24 October 2002

Dear Colleagues

Commission for Health Improvement (CHI) – Clinical Governance Review

Following the CHI Review Team’s visit to the Trust in August the report is now available and contains key findings and recommendations and identifies best practice and areas for improvement.

I have always taken the view that if an organisation is open to change then you cannot have a bad CHI review. The findings within the CHI report show that patient care at West Suffolk Hospital is better than average and the overall findings are good!

A copy of the full report is available on the CHI website as well as the Trust’s intranet/website.

The CHI review aims to test whether clinical governance arrangements are effective and assesses nine areas of clinical governance. The Trust receives a scoring in seven areas and details of these are attached.

Staff briefing meetings are being arranged for all staff as follows:

Thursday 24 October 8.30 – 9.30 am Lecture Theatre, WSH

4.00 – 5.00 pm Committee Room, WSH

Tuesday 29 October 8.30 – 9.30 am Lecture Theatre, WSH

A briefing meeting will also be held in Sudbury:

Wednesday 30 October 11.30 – 12.00 noon Staff dining room.

The briefings are an opportunity for staff to hear about the report’s findings and to ask any questions they may have. For those unable to attend the meetings a briefing is attached which is also available on the intranet/website.

Hard copies of the CHI report will be placed in the library as reference documents and in the Walnuttree Resource Centre.

An action planning workshop is taking place on 5 November to look at the recommendations made by CHI in the report. Staff from every area/department across the Trust have already been invited along with members of the clinical teams involved with the CHI visit, members of the Trust Board, Assistant Directors of Modernisation and the Clinical Directors. Key members of the Strategic Health Authority and the Primary Care Trust will also be involved. The resulting Action Plan will appear on the CHI website and the Trust’s intranet/website and its implementation monitored by the Strategic Health Authority.

I would like to take this opportunity to thank you for ensuring that patients receive good care at West Suffolk Hospital. Well done.

John Parkes

Chief Executive

Commission for Health Improvement (CHI)

Clinical Governance Review

This briefing explains the outcome of the CHI report.

What are the aims of CHI?

CHI gives an independent assessment of how well the Trust ensures high standards of care and highlights what it is doing to continuously improve the quality of services. The review:

· aims to test whether clinical governance arrangements are effective

· identifies best practice and areas for improvement

· looks at systems and processes needed to monitor and improve services and whether they are working and making a difference to patient care.

What are they measuring?

There are seven main components that are reviewed by CHI:

Processes for quality improvement

· Patient and public involvement

· Clinical risk management

· Clinical audit

· Research and effectiveness

Staff focus

· Staffing and staff management

· Education training and continuing personal and professional development

Information

· Use of information to support clinical governance and health care delivery

CHI also assesses two further areas which are not scored against:

· the patient experience

· the Trust’s strategic capacity for developing and implementing clinical governance.

How were the scores calculated?

On the basis of the evidence collected, CHI’s reviewers assess each component of clinical governance against a four point scale measuring progress at strategic, planning or operational levels:

1 little or no progress

2 worthwhile progress and development in one, two or all three of the following levels: strategic, planning, operational

3 Good strategic grasp – and substantial implementation

4 Excellence – co-ordinated activity and development.

What are the results for the Trust?

Patient and Public Involvement	2
Clinical Risk Management	2
Clinical Audit	2
Research and effectiveness	2
Staff management	2
Education	2
Information	3

How do we compare with our peers?

	Patient & Public Involvement	Clinical Risk management	Clinical Audit	Research & Effectiveness	Staff management	Education	Information
James Paget	2	2	2	2	2	2	2
Papworth	2	3	4	4	3	3	2
Hinchingbrooke	1	2	1	1	1	2	1
Addenbrookes	2	2	3	3	2	3	2
Peterborough	2	2	3	2	2	2	2
West Suffolk	2	2	2	2	2	2	3

Key messages

· Both the Trust Board and staff show a strong commitment to the delivery of high quality care for outpatients.

· The Trust’s death rates are significantly lower than the average for England for both emergency and non emergency admissions.

· Staffing levels need to be reviewed.

What areas of notable practice were identified?

· The Trust has developed and implemented an ‘early warning score’ to help clinicians appropriately assess changing needs in the level of care for patients.

· The Trust has implemented a ‘patient friend’ scheme for patients undergoing cataract surgery. These are volunteers who provide support to patients during and after the surgical procedure.

What if anything, did CHI find that the rest of the NHS can learn from?

· The Trust has established a ‘pink book’ which provides staff and GPs with updated clinical guidelines.

· The Trust has developed an electronic journal of evidence based practice and research carried out by clinicians which provides staff and GPs with updated clinical guidelines across the health community.

What happens now?