{"id":2716,"date":"2013-02-06T20:58:21","date_gmt":"2013-02-06T20:58:21","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=2716"},"modified":"2013-02-06T20:58:21","modified_gmt":"2013-02-06T20:58:21","slug":"the-francis-report","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=2716","title":{"rendered":"Robert Francis QC"},"content":{"rendered":"

\"press_on_screen_anim_150_wht_7028\"<\/a>Today is an important<\/span><\/strong> day.<\/p>\n

The Robert Francis QC Report and recommendations\u00a0from the Mid-Staffordshire Hospital Crisis has been published – and it is a sobering read.\u00a0 The emotions that\u00a0just the executive summary evoked in me were sadness, shame and anger<\/strong>.\u00a0 Sadness for the\u00a0patients, relatives, and staff who have been irreversibly damaged; shame that\u00a0the clinical professionals\u00a0turned a blind-eye; and anger that the\u00a0root cause has still not been exposed to public scrutiny.<\/p>\n

Click here<\/a> to get a copy of the RFQC Report Executive Summary.<\/p>\n

Click\u00a0here<\/a>\u00a0to see the video of RFQC describing his\u00a0findings.\u00a0<\/p>\n

The root cause is ignorance<\/strong> at all levels of the NHS.\u00a0 Not stupidity. Not malevolence. Just ignorance.<\/p>\n

Ignorance\u00a0of what is possible and ignorance of how to achieve it.<\/p>\n

RFQC rightly focusses his recommendations on putting\u00a0patients<\/strong> at the\u00a0centre of healthcare\u00a0and on making those paid to deliver care accountable\u00a0for the\u00a0outcomes<\/strong>.\u00a0\u00a0Disappointingly, the report is\u00a0notably thin on\u00a0the financial\u00a0dimension other than saying that financial targets took priority over safety and quality.\u00a0 He is correct. They did. But the report does not say that this is unnecessary – it just says “in future put safety before finance<\/em>” and in so doing\u00a0he does not challenge the belief that we are playing a zero-sum-game.\u00a0The\u00a0 assumotion that higher-quality-always-costs-more.<\/p>\n

This assumption is\u00a0wrong and can easily be disproved.<\/p>\n

A system that has been designed to deliver safety-and-quality-on-time-first-time-and-every-time costs less. And it costs less because the cost of\u00a0errors, checking, rework, queues, investigation, compensation, inspectors, correctors, fixers, chasers, and all the other expensive-high-level-hot-air-generation-machinery that overburdens the NHS and that RFQC has pointed squarely at is unnecessary<\/strong>.\u00a0 He says “simplify<\/em>” which is a step in the right direction. The goal is to render it irrelevent.<\/p>\n

The ignorance is ignorance of how to design a healthcare system that works right-first-time. The fact that the Francis Report even exists and is pointing its uncomfortable fingers-of-evidence at every level of the NHS from\u00a0ward to government is tangible proof of this collective ignorance of system design.<\/p>\n

And the good news<\/strong> is that this collective ignorance\u00a0is also unnecessary … because the knowledge of how to design safe-and-affordable systems already exists. We just have to learn\u00a0how. I call it 6M Design\u00ae – but\u00a0 the label is irrelevent –\u00a0the knowledge exists and\u00a0the evidence that it\u00a0works exists.<\/p>\n

So here are some of the RFQC recommendations viewed though a 6M Design\u00ae\u00a0lens:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

1.131 Compliance with the fundamental standards should be policed by reference to developing the CQC\u2019s outcomes into a specification of indicators and metrics<\/b> by which it intends to monitor compliance. These indicators should, where possible, be produced by the National Institute for Health and Clinical Excellence (NICE) in the form of evidence-based procedures and practice which provide a practical means of compliance and of measuring compliance with fundamental standards<\/em>.<\/p>\n

This is the safety-and-quality outcome specification for a healthcare system design – the required outcome presented as a relevent metric in time-series format and qualified by context.\u00a0 Only a stable outcome can be compared with a reference standard to assess\u00a0the system capability. An unstable outcome metric requires inquiry to understand the root cause and an appropriate action to restore stability. A stable but incapable outcome performance requires redesign to achieve both stability and capability. And if \u00a0the terms used above are unfamiliar then that is\u00a0further evidence of system-design-ignorance.\u00a0\u00a0\u00a0
\n\u00a0
\n1.132 The procedures and metrics produced by NICE should include evidence-based tools for establishing the staffing needs of each service<\/b>. These measures need to be readily understood and accepted by the public and healthcare professionals.<\/em><\/p>\n

