Leadership for compassion and safety
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Leadership for Compassion and Safety. Julie Moore CEO University Hospitals Birmingham NHS Foundation Trust. Agenda. Story of UHBFT Our strategy for clinical and care quality Culture in one hospital and how we changed it First some facts about the Trust. University Hospitals Birmingham.

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Leadership for compassion and safety

Leadership for Compassion and Safety

Julie Moore

CEO

University Hospitals Birmingham NHS Foundation Trust


Agenda

Agenda

  • Story of UHBFT

  • Our strategy for clinical and care quality

  • Culture in one hospital and how we changed it

  • First some facts about the Trust


University hospitals birmingham

University Hospitals Birmingham


Some facts

Some facts

  • We treat 806,000 p.a.

  • Regional, National & International services in cancer, burns, plastics, neurosciences, trauma, cardiac, transplantation, liver and renal services

  • Annual budget of £640m

  • UK centre for military trauma and acute care

  • Host Royal Centre for Defence Medicine

  • National Research Centre for Surgical Reconstruction & Microbiology

  • Largest organ transplant programme in Europe

  • Largest single critical care unit in Europe


How we devised our strategy for clinical and care quality

How we devised our strategy for clinical and care quality

  • History

  • Current team came together in 2006

  • Focus of previous team - the new build

  • We needed to define our focus

  • We wanted to be the place people wanted to visit to see how it was done - reputation

  • Condensed to “Best in Care”

  • So, how to deliver the best?

  • Firstly, what do we mean by quality?


What is quality

Outcome

Efficiency/costs

Experience

What is Quality?


Quality triangle 2004

Outcome

Efficiency/

costs

Experience

Quality triangle: 2004

  • Mid Staffs

  • Money prioritised


Quality triangle 2008

Outcome

Experience

Efficiency

Quality triangle - 2008

  • Friends and Family

  • Example


Quality triangle uhb

Outcome

Experience

Efficiency

Quality triangle – UHB

  • What measures?


What is quality1

What is Quality?

  • Not cute and fluffy

  • Hard edged and very serious

  • UHB belief: must be part of everyone's remit

  • Also

    • Staff want to do a good job

    • Make it easy to do right thing

  • Very difficult to measure due to lack of information

  • Proxy measures often used


Approach to quality

Approach to quality

  • The best in care

  • In all three dimensions

  • Firstly clinical quality

  • Car industry

  • Visit to BMW factory in Birmingham

  • Learnt more than we expected


Underpinning philosophy

Underpinning philosophy

  • Local BMW engine factory

  • 99.9% perfect leaving plant

    • Should be 100%

  • Real interest

    • % trouble free at 5 years

  • Bolts on engine head line up

    • Different take on errors


Important errors

Important Errors


Unimportant errors

“Unimportant” Errors?


Approach to quality1

Approach to quality

  • The best in care

  • Reduce errors to a minimum

  • All errors, even seemingly insignificant

  • Precision of care

    • if something should be done, then we expected to be done and done in a timely manner

    • if something should not be done, we expect it not to be

  • Set standards for these expectations


Examples of standards

Examples of standards

  • Interventions with evidence of benefit

  • All seem obvious – but evidence to the contrary

  • Correctly prescribed drugs to be given

    • Nationally/internationally 9-18% not given

  • Antibiotics given within 60 mins of a new prescription

  • Every patient to have two sets of observations per day

  • Assessments to be done in timely manner eg pressure areas within 2 hours admission

  • Prescribed therapies given e.g. antiembolic stockings

  • Specialty specific standards - more later


How can you monitor this

How can you monitor this?

  • Unannounced Board visits

  • Traditionally, retrospective audit

  • At best give results of 6 months ago

  • Always a reason why things are better now

  • Need live information

  • Florence Nightingale

    • Pioneer in the graphical presentation of data

    • A passionate statistician (Evidence Based Nursing 2001)

  • Need IT


Informationtechnology

InformationTechnology

  • Airlines

  • Car industry

    • Warning about lights left on

    • Parking sensors

    • Automatic parking

    • Automatic braking

    • Changing lanes

    • Airbags

  • Stops you making mistakes

  • Does some things for you

  • Why not health care?


It to its full potential

IT to its full potential

  • Reduce errors

  • Increase speed

  • Increase efficiency

  • Compare


Systems at uhb

Systems at UHB

  • Patient based system - PICS

  • Internal informatics dashboards

  • External informatics suite


Leadership for compassion and safety

PICS

Prescribing

Information

Communication

System

Decision-support prescribing

Observations and assessments

Test results

Order Comms

PICS


Some benefits

Some benefits

  • Improve Prescribing Behaviour

    • Appropriate sedation

  • Reduce Errors

    • By 60%

    • E.g. Antibiotic allergies

  • Save Money

    • 9.5%

  • Enforce Policies

    • 5 days antibiotic

    • MRSA decolonisation

  • Improve Efficiency

    • Pathology tests reduced by 50%


Live feedback

Live feedback

  • Every interaction logged

  • Live information

  • Information by

    • Specialty

    • Ward

    • Clinician

  • Clinical dashboards


Clinical dashboard

Clinical dashboard


Medicines management

Medicines management


Missed doses by ward

Missed doses by ward


Missed doses by individual

Missed doses by individual


Having a system is not enough

Having a system is not enough

  • It’s how you use it

  • Like any piece of kit


Information is not enough

Information is not enough

  • IT systems don’t result in change

  • Informatics systems don’t result in change

  • Both are tools to enable action to be targeted

  • Concept of appropriate and fair accountability

  • Clinical quality the focus of the organisation


Rca meetings

RCA meetings

  • Started for bacteraemias

  • Moved to missed doses

  • Initially selected by execs

  • Now referred by clinicians

  • Any event where care was not optimal

    • more later


Team accountability ceo rca meetings

Team accountabilityCEO RCA meetings


The outcome

The outcome?


