Use of information about compliance by regulator from: Media

Accepted in part.
The Care Quality Commission’s new approach to inspection includes a published set of ‘Intelligent Monitoring’ indicators for monitoring quality in providers: for the first time indicators in relation to acute trusts were published on 24 October 2013, and these will be published quarterly. The indicators use information on serious incidents and avoidable harm, all of which is valuable to the Care Quality Commission. While it would not be feasible to follow up on every reported incident of patient harm as there are more than 250,000 incidents each year with over 200,000 of these categorised as low harm incidents, the Care Quality Commission has defined a number of these indicators as ‘tier one indicators’, which always trigger rigorous follow up action to obtain assurance. Tier one indicators include serious incidents such as ‘never events’. The Care Quality Commission’s new Intelligent Hospital Monitoring system will also trigger a response whenever there is a statistically significant number of severe harm incidents or avoidable deaths at a provider location. The Care Quality Commission also analyses information over time and takes action on patterns of differences between expected and observed outcomes of care, and patterns of incidents.
The indicators on their own will not be used to draw definitive conclusions or judge the quality of care – that will be a matter for inspection. Instead the indicators will be used as ‘smoke detectors’, which will start to sound if a hospital is outside the expected range of performance for one or more indicators. The Care Quality Commission will then assess what the most appropriate response should be. Providers are required to inform the Care Quality Commission of a range of incidents that may point to failings in the care provided.
The Care Quality Commission will consider further ways to monitor and act on incidents and avoidable harm as its new system of monitoring providers matures, in order continuously to improve its sensitivity to this aspect of quality of care. However, it needs to avoid any duplication with local arrangements for ensuring that providers address serious incidents and avoidable harms and demonstrate learning, as set out in NHS England’s Serious Incident Reporting and Learning Framework. For this reason, while the Care Quality Commission should ensure high priority to responding to concerns about patient safety, it should not follow up any serious incident or avoidable harm, given that other arrangements are in place and the Care Quality Commission needs to target its resources where it will have greatest impact in promoting better quality care.

This function transferred to NHS England. Please our response to recommendation 42 above for information on the Patient Safety Incident Response Framework (PSIRF). PSIRF makes no differentiation between patient safety incidents and serious incidents – as such it removes the serious incident classification and the threshold for it. PSIRF requires organisations to develop a thorough understanding of their patient safety incident profile, ongoing safety actions and established improvement programmes, and a patient safety incident response planning exercise is used to inform what the organisation’s proportionate response to patient safety incidents should be. A key part of PSIRF is that the response must enable the organisation to learn from its incidents, and the response process is completely separated from processes which seek to apportion blame. Whilst the organisation needs to respond to each incident, they do not have to carry our a full individual investigation based on the level of harm caused by the incident.

Each organisation must publish their Patient Safety Incident Response Policy and Patient Safety Incident Response Plan on their website, so that patients and the public can understand which type of response each incident type will receive.

CQC will assess how an organisation is meeting the patient safety incident response standards in its assessments and inspections.

The Care Quality Commission’s Intelligent Monitoring system triggers a response where there are a statistically significant number of severe harm incidents or avoidable deaths at a provider. ‘Never events’ trigger an automated elevated risk in Intelligent Monitoring which inspectors are expected to follow up individually. The Care Quality Commission uses this information to determine whether to inspect a provider and what line of enquiry to take on inspection.

The Care Quality Commission is currently reviewing internally its role and approach to serious incident reporting and investigations, this includes a thematic probe into complaints, concerns and whistleblowing, a part of which is the examination of what the Care Quality Commission does with this information and how it can be used better.

This recommendation was accepted in part by the Government.

In the January 2014 Hard Truths report, the Government referred to the Care Quality Commission’s new inspection regime, in which indicators used for monitoring quality would use information on serious untoward incidents and avoidable harm. However, the Government said it would not be feasible to follow up on every reported incident of patient harm as there more than 250,000 incidents each year. The Government said that the Care Quality Commission had defined a number of these indicators as ‘tier one indicators’ (including serious incidents such as ‘never events’) which would trigger rigorous follow-up action to obtain assurance.

In the February 2015 Culture Change report, the Government referred to the Care Quality Commission’ new Intelligent Hospital Monitoring system, which would trigger a response where there is statistically significant number of severe harm incidents or avoidable deaths at a provider location. However, the Government also referred to the need to avoid duplication with local arrangements for ensuring that providers address serious incidents and avoidable harms, meaning that the Care Quality Commission should not follow up any serious incident or avoidable harm.

In the 2015 Culture Change Report, the Government said that the Care Quality Commission was reviewing internally its role and approach to serious incident reporting and investigations.