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How to take a trust out of special measures

Thanks to consultant nurse Cliff Evans and a team of senior staff, patients at a Medway NHS Foundation Trust emergency department, Kent, are no longer being treated in corridors.

Thanks to consultant nurse Cliff Evans and a team of senior staff, patients at a Medway NHS Foundation Trust emergency department, Kent, are no longer being treated in corridors.

Cliff_Evans
Consultant nurse and educationalist Cliff Evans. Picture: Nathan Clarke

Medway NHS Foundation Trust, Kent, has spent more time in special measures over the past four years than any other trust.

In 2013, a mortality rate of 26% above the national average prompted a Care Quality Commission (CQC) inspection.

Substantial safety issues were discovered in Medway Maritime Hospital’s overstretched emergency department (ED), where about 1,000 patients a month were cared for in corridors, resulting in significant episodes of harm.

In March 2017, however, the CQC’s chief inspector of hospitals recommended the trust come out of special measures because of the ‘significant improvements’ it had made.

Central to the presentation given to CQC inspectors was work to transform patient safety in the ED.

The driving force behind this work is consultant nurse Cliff Evans, who in September 2015 was seconded to Medway for one day a week by NHS England under the ‘mutual aid’ scheme before taking up post permanently.

His initiatives have resulted in reductions in episodes of patient harm and vacancy rates, while development programmes have improved clinical skills and morale among senior and junior nurses. No patients are cared for in corridors any more.

Strategy and workforce

Mr Evans had been working at neighbouring Maidstone and Tunbridge Wells NHS Trust, having been brought in when it was in special measures.

‘They shared a similar situation,’ says Mr Evans. ‘Insufficient workforce, poor processes and systems, and an element that the majority of nurses – the most experienced – did not have the skills and knowledge base you would expect them to have at that point of their careers.

‘My main skills are linking strategy and workforce development. The two things have been intrinsic to improving care at both trusts.’

At Medway, with the senior team in the ED, Mr Evans put together a comprehensive three-month strategy focusing on patient safety, workforce development and education, and sustained improvement.

‘I have never worked anywhere that was so unsafe for patients,’ he recalls. ‘There were three to five incidents a week.’

As well as a 65% nurse vacancy rate, only four nurses had emergency care qualifications relevant to their posts.

‘You cannot run a service on those levels,’ says Mr Evans. ‘There were good nurses working in horrible circumstances. Morale was rock bottom.’

Patient safety had to come first. ‘People were dying. It is a juggling act; you know you have to get plans going, but in a crisis you have to make it safe as quickly as possible.’

Observational study

Audit is central to Mr Evans’s approach, to the extent that his staff think he is ‘obsessed with it’. But audit quickly identified the prime causes of poor outcomes: keeping patients in corridors and patients having no effective initial assessments.

He spent one of his first days undertaking an observational study of 24 patients cared for by one nurse and a support worker in the corridors.

The trust board knew corridors were being used in this way and that it was bad for public relations, but thought the patients were at low risk. However, Mr Evans’s study showed that 70% of the patients were emergency cases, including some with stroke, heart attack and sepsis.

His response was to develop a bespoke initial-assessment tool based on early warning scores (see box 1).

Mr Evans’s next step was to devise an education and development programme to improve clinical skills and help recruitment and retention (see box 2).

‘All nurses want to do is to provide great care,’ says Mr Evans. ‘It’s what they came into nursing to do and there is no better carrot than training to help them do it.

‘If you offer a development programme, they will flock to you. I have seen that in every trust I have been to. Our vacancy rate is now 16%.’

Training helped embed improvement, says general manager of the emergency programme John Ferguson. ‘The challenge in any organisation in difficulties is change and one of the first casualties in such organisations is education.

‘But the increased number of trained staff, the preceptorship programme, and an ED module at band 6 and 7 have improved the abilities of staff, making change easier, and improvement consistent and sustained.’

Education

Nurses at all levels testify to the significantly better care and working environment. Senior sister Charlene Gibb, for example, says patients are ‘a lot safer’.

‘Previously, patients were not examined thoroughly or prioritised clinically. I felt helpless in this situation. Now, patients receive more appropriate treatment. Flow through the department has improved and there is clear leadership.’

There is also growing interest in working at the Medway ED, she says, and more nurses want further training.

Senior sister Emma Parkinson adds: ‘The development programme will improve retention because staff appreciate the investment in their education.

‘This in turn will develop their roles clinically and have a positive impact on the department and patient care.’

Charge nurses from other areas are applying for ED roles and morale among staff already there has improved.

Band 6 nurse Sharon Hemsworth-Smith says: ‘Before, patients were never safe. I had no job satisfaction whereas now I feel I work in a safe environment.’

Charlotte Weymouth-Hollywell agrees: ‘I felt stressed and undervalued working in the corridor, but we worked hard as a team to do the best for patients. There was not much training on offer.

‘The triage system is now more robust. We have a good team, who are always happy to offer advice if in doubt.

