH should improve their multi-disciplinary teamwork and communication during handovers and across the management and leadership at all levels. Also, clinicians should be actively involved in decision-making procedures.

LCH should adopt a “Just” culture where honesty and transparency are a crucial ingredient to recognize the root cause if care does not meet standards, or when care is not executed as planned. It mandates that staff operate in an open and transparent setting, where employees expose cases and identify near-miss incidences to avert adverse occurrences on care. Likewise, it obliges employees to pursue a duty of forthrightness procedure with patients and families when a patient safety incident happens and impairpublic confidence (Langley et al., 2009, p.20). LCH’s culture of prejudice,distrust, andanxiety, with an apparent absence of care for the employees’ capability to offer services to the standards needed, impaired their compliance to declare incidents and learn from them.

LCH should adhere to Regulation 17 HSCA (RA) on good governance. LCH systems and procedures as per the CQC report were not often operated effectively in ensuring that the risks about the health, safety, and wellbeing of service users and others were evaluated, monitored and mitigated in a timely way. LCH has unacceptable waiting times in some allied health and treatment specialisms. The number of patients reporting to one team leader was excessive, and though this was documented as a danger, steps were not taken to mitigate this risk in a timely way. Operational, clinical governance is a prerequisite for all NHS providers to guarantee that patient safety and clinical efficiency are monitored and enhanced. This was lapses in care standards are recognized and corrected immediately. It relies on useful information, structures to supervise and evaluate, and leadership to guarantee that signals are not only accepted but are likewise acted upon (Langley et al., 2009, p35). Good clinical governance relies on pro-active intervention, mostly to guarantee that risks are acknowledged and that learning from safety occurrences leads to improvement.

To enhance patient safety, LCH should encourage constant staff training to be up to date with compulsory and legal training prerequisites, comprising fundamental life support training, which is of concern in a high-risk environment. 

LCH should use the decision support toolkit authorized by NICE to foster the systematic method of ascertaining the nursing staff necessities. Also, LCH should identify the suitable expertise and nursing aptitude mix needed in the team in meeting the nursing needs of LCH patients. The nursing staff requirement should be based on the staff hours and the activities that can be safelyassigned to trained and skilled staff. This will ease the problem of burdening staff excess workload. LCH should likewise consider hiring more staff because the current staff number they have been overwhelmed.

Task 3

Reducing Medication Management Errors using Root Cause Analysis

Safe care requires healthcare providers to make choices and act when facing dangerous circumstances that imperil patient security and handle possible incidents. Patient safety implies lessening the risk of unwarranted harm to a tolerable minimum. The healthcare providers oversee the risk process evaluation for the resultant decrease and prevention of patient harm. Mostly in inpatient settings, various factors add to incidents happening like patient severity, the usage of sophisticated equipment, amongst other factors. 

From the case study, IG&QC Meeting minutes in December 2014, an incident was identified where a patient was not given the prescribed epilepsy drugs, resulting in the patient having a seizure the next day. Also, there has been a near-miss when another patient was not given their medications for four weeks at HMP Liverpool (Kirkup, 2018, p.32). HMP Liverpool had no secure and suitable processes in place for controlled drugs management. There were no verifying and no double-signatory when drugs were distributed. The staff was not trained, and there was a failure to undertake continuously controlled medicine register inspections and weekly balance assessments when these incidents happened. The team was giving substitute drugs if the prescribed medication were out of stock. The staff was under pressure to administer medicine to many patients in a limited time, leading to teams finding inadequate methods to save time. 

The review further highlighted another medical error case where the patient was given medicine that was not prescribed for that medical condition. The notification registries highlighted that the drug was suspended and not communicated. From the interviews and observations done by the CQC report team, it was revealed that the medical warning is transcribed on an individual’s card for every patient and is used for workforces as a guide for drug administration (Kirkup, 2018, p.33). The cards are not customarily updated during the sift due to time constraints. Following case analysis, these unsafe actions were identified as the staff failure to revise the patient’s card, which is a circumstance that could be avoided if the staff had communicated the change. Hence, insufficient communication amongst the nursing team, poor drug administration, lack of staff training, and competence and policies and procedures not being followed were identified as the contributing factors to the medication management errors at LCH that caused patient harm.

Therefore, to ensure safe care for patients at LCH, LCH must train the multi-disciplinary team on communication with importance given to topics linked to efficient communication when providing patient care (Kim & Bates,2006, p.150). Also, LCH must implement a program for the induction of staff and integrate this program in the Trust. For quality improvement to become an essential and daily practice at LCH, the Trust will establish a Quality Improvement Committee by August 30, 2020. The Committee will be tasked with ensuring that LCH receives zero patient harm cases through monitoring the performance improvement outcomes of staff and helping in key processes when needed.  Also, the Committee will perform monthly performance reviews. The Committee will also ensure that the team is trained on the quality improvement plan annually and other training on improving patient safety.

Plan, Do, Study, and Act Approach to Reduce Patient Harm Through Staff Training

Aim

By December 2020, LCH intends to improve on service delivery at HMP Liverpool caused by poor organizational culture, lack of systematic clinical governance, and clinical competence from 10% to 60%.

Plan

Activities to be done to effect the change.

Predict what will occur when the activity is done

Do: Describe what occurred when the activity was done.

Study: Describe the measured outcomes and how they compared to the predictions

Act: Describe what modification to the plan will be made for the next cycle from what you learned

In conclusion, this paper has adequately discussed the patient harm aspect of service failure in the case study. Also, this paper has provided recommendations for improvement, and devised an implementation plan for avoiding medical management errors and staff training.