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Queen Elizabeth Hospital Birmingham Good

Reports


Other CQC inspections of services

Community & mental health inspection reports for Queen Elizabeth Hospital Birmingham can be found at University Hospitals Birmingham NHS Foundation Trust.

Inspection carried out on 8 October to 29 November 2018

During a routine inspection

Our rating of services stayed the same. We rated it them as good

For an overview of our findings at this inspection please see overall summary above.

Inspection carried out on 21-22 December 2015

During an inspection to make sure that the improvements required had been made

The cardiac surgery service at the Queen Elizabeth Medical Centre provides cardiac surgery to adult patients either as an elective (planned) case or as an emergency. The service performs a number of specialist cardiac surgery procedures as well as conventional surgery. Patients are referred locally and nationally to the service. A cardiac transplant service is also provided.

The Care Quality Commission (CQC) received notification of potential concerns regarding patient outcomes following cardiac surgery at University Hospitals Birmingham NHS Foundation Trust. There were two separate sources of statistical analysis:

  • We were notified in 26 August 2015 of an outlier alert for in-hospital mortality associated with coronary artery bypass graft (‘CABG (other)’) procedures, generated by the Dr Foster Unit at Imperial College London.
  • We were notified on 11 September 2015, of an outlier alert for in-hospital survival rates following adult cardiac surgery, generated by the National Institute for Cardiovascular Outcomes Research (NICOR) in association with the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) (April 2011 to March 2014). The data was formally notified to the trust in August 2015 and published in September 2015. The trust was first alerted to concerns March 2015.

We requested information from the trust on the actions taken in response to the outlier alert on 4 September 2015 and requested information on trust’s audit outcomes for adult cardiac surgery. The trust responded to us on 14 September 2015 and identified ‘significant methodological issues’ with the outlier data and told us they had implemented a quality improvement programme. The trust challenged the statistical methodology that had been applied with Imperial College and NICOR. We received confirmation from Imperial College and NICOR on 15 October 2015 that the statistical analysis of the outlier data was accurate. The outlier data is risk adjusted and is therefore not contributed to by the complexity of surgery. We received further information of concern from Health Care Quality Improvement Partnership (HQIP) following a meeting with them in November 2015.

We carried out a short notice focused responsive inspection of cardiac surgery services on 22 and 21 December 2015. The inspection was announced to the trust on 14 December 2015. We inspected this service because of the serious concerns relating to cardiac surgery mortality, and a lack of specific information provided by the Trust in order to understand the significance of the concern or the immediate actions being taken.

We followed the pathway for patients and inspected the pre-operative assessment, operative care (in theatres), post-operative critical care and care on the cardiac ward. We did not inspect heart transplant surgery. We inspected cardiac surgery services, which is part of a surgical services core service. We have therefore not provided ratings for the service.

Our key findings were as follows:

  • The cardiac surgery service had been identified as a significant mortality outlier when compared to similar services. The cardiac surgery service monitored patient outcomes, but the results of this monitoring were not used effectively to improve quality.

  • The trust had only recently started a quality improvement programme (QIP), despite concerns being identified in 2013 during an internal review and consultants approaching the executive team in 2014 with concerns around patient mortality and morbidity. The trust was also informed about the NICOR mortality outlier in March 2015. The trust had failed to take effective action in response to these concerns. There had also been many concerns raised by staff with service, divisional and trust leads that had also not triggered effective action. Some staff we spoke with were not aware that the service had been identified as a significant outlier through a national audit and national outlier programme, nor that a QIP had been started by the trust.

  • The cardiac surgery service had no vision or strategy and lacked clear clinical and operational leadership at service and divisional level. This resulted in a service that was fragmented and dysfunctional, with departments working in isolation rather than as a team. There were delays in decisions being made both clinically and organisationally which impacted on patient care. The service had not anticipated, and was not monitoring, the impact of taking an increasing number of complex patients for heart failure and transplant surgery which had decreased the volume of routine heart operations.

  • There were significant concerns around the lack of governance processes to monitor quality, safety and risk. Patient outcome data was collected but was not shared or used effectively by the service to improve quality. There was insufficient attendance, and challenge about patient outcomes, at mortality and morbidity meetings and multidisciplinary team meetings. The service did not consistently take account of relevant national guidance and evidence based practice to ensure a standardised approach to patient care and treatment.

