In September 2013, shortly after starting in post as a national medical director’s clinical fellow at the BMJ and NHS England, I received an email inviting applicants to join “Mike’s army” as a junior doctor on a CQC (Care Quality Commission) inspection. My application was duly accepted and I was signed up to inspect one of the first wave of hospitals under a new model of inspection developed following the widely acclaimed methodology of the “Keogh reviews” earlier in the year.
The new inspections, developed by a team led by the first chief inspector of hospitals, Mike Richards, were initiated in part in response to the Francis reports, and aim to fundamentally improve the quality of the inspections that the CQC carry out. Having been on the receiving end of a number of inspections, I was intrigued to gain an insight into this.
From my own experience, I was somewhat cynical about the value of inspection in driving up the quality of care as a result of a number of things: in the most recent organisation that I worked in, the threat of a CQC inspection generated an enormous amount of stress and anxiety. This generally did not lead to positive behaviours or outcomes and in many cases, “CQC” became a threatening verb, as in “if you don’t sort that out, it be will CQCed.” Also, the inspection did not necessarily represent the organisation in its true form, and led to short-termist actions designed to gloss over cracks in the walls. Therefore, my perception was that inspection often directs focus on particular aspects of a service that are perceived to be failing rather than than a holistic view of quality improvement.
It was made clear from the outset that the model of inspection was being trialled and that frequent changes and improvements were being made, based on feedback. Of the changes to the methodology, two seemed to me to be fundamental: firstly, the inspection teams were larger (ours was around 30 people) and multidisciplinary, made up of professional CQC inspectors (the ones who strike fear into everyone when they enter the doors of the hospital), clinicians, including myself as a junior doctor, consultants, a nurse and student nurse, analysts, experts-by-experience, and patients. Secondly, whereas previous inspections were focussed on binary compliance with regulations, we were inspecting for good, as well as substandard practice against five domains: safe, effective, caring, responsive, and well led.
The inspection was divided into three phases: the first part —the preparation —involved a webinar, a huge datapack, and a teleconference.
The second phase —the visit itself —started with day 0 where the team collected in the base hotel which immediately provided an opportunity for team bonding, brought together by the sheer mediocrity of the facilities including reports of lack of hot water, heating, and an insect infestation. However, the day itself provided a really valuable start to the inspection. I particularly enjoyed the input from the analysts who had diligently put together a comprehensive data pack, on which key lines of enquiry (affectionately known as KLOEs) were developed. This was essential to deciphering the mass of information provided. The day provided an opportunity to meet other members of the team and subteam and also for the CEO of the trust to provide a candid presentation to put the visit in context.
The inspection proper started on the second day with subteams being sent in different directions depending on their responsibilities. General guidance on how and what to inspect was provided by the chair and team leader but importantly, the detail was devolved down to the sub team leaders in an effective demonstration of distributive leadership.
Visiting the wards, the tension was palpable. Staff looking over their shoulders, smiling nervously, and I felt sorry for them, knowing how it felt to be in their position. However, I knew that I was there to do a job. This involved a series of things from observation, to interviewing staff, patients, and relatives, doing case note reviews, looking at rotas, protocols, and incident reports. All the while, we referred to our data and KLOEs to guide us, for example to the ward with the low Friends and Family Test or to dig deeper into the service with a high rate of catheter related urinary tract infections. I found this to be an enormously valuable exercise giving me an insight into the operations of the hospital which would not normally concern me.
The highlight was the opportunity to conduct the junior doctors’ focus group, where I resolved to spend at least a quarter of the time discussing positive issues. I know how candid junior doctors are, especially as they are in the almost unique position of being able to benchmark a hospital given the amount of time we spend rotating around different institutions. I felt great value in having a peer-to-peer discussion and this must remain central to the inspection methodology. I was offered a range of responses from overly positive to an unsettling account of a junior doctor who had been involved in a serious incident and not been offered any feedback or learning opportunity.
At frequent points during the inspection, the whole team came together for corroboration sessions which I found very helpful. These provided an excellent learning opportunity as different perspectives were offered from different members of the team, giving me an insight into the hospital operations and strategy. These were assisted by the excellent analysts who provided a two-way conduit between the inspection team and hospital to gain further information or rapidly distill the data into a usable form.
The final phase is the report writing, which was mainly conducted by the professional inspectors, with input from the team into the final draft.
I have spent some time after the inspection reflecting on its value, especially in relation to my preconceived cynicism. These would be my top five:
On a personal level, I really enjoyed the experience and found it very enriching. I met some great people, in particular one of the experts-by-experience who, despite undergoing chemotherapy, found it important enough to join the inspection team. I learned in depth about the operations of a hospital and its relationship to other organisations, something that will stand me in good stead for years to come. I am really grateful for this and have certainly changed my perceptions of medical leadership.
I was impressed by the “new” CQC: they are clearly learning from the issues that have arisen in the past, and eager to improve the process as diligently as possible. Although there are flaws in the methodology, particularly with the training, they were eager to receive feedback and were impressively transparent about everything that is going on.
The main drawback of the inspection methodology was the feeling that we were just scratching at the surface: inspecting during the daytime over two weekdays, I felt that it was difficult to give an accurate reflection of the state of the hospital. From experience, these are not the times that services are stretched and moreover, with prior notice of the CQC arriving, adequate staffing and compliance can be ensured to a certain extent. This issue is countered somewhat by the subsequent unannounced visits and having more of the right intelligence prior to the inspection to focus on particular aspects.
The big question for me is who owns the “quality agenda.” Inspection will only be effective if the providers themselves are able to work together with other stakeholders, assisted by others, most importantly Monitor and the Trust Development Authority, to improve. If any of these relationships are strained, in particular with commissioners, I have concerns that this will not occur.
This links to the organisation itself: the message for me is that it is vital that from “board to ward,” a hospital is able to demonstrate and live the fact that it is a learning organisation. Error will always happen in healthcare, but the tragedy happens if mistakes re-occur due to the analyses of the cause of these not being done and lessons learnt and implemented. Enforcement alone will not do that —it takes a culture of transparency, humility, and openness to achieve this.
Declaration of interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interests: I was employed by the Care Quality Commission as a clinical expert to take part in the hospital inspection.
Marc Wittenberg is the clinical fellow to Fiona Godlee, editor in chief of the BMJ. He is a senior registrar in anaesthesia and intensive care in North London and is spending a year as the National Medical Director’s Clinical Fellow seconded to BMJ and NHS England.