CQC recommends systems and flow improvements in special measures report

The Norfolk and Norwich University Hospital NHS Foundation Trust has been put into special measures following a Care Quality Commission (CQC) inspection that rated it inadequate. One of the notable features of the report and recommendations is the prominence of systems and processes that impact flow. Does this signal that the CQC is beginning to consider patient flow as an important part of improving hospital performance?

The Norfolk and Norwich University Hospital is a 1,237 bed NHS Foundation Trust which provides acute hospital care for a catchment area of up to 822,500 people. A team of CQC inspectors visited between October 2017 and March 2018 and inspected urgent and emergency care, surgery, end of life care, outpatients and diagnostic imaging services.

What the CQC report revealed

While there were some areas of outstanding practice and innovation, and staff at the Trust were said to be caring and committed, inspectors stated the running of the Trust has deteriorated overall since their last visit.

“We were very concerned by how the Trust is being led and with many of its systems and processes,” said The Chief Inspector of Hospitals, Professor Ted Baker.

Of the inspection areas CQC review, the categories of Safe and Well Led were rated as ‘inadequate’, Effective, and Responsive were rated as ‘requires improvement’ and Caring was rated as ‘good’.

Where the systems failed

“There was a lack of grip and oversight over access and flow in the emergency department.”

The CQC rated the Trust’s urgent and emergency services as inadequate for safety and inadequate overall. It found that effective systems were not in place to ensure patient safety improvements were made following incidents, complaints and audits. The action plans for serious incidents were not kept up-to-date and lessons learned were not embedded into practice.

Patient flow was compromised by the number of patients waiting in corridors, delays in treatment and in admission to beds on wards, as well as an active policy of placing patients in trolleys to await beds.

“We found increased capacity pressures had increased risk to patient safety with staff reporting an increase in serious incidents, cohorting of patients in the emergency department corridor and significant waits, of several hours, to offload from ambulances at times of peak pressure.”

The importance of patient flow

The CQC has made a comprehensive list of required improvements which demonstrate the importance it places on robust systems, including patient flow:

• Bed management and site management processes need to be reviewed in order to increase capacity and flow, and to ensure there are effective formalised processes which ensure patient safety in all escalation areas
• The Trust must ensure that there is a system in place, which is adequately resourced, to ensure that patients are assessed, treated and managed in a time frame to suit their individual needs
• There needs to be an effective process for quality improvement and risk management across all departments
• The Trust must ensure that there are effective systems and processes in place to ensure assessing the risk of, and preventing, detecting and controlling the spread of infections, including those that are healthcare associated

It is clear that a patient flow system would have supported a cohesive strategic plan for access and flow, something that the Trust sorely lacked. Mr Davies said: “We must improve next winter’s escalation plans and improve our systems and processes overall. We are working on our improvement plan with the help and support from NHS Improvement and also the King’s Fund.”