  • The Five Steps to Safer Surgery were not always completed to minimise the risk of avoidable harm to patients. Surgical trainees were not always supervised by a consultant in theatres when it was appropriate to do so. There had been instances where it had been difficult to quickly locate a surgeon when a complication had arisen in theatre. Some operations took longer than expected and patients were on cardiopulmonary bypass for long periods and higher than expected use of blood products. Re-bleeding rates post-surgery were higher than expected, and proportion of patients having to return to theatre for re-exploration and further surgery was much higher than that nationally.

  • Consultant cardiac surgeons did not consistently undertake ward rounds on the cardiac surgery ward, they were not always in theatre at appropriate times and they were failing to effectively communicate with nursing staff and intensivists in critical care.

  • There was a high rate of cancellations for elective patients (planned surgery), with some patients’ surgery being cancelled on multiple occasions. Staff repeatedly raised concerns about cancellations and the impact on patients as well as the morale of staff. The majority of cancellations were due to a lack of critical care beds and staffing. However, institutional behaviours of surgeons including late starts to operations, extended length of operation times and waiting for confirmation of a bed in ITU often resulted in the cancellation of the second case. Actions to decrease the number of cancellations were not having sufficient impact. Weekly meetings took place to review cancellations but there had not been significant change or action by the trust despite the data being collected. Clinical staff had identified for areas for improvement, for example, a step down cardiac ward, but there we not clear plans to implement these changes.

  • There was no monitoring of risk for patients whose surgery had been cancelled or those who were on the waiting list for longer than they should be. Waiting lists were not shared across surgeons via ‘pooling’, which resulted in some patients waiting longer than the 18 week target. Cardiologists at the trust were increasingly referring patients to other local hospitals for surgery where there were the shorter wait times, fewer cancellations, and good patient outcomes. This was leading to the service operating at a low volume with associated risks

  • Staff described a bullying and blame culture in theatres and critical care. Staff found it difficult to raise concerns or challenge poor performance and behaviours. Staff did not always report incidents; where these were discussed the blame culture prevented an open discussion to encourage learning and improvements to patient safety.

  • There were issues regarding low staffing numbers and the insufficiency of training for staff to undertake their role. There were vacancies in theatres that resulted in operations being cancelled or staff working additional shifts. Nursing staff in critical care were concerned that they had not received specific training to look after cardiac patients or in the specialist equipment they required. Medical staff in critical care were not all cardiac trained and at night there were difficulties accessing the on-call surgeon or the consultant anaesthetist. There had been a number of near misses and unexpected patient deaths in critical care.

  • Consultant staff in particular felt demoralised about their service. Staff had become disengaged and morale was low. Staff were not confident that the QIP would address all the concerns they had about the service and ensure the safe care and treatment of cardiac surgery patients.

  • Patient feedback was very positive. Staff treated patients with dignity and respect. Patients described the excellent quality care they received from staff.

  • Patients told us they had been involved in making decisions about their care. Staff took the time to speak with them and treated them holistically, rather than just focusing on their medical needs.

  • Staff working in the cardiac surgery service were positive about this inspection. They wanted to improve the quality of their service and saw the inspection is as an opportunity to ensure this happened.

There were areas of poor practice where the trust needs to make improvements.

We told the trust to immediately:

  • Commission, and undertake, an external review of cardiac surgery to identity the key actions that are necessary in response to the concerns identified.

  • Provide information to CQC on patient outcomes to provide assurance around safety and quality pending the outcome of the external review and to take steps to ensure patient safety.

The trust must ensure:

  • Patient outcomes, based on SCTS data set, are regularly reviewed and monitored and action is taken in response to any patient safety concerns both at individual and service level.

  • There is a positive reporting culture for reporting incidents across the whole service with learning as the key objective

  • The impact of cancellations and patients waiting is monitored and actions taken to minimise the risk to patients arising from long waits and multiple cancelled operations.

  • The Five Steps to Safer Surgery checklist is implemented appropriately and regular observational audit takes place to ensure this is happening.

