Imelda McCarthy, Gabi Jerzembek, Evangelia Griva,

1. Institute for Health Service Effectiveness Looking in on NHS Trust Board decision-making and its potential impact on care, nationally & locally Imelda McCarthy, Gabi Jerzembek, Evangelia Griva, Krisna Patel, Mathew Gostelow, Jeremy Dawson and Michael West

2. Content and Structure • Overview Quality and Safety in the NHS (QSN) study • Qualitative component: • Mixed methods analysis: early findings and opportunity to contribute to data collection • In-depth approach: early findings and opportunity to comment

3. Quality and Safety in the NHS (QSN) • Funded by the Department of Health Policy Research Programme • Evaluates the extent to which cultural and behavioural changes are occurring in the NHS, in response to recent drives to increase quality and safety in healthcare, driven by Equality and Excellence Liberating the NHS (July, 2010) • Focused on generating sustainable lessons about how to improve quality and safety in the NHS. • Different components: team working questionnaire surveys, 7 case studies using interviews and ethnographies, and analysis of publicly available information.

4. Qualitative analysis of board meeting minutes • Aim 1: to identify innovations aimed at improving quality of healthcare (effectiveness, safety and patient experience) as well as productivity and staff engagement, to identify how NHS Trusts differ in their innovativeness and how this changes over time. • Aim 2: to explore Trust Board discussions, how they represent quality, safety, prevention and collaboration, how these representations differ between types of Trusts, between high and low performing Trusts and how the HQCfA review (2008) has impacted on decision-making. • Two research approaches: 1) mixed methods and 2) in-depth qualitative

5. MIXED METHODS: Innovativeness of Trusts over time • Framework (content) analysis of whole QSN sample (62 Trusts); approach previously used in healthcare settings (Ritchie & Spencer, 1994). • At least 10% of coding validated by at least two members of the team; • 3 Waves: (Jan – Jun 2010, Jul – Dec 2010, Jan – Jun 2011); • Questionnaires are the result of this analysis; • Innovations are new processes or systems implemented in an organisation that are intended to benefit outcomes; • Innovations are to be rated on Magnitude, Radicalness, Novelty and Impact on patient care; • Ratings will be compared over time – statistically.

6. MIXED METHODS: Rating innovation questionnaires • Please refer to the questionnaires printed on coloured paper; • Throughout the remainder of the session, or if you wish later on, please evaluate the innovations listed; • We would be very grateful for any additional comments or views written on the questionnaires; • If you are interested to receive further updates by email as our analysis progresses please add your email address to the questionnaire. THANK YOU!

7. IN-DEPTH QUALITATIVE: Representations in Trust Board decision-making • In-depth analysis of systematically selected set of 2 Trusts per type (high and low quality ratings); • 2 sets: January – June 2008, and January – June 2011; • Sententious group analysis (Rapport et al, 2009) previously used in qualitative health research; • Iterative process of individual analysis and subsequent group discussion– to extract the ‘essence’ whilst ensuring robust findings.

8. IN-DEPTH QUALITATIVE:your views on our findings so far • Emerging findings from our 2008 data: • How do our findings relate to your experience/ practice? • How would these reflect practice, locally or nationally?

9. IN-DEPTH QUALITATIVE:your views on our findings so far Mental Health Trusts: In the high performing Trust, quality is represented through a focus on patient experience (including complaints and clinical negligence) and the receipt of compliments is considered as measure of it. Board members consider the specifics of liberty deprivation and how best to avoid it. However, data from the low performing Trust suggests a struggle with basic issues such as infection prevention and control as well as the reduction of violence and aggression related incidents. • How do our findings relate to your experience/ practice? • How would these reflect practice, locally or nationally?

10. IN-DEPTH QUALITATIVE:your views on our findings so far Ambulance Trusts: Data from the low performing Trust indicates a focus on control measures to ensure safety of care, compliance with standards, twice daily capacity stock take and regular, detailed performance review of individual stations. The high performing Trust shows concerns over lack of staff training, motivation and engagement as well as learning from incidents. • How do our findings relate to your experience/ practice? • How would these reflect practice, locally or nationally?

11. IN-DEPTH QUALITATIVE:your views on our findings so far Acute Trusts: Board discussions in the low performing Trust were dominated by investments, marginalising a focus on the quality and safety of patient care. Publicity is a major concern; complaints and incidents appear to be ‘brushed over’ or used to identify ‘scapegoats’ rather progressed to support organisational learning and improvement. The high performing Trust is focused on impression management and implements reactionary measures aimed to support target achievement. Cost improvement measures are considered, as are environmental issues. Budget allocation for R&D was significantly higher than for patient care. • How do our findings relate to your experience/ practice? • How would these reflect practice, locally or nationally?

12. Thank-you qsn_abs@aston.ac.uk