Analysis of Mid Staffordshire Trust Inquiry Executive Summary Report

This report provides an executive summary of the Mid Staffordshire Trust Inquiry, focusing on the failures in service quality and the compromise of national quality standards within the hospital. The assignment analyzes the process map of deteriorating health services, highlighting issues such as patient deaths due to substandard care, medication errors, and inadequate staff training. It emphasizes the need for adherence to national quality standards, including patient safety, proper medication administration, and effective communication. The report offers five recommendations for service delivery improvement, including benchmarking, following national quality standards, conducting audits, implementing a central system for duties and responsibilities, and adopting evidence-based practices. It then details an implementation plan for a central system and evidence-based practice to improve service quality. The report concludes by emphasizing the importance of these recommendations for enhancing patient care and overall healthcare outcomes. The analysis includes process mapping, recommendations, and an implementation plan for addressing the issues highlighted in the Mid Staffordshire Trust Inquiry.

MID STAFFORDSHIRE TRUST INQUIRY

EXECUTIVE SYMMARY
The report has provided the case analysis of Stafford hospital in which all necessary legislation
and service quality standards were compromised. The case study has discussed that how service
quality and standards of the hospital were compromised by the service providers. The study has
also discussed the process mapping of deteriorating health services provided by hospital. The
study has also provided appropriate recommendations so that such irregularities in health care
can be addressed. On the basis of these recommendations the report also included an
implementation plan for the Stafford hospital.

TABLE OF CONTENTS
EXECUTIVE SYMMARY.............................................................................................................2
INTRODUCTION...........................................................................................................................1
TASK 1............................................................................................................................................1
Service failure in terms of National quality standards.................................................................1
TASK 2............................................................................................................................................3
Five recommendations for improving service delivery...............................................................3
TASK 3............................................................................................................................................5
Implementation plan....................................................................................................................5
CONCLUSION................................................................................................................................7
REFERENCES................................................................................................................................8

INTRODUCTION
One of the most important requirements which is required to be focused on in healthcare
organizations as their first and the foremost priority is to provide quality service to their patients
(World Health Organization, 2015). In order to maintain and provide quality service to their
patients, there are various local and national standards that are required by the organization to
follow. This assignment is based on a case study of Mid Staffordshire Trust inquiry in which in
Mid Staffordshire Trust between January 2005 and March 2009 approximately 1200 patients
died due to poor quality service. Doctors and nurses of Mid Staffordshire trust didn’t answer
their patient buzzers, provided wrong medications or none at all, inexperience doctors treating
patients and many more. This assignment will focus on process map which will help in
analysing different aspects of service failure, recommendations that will help in improving
service delivery and implementation plan which can be used to improve their overall quality of
service.
TASK 1
Service failure in terms of National quality standards
Analysis processing map in negative ways by using case study:
As per analysis through case study, it has found that there are large number of patients died
in hospitals which result of substandard care and employee not properly provide facilities in
proper manner. It has analyzed that the hospital does not taken any type of responsibilities
regarding safe care which are not properly give answer and preferred the wrong medicine that
negatively effects on the patient life (Brown and et.al., 2019). As per case study, it has
summarized that many juniors focused on the charges and having lack of experience in term of
medical treatment where most of nurses switches off the equipment because they don’t have
proper knowledge, how to use it. In this way, it has increased the chances of failure and
maximum overall mismanagement system. Many patients are faced the problem of dehydration
because they are avoiding to drink water in properly, it directly affecting the patient’s body.
After few years, The Mid Staffordshire exposed in 2007 where it has found that there are 1200
patient died due to irresponsibility of doctors in hospital (Brimhall, 2019). this was main causes
of hospital failure because of their mismanagement which directly affecting on patient, who are
visiting the hospital for purpose of treatment. In 2010, Health secretary has announced to
organize inquiry against the hospital and examine overall process of organization and how they
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were treated their patient. It also conducting the proper inquiry which help for finding the overall
business operations and functions. It separated highly critical report by other commission which
revealed about the failing at trust and also determined the risk regarding patients (Michaud,
Weber and Ambresin, 2019). As per report, it has found that there are approximately 1,200 more
patients died as per expectations. Another failure is that when NHS managers staffed not
properly consult with their supervisor who took many instructions from the seniors. Below are
few standards and expectations explained that can be used to bring improvement in failure
process map.
