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Healthcare Quality Improvement Plan
Designed to Deliver
November 2006
Printed in Wales on recycled paper using techniques which help minimise harmful effects on the environment.75% of the furnish is made from 100% de-inked post-consumer waste. The remaining 25% being mill broke and virgin fibre.
G/380/06-07 November Typeset in 12ptISBN 0 7504 9016 0 CMK-22-12-075 © Crown copyright 2006
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CONTENTS
Purpose and Context
What needs to be addressed?
What are some of the major �ssues?
Thepatient Frontlinestaff Thosemanagingthesystem,locallyandnationally
How we w�ll get there?
TheFoundationProgramme MakingStandardsmatter SystemLevelMeasures LifeSavingInterventions The‘EngineforChange’
QualityRe-alignment Aligningandsupportingqualityimprovementactivities StrengtheningtheLHBandTrustfocusonquality ImprovingqualitythroughCommissioning Aclearerroleforthepublicandpatients Aneasiertaskforhealthcarestaff
Conclus�ons
Appendix1:SummaryofActionsAppendix2:Acknowledgements
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Purpose and context
Overtheyearsahugeamountofefforthasbeenputintoensuringthatthequality
ofservicesintheNHSinWalesishigh,forwhichourstaffdeservegreatcredit,
butthereismorestilltodo.The Healthcare Quality Improvement Plan (QuIP)
describeshowweaimtocreateaworldclasshealthcareserviceinWalesdrawing
ontheenergyandenthusiasmofthosewhoworkintheserviceandinformedby
thosewhouseit.Itstartsbyoutliningsomeofthechallengesandopportunitiesat
presentfacingtheNHSinWales.
InSeptember2003Wales: A Better CountrysetouttheAssembly’svisionfora
fairer,healthierandbetter-educatedcountryrootedinacommitmenttosocial
justiceandtoputtingsustainablehealthimprovementandwealthcreationatthe
heartofpolicymaking.Buildingonthis,inMay2005theAssemblyGovernment
issuedanewstrategyforhealthandsocialcareservices-Designed for Life.Inthe
faceofthechallengestotheNHS-anageingpopulation,rapidtechnological
change,theneedtoupdateandupgradetheinfrastructure-radicalreformof
servicesisvital.
The Healthcare Quality Improvement Plansetsouthow,bystrengtheningthefocus
onquality,wewillradicallychangethewaytheNHSworkstoenableustoachieve
theDesigned for Life objectivethat‘by 2015 Wales will have minimised avoidable
death, pain, delays, helplessness and waste’.
strengthening the focus on quality ...
... delivering high quality services
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What needs to be addressed?
Designed for Lifestatesthatpatientsshouldbetreatedintherightplace,atthe
righttime,bytherightpeople.Toachievethisobjective,consistentlyandinline
withbestpracticeandlatestthinking,wemustcreatetherightsystem.
Designed for Lifesaidthatthosewhouseandprovideserviceswillbebestplaced
todesignservicesthatworkwell.Theyarealsobestplacedtojudgethequality
ofservices-andknowhowbesttoachievehighquality.Theyknowwherethe
obstaclesareandwhatneedstochange.Usingtheirinsightsandexperiencewillbe
vitalinrealisingthevisionofhighqualityhealthcare.
WhilethereismuchtobeproudofintheWelshhealthcaresystemitstalented
anddedicatedstaffoftenfaceproblemsthatshouldnotbethere.TheReportof
theReviewofHealthandSocialCarein2003(theWanlessReport)identifiedthat
staffinthehealthandsocialcaresysteminWales”are working within systems
which militate against good performance, and where there is excellence in our view
it is despite rather than because of the system”andakeyobjectiveofDesigned for
Lifeisthatpatientsandstaffaremastersoftheserviceandnotitsservants.
If,asDesigned for Lifesays,wewantpatientstreatedintherightplaceattheright
timebytherightpeople,andtheminimisationofavoidabledeath,pain,delays,
helplessnessandwaste,weneedtofocusonquality.Integraltothissystemis
effectiveWelshandEnglishbilingualserviceswhichareessentialtoproviding
qualitycare.FullrecognitionwillbegiventotheWelshLanguageAct1993and
WelshLanguageSchemesofeachstakeholderorganisation.
Designed for Lifeindicatedthattoachievethis,performancemeasurementcriteria
mustbemuchmoreclinicallyfocusedthanbeforethroughagreateremphasison
clinicalauditaspartofstrengthenedclinicalgovernancearrangements.Weshould
alsoseehealthcommunitiesaswholesystems,allowingtheuseofsophisticated
techniquessuchasflowanalysis,leanthinkingorstatisticalprocesscontrol-allof
themprovenwaystogenerateimprovement.
Designed for Lifeidentifiedtheinformationelementsthatwouldallowservice
users,thepublicandtheAssemblyGovernmenttoassessmoredirectlythequality
ofservices,therebyimprovingengagementandsharpeningaccountability.Ittalks
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aboutthefivemeasuresofquality:safety,effectiveness,patientexperience,
timelinessandefficiencyandahealthservicethatscoreswellinalltheseareas
deservestobedescribedasofhighquality.
Achievingthis,ensuringthatallservicesmeetthenewHealthcare Standards for
Wales,willrequirethreeelements-
- acompleteengagementofstaffandmanagementwithinorganisations,
andofcitizensandcommunitiesinthedesign,planninganddeliveryof
localserviceswitharecognitionofthediverseneedsrelatedtorace,
disability,language,religion,sexualorientation,ageandgender
- helpandsupportfromexpertadvisorstoaccelerateimprovementand
bringnewskillsandideas,and
- anindependentsystemofexternalreview,throughHealthcare
InspectorateWalesandotherorganisations,thatwillidentifyareasfor
improvementandprovideassurancetothepublic.
Theintentionisthatfrom2008/09healthcareinWaleswillbedrivenby
objectivesandtargetsfocusedondeliveringhigherstandardsofclinicalservice.
Bythenthethreeelementsmentionedabovewillinterlockinsupportofthisaim.
The Healthcare Quality Improvement Plan outlinesthestepsweneedtotakenow
inordertoestablishthefoundationsanddeliverthisgoal.
delivering higher standards of clinical service ...
... patients treated in the right place at the right time
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What are some of the major �ssues?
The pat�ent
OverallpublicsatisfactionwiththeNHSinWalesishigh.Thepublicappreciates
theNHSandvaluesitsworkanditsstaff.Nevertheless,itisclearthatsome
aspectsoftheservicescouldbebetter.
The patients’ experience
InJune2005theNuffieldTrustpublishedThe Quest for Quality in the NHS
-achartbookcomparingthequalityofcareacrosstheUK.InrelationtoWales,
performancerelativetotheotherUKcountrieswasstronginsomeaspects,eg:
- Waleshasthehighestrateofstatinsprescription
- WaleshasthelowestMRSAbacteraemiaratesper1000beddays
However,despiteexcellentperformancegenerallyandrecentimprovements,
still-
− Waleshasthelowestinfluenzavaccinationratesforpeopleaged
over65yrs
− Waleshasthehighestcaesareansectionrate
− Mortalityratesfromcolorectalcancer,stroke,diabetesandcoronary
heartdiseasecanbefurtherimproved
Inaddition:
- clinicalnegligenceclaimscosttheNHSinWales£85mforthe
year2004/5(WelshRiskPool)
- patientsafetyfindingsacrosstheUKindicatethataround10%of
patientsexperienceanadverseeventduringanacuteadmission.
Theoverwhelmingmajorityresultinnoharm,however,around
50%arebelievedtobeavoidable.
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Patientsshouldfeelconfidentthatcareissafeandofthehighestquality,inline
withpublishedstandardsandevidence.Theyshouldhaveeasyandrapidaccessto
thecaretheyneedandaccurate,easilyavailableinformation.Individualpatients
mustreceivewell-managedcareatalltimesandhardlynoticethatanumberof
differentorganisationsorteamsarecontributingtotheircare.
Frontl�ne staff
Somefrontlinestaffreportthattheyareoverwhelmedbydemandandtime
pressures,oftenrecordingdatathatdoesn’tseemimmediatelylinkedtotheir
workprioritiesandfrustratedbytheirinabilitytohaveinformationaboutthe
patient,ornecessaryfortheirowndevelopment,attheirfingertips.Theireveryday
experiencescancramptheirowneffortsforcreativityandimprovement.Astaff
surveyacrosstheNHSconductedinlate2005givessomeadditionalinsights.
... individual patients must receive well-managed care
The staff experience
The2005NHSStaffSurveyfoundthatwhilethegreatmajorityofstaff
surveyedfeltsatisfiedwiththesupporttheygetfromtheirworkcolleagues
andthattheyhaveclear,plannedgoalsandobjectivesfortheirjob,therewere
someissues-
onlyabout40%feltthat
- thedifferentpartsoftheirorganisationcommunicateeffectivelywith
eachother
- communicationbetweenstaffandmanagementiseffective
- staffgetclearfeedbackonhowwelltheyaredoingtheirjob
- theyhavetimetocarryoutalltheirwork
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ThosewhoworkonthefrontlineintheNHSshouldbeabletomaketheirviews
knownandgetanswerstotheirquestions.Theyshouldfeelwellinformed,and
havesupporttokeepuptodateandtodevelopprofessionally,receivefeedback
andhaveeasyaccesstorelevantinformation.Allstaffshouldfeelthattheyare
workinginasystemwherecollaborationthrivesandcreativityandinnovationare
prized,andtheyhavetheconfidenceandskillstoengageinqualityimprovement
activities.
Those manag�ng the system, locally and nat�onally
TheNHSexiststoensurethatpeoplegetthecaretheyneed.Itmusthavesimple,
clearobjectivesandgoodmanagementsystemsorqualitywillsuffer.
those who work on the front line in the NHS should be able to make their views known… and feel informed …
The System
TheReportoftheReviewofHealthandSocialCare(theWanlessReport)
foundthat-
Atpresentwehaveasystemwhich:
• isunabletodelivertheoutputsoroutcomesweaspireto
• inimportantrespectsdoesnotgivevalueformoney
• isunsustainablewithcurrentandplannedworkforcecapacity
• isoverlyfocusedoninstitutionalsettings
Thereissomegoodandsomeexcellentperformanceinhealthandsocialcare.
Butthereisalsowidespreadunder-performanceassociatedwithsystemic
defects.
Differentareasofnationalpolicymakingneedtobebetterintegrated.
Thequalityofinformation,andsoofthedecisionsbasedonit,isunsatisfactory
ateverylevel.
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Theimportanceofachievingandmaintainingqualitymustbecontinually
reinforcedalongsideotherrequirements.Thereshouldbeclarityaboutwhatis
meantbyquality,whatisexpectedfromorganisationsandhowwelltheyare
performing,individuallyandtogether.Thereshouldbeappropriatecentralsupport
forserviceimprovementtohelporganisationsdeliverhighstandards.Leversfor
changeshouldbeidentifiedandused.Requirementsandactivitiesthatcause
confusionorinhibitthedeliveryofhighqualitycareshouldbeeliminated.
Theaim,therefore,isahealthcaresystemforWales,suchthat:
• consistent,evidencebasedcareisprovidedtoagreedstandards
• thesystemsupportscontinualimprovementacrossthedimensions
ofqualityanddrawsonexperiencesinothersectorsandadopts
others’tools
• thereisstrongleadershipandcleargovernancearrangements
• patientscanexerciseasmuchoraslittleinfluenceovertheircareasthey
choose,aslongasthosepreferencesfallwithinboundariesofevidence-
basedpractice,aspartofapatientcentredcareapproach
• servicesareco-ordinatedbetweenhealthcareprovidersusingeasily
accessibleandreliableinformationsystems
• lessonsarelearntfrommistakesandgoodpracticeissustainedandspread
• thereisefficientandflexibleuseoftheworkforcetoimplementchange
• everyorganisationisheldaccountabletoitspatientsandpopulationfor
itsclinicalperformance.
patients should feel confident that care is safe and of the highest quality …
… staff should feel that they are working in a system where collaboration thrives and creativity and
innovation are prized
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How we w�ll get there?
Qualitygrowsfrominsideorganisations-itcannotbeimposed.Thereforeouraim
willbeto:
- enhancetheabilityofthosewhoprovidecarewithinorganisationsto
achievehighlevelsofquality
- increasetheinfluenceofthepublicandusersoncare
- reduceconfusionanddistractionsthatinhibitthedeliveryof
highqualitycare.
Basedonthatanalysis,weneedtoaddresstheissuesinrelationtopatients,staff
andthesystem.Soweproposeto
1. takestepstogivequalityaclearandpowerfulfocusacrossthesystem
throughaFoundationProgrammeofwork(describedbelow)withafocus
onclearstandards,measurementofachievement,lifesavinginterventions
andanew‘engineforchange’toengageandsupporthealthcareworkers
2. clarifyhowqualitywillbemanagedandmonitored,includingdeveloping
theServiceandFinancialFramework(SaFF)andthecommissioning
frameworktosupportimprovementinquality.
3. givethepublicandpatientsamuchclearerpartinmonitoringqualityand
ensuringthattheservicestheyreceiveareofhighquality
4. makeiteasierforclinicalprofessionalstoassesstheirownperformance
anddeliverhighqualitycare
The Foundat�on Programme
QualityhastobeatthecoreoftheNHSandstrategicactionisrequiredtoachieve
this.Aclearnationalfocusandanationalleadisrequiredtoengage,enthuseand
supporthealthcareworkers.TheFoundationProgrammewillincludefourelements
whichwillapplytoallNHSorganisationsinWales:
• settingtough,achievablestandards
• sharpeningthefocusonachievement–systemlevelmeasures
• lifesavinginterventions
• anew‘engineforchange’–theFacultyforHealthcareImprovement
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Mak�ng Standards matter
Healthcare Standards for Wales,publishedinMay2005,isdesignedtoensure
thathighqualityservicesareprovidedequitably,robustlyandethicallyacrossthe
fullrangeofservicesprovidedbyorfortheNHSinWales,nomatterwhatthe
setting.Thestandardsofcarecameintoeffecton1June2005andallhealthcare
organisationsareexpectedtoassurethemselvesandthecommunitiesthey
servethattheyareachievingorworkingtowardsthestandards.Thisincludes
demonstratingprogressagainstthevariousqualityrequirementsofthesixNational
ServiceFrameworks(NSFs)whichremainakeycomponentinthedrivetoraisethe
qualityandsafetyofpatientcareinWales.
Workiscurrentlyinhandtodeveloptheassessmentprocesstounderpinthe
standards,tobeconsistentwiththecustomerservicecoreprinciplesbeing
developedaspartofthe Making the Connectionsagendaandtorationalisethe
rolesofexternalinspectoratebodies.Thisguidancewillrecognizethediverse
needsofrace,disability,language,religion,sexualorientation,ageandgender.
Eachhealthcareorganisationwillberesponsibleforassessingitselfagainstthe
standardsandaccompanyingcriteriaonanannualbasisandmakingpublicthe
outcomeofthatassessment.HealthcareInspectorateWaleswillthencarryout
externalindependentreviewsoftheorganisationstocorroboratecompliancewith,
orprogresstowardsmeetingthestandards.
System Level Measures
Ifwearetodemonstrateimprovedquality,wehavetomeasureit.Thisinvolves
reviewinginformationneedsanduseacrossthesystem,tobringitinlinewiththe
fivemeasuresofquality:safety,effectiveness,patientexperience,timelinessand
efficiency.
Action 1
DraftguidancecoveringHealthcareStandardsassessmentcriteriaand
theassessmentprocesswillbepublishedforfullpublicconsultationin
October2006withaviewtothesystembeinginplaceforthebeginningof
the2007-08financialyear.
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Designed for Life indicatesthatby2008therewillhavebeenagreedwith
professionalsandserviceusersthemostclinicallyappropriatetargetsand
measurestojudgeourservices,andhowtheywillbemonitoredandprogress
reported,andourinformationsystemswillbeupdatedtoprovidesuchinformation
accuratelyandfairly.
Thereisaparticularvalueinselectingsomehighlevelsystemmeasuresacrossthe
wholehealthcaresystem(suchasameasurethatmonitorsdeathsinhospitals)that
willallowustoseethecurrentstateofservices,andwhatprogressismadeover
time.Suchmeasurescouldhelppractitionersandorganisationslearnfromeach
otheracrossprimary,secondaryandtertiarycare.
Itis,therefore,proposedtoagreeasmallnumberofsystemlevelmeasures,tobe
identified,developedandintroducedbyMarch2008.Thesesystemlevelmeasures
willmaptothehealthcarestandardsandtothe5domainsofquality.Theywill
bedesignedwithcareprovidersandwilllinkwithsocialcareindicatorswhere
possible.Thisworkwillbeurgentlyputinhandandwillconsiderthedifferent
methodologiesavailabletoWales.
Trackingchangesintheseindicatorswillbeimportant.Theircriticalvalueisas
measuresofachievement,andmakingprogressonthesesystemlevelindicators
willbecomeamajorfocusinplanningandinassessingperformance.Possible
examplesinsecondarycareare:
Safety: Patient safety incidents
Effectiveness Standardised mortality rates; quality of life indicators
Patient
Experience
Patient satisfaction; healthcare associated infections;
length of stay; cleanliness of environment;
communication; quality of information
Timeliness Meeting specified targets for waiting times
Efficiency Healthcare costs per capita; readmission rates,
adherence to patient pathways
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Appropriatesystemlevelmeasureswillinfluencereportingatalllevels-from
individualstaffappraisalthroughtonationallevelmonitoring.Allstaff,teams,and
organisationswillbeabletomaptheiractivitiesagainstthesemeasures.Theywill
beusedintheannualreportsontheperformanceoftheNHSandwillformacore
partofassessingcomplianceagainstHealthcare Standards for Wales.
Informationcollectionmorewidelywillalsoneedtobejudgedagainstthisnew
approachandwherepossibledatacollectionthatdoesnotfitandhasnoother
usefulpurposewillbediscontinued.Thereductionofwhatwillbecomenon-
essentialdatacollectionandadministrationispartofthisnewapproach.Other
actionswillincludeassessingallhealthstrategiesagainstthesekeymeasures,and
re-alignmentwhererequired.
Intakingthisforward,theexperienceofothercountrieswillbeusedandtherewill
beaprogrammeofpublicawarenessandinvolvementinthework.
L�fe sav�ng �ntervent�ons
Thenewapproachtoqualityneedstoquicklyestablishaprofileandanimpact.
Onewayofcreatinginterestandachievingrealbenefitwouldbeaninitiativeto
engagethepublicandprofessionalsindeliveringsignificantimprovementagainst
keysystemmeasures,particularlymortality(butperhapsothermeasuressuchas
patientsatisfactionetc).ThisapproachhasbeensuccessfullyappliedintheUSA,
CanadaandAustraliaanditiscurrentlybeinglookedatinGwent.
Throughthesystematicuptakeofjust6evidence-basedinterventionsinhospitals
acrosstheUSA,andwithnoadditionalinjectionofresources,theInstitutefor
HealthcareImprovementisaimingtosave100,000livesin18months.Theinterim
resultsarejustover122,000livessaved.Walesiswellpositionedtolearnfrom
andbetterthisinitiative,andtodetermineifsuchanapproachwouldbring
Action 2
ByMarch2008identifyandbegincollectionofthehighlevelindicatorsthat
willhelpustoassessthequalityoftheNHSandthatwillfigureinreportson
itsperformance.Thekeymeasureswillberuninshadowformthrough2008/9.
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significantbenefittoourpopulation.Itisproposedthatpreparatoryworkwillbe
undertakentodevelopanapproachtoassessandquantifytheeffectoflifesaving
interventionsatanationallevel
The ‘Eng�ne for Change’
Realisingthevisionof2015inDesignedforLifewillnothappenbychance.
Theremustbeanenginetodrivediscussion,generateenthusiasm,commitment
andaction,supportandadvisepolicyworkandcreateaconduitbetweenthe
manypeopleonthegroundinvolvedinhealthcarequalityimprovement.
ItisproposedthereforetoestablishaFacultyforHealthcareQualityImprovement
throughtheWalesCentreforHealththatwillengage,enthuseandsupport
healthcareworkersandotherconstituents,givethemownershipofthechanges
andbecomethesourceofenergyforthequalityimprovementprogrammeon
theground.ThisFacultywilllinkcloselywiththeClinicalChampionsNetwork
proposedinDesigned for LifetobeestablishedthroughNLIAH.
TheFacultywillgenerateamovementthatincludesthepublic,patients,
academics,professionalgroupsandpolicyleadsintheWelshAssembly
Government.Itwillbecross-organisational,flexibleandinnovativeandexpressly
nota“talkingshop”,withsomemembersinvitedfromsuccessful,butperhaps
uncelebrated,services.Itwillprovideanationalcapacitytoinspire,supportand
drivechange.
Bybringingtogetherhealthcarestaffdemonstratingprovensuccessoranenergy
forserviceimprovementitwillpromotesharingofbestpractice,learningfrom
success,andwillalsosharefeedbackofongoingwork.Itwillfocusandgenerate
energyandenthusiasmforimprovementaswellasactingasaforumformulti-
professionaldialogueandlearninganditwillbecentraltotransformingtheculture
inNHSWalestoapositive‘cando’environment.Thegroupwillalsobeacritical
friendtotheAssemblyGovernment’sDepartmentofHealthandSocialServices,
actingasanauthoritativeindependentsourceofsupportandadvice.
Action 3
BySeptember2007,todevelopanapproachtoassessandquantifytheeffect
ofintroducingpotentiallifesavinginterventionsatanationallevel.
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TheFacultywillprovideanenvironmenttostimulateandhelpcreateleaders
acrossorganisationalandcareboundaries.Peoplewillwanttobecomefaculty
membersbecauseoftheenergy,learningandsupportforimprovement,but
importantlytobeinanenvironmentwheretheycaninfluencepolicy.
TheWalesCentreforHealthwilldeveloptheremitandhostingarrangementsfor
theFaculty,ensuringtherolescomplementpublic,patient,academicandother
relevantgroupingsinplaceorplanned.
Qual�ty Re-al�gnment
IfqualityistobethecorefocusofNHSmanagement,itmustbemadeeasierto
manageandimprovequality.Accordinglyitisproposedthatthereshouldbe
- arrangementstoalignandprioritisequalityandsafetyimprovement
activities
- astrongerLHBandTrustfocusonquality
- afocusonqualitythroughCommissioning
- aclearerroleforthepublicandpatients
- supportforhealthcarestaff
Al�gn�ng and support�ng qual�ty �mprovement act�v�t�es
ThequalityapproachinWalesmustbeclearandstraightforward.Itissensible
atthispointtolookatallqualityinitiativesandorganisationscurrentlyinplace,
assesstheirrelevancetothisnewagenda,streamlinetheirworkingandidentify
whatgapsmustbefilledandwhatelementscanbepruned.
TheMinisterforHealthandSocialServiceshasrecentlyagreedforanexternal,
independentreviewtotakeplaceofanumberofkeypublichealthbodies/
organisationsoperatinginWales.Thepurposeofthisreviewistoidentifyany
existingoverlapoffunctionsundertakenbythebodiesconcerned,andfor
Action 4
ByMarch2007developandlaunchtheFacultyforHealthcareQuality
Improvementtosharelearning,facilitateengagementandenthusiasmfor
qualityandsafetyimprovement.
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recommendationsforimprovementstobemadetoeliminateduplicationofeffort,
improveefficiency,effectivenessandvalueformoneyandultimatelyprovide
abetterdeliveryofservicestothepublicinWales.Subjecttotheoutcomeof
thispublichealthreview,itisproposedthatexistingqualityimprovementand
inspectorateorganisationswillcometogetherinanationalQualityImprovement
Boardensuringanintegratedapproachtoqualityimprovementsupport
mechanismsacrosstheNHSinWales.Interventionalworkcarriedoutbythe
DeliveryandSupportUnit(DSU)whichidentifiesandspreadsserviceimprovement
activitywillalsobeincluded.
ThisBoardwillfacilitatea“concordat”oftheorganisationsthatoverseequality,
safetyimprovementandclinicalgovernanceinWales,allowingapooling
ofresourcesandexpertise,prioritisationofworkandclarificationofroles.
TheBoardwillalsohostareviewofqualityimprovement,clinicalgovernance,and
modernisationresourcesacrosshealthcareorganisationsinWalesandidentify
successesandthefactorsthatpromotesuccess,toalignavailableresourcetothe
newqualityagenda.
Thereisincreasingevidencethatatanorganisationallevelthe‘businesscase’
canbemadeforqualitywhereafocusonqualityresultsinfinancialreturnson
investmentinareasonabletimeframe.TheBoardwillengagethefinancialleadsin
organisationsindiscussionsonthisissue.
CollaborativeworkisalreadyunderwaywithintheWelshAssemblytoalign
thequalityandperformancemanagementprogrammessothatby2009the
performanceofthehealthcaresysteminWaleswillbeassessedintermsofthe
fivebroadaspectsofquality.
Action 5
Subjecttotheoutcomeofthepublichealthfunctionalreview,byMarch2007
establishanationalQualityImprovementBoardtoensureanintegrated
approachtoqualityandsafetyimprovementactivitiesandclarifyrolesand
responsibilities.
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Strengthen�ng the LHB and Trust focus on qual�ty
Thefocusonqualitymustbeledthroughstrongleadershipfromthetopofthe
organisation.AclearerstatementofexpectationswouldenableTrustandLHB
Boardstoidentifywhatneedstobedoneandhowitrelatestootherspecified
priorities.
Greaterclarityabouttheplaceofqualityintheperformancemanagement
arrangementsisobviouslyoneimportantelement.Anothermightbetosetclear
requirementsthatBoardsreceiveamonthlyreportonperformanceagainstthe
5informationdomains-i.e.efficiency,timeliness,safety,patientexperience,
effectiveness;thecontentshouldbenationallyspecified.
Withinthiscontext,wewillbedevelopingplanstofurtherimprovethewayin
whichtheNHSrespondstoconcernsanddissatisfactionregardingthequalityand
safetyofcare,includingarrangementsforappropriateredress.Systemswillbe
furtherdevelopedtoensurelearningfromcomplaintsanderrorsandnearmisses
Action 6
ByMarch2008haveidentifiedprogrammestospreadQualityImprovement
learningincollaborationwithleadersintheimprovementfieldforexample
theInstituteforHealthImprovement,theHealthFoundation,NationalPatient
SafetyAgency,NLIAH,andtheDSU.
Action 7
ByMarch2008reviewalltargetsforhealthserviceswithaviewtoensuring
thattheysupportthedevelopmentanddeliveryofbalanced,integrated,high
qualityservices.
Action 8
ByMarch2008establishastrategyforBoardengagementinsafetyandquality,
withallTrustandLHBBoardsdemonstratingengagementwithqualitythrough
theBoardagenda.
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inthecareweprovide.TheNationalReportingandLearningSystemforpatient
safetyincidentswillbeakeydrivertofeedbacklearningandopportunitiesto
improve.
Improv�ng qual�ty through Comm�ss�on�ng
Commissioningistheprocessofusingmoneytosecuretheobjectivesofthe
NHS.Ifqualityisamajorobjective,itmustbeacoreelementincommissioning.
Thiscouldbeachievedbylinkingcommissioningtoexplicitevidence-based
pathwaysofcare.
Thetermpatient(oruser)pathwayisusedtodescribetheevidencebasedsteps
inthecareprocesswhichapatientwithaparticularconditionshouldfollow.
Designed for Lifemilestonesforpatientpathwaysarethatcommissionersand
providersshouldhavenetworklevelpatientpathwaysinplaceforsuspected
CHDorstableangina;suspectedheartfailure;careofCHDincludingcardiac
rehabilitationforacutecoronarysyndromepatients;atrialfibrillation,allby
March2008.
Thetermintegratedcarepathways(ICPs)isusedtodescribeaprocesswhich,
buildingonapatientpathway,setsoutlocallyagreed,evidence-basedbest
practice.Itidentifiesthecontributionofdifferentprofessionalsoveradefined
time-line,andcanbeusedtotrackandanalysevariancesfromtheexpected
patternofcare.TheICPdocumentationsupportscaredeliverytoanindividual
patientandcontaindetailsofthetreatmