Hospital CQC Improvement Programme Development & Delivery

Partnering with a Teaching Trust to develop and implement a Care Quality Commission (CQC) Improvement Plan.

To discuss how we can help you with similar challenges please contact Mark Ellis.

The Problem

  • A Teaching Trust made up of two acute hospitals and one elective centre were looking to implement a CQC Improvement Programme.
  • Following a visit from CQC, concerns were raised that resulted in Section 29a measures being implemented, thereby rating the Trust as inadequate.

The Solution

  • One of the 4C team developed a two-phased approach, working alongside NHS Improvement, to ensure the Trust reviewed the governance and skill sets required. This was done through programme development and staff review, along with the establishment of a clinical quality improvement programme to address all concerns raised by inspectors.
  • Following a data set review, an outline plan was developed, including the required clinical quality improvements identifying new actions and interventions to address all concerns raised by both CQC and NHSI.
  • They organised daily huddles to review actions, identify blockages and areas for escalation once all the plans were signed off, agreed and aligned with the expectations of senior leaders.

The Impact

  • As a result, the client benefited from a removal from special measures, delivery of £20m efficiencies, joint planning with CCG for future years and an enabled PMO function.
  • The review of the 12-hour breach process and re-designed process to improve flow, the review of the bed management function and a re-design to reduce agency spend and improve discharge procedures.
  • They worked on joint initiatives with the CCG and many of the hospital improvement projects featured in the system wide transformational plan to deliver activities associated with partnership boards such as the A&E Delivery Board.
  • In addition, they provided monthly reports to both the Trust and NHSI ensuring that they gathered and identified the evidence base to support delivery of the response to CQC.