  • Staffing levels in theatres and critical care are reviewed to meet national guidance and ensure rotas clearly identify staff roles.

  • Consultant surgeons are always available to provide supervision and immediate support whenever trainee cardiac surgeons operate to meet national guidance.

  • Sufficient surgical and medical staff are available and have the appropriate skills, knowledge and expertise to care for patients on the ward and in critical care

  • Medical staffing rotas (including on-call) mean staff are appropriately available and also not on-call for two departments at the same time.

  • All staff complete safeguarding children and vulnerable adults training in line with trust targets.

  • The storage room in theatres are appropriately maintained so all equipment and supplies can be accessed. Review the appropriateness of all items stored in this room to ensure staff and patient safety.

  • Medicines are stored and managed safely.

  • Standardised care pathways are further developed in surgery and developed in critical care and these take account of national guidance.

  • There are best practice based standard operating procedures and protocols for all areas within cardiac surgery services and these are reviewed routinely and kept in date.

  • All discussions with patients about their care are documented in the patients’ medical record.

  • There is regular attendance at MDT meetings by relevant staff.

  • Patients are nil by mouth for the minimum time necessary pre operatively.

  • Nursing staff on critical care have the appropriate competence and skills to provide the required care and treatment to cardiac surgery patients, including the safe use of equipment.

  • There are effective operational improvement plans to improve patient flow.

  • Cardiac surgery theatre use and productivity improves to meet the demands of the service and to minimise the risk to patients from long referral to treatment times (RTT).

  • Cancellations of elective cardiac surgery for non-clinical reasons are significantly reduced.

  • Patient on waiting list are prioritised appropriately and they receive treatment within national waiting times.

  • There is effective multidisciplinary working in the cardiac surgery service.

  • A clear strategy and vision agreed by all across cardiac surgery services.

  • The pace of change within cardiac surgery services is significantly and demonstrably increased to ensure patient safety.

  • Appropriate clinical and operational leadership arrangements are in place to support improvement across the cardiac surgery service.

  • Robust governance processes to monitor quality and to identify, assess and manager risk.This includes an effective clinical audit programme and national benchmarking. Keys areas of concern are reportedly on regularly and action taken promptly.

  • Action is taken to address issues of bullying of staff, promote staff welfare and manage poor performance appropriately.

  • Action is taken to identify and take action on the reasons why staff are leaving the service and to develop retention plans.

  • Staff concerns across the service are listened to and responded to in a timely manner.

  • Patient consent is obtained appropriately at all times, including when their personal confidential information is displayed in public areas.

Action the hospital SHOULD take to improve

The trust should:

  • Develop more effective ways to actively involve patients and their families or carers in the development of the service.

We informed the trust of our serious concerns immediately after the inspection and told them to take immediate action. We instructed the trust to undertake an external review and to supply us with weekly reports on patient outcome and activity data. We are monitoring the service and patient care with our specialist advisors.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 December 2015

During Reference: R6 not found

Inspection carried out on January 2015

During a routine inspection

University Hospitals Birmingham NHS Foundation Trust is large teaching hospital with a reputation for quality of care, information technology, clinical training and research. It provides care from the Queen Elizabeth Medical Centre which is a new hospital on the site of the original. At the time of our inspection some wards in the old Queen Elizabeth hospital building were open. The trust also provides sexual health services from a number of locations across Birmingham.

The new Queen Elizabeth Medical Centre opened in June 2010 and was constructed under the public sector private finance initiative.

The Trust provides direct clinical services to over 900,000 patients every year, serving a regional, national and international population. It is a level 1 trauma centre, and is a regional centre for cancer, trauma, renal dialysis, burns and plastics; and provides a series of highly specialist cardiac, liver, oncology and neurosurgery services to patients from across the UK.

We inspected this service in January 2015 as part of the comprehensive inspection programme.

We visited the trust on 28, 29 and 30 January 2015 as part of our announced inspection. We also visited unannounced to the trust until Friday 13 February. This included visits to critical care, accident and emergency and medical care services.

We inspected all core services provided by the trust (note the hospital does not provide maternity nor children’s services). We also inspected sexual health services as an additional core service of Outpatient’s.