Explanation of processing map in positive ways by using case study:
The Stafford hospital put the life of huge number of patients at risk. The health professionals
providing services within hospitals were also equal contributors in the case. As per the national
health standards health service providers must put the patient safety at the priority. However, no
such efforts were taken by the hospital. Instead in the hospital basic needs of patients such as
water, food or medications were also not fulfilled. It is the responsibility of the health
professionals and nurses to ensure that the medication they are providing to patient is safe and
does not have any adverse effects (Compston, 2017). There must be regular monitoring of the
vital signs so that medication allergies or reactions can be identified or addressed. It is the most
fundamental quality standard for health care services that patient safety must not be
compromised.
However, in Stafford hospital health professionals were not concerned about the
medications or clinical errors. It is the responsibility of the health professionals to identify all the
risk factors which can threaten the life of patient. No such efforts were taken by the hospital
staff. For instance, all patients were provided with soiled bedsheets. Even if they had any
requirement no proper response was given to the patient buzzer. It is also expected from the
health service providers that they must deliver the high quality and accurate care services. Thus,
suitable training must be provided to them. However, in the given case study it has been
identified that nurses were not even trained to respond towards patient needs.
As per the NICE guidelines health service providers must also assure that they ensure the
equal participation of patient and their family members in decision making. It leads to quality
health outcomes. Contrary to this in Stafford hospital all clinical judgements and decisions were
taken by the receptionists who did not have any authority or required knowledge to take decision.
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The decision making by unauthorised individuals can threaten the safety of patients. The same
was observed in the case study. For all the health care service providers it is expected that they
must have sensitivity and understanding capability towards the patient needs and care
requirements. The health care service providers must not compromise with the life of patients at
any cost. The treatment and service efficiency can be improved by encouraging communication
between patient and service providers. Contrary to this in Stafford hospital service providers
used no such attempts to pay attention to the feedback or requirements of people. As per the
guidelines of NICE nurses or doctors can also whistle blow such irregularities identified in health
and social care institutes and their confidentiality is fully maintained (Hignett and et.al., 2015).
However, despite such supporting agencies none of the staff member of Stafford hospital took
effort to draw attention of the senior authorities or CQC. For all staff members there must be
essential training programs so that their professional expertise can be increased, however in the
given case study no such programs were present.
Training always helpful for organization that support to improve quality of services which
also supporting the patient’s life otherwise, it will increase the confliction between the
employees. It also increases the issues and problems where many patients died with lack of
proper care. It has required to take feedback from other employee, who always supporting in
terms of overall hospital management (Rezapour and et.al., 2019). In this way, it improves
quality of hospital health care where they provide proper medical services on time to time. it
must require to handle overall hospital medical scheduling process which provide better quality
of medical treatment effectively.
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Figure 1 Failure process Mapping
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TASK 2
Five recommendations for improving service delivery
There are various kinds of local as well as national standards that can help Mid Staffordshire
Trust to improve their service quality. These standards help the healthcare organization to meet
their patients’ needs and requirements in order to provide quality service and adopt best practices
which will help them to bring improvement within their service quality which is being delivered
to their patients. Here are few recommendations that can be used by Mid Staffordshire Trust to
bring improvement within their services:
Recommendations:
1. First of all they can set some benchmarking standards which will work as a guidelines or
rules that can be used by the organization to improve their quality standards. Setting these
benchmarks will help them set some changes that are required to be brought within the
organization (Jennings and et.al., 2015). Mid Staffordshire Trust can set their benchmarking
in such a manner that it examines all the internal departments of the organization such that
their internal process can be improved and all the doctors and nurses will be focuses more on
treating their patients in a proper manner. This benchmarking will also help them to bring
improvement within their admit or discharge time of their patients as well.
