Quality Care And Situational Analysis Of Southern Health NHS Foundation Trust

pages Pages: 4word Words: 890

Question :

University: Anglia Ruskin University

Module Code: MOD004064

1) Undertake a situational analysis of an aspect of the service provide by Southern Health NHS Trust.
2) Evaluate your analysis against the organization's standards and expectations for the service delivery to their customer/client using a process map.
3) Make recommendations to the management for improvements to the standard of service being delivered and include an implementation plan for southern Health NHS Trust.

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Answer :


It is important for the institutions, which are dedicated to medical practices to provide high effort in order to provide quality healthcare services. Through the implication of specialized methods for health care setting, any healthcare organization needs to stream measurable in association with the quality improvement of healthcare services. Quality improvement is significant for enhancing the safety and effectiveness, both quantitative and qualitative healthcare improvement has become significantly imperative (Carayon et al, 2014). As health care services deal with patients’ safety and wellbeing, it is significant for care units to look after quality care, efficiency, safety and equitability. In this assignment in the light of the mentioned case, several aspects of healthcare are to be discussed. Based on the background of the case study, a situation analysis and process mapping have been done associated with Southern Health NHS Foundation Trust. Based on the study possible recommendations have also been mentioned.


The Southern Health NHS Foundation Trust is one of England’s largest mental health trusts. In spite of its renowned position in the country, the organization has failed more than once to provide quality services to its patients. The situation worsened when 18 year old Connor Sparrowhawk who have had an epileptic seizure died due to drowning in bath at an NHS care unit in July, 2013 (www.bbc.co.uk, 2017). According to reports the care unit has not investigated 272 unexplained deaths in the organization. The trust has also faced a prosecution by the Health and Safety Executive. It is evident from the mentioned incident that the service quality of this care unit has not been up to the mark and failed to provide required patient safety.

Regarding this particular case a doctor has admitted several failings in the treatment of this teenager. Dr. Valerie Murphy was employed by Southern Health NHS foundation Trust which runs this healthcare unit (www.bbc.co.uk, 2017). After essential investigation she accepted the failure of the unit in providing necessary protection to the epileptic teenager as she reportedly accepted that she did not consider the possible hazards of allowing an epileptic teenager to use a bath alone even though he was checked by staff in every fifteen minutes. It is a noteworthy fact that Dr. Murphy has accepted total 30 failings on the part of the organization which also includes the fact that she did not effectively make a risk assessment for Mr. Sparrowhawk using a bath alone. The accepted failings have been considered by a Medical Practitioners Tribunal hearing that began in Manchester (www.bbc.co.uk, 2017). Dr. murphy has not accepted several allegations which includes a claim that she did not effectively planned risk assessments as far as the case of Connor Sparrowhawk is concerned. Later on the healthcare unit has accepted the allegation of being responsible for the death of the 18 year old and offered his family a compensation of 80,000 pounds. In December NHS commissioned a much awaited investigation which has found that only 272 of the 722 deaths in the healthcare unit over the period of last four years were properly investigated (www.bbc.co.uk, 2017).

Situation analysis 

In order to choose new interventions for the improvement of the service quality in a health system, the existing policies and the priorities of the organization require to be assessed as the new interventions always depend upon the background of existing policies (Taylor et al, 2013). These factors are unavoidable and needs to be part of the thinking process. Therefore, it is important to conduct a situational analysis of the organization.

The incident under study clearly puts forth several organizational failures, which has ultimately adversely affected the long build organizational reputation of this particular health unit. The incident evidently shows that this organization is lacking in its service ( J.Liberatore, 2013). There are several lacking areas of management that require improvement. In order to understand the organizational lacks a SWOT analysis has been done prior to the mentioned health unit which effectively brings parity to the areas of improvement and analysis of the internal environment of the organization.

SWOT analysis of Southern Health NHS Foundation Trust

  • Identity as the   country’s renowned mental health care units.
  • Access to highly   advanced technological equipments necessary for patient care.
  • Special expertise in   mental health care.
  • Experienced medical   experts.
  • Innovative services   for patients and clients. 

  • Damaged reputation
  • Multiple failures   regarding quality of the service
  • Several gaps in   capabilities and service areas
  • Undifferentiated   service lines
  • Management problems
  • Staff related issues
  • Failure in risk   assessment
  • Failure in effective   handling of sensitive and severe patient cases.

  • Reconstruction of   previous reputation
  • Effectively   encountering media
  • Lack of dominant   competition in the field of healthcare.
  • Introducing new   market segments in order to improve profit.
  • To improve the   quality and the performance of the healthcare system.

  • New competitors in   the home market.
  • Adverse changes in   existing regulations.
  • Loss of necessary   staff and executives due to the identified case.
  • Noticeable shifts in   the market due to its degraded reputation.

The SWOT analysis is significant in order to identify the gaps in the internal environment of the organization. Such identified gaps need to be focused on by the organizational personnel in order to make a high value assessment of the recurring problems that the organization is encountering. The prevailing problems required to be treated with extreme importance in order to strategize an effective plan for the sustainable future success of the organization.