Our key findings were as follows:

  • Services in the trust had strong clinical and managerial leadership at many levels.
  • Staff were highly engaged with the trust and felt valued. This gave them a strong sense of purpose during their clinical interactions with patients.
  • A culture of local and national audit and analysis was encouraged. This led to change and improvements in practice and care.
  • Critical Care services provided outstanding effective outcomes focused care and leadership.
  • Medical Care and End of Life Care services were outstanding in their responsiveness to patient’s needs.
  • Urgent and Emergency Care Services had poor infection control practices.
  • In surgery, we saw that safety checks of resuscitation equipment were not systematically carried out and some records were not completed appropriately
  • 55% of staff waited over 30 minutes for their scheduled appointment in outpatients. During our inspection six patients waited over two hours.
  • Staffing levels were good across the trust.

We saw several areas of outstanding practice including:

  • We saw examples of excellent care and innovative practice, such as the interaction of trauma team with members from different disciplines.
  • Urgent Care services ‘clinical quality and safety’ newsletter which informed staff of quality and safety issues such as earning from incidents, directed them to learning resources through e-links and shared information. It reduced the burden of emails to staff having this in one single issue.
  • Critical Care Services had specialist ‘burns shock’ rooms (specially designed rooms with self-contained care and treatment facilities) to support best outcomes for these patients.
  • Reduction in length of stay and reduction in use of a ventilator through physiotherapy multidisciplinary intervention in critical care.
  • The trust used pioneering treatments to achieve positive outcomes for surgical patients with complex trauma cases and transplant needs.
  • Introduction of sleep packs and hearing aid storage boxes to all patients who require them.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve the infection control issues within Urgent and Emergency Services; both in clinical practice and in cleaning schedules.
  • Resolve the poor labelling practices of blood samples in Urgent and Emergency care services.
  • Increase focus on delivering the 18 week Referral to Treatment target.
  • Improve safety checks of resuscitation equipment and recording in surgery
  • Ensure the cleaning and hygiene in the ward based regeneration kitchens is consistently maintained.
  • Reduce waiting times in the outpatients department
  • Increase consultation time in outpatients particularly for patients with complex conditions
  • Improve pain relief response in Urgent and Emergency Care services

In addition the trust should:

  • Ensure the responses to the issues on West 2 are sustained, especially with regard to staffing levels.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 28 November 2014

During an inspection to make sure that the improvements required had been made

This was not an inspection of all of the services provided by the Trust.

When we last visited the trust in July 2013 we identified some concerns about how the care provided to patients, was checked and monitored by senior staff on wards and units. Whilst the hospital looked into all serious issues, some routine checking to ensure people received planned care and treatment was not evident.

When we visited the hospital on 28 November 2014 we found improvements had been made. We specifically focussed on how the hospital managed the care of patients at risk from pressure ulcers (an ulcer as a result of pressure damage) and we looked at how the risk of poor nutrition was managed. We found the trust had taken steps to reduce the incidence of preventable pressure ulcers. There were good systems of governance at board and at ward level to check patients were receiving the right care and treatment at the right time. Senior and middle managers, as well as ward staff were committed to these systems.

We followed the care and treatment pathway of 20 people across eight wards that included surgical, medical and the emergency department.

We found that the trust reported incidents of pressure ulcers and learned from adverse events in order to improve patient safety. There were standard procedures and treatment protocols in place and staff knew what these were. Care activities for each patient were recorded and monitored to support consistent care.

Patients were assessed to establish the care they needed and care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Risks of pressure ulcers and risk of poor nutrition were identified and managed. Plans of care and treatment were implemented and reviewed, including when patients transferred between wards and departments. There were systems in place to identify and ensure support at mealtimes for patients at nutritional risk. We found some care records about people's support with nutrition in some wards could be improved.

There was generally good multi-disciplinary team and mult-agency work to treat and support patients and staff had access to appropriate training and specialist nurses. There was appropriate and sufficient specialist equipment to ensure patient's safety and comfort.