‘The triage training has benefited junior staff and senior members who had no formal training to make safer decisions.’

Counselling

There have been challenges, however. Medway faced heavy criticism and intense scrutiny.

Mr Evans recalls: ‘As a senior nurse, there is nothing worse than when you feel unsafe. In the first few months you don’t know what you will come in to. You could be on the tabloid front pages.

‘Then, after a couple of months, you can get a good night’s sleep.’

The past is not forgotten, however. In teaching, older assessments are presented to highlight differences in care.

‘These were good staff working in a horrible environment,’ says Mr Evans. ‘One of the vital factors over the first year was revisiting the past in a non-blame way.

‘Staff were part of those poor outcomes and had felt powerless to challenge or do anything about it. We have had to put counselling in place and they break down regularly about the care given in the corridors.’

But the future looks bright. The trust is celebrating better friends-and-family test ratings while mortality rates are now below the national average.

‘If you walk around the department, you can see what is going on,’ says Mr Evans. ‘All along our walls, you will find all the audit data and guidance for staff. It is a visual campaign.’

Teamwork and leadership

So why did his plan work when others have failed?

Clinical lead consultant Ashike Choudhary says: ‘As a department, we were ready and waiting to change. Cliff came along with knowledge and experience – he had done it at four trusts – of what we could do.

‘In the middle of the worst time, when we were in dire straits, it was quite hard to see where the problem was.

‘We would not know where the sick patients were; we had to use a sixth sense to find them. It was a stressful and difficult environment to work in, but you’d get to the point where you think it’s normal.

‘We had tried to change ED processes several times and had got to the point where we did not know what we were trying to do. We were chasing impossible targets that did not make any sense.

‘Cliff said: “Let’s get back to a meaningful assessment done properly and the targets will follow”.’

The senior team shared his vision. ‘I fitted in well with them and they were supportive,’ says Mr Evans. ‘The trust had never had good nursing leadership in the department before. Doctors and nurses now work together.’

He also credits the excellent nurses at Medway, including senior nurses he brought with him from his previous post: ED matron Kathy Ward, and senior matron for acute and continuing care Clare Hughes.

Mr Ferguson, however, says that Mr Evans has been the driving force behind the educational and operational strategy.

‘This was coupled with a further strategy for consistent and sustained improvement. His support for colleagues has created a strong, dynamic team that focuses on each patient as the centre for all improvement and development.

‘Medway ED is significantly safer than it was, and the benefits for patients are clear to see.’

 

Box 1. Initial-assessment tool

Consultant nurse Cliff Evans, supported by the senior emergency department (ED) team, developed a bespoke initial-assessment tool based on national early warning scores (NEWS) because a retrospective audit of patients’ notes had shown patients were not escalated appropriately.

Mr Evans says: ‘It took about 34 before I found a patient with an early warning score and the 35th had been calculated incorrectly.’

Previously, patients were seen in line with a ticketing system rather than being assessed and prioritised.

Emergency programme general manager John Ferguson explains: ‘As part of the Care Quality Commission assessment, a directive was made to see all patients within 15 minutes. This led to a model of “seeing people”, but it was not meaningful or NEWS based and did not provide a plan of care.’

Mr Ferguson, a nurse, adds: ‘Cliff's model is a NEWS-based, meaningful – and that is the important word here – assessment, with a plan of care put in place and clear actions relating to the triage colour.’

Every member of staff completed a two-day course before the tool went live.

‘Introducing a new triage system anywhere is worrying and this was in a challenged unit,’ says Mr Evans. ‘I didn’t sleep for days. We monitored it daily and I was on call 24 hours a day, but we quickly noticed a level of safety that we had never had before.’

In just six months, there was a 50% reduction in mortality, a 70% reduction in harm to patients and the number of incidents resulting in long-term harm was halved.

 

Box 2. Staff education and development programme

Education and staff development are core elements of Mr Evans’s strategy.

Job descriptions were re-written – and watered down in an attempt to fill positions – but, with a 65% vacancy rate, it was essential to keep staff in post and address senior nurses’ lack of specialist qualifications.

A former university lecturer, Mr Evans wrote a University of Greenwich-accredited degree and master’s emergency nursing course for all senior and junior sisters.

‘By writing and delivering the degree course ourselves, we ensured the cost per student is about one tenth of the cost of sending them to a university,’ he explains. ‘This means ten times more people can have specialist qualifications.’

He also increased the proportion of staff being appraised, from 16% to 98%. ‘Appraisals show that you value your workforce and are committed to their development.’

Mr Evans persuaded local universities that had banned students from undertaking placements to let them return. ‘Without students, how do you build your workforce of the future?’ he says.

A series of workshops on emergency nursing careers attracted 16 job applications, and the recruitment plan includes the provision of a support package and 18 months of preceptorship for newly registered nurses, as well as a good working environment.

Staff nurses already in post have also started a development programme so they have the same opportunities available to nurses under preceptorship, but in a less structured way.

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