2. They can also focus on following national quality standards. Mid Staffordshire Trust should
focus on ensuring whether all the quality standards are being fulfilled or not for prevention
and treatment of ill health of patients (Silver and et.al., 2015). National quality standards help
a healthcare organization to ensure that good healthcare practice is being used for the
patients, it also helps them to resolve uncertainty of their junior doctors. This will further
help them to improve their availability of doctors in order to improve quality of service.
3. They can focus on conducting an audit to ensure whether all the quality standard are being
followed or not. For this chief inspector of audit social care can conduct an audit where they
will be asking the patients of the hospital that all the services provided to them are safe,
appropriate and effective (Suphanchaimat and et.al., 2015). They can also ask the doctors or
nurses of the hospital and can verify whether they are being guided properly or not. Audit
inspector can conduct an inspection at the hospital to identify flaws, scope of improvement,
faults, indelicacy of the service etc.
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4. They can also build a central system which will be recording all duties and responsibilities of
all the doctors and patients of the hospitals. All the doctors and nurses of the hospital can be
connected to this system so that they will directly get updates related to their duties
(Smolowitz and et.al., 2015). This system will also help the hospital to record needs,
requirements of all kinds of services or medication or treatment of the patients. These needs
and requirements of the patients will be directly sent to the respective doctors or nurses such
that they can attend their patients on time in an appropriate manner.
5. Mid Staffordshire Trust can adopt evidence-based practice so that they can they can provide
effective services to their patients in order to improve outcome of their services provided to
their patients. Evidence based practice will help them to focus on all the critical case patients
such as heart failure, diabetes etc. Mid Staffordshire Trust can focus on conducting proper
required training to their nurses and doctors so that they can ensure that proper and effective
treatment is being provided to the patients (Koblinsky and et.al., 2016). Organization can
also collect feedback from their customers so that they can get to whether they are being
treated properly or not and whether they are being provided with proper and appropriate
services or not. This will help them to ensure that evidence-based practice is available and
being provided to their patients or not.
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Figure 2 Ideal process Mapping
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Implementation of these recommendations can help Mid Staffordshire Trust in improving
their service delivery and adopt best practices in order to bring improvement within their services
that are being delivered to their patients.
TASK 3
Implementation plan
Recommendations to be used for implementation plan are:
 Implement a central system
 Evidence based practise
Implementation plan for two of the above recommendations are:
Aim:
To improve the quality service which is being delivered to the patients at Mid
Staffordshire Trust
Objectives:
 To implement a central system for continuous monitoring of quality service provided to the
patients
 To improve evidence-based practise within the organization in order to ensure provision of
quality service to the patients.
Actions:
In order to achieve the objectives of the implementation plan it is important for the
organization to follow various kinds of activities so that they can bring improvement within their
quality services which is delivered to the patients.
Two major activities to be implemented are:
 Implementation of a central system
 Improve evidence-based practise
Implementation of a central system
Objectives:
 Identify basic requirements of the new central system
 Allow staff members to provide their suggestions and viewpoint for the system
 Implement the central system
These are the objectives which will help Mid Staffordshire Trust to implement central system
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within their organization. With the help of these objectives Mid Staffordshire Trust will not only
be able to implement the central system but will also be able to continuously monitor their
doctors and nurses and check whether all the requirements and needs of their patients are being
fulfilled or not. This system will provide a close monitoring to the organization where they can
easily identify flaws within any process and correct fulfilment of their services (Sharma and
et.al., 2015). In order to implement a central system organization, need to identify and collect all
the basic requirement of the system this will help them to identify all the main and important
functionalities of the system. they can also ask for suggestion from the staff members so that if
there is any kind of requirement of bringing any improvement then it can be identified. One the
basis of these requirement central system can be implemented such that monitoring of complete
system can be done.