As per the case of Mr. Sparrowhawk it is evident that the management team of the entitled organization is not functional enough as several cases of patient dead have led to unsatisfactory public feedback regarding the care services of the organization. According to experts, this particular healthcare unit of NHS requires to take a closer look at their internal; services which are directly related to patient care services. As per the reports, there are plenty of cases where the mysterious deaths of the patients have not been investigated properly and the organization is not paying much attention in order to improve their services. It is important for the organizational manager to enforce effective investigation team which can perhaps, help in identifying the source of such mismanagement (Bris et al, 2016). It is clear from the SWOT analysis that this organization does not lack in technological advancement or medical support. The case identifies the possible negligence on part of the health unit and the medical expert under duty. It is important for the medical experts to understand the necessity and the gravity of the patient care. It is important for the health unit to have effective health assessment of the patients in order to understand the risk factors that might harm the patients. The staff and the medical experts require to work accordingly and require to take a closer look at each and individual case studies of the patients under treatment.

Quality management of the organization

As per Total Quality Management total quality of any service organization is the description of the culture, attitude and structural organization of any service unit that strives to provide the customers with services that satisfies their service needs (DelliFraine et al, 2013). It is important for a health service unit to maintain the culture of the organization which requires quality in different aspects of the organization’s operations. The successful TQM implementation requires concentration on the following key terms:

  1. Ethics
  2. Trust
  3. Integrity
  4. Training
  5. Leadership
  6. Teamwork
  7. Communication
  8. Recognition

Ethics, trust and integrity are the foundation of quality management. The organizational ethics is associated with the business code that the employees are to adhere to in the performance of their work. This also includes personal right and wrong. As evident from the case study Southern Health NHS Foundation Trust lacks in implementing effective business code for the employees of the organization as it has been found that the employees have failed to function as accordance to their duties. The medical expert who had been employed to investigate the whole incident did not behave accordingly and also neglected her duty. The media has also accused her due to misconduct on her part. Lack of ethics has had adverse effect on the customer trust and the reputation of the organization has been affected. The negative impact of the case can be due to lack of proper management of the organizational structure. In fact the aftermath of the incident also shows lack of organizational maintenance and has problematized the issue of leadership as well. Several experts are of the opinion that the case puts light on the lack of effective leadership as the authority personnel of this health unit failed to take effective steps and the accused ones repeatedly chose to resign from their respective designations.

The accused medical investigators resigned because of the accusation and did not opportune the scope of improvement. This attitude is considered as unprofessional and has affected the organization even more (Evans and Lindsay,  2014). Therefore, it is evident that the because of ineffective leadership skills the teamwork in the organization has also failed to function in an effective manner leading the employees of the organization the opportunity to quit from their respective functions as the participants of the organization. All of these factors have affected the roof of the organization that is the recognition of the organization.

Quality control, CQC and Six Sigma

Six sigma is considered to be a way of thinking that yield a spectrum of improved choices which is based on the values and risk. It is an effective assessment procedure that helps the organizations to produce high quality services in order to meet customer needs and satisfaction. It is a complex process that leads to achieving six sigma and firstly the focus needs to be on the top executive leadership of the organization (). Along with the effective leadership it is also dependent on managing decision on data based analysis of a recurrent situation. This methodology emphasizes on proper use of available data in order to analyse, measure, improve and control performance of any foundation. This is a process oriented methodology and the performance of any service organization can be commenced through two different methodologies. In this case the mentioned health care unit requires to assess the existing drawbacks of their services and also improve the existing process. 

DMAIC Methodology


The problem of this organization is regarding the safety and the security of the patients. Most of the higher authority personnel quitting their designation can be considered as the secondary problem for the organization.


It is important for the organization to identify the statistical measures in order to monitor the key process. The statistical data in this case can be the the number of patients who have died in the last four years due to organizational hazards and safety issues. It also includes the number of unsatisfied clients. This data collection can prove to be helpful in order to understand the gravity of the current problem.


As per the analysis of the cases it is evident that the root causes behind the organizational decline is the organization’s ineffective risk assessment and inability to provide required protection and safety to the patients. These areas necessarily require improvement in order to meet patients’ and clients’ satisfaction.


The health unit needs to focus on the investigation team in order to provide proper investigation of the accusations and also the risk assessment and patient safety need to be taken care of with utmost gravity.


The complete process requires to be documented in order to implement the plan properly for continuous and sustainable improvement.

Based on the TQM the Clinical Quality Measures that required to be taken are primarily regarding the clinical processes and patient safety along with the adherences to the clinical guidelines. It is also important for the mentioned organization to participate in the Medicare and Medical Electronic health record.

