Methods of Regulation Inquiry Seminar We live life forwards but
understand it backwards Peter Homa Chief executive 13 th October
2011
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Agenda Biography and caveat emptor Creating an inspectorate
Lessons from healthcare regulation Setting, monitoring, improving
and enforcing healthcare standards A chief executives perspectives:
how inspectors findings are best implemented Coda
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Biography 1989 - 1998: CE, Leicester Royal Infirmary 1998 - 99:
Head, National Patients Access Team, Department of Health 99 -
2003: Inaugural CE, Commission for Health Improvement 2003 - 06:
CE, St Georges Hospital, London 2006 - present: CE Nottingham
University Hospitals
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Creating an inspectorate Substantial, complex task to design
and build an inspectorate including method development, staff
recruitment and training and excellent governance structures and
process Develop inspectorates values, strategic and operational
plans Design and embed quality assurance processes to ensure
inter-rater reliability Establish effective relationships with
internal and external stakeholders including (sometimes with MOUs)
patient and public groups, NHS, DH, 10 Downing Street, Treasury,
other regulators, Royal Colleges and media
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Creating an inspectorate Government often assumes that newly
created inspectorates can operate more quickly than practical
Considerable risk during a new inspectorates early days due to new
legal duties, staff, methods untested QA and internal and external
relationships
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Lessons from healthcare regulation Focus on patient outcome,
safety and experience c.f. The Apple Ipad approach: design methods
outside in not inside out Inspection methods should be subject to
the same rigorous continuous improvement as the organisations that
are inspected. Avoid inspectorial methodological rigidity and
develop effective change procedures for inspectorate staff.
Benchmark inspectorate performance against global best
practice
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Lessons from healthcare regulation NHS and provider Boards are
the focus of governance accountability and responsibility. They
operate in a complex context that must be understood by the
inspectorate Inspections should form part of an overall process for
improvement lead by the Board and not an isolated event Establish
open, transparent and published inspection methods and standards
that Boards can use to guide and measure their own work to improve
the quality of patient care
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Lessons from healthcare regulation Well prepared peer reviews
of organisations against agreed standards by lay people, practicing
clinicians and managers help to improve the quality of patient
care. Such peer review can be separate or integrated to
inspections. Multiple benefits include providing inspections with a
deep understanding of everyday healthcare practice and this
experience is taken back to peer reviewers own organisations
Inspectorates should try and anticipate and avoid unintended
consequences of their inspection methods/standards for example
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Lessons from healthcare regulation Inspectorates should develop
predictive analyses to try and anticipate major organisation
healthcare failure before they occur e.g. small specialist
geographically isolated units (See CHIs Lakeland NHS Trust
investigation 2000) There should be as few inspectorates as
possible and those that exist should have a duty to operate as a
coherent system where the whole is greater than the sum of the
parts. Given inspectorates legal duties this is often challenging
to achieve but essential if patient care is to improve as much as
possible (See Michael Power, Inspection Society)
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Lessons from healthcare regulation Inspectorate judgement of
organisations performance should take into account the
organisational context including PCTs, CCGs, SHA One of the
Inspectorate's main contributions is providing a Board with a
thoughtful, authentic, assessment of their organisations
comparative performance. Holding a mirror to the organisation High
quality data about the quality of clinical outcome, process and
patient experience comprise the oxygen for service improvement.
Data quality assessment should be made at all levels (see
Nottingham case study)
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Data Quality Kitemark
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12 This page gives guidance on how to update the Data Quality
Kitemark for the Integrated Board report. For all indicators please
state whether they adhere to the following measures or whether the
measure is not relevant to the indicator. Data Quality Kite
Mark
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Setting, monitoring, improving and enforcing healthcare
standards Standards should draw on global best practise e.g.
matching Michigan, infection control, stroke services and must
incorporate assessments of the humanity of patient care. See
Jocleyn Cornwell, The Point of Care, Kings Fund, and the Institute
of Healthcare Improvement, Boston MA. Boards assessments against
agreed standards should be published at least annually supplemented
where possible by the inspector's judgements. Standards against
which Boards self assessments and inspectorates assessments are
made should be both core and aspirational.
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Setting, monitoring, improving and enforcing healthcare
standards Boards should have locally owned action plans to improve
patient care delivery and these should be regularly reviewed.
Progress should be measured through improvements in clinical
outcome, process and patient experience. Inspectorates should have
a repertoire of interventional instruments to require and where
necessary compel organisations to improve patient care. These
should be a clear, well understood interventional escalator. The
intervention selected will be proportionate to the scale of
performance failure. These instruments should be consonant with
other inspectorates legal duties and requirements. Boards should be
held to account to deliver improvements.
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A chief executives perspective: how inspectors findings are
best implemented Boards provide a vital role in setting the values,
direction, tone and public accountability and responsibility for
the organisations delivery of high quality patient care. The
regulatory environment should be designed to take this into
account. Boards must demonstrate that patient safety is the top
priority. On occasions e.g. investigations into major service
failure, inspectorates must examine the respective contributions of
all levels of NHS/DH management Boards should compare their own
organisation against others to understand their relative
performance across the breadth of patient services. This requires
high quality data and information and investment in information
systems and analytical capacity.
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A chief executives perspective: how inspectors findings are
best implemented Boards should demonstrate the capacity to deliver
high quality care using available resources wisely. Boards should
avoid asymmetrical attention to the domains of money and patient
safety and patient experience. There should be movement of staff
between NHS providers and inspectors to ensure that both have a
good understanding of the others perspective. This should help
avoid provider capture but achieve provider understanding and vice
versa. Inspectorates need to earn credibility among multiple
stakeholders through sound, wise, thoughtful and proportionate
judgements and responses. Such credibility is to a degree
correlated to the inspectorate's access to contemporary provider
working experience.
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A chief executives perspective: how inspectors findings are
best implemented Welcome the opportunity for staff to become peer
reviewers as this develops skills and experience in the
organisation to improve patient care (trickle down effect).
Inspectors should recognise the interorganisational opportunities
to improve patient care and ensure that all appropriate elements of
the local healthcare system are assessed. Inspectorates must
operate as a coherent system even though they may be statutorily
separate. This is to avoid a conflicting inspectorial requirements
upon providers.
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Coda Excellent healthcare Boards focus on how to deliver high
quality patient care within available resources. Excellent Boards
do not describe this as mutually exclusive requirements but rather
as a complex simultaneous equation that must be solved using the
considerable commitment, energy and ingenuity that so often define
healthcare staff. Constant NHS and inspectorial reorganisations
inhibit development of well established relationships and
inspectorial methods and improvement plans. This reduces momentum
to improve services.
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Coda The separation of financial/governance and quality
functions between Monitor and CQC creates additional complexity for
NHS providers and both regulators. The further a commentator from
the healthcare front line the more time is devoted to speculating
about gaming of inspectorial regimes.
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Coda Regulators legal structures and duties provide the
regulatory anatomy. However, it is the leadership of inspectorates
that provide the physiology i.e how well they work. Sound legal
structures can be confounded by insular leadership behaviours.
Suboptimal legal arrangements can be made to work through well
intended leadership. The tough economic environment in the NHS is
going to place increasing pressure on providers, commissioners and
inspectorates.