Leadership for compassion and safety

UHB (PICs)

System A

System B

External Comparators

Omitted doses: Non antibiotics

30.00

20.00

Percentage

10.00

Current

performance

0.00

Jun-10

Apr-10

Feb-11

Oct-10

Aug-10

Dec-10


Leadership for compassion and safety

UHB (PICs)

System A

System B

External Comparators

Omitted doses: Antibiotics

16.00

12.00

8.00

Percentage

4.00

now

0.00

Jun-10

Apr-10

Feb-11

Aug-10

Oct-10

Dec-10


So what

So what?

  • Could just be spending more on drugs


Uhb vs england mortality

UHB vs England Mortality

IN PRESS. J R Soc Med


Mortality and missed plus non charted antibiotics

Mortality and missed plusNon Charted antibiotics


Types of standards

Types of standards

  • General universal standards

    • Bacteraemias

    • Drug omissions

    • Time from prescription to 1st administration

  • Specialty specific

  • Live information enables clinicians to take action


Specialty specific standards

Specialty Specific Standards

  • Cardiac Surgery as an example

  • Interventions with evidence of improved long term outcome

    • Beta blocker on day of surgery

    • Discharged on anti platelets

    • Discharged on ACE inhibitor

    • Discharged on statin

  • Compliance emailed to cardiac surgeons

    • Only information no commentary


Leadership for compassion and safety

Information Enables Clinicians


3 year cabg survival

3 Year CABG survival

Post Intervention

Pre Intervention


Care quality

Care Quality

  • Approach widened to include care quality

  • Nursing assessments

  • Pressure area care

  • Complaints

  • Any occasion where care was not optimal

  • Initially issues raised by execs

  • Issues raised by staff

    • Missing ward rounds

    • Doctors not completing documentation


Using it in other ways

Using IT in other ways


Partners with our patients

Partners with our patients

  • Live feedback

    • Digital TVs

    • Encourage daily feedback

    • Live messages to matrons

    • 24,000 feedback “forms”

    • Cf 400 returned questionnaires 18 months after event


Partners with our patients1

Partners with our patients

  • Live feedback

  • Outpatients system

    • [email protected]


Partners with our patients2

Partners with our patients

  • Access records

  • Access results

  • Communicate with clinical team

  • Access to correspondence

  • Appointments and reminders

  • Upload other info

  • Informed patients.


Partners with our patients3

Partners with our patients

  • Live feedback

  • Outpatients system

    • [email protected]

  • Inpatients system

    • [email protected]


Use of it

Use of IT?

  • Current controversy over use Care Data

  • Security concerns

  • Correctly handled – more secure

  • Benefits are huge

  • Research

  • Communication

  • Potential dangers need to be managed


Wise use of it and informatics

Wise Use of IT and informatics...

...with appropriate accountability has helped:

  • Improve quality of care

  • Reduce mortality

  • Improve efficiency

  • Reduce costs

  • Allow patient and public access

    • To quality information

    • To own records and to consultant

  • Compare performance


  • Culture change

    Culture change?

    • Culture of quality of care in all we do

    • Emphasis on what is important for patient care

    • Is it working?


    Cultural shift non charting

    Cultural shift?Non charting

    Hospital moves

    Agency


    However

    However

    • Leadership needed at all levels to achieve this

    • Not just to drive this internally

    • Deal with outside pressures

      • to introduce different approaches

    • Culture of tick boxes and checklists

    • Defensive practice

    • Drowns out creativity and innovation

    • Best educated workforce

    • Allow professionalism to drive up care quality

    • Do the right thing

      • examples


    Evolution of nhs

    Evolution of NHS

    • Hospitals used to receive blanket allocation of funding

    • Good hospitals who treated more patients spent more money, often overspent

    • Griffiths report

    • Ken Clark

    • Purchaser /provider split

    • Business cases and ROI

    • Lowest unit cost

    • Outsourcing


    Agency nurses

    Agency nurses

    • Introduced in the 90s as a cost-effective way of staffing wards

    • Although more expensive the organisation did not pay National Insurance, holiday or sick leave pay

    • Pressure applied via regional structures for organisations to increase the percentage of temporary staffing in this way


    Uhb example

    UHB example

    • At UHBFT can demonstrate that use of agency nurses results in lower quality of patient care

    • A sweeping generalisation however the following points contribute to this

      • unfamiliar with patients

      • unfamiliar with staff

      • layout of Ward

      • where to get additional supplies

      • culture


    Uhb approach

    UHB approach

    • Try to over recruit

    • Never allow a good person to NOT be appointed

    • Quality increased

    • Saved £850,000 in one year

    • Now being used by Ministers as good practice

    • Not always possible

      • due to rapidly fluctuating demands e.g. Open 170 extra beds

      • shortages


    Current environment

    Current environment

    • Where will next generation leaders come from?

    • Backdrop of reorganisation and constant change

    • Average tenure CEOs is 20 months

    • Nationally 10% posts vacant

    • 30% CEOs in post less than 10 months

    • Although “health protected” £3.8b moved to social care and 10% rising demand


    Summary

    Summary

    • Doing the Right Thing

    • Being open and honest

    • Raising quality issues

    • Deal with poor performance

    • Go against the flow

    • Do the right thing

    • Always use it as guide to decision making


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