WHO dimensions of quality improvement

As per the WHO guidelines, quality improvement is necessary for the success of any healthcare organization and in order to maintain the quality of the service of any healthcare it is important to differentiate among the roles and responsibilities of the employees (www.who.int, 2017). Therefore, it is significant to implement the policy and strategy development plan. Implementing new procedures and policies require commencement of three necessary stages. Firstly, decision makers of new strategies need to consider the health service providers communities and the service users. Health service providers require to function according to the implementation by understanding the needs and expectations of the clients. Improving the quality can be summarized as the following figure.

WHO dimensions of quality improvement

Figure 1

(Source: www.who.int, 2017)

As per the WHO guidelines the situational analysis of a health care unit need to cover several areas. As per the guidelines this organization needs to work on the following areas:

  • Prevailing structures and systems of the health care unit within the ministry of health related to the quality improvement.
  • Current goals and facilities need to be addressed.
  • The overall performance of the health care unit need to be assessed against the dimensions of quality.

It is significant to note that the success of the situational analysis depends on the effective understanding of the cycle of strategic development, implementation of new policies and review of the current performance (Evans and Lindsay, 2014).

Evaluating the current performance of the services of the mentioned organization it is evident that there are several gaps in the strategy management and the policies of the organization.

Identified gaps

The gaps that has been identified in the light of the internal study on the organization nare:

  • Patient safety and security department of the health unit requires to be improved.
  • The recruitment procedure needs improvisation.
  • The organization needs to work on the investigation team.
  • The management of the health unit needs to work on the leadership abilities of the CEOs. in order to ensure effective leadership it is important to select organizational heads carefully.
  • Public relations of the organization requires attention and care.
  • The patient parties and the clients need to be handled tactically.

As per the evaluation it is evident that the employees of the organization need to be motivated in order to function effectively and it will indicate better productivity. Motivating the employees is an important part for the organizational success. As per the opinion of maslow it is important to understand the needs of the employees in order to motivate them accordingly.

Need of Employees in Organization

Figure 2

(Source: self developed)

Process mapping 

Business process making refers to the activities, which are involved in defining the activities done by any entity. In terms of a healthcare organization the service provided by the health care unit undergoes several stages and the process mapping identifies the stages. Healthcare organizations differ in their tools and experience but their aim is primarily to serve the same level of medical care to every patient.

The benefits which are associated with process mapping are:

  • Obtaining improved outcomes from a population that includes improved enhanced patient experience and also indicates towards the effective reduction of cost.
  • It is important for the organization under study to figure out adaptable processes in order to deliver consistent excellent service to the patients.
  • The current processes need to be understand in order to implement effective policies prior to the possible improvement of the service of the organization.

Process mapping for Southern Health NHS Foundation Trust

Step 1: identification of the care segment: specific area that has been identified is the patient safety and security department of the health unit.

Step 2: developing the first draft of a care segment process map: gathering a representative for the roles involved in the patient care segment and the department of patient safety and security.

Step 3: notes and its electronic version: The first draft which has been prepared on the basis of the data gathered from the employees and the patients in order to understand the security needs if the patients have been concluded in a process map and it is important to convert the map in an electronic version. This version highlights the areas that require concern and refers back to the improvement opportunities.

Step 4: observation of the identified segment and validating the process map: it is important that the map clearly depicts the areas of improvement and the general flow of the process needs to be validated accordingly. The observation procedure requires to be repeated time to time in order to catch possible variations in the practice. Observing the procedure can ensure that the security issues of the patients which are subject to change are covered effectively by the department and individual security needs of the patients are prioritized during this stage of the process map. 

Step 5: closing the loop with the experts after the observation: After completing the process map it is important it is important to identify the possible loopholes of the plan and subject matter experts and the managers need to take further step in order to ensure quality services.

Recommendation and implementation plan 

As per the apprehension that the framework of TQM has vehemently transmitted, it is very evident the potential subordinates of  Southern Health NHS Foundation Trustare considerably devoid of moral empathy. Apparently, they appear sound in terms of technological expertise and have been able to sustain a professional demeanor throughout the unit, though the lack of compassion is a very flagrant impediment that is coming in the way of a complete treatment. The pursuit of this attitude might be lethal since the virtual hostility that the potential patients are continuously feeding with is consequently disabling them to share their views, specifications and suggestions regarding the mode of treatment. Furthermore, the celestial gap that significantly underlies among the patient and respective caregiver will eventually brew misconception and dilemma regarding the treatment procedure. On that note, the management of Southern Health NHS Foundation Trust can be recommended to work on the moral behavior that might facilitate the bridging of this fatal void and eventually lead the entire concern towards complete treatment.



In the light of the above study, the healthcare unit of Southern Health NHS Foundation Trust has been evaluated against the established frameworks of Quality management. The circumspect apprehensions of this analytical study has been able to evaluate every aspect of the issues that the underlying unit is undergoing or expected to undergo. The anticipating nature of the discourse also enables the recurring study to identify the paramount issue that is acting as a potential hindrance in the trajectory of complete treatment. Furthermore, subsequent recommendations have been posed on the same tone in order to cater the broader cause that might appear useful for other similar concerns.