Evidence based practise
Objectives:
 Check qualification of all the doctors and nurses working within the organization
 Provide required training to the doctors and nurses
 Conduct time to time development activities
 Collect feedback from the patients
These are the objectives which will help Mid Staffordshire Trust to bring improvement within
their evidence-based practise. For this at the time of recruitment organization need to check and
verify documents and qualification of all the doctors as well as of nurses so that they can ensure
that they are capable of treating their patients. Organization can also focus on providing proper
training to their staff members. Training will help the staff members to develop required skills
and enhance their knowledge which will further help them to increase their efficiency and ability
to treat their patients. Various kinds of development Activities should also be organized so that
all the doctors and nurses can update their knowledge and skills and learn or develop new
knowledge and skills required by them. This will help the organization to enhance their ability
and skills to treat their patients in an effective manner. This will also help the organization to
provide quality service to their patients in order to be treated. Other than this Mid Staffordshire
Trust can ask their patients to provide feedback on the service which is being provided to their
patients. Feedbacks collected from the patients will also help Mid Staffordshire Trust to check
whether proper evidence-based practise is being implemented within the organization by the
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doctors or not. These objectives and activities will help Mid Staffordshire Trust to improve their
service quality delivered to the patients.
CONCLUSION
From the above assignment it has been concluded that there were various kinds of issues
within the functionality and process of Mid Staffordshire Trust due to which their overall service
quality was extremely poor and as a result more than 1200 patients died. From the above analysis
it was analysed that NHS lacked enough consultants who can supervise their junior doctors due
to which they took their instruction from head nurses as a result their overall service quality was
disturbed. It has also been analyzed that there are various ways through which service quality can
be improved such as: implementation of central system, adhering Local and national quality
standards, conducting a yearly audit, improving their evidence-based practice and many more.
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REFERENCES
Books and Journals
Brimhall, K.C., 2019. Inclusion Is Important... But How Do I Include? Examining the Effects of
Leader Engagement on Inclusion, Innovation, Job Satisfaction, and Perceived Quality of
Care in a Diverse Nonprofit Health Care Organization. Nonprofit and Voluntary Sector
Quarterly. p.0899764019829834.
Brown, M. V. and et.al., 2019. Morehouse Choice Accountable Care Organization and Education
System (MCACO-ES): Integrated Model Delivering Equitable Quality
Care. International journal of environmental research and public health. 16(17). p.3084.
Compston, J., 2017. NOGG and NICE: New guidelines and quality standards for
osteoporosis. Maturitas. 106. pp.97-98.
Jennings, N., and et.al., 2015. The impact of nurse practitioner services on cost, quality of care,
satisfaction and waiting times in the emergency department: a systematic review.
International journal of nursing studies. 52(1). pp.421-435.
Koblinsky, M., and et.al., 2016. Quality maternity care for every woman, everywhere: a call to
action. The Lancet. 388(10057). pp.2307-2320.
Michaud, P.A., Weber, M.W. and Ambresin, A.E., 2019. Improving the quality of care delivered
to adolescents in Europe: a time to invest. Archives of disease in childhood. 104(3).
pp.214-216.
Rezapour, A. and et.al., 2019. Designing a pragmatic model for strategic purchasing of health
services in health insurance companies: the feasible pivot of strategic purchasing in a
developing country. International Journal of Health Governance. 24(1). pp.42-55.
Sharma, G., and et.al., 2015. Quality care during labour and birth: a multi-country analysis of
health system bottlenecks and potential solutions. BMC pregnancy and childbirth. 15(2).
p.S2.
Silver, J.K., and et.al., 2015. Cancer rehabilitation and palliative care: critical components in the
delivery of high-quality oncology services. Supportive Care in Cancer. 23(12). pp.3633-
3643.
Smolowitz, J., and et.al., 2015. Role of the registered nurse in primary health care: meeting
health care needs in the 21st century. Nursing Outlook. 63(2). pp.130-136.
Suphanchaimat, R., and et.al., 2015. Challenges in the provision of healthcare services for
migrants: a systematic review through providers’ lens. BMC health services research.
15(1). p.390.
World Health Organization, 2015. The growing need for home health care for the elderly: home
health care for the elderly as an integral part of primary health care services. World
Health Organization. Regional Office for the Eastern Mediterranean.
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