GOOD progress is being made by some NHS hospital trusts in England in learning from deaths, although some are struggling to improve engagement with bereaved families and carers.
That’s the conclusion of a new Care Quality Commission (CQC) report, which also describes the current pace of change as “not fast enough”.
The regulator reviewed inspectors’ observations from the first year of assessing how well trusts are implementing national guidance introduced to support improved investigations and better family engagement when patients die.
While some trusts were praised for showing “good progress”, the report stated that “failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed.”
National guidance for trusts to initiate a standardised approach to learning from deaths was published by the National Quality Board (NQB) in March 2017, followed by guidance for trusts on working with families in July 2018. The NQB’s guidance called for trusts to improve processes for identifying deaths resulting from problems in care, to introduce a clear policy for engaging with bereaved families and carers in a meaningful and compassionate way, and to appoint a senior member of staff to hold responsibility for learning from deaths across the organisation. It also set specific requirements for trusts to collect and report information about deaths of patients in their care.
The CQC’s review revealed that, one year on, awareness of the guidance is high and inspections have found evidence of some trusts having taken action to revise policies and establish more robust oversight of the investigation process to ensure learning is shared and acted on. But some trusts were found to have made better progress than others, with some struggling in particular to improve engagement with bereaved families and carers. This has been blamed on various issues including a fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers.
The report went on to state that "problems with the culture of some organisations may be a barrier to putting the guidance into practice". It said the key to enabling good practice is an open and learning culture, clear and consistent leadership, values and behaviours that encourage engagement with families and carers, positive relationships with other organisations and the ability to support staff with training and the wider resources needed to carry out thorough reviews and investigations.
CQC chief inspector of hospitals Professor Ted Baker said positive changes have been made, but added: “[P]roblems with the culture of some organisations is preventing sufficient progress. Cultural change is not easy and will take time, but we cannot lose momentum and the current pace of change is not fast enough.”
He urged trusts to use the examples of good practice set out in the CQC report to make progress in their own organisations.
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