This is the capacity-and-cost specification of any healthcare system design – the financial envelope within which the system must operate.\u00a0The system capacity design works backwards from this constraint in the manner of \u201cWe have this much resource – what design of our system\u00a0is capable\u00a0of\u00a0delivering the required safety and quality outcome with this capacity<\/em>?\u201d\u00a0 The essence of this challenge is to identify the components of poor (i.e. wasteful) design in the existing systems and remove or replace them with less wasteful designs that achieve the same or better quality outcomes. This is not impossible but it does require system diagnostic and design capability. If the NHS had enough of those skills then\u00a0the Francis Report would not exist.<\/p>\n

1.133 Adoption of these practices, or at least their equivalent, is likely to help ensure patients\u2019 safety. Where NICE is unable to produce relevant procedures, metrics or guidance, assistance could be sought and commissioned from the Royal Colleges or other third-party organisations<\/b>, as felt appropriate by the CQC, in establishing these procedures and practices to assist compliance with the fundamental standards.<\/em><\/p>\n

How to implement evidence-based research in the messy real world is the Elephant in the Room. It is possible but it requires techniques and tools that fall outside the traditional research and audit framework – or rather that sit between research and audit. This is where Improvement Science sits. The fact that the Report only mentions evidence-based practice and audit implies that the NHS is still ignorant of this gap and what fills it – and so it appears is RFQC.\u00a0\u00a0\u00a0<\/p>\n

1.136 Information needs to be used effectively<\/b> by regulators and other stakeholders in the system wherever possible by use of shared databases. Regulators should ensure that they use the valuable information contained in complaints and many other sources. The CQC\u2019s quality risk profile is a valuable tool, but it is not a substitute for active regulatory oversight by inspectors, and is not intended to be.<\/em><\/p>\n

Databases store data. Sharing databases will share data. Data is not information.\u00a0Information requires data and the context for that data.\u00a0\u00a0Furthermore having been informed does not imply either knowledge or understanding. So in addition to sharing information, the capability to convert information-into-decision is also required. And the decisions we\u00a0want are called “wise decisions” which are those that result in actions and inactions that lead inevitably to the intended outcome.\u00a0 The knowledge of how to do this exists but the NHS seems\u00a0ignorant of it. So the challenge is one of education not of yet more investigation.<\/p>\n

1.137 Inspection should remain the central method for monitoring compliance with fundamental standards. A specialist cadre of hospital inspectors should be established<\/b>, and consideration needs to be given to collaborative inspections with other agencies and a greater exploitation of peer review techniques.<\/em><\/p>\n

This is audit. This is the sixth stage of a 6M Design\u00ae\u00a0– the Maintain step.\u00a0\u00a0Inspectors need to know what they are looking for, the errors of commission and the errors of omission;\u00a0 and to know what those errors imply and what to do to identify and correct the root cause of these errors when discovered. The first cadre of inspectors will need to be fully trained in healthcare systems design and healthcare systems improvement – in short – they need to be Healthcare Improvementologists<\/em>. And they too will need to be subject to the same framework of accreditation, and accountability as those who work in the system they are inspecting.\u00a0 This will be one of the greatest of the challenges. The fact that the Francis report exists implies that we do not have such a cadre. Who will train, accredit and inspect the inspectors? Who has proven themselves competent in reality (not rhetorically)?<\/p>\n

1.163 Responsibility for driving improvement in the quality of service should therefore rest with the commissioners through their commissioning arrangements. Commissioners should promote improvement by requiring compliance with enhanced standards that demand more of the provider than the fundamental standards.<\/em><\/p>\n

This means that commissioners will need to understand what improvement requires and to include that expectation\u00a0in their commissioning contracts. This challenge is even geater that the creation of a \u201ccadre of inspectors\u201d. What is required is a \u201cgeneration of competent commissioners\u201d who are also experienced and who have demonstrated competence in healthcare system design. The Commissioners-of-the-Future will need to be experienced\u00a0healthcare improvementologists.<\/p>\n

The NHS is sick – very sick. The medicine it needs to restore its health and vitality does exist –\u00a0and it will not taste very nice –\u00a0but\u00a0to\u00a0withold an effective treatment for an serious illness on that basis is clinical negligence.<\/p>\n

It is time for the NHS to look in the mirror and take\u00a0the strong medicine. The effect is quick – it will start to feel better almost immediately.\u00a0<\/p>\n

To deliver safety and quality\u00a0and quickly and affordably\u00a0is possible –\u00a0and if you do not believe\u00a0that\u00a0then you will\u00a0need to\u00a0muster the humility to ask to have the how<\/strong> demonstrated.<\/p>\n

\"6MDesign\"<\/a><\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Today is an important day. The Robert Francis QC Report and recommendations\u00a0from the Mid-Staffordshire Hospital Crisis has been published – and it is a sobering read.\u00a0 The emotions that\u00a0just the executive summary evoked in me were sadness, shame and anger.\u00a0 Sadness for the\u00a0patients, relatives, and staff who have been irreversibly damaged; shame that\u00a0the clinical professionals\u00a0turned … <\/p>\n

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