People generally made very positive comments about the service including:

'Excellent care- even down to the cleaner'

"They look after him well but he doesn't like the food"

"The nurses have been brilliant"

'Nothing is ever too much trouble for them'

"They've all been polite and involved in his care"

"The staff are good and the food is OK"

Inspection carried out on 22, 23, 24, 26 July 2013

During a routine inspection

During our inspection we looked at how people were cared for at every stage of emergency treatment. We spent time in the emergency department and in the clinical decisions unit where people were often transferred to from the emergency department. We visited the planned treatment / day surgery unit. We also visited three wards for a short time (513, 514 and 516) to follow up on the care of people who had been admitted via the urgent care route. We spoke with 56 people who used the service and 48 staff.

People made positive comments about the care and treatment, one person commented that: “Staff are very informative.” “I was in a lot of pain when admitted but the staff sorted that out.” People spoke about staff being attentive and responsive but we did receive comments about delays experienced: “We were let down by the delay because the scan took so long [to be carried out ].” We received many positive comments from people attending for day surgery: “It has been excellent.” “They treat you as a person and take into account your feelings.”

We followed up on concerns we raised last year in respect of surgical theatres and had evidence that action had been taken to address concerns.

We have identified some concerns about how the care provided to people is checked and monitored by senior staff on wards and units. Whilst the hospital does look into all serious issues, some routine checking to ensure people received planned care and treatment was not evident.

Inspection carried out on 10, 11 October 2012

During a routine inspection

During our inspection we spoke with over 60 people who were using the hospital, we also spoke with relatives, staff and visiting health professionals. In addition to the inspectors and expert by experience we were supported during the visit by a pharmacy inspector and a specialist theatre clinician. We looked at the care and treatment that people on five wards were receiving, visiting wards 303, 306, 511, 620 and 727. We went to five theatres to look at the care and treatment people were receiving when they were having an operation. We also looked at some of the systems in place to ensure the surgery was being undertaken in the safest way possible. In addition to wards and theatres we visited the departments of the hospital that dealt with complaints and clinical governance. In these departments we looked at the management of complaints and how the hospital monitored clinical practice and the care provided.

The majority of feedback we received was positive about the care and treatment people had received. Comments included, "I felt well prepared, informed. Staff have made it as easy as possible for me", "I can't fault it, my care has been exceptional from start to finish" and "I do believe I am getting the best possible care I can have."

The evidence we collected in theatres identified some minor concerns about the risks relating to surgical safety. We have issued a compliance action to ensure the improvements needed are made.

Inspection carried out on 30 December 2011

During an inspection in response to concerns

People who were receiving the service told us that they were treated with respect and that staff were helpful and informative. They told us that nurses and doctors gave them clear information about their health conditions, what investigations were needed and the treatment they required.

Comments received included:- ''They have been really good. Have kept us informed.''

We observed the activities within the department and noted that people's privacy and dignity was being maintained at all times.

Inspection carried out on 20 April 2011 and 20 September 2012

During a themed inspection looking at Dignity and Nutrition

We spoke with seven patients. Their feedback was generally very positive regards the respect and dignity showed to them by the staff that support them, and the food and drinks provided, and help they were given with eating and drinking.

We observed the care and support people were offered. We found staff spoke to people kindly, and met their needs sensitively.

We found the environment had been designed in such a way that people’s dignity and privacy was respected. People were cared for in single rooms, or in small bays with people of the same gender. People told us,

Is your care given in a respectful way? “Yes, always. I have my bathroom, and staff always pull the curtains round me.”

“Staff do respond quickly, I am not left uncomfortable or in pain for very long.”

We looked at the food and drinks people were given, and the way staff supported them.

We saw people get a choice of meals each day. There were options for people with specific dietary needs. People were helped by staff to cut up their food, eat and drink. This was undertaken in a sensitive way. The people we spoke with were mainly complimentary about the food they were offered. Their comments included,

“The meals are always good, have been good everyday. I would not eat them if they were not, I enjoyed that, and I could eat it again.”

“Food is very good, although the first meal I had was horrible. (They did get me a replacement.) You can have as much as you like. One or two staff are inpatient if you don’t eat quickly enough.”

“Overall very good, food is on time, and there is plenty to drink.”

Some people told us the food was not good. We found the meals available for people who need a puree diet was very limited in choice, and needed to be improved in taste and appearance.

We found some records regards people’s nutritional needs and recording what people had eaten were not up to date.