The visit from the Commission for Health Improvement team is a distant memory, the report is out, and the nasty local media stories are yesterday's fish and chip paper.
Time to relax?
Only the most confident or unwise chief executive would put out an action plan and simply cross their fingers. So how do they ensure the right transformations take place after a critical clinical governance review - or a report that at least leaves a few challenges to tackle?
How quickly can patients see benefits?
The review of Hull and East Yorkshire Hospitals trust was published in August. While recognising a strong commitment to clinical governance, it calls for a number of improvements. These include dealing with waiting times in the acute assessment unit (AAU), systems for learning from complaints, the setting up of a nursing strategy, improved patient and carer participation, and more privacy and dignity in mixed-sex wards.
It is early days, but are patients better off already? The trust's general manager for quality, Liz Thomas, says the trust has not yet been deluged with deadlines, but it is already buying a new system for integrating incidents and complaints information.
It has begun to put up screens in mixed-sex wards, started an AAU review, and makes sure patients are offered covers during transfer between units.
Chief executive Chris Appleby says he 'didn't necessarily disagree in principle with CHI' - so there was 'not that level of difficulty in ...putting together an action plan', compared to places like Epsom and St Helier or University Hospitals Coventry and War-wickshire trusts, which have seen drafts of action plans bounce to and fro from CHI.
Inviting outside bodies to take part in the 'stakeholders' day' after the report is agreed is 'helpful', Mr Appleby believes. 'It is useful to get external focus.'
So does the action plan mean extra layers of systems and checks? Mr Appleby is happy to tie monitoring into existing performance- management structures. 'If you do not, you end up with more processes and less action.'
Meetings are 'just an excuse for not making a decision' and the trust 'already knows' who has to deliver.
According to Liz Thomas, an update goes to every trust board meeting, but she does not believe she should be 'telling a director how to implement'.
In its report on Northern Birmingham Mental Health trust, CHI found some good practice such as involvement of users in developing services for ethnic minorities. But overall, the reviewers pulled no punches.
They flagged up high levels of reported abuse, harassment and violence, particularly poor nursing leadership, the absence of a clinical-risk strategy or structure.
Patients showed signs of overmedication and were excluded from decisions about their care.
Chief executive Derek Kitchen has set up a weekly progress review meeting by a team of executive directors and a bimonthly clinical governance subcommittee meeting. A group of stakeholders and users meets representatives from the clinical governance sub-committee.
How have things improved? 'A revised management structure is being devised to align with emerging primary care trusts, ' Mr Kitchen said last week. 'Tomorrow, we begin two months of roadshows to raise awareness of clinical governance. We will shortly be signing off job descriptions for clinical governance leads in each of the localities, and It is important those leads are practising clinicians in the trust.'
But have services benefited yet? 'We are two months and two weeks into our action plan. Despite work, focus, energy and progress, It is unlikely real impact will have been felt by users and carers.'
Southampton University Hospitals trust published an action plan alongside its pilot review last December. The report noted betterthan-average performance on six out of seven clinical indicators. But it urged greater use of information from incidents, claims, complaints and clinical audit, and had 'serious concerns' about the quality of care given to trauma and orthopaedic patients.
CHI touched surprisingly gently on patients' concerns over time spent waiting for outpatient appointments. Yet only last week, the trust confirmed that a wait of 20 months for a knee, hip and hand outpatient appointment, followed by a 54- week wait for an MRI scan and a further 18 months for surgery is the norm Trust associate director for clinical development Sue Davies keeps an overview of action-plan implementation. Orthopaedics is 'a service under great pressure and It is needing and getting investment, but I do not know whether It is because of the CHI report, ' she says. There is£3m for two new theatres and 40 extra beds.
The action plan says that waiting lists and waiting times should be addressed by the transformation team, which is also the vehicle for service reconfiguration. There are new multiprofessional triage teams in primary care.
Have there been tangible improvements since December? 'Clinical governance is a much closer part of the business-planning process than it was a year ago, ' says Ms Davies.
The trust also tries to make money available each year for the clinical governance programme to integrate it with the CHI programme.
In trauma and orthopaedics, 'the department had to come together and work really positively, and that is having good results'. Radiotherapy waiting times will benefit from a capital-building programme and 'we are looking at whether other trusts can help'.
There are 'one or two' areas where the timescales have not been met. 'Key individuals have left and inevitably there is a six month hold up, ' admits Ms Davies.
She says action points are 'integrated as far as possible, so that we are not adding to what people do'. Lead managers have been identified to drive implementation and they are responsible to the clinical governance steering group, which 'keeps an eye on things'.
As leaders of the clinical development directorate, the nursing and medical directors keep the trust board up-to-date by submitting quarterly reports to the audit committee.
Throughout it all, the trust has had 'a strong commitment to clinical governance and to being a CHI pilot'. Ms Davies adds: 'We approached the whole review as an opportunity to learn.' l Off the shelf: making a difference When it comes to clinical governance reviews, 'we do not want to be involved in something and then see it sit on the shelf', says Commission for Health Improvement director of nursing Elizabeth Fradd.
What will help trusts to smooth the action-plan implementation process? Once the report is agreed, the objective-setting day is key, she says. It builds in a 'handover' by CHI to the organisation so that it gets 'some real ownership'.
She recommends that regional office and the health authority are there in the case of acute trusts and other groups, as appropriate. CHI might recommend that the Clinical Governance Support Team comes along. Inviting the right people is 'an area that could be developed more'.
What about trusts which can present robust arguments that financial problems are a significant threat to the action plan? She 'can't say that CHI is always going to be the catalyst for more money', but points to North West Wales trust. Here, a 'considerable amount of money was found for cardiac services' as a result of 'some really helpful discussions at the objective-setting day'.
In order to help those less used to compiling action plans, CHI is putting together a guide to structure and content.
Regional office should be involved with CHI at every stage - during the review itself, at the objective-setting, then every quarter a CHI assistant director will discuss outstanding issues, from missing action plans to timetable slippage.
The eight regions differ in 'how good they are at seeing stuff through', according to one CHI source. People are looking for jobs and 'everything at region is affected by the fact that there is lots of change going on'. The most successful trusts will be 'those who have read some of our reports before, talked to us and to other organisations We have visited and are much more in a state of continuous improvement - their mindsets are already working the right way'.