England’s Chief Inspector of Hospitals, Professor Sir Mike Richards, has published his report following an inspection at University Hospital Birmingham NHS Foundation Trust.
The Care Quality Commission (CQC) inspection team identified significant concerns with regard to the safety, effectiveness and responsiveness of cardiac surgery. In response CQC used its urgent enforcement powers to request individual patient safety and outcome data from the trust on a weekly basis. CQC also asked the trust to commission an external review to identify all the actions it needs to take to address the concerns identified.
The CQC carried out the inspection in December 2015 following concerns about high mortality rates for patients receiving cardiac surgery services at the Queen Elizabeth Medical Centre in Edgbaston, Birmingham.
The inspection looked specifically at pre-operative assessment, care received in operating theatres, and post-operative care for patients on the cardiac ward and critical care unit.
A full report of detailing the findings from the inspection is available on the CQC website.
Professor Sir Mike Richards said:
“When we inspected cardiac surgery at the Queen Elizabeth Medical Centre we found a lack of strong leadership and a staff team with low morale that felt unable to raise concerns or report incidents. Processes were not robust enough to ensure that staff could respond effectively to the needs of patients, and staff shortages as well as insufficient training and experience for staff to undertake their roles were impacting on the quality of patient care.
“Following our inspection we asked the trust to take immediate action and to commission an external review. We have been monitoring individual patient safety data on a weekly basis.
“Initial data regarding surgery outcomes in the months since our inspection show an improvement but we need to continue to monitor the service. I have made it clear to the trust that it must continue its work to develop a culture of strong team working and improve staff training as it addresses the wider issues identified on inspection. The recommendations from the external review will be central to this.
“CQC will monitor the trust’s improvement plan closely and will return to check that all the required action is taken and that improvements are made and sustained.”
During the inspection CQC found the trust was not able to effectively monitor quality, safety and risk within cardiac surgery services. Patient outcome data was being collected, but was not being shared or used effectively to improve the quality of care provided.
Inspectors found that the trust had failed to take effective action in response to concerns about high death rates in cardiac surgery and had only recently started to implement a quality improvement programme to address these at the time of the inspection. The concerns had been brought to the trust’s attention in March 2015 by the National Institute for Cardiovascular Outcomes Research (NICOR), which analyses information submitted by heart surgeons around the country.
Consultant surgeons were not always completing “The Five Steps to Safer Surgery Checklist” to minimise the risk of avoidable harm to patients, and surgical trainees were not always supervised by a consultant in theatres when it was appropriate to do so.
Consultant cardiac surgeons did not consistently undertake ward rounds on the cardiac surgery ward, were not always in theatre at appropriate times, and were failing to effectively communicate with nursing and medical staff in critical care.
Low staffing levels in theatres and a lack of critical care beds were leading to an unacceptably high number of planned operations having to be cancelled, with some patients’ surgery cancelled more than once. Some operations were taking longer than expected nationally and more patients had to return to theatre as a result of surgical complications.
Nursing staff working on the critical care unit expressed concerns that they had not received the specific training needed to care for cardiac patients or to operate the specialist equipment required, and medical staff on the unit were not all cardiac trained.
There were delays in decisions being made both clinically and organisationally and the trust had not anticipated, and was not monitoring, the impact of taking on an increasing number of complex patients for heart failure and transplant surgery.
Waiting lists were not shared across surgeons and this had 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 waiting times, fewer cancellations, and good patient outcomes.
CQC identified a number of areas where the trust must improve including:
- The trust must ensure that patient outcomes are regularly reviewed and monitored and action is taken in response to any patient safety concerns.
- The trust must implement a positive reporting culture for reporting incidents across the whole service with learning as the key objective.
- The impact of operation cancellations and patient waiting times must be monitored and actions taken to minimise the risk to patients arising from long waits and multiple cancelled operations.
- Staffing levels in theatres and critical care must be reviewed to meet national guidance and rotas must clearly identify staff roles.
- The trust must ensure that sufficient surgical and medical staff are available and have the appropriate skills, knowledge and expertise to care for patients on the cardiac ward and in critical care.
- Nursing staff on the critical care unit must have the appropriate competence and skills to provide the required care and treatment to cardiac surgery patients. This includes the safe use of equipment.
An inspection team which included two consultant cardiac surgeons, a cardiothoracic theatre manager, CQC inspectors and analysts spent two days at the Queen Elizabeth Medical Centre in December 2015. They examined the care provided in the cardiac surgery ward, critical care, theatres and outpatients.
CQC will return in due course to check that improvements have been made.
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