Lack of adequate systems to ensure some trust boards are properly informed about trends or potential issues in wards or specialist services is highlighted in a new report from regulator, the Healthcare Commission.

The report, Learning from investigations, reviews all investigations undertaken by the commission under its statutory powers from August 2004 to April 2007. Investigations are undertaken where patient safety is seriously at risk.

Good leadership, effective management and systematic use of information are picked out as common actions needed to resolve the kind of problems the commission found.

The report says: “We have been surprised at the extent to which some large, complex organisations have not had adequate systems in place to ensure that the board is properly informed about trends or potential issues at ward level or in specialist services.

“The collection and proper use of data on outcomes is essential for every trust, for board members to assure themselves about the quality of services for which they are responsible.”

The commission also found that some trusts were collecting information but not using it to inform decisions

“Apart from exposing patients to unnecessary risk, these situations can have the added danger of providing ‘false assurance’ within the trust because board members take comfort in the knowledge that data is collected and that no concerns have been raised,” says the report.

It adds that this ‘false assurance’ can also inappropriately reassure strategic health authorities monitoring trust performance and primary care trusts commissioning services.

“Every NHS board member has a responsibility to ensure they understand the data they are given. What is more, they need to challenge or question information whenever it appears unclear, so that they can provide a genuine assurance that patients are receiving safe, appropriate care,” the report concludes.

Poor use of mortality data is highlighted in a case study from Oxford Radcliffe Hospitals NHS Trust where concerns about death rates for patients undergoing coronary artery bypass grafts (CABG) triggered an investigation in 2005.

The report says the commission was critical of the trust for not using its own data to monitor or improve treatment.

“This was particularly crucial because our analysis confirmed that the trust was operating on a greater proportion of patients who were at high risk than many other trusts. Elements of the service had not been developed to meet the needs of these patients,” says the report.

The commission’s analysis of the trust’s data also showed that the trust had a higher-than-average death rate in all risk groups.

Recommendations were made to improve the process for obtaining consent, the planning for patients assessed as high risk for CABG surgery, clinical governance and leadership and the collection and use of data for cardiac surgery.


Healthcare Commission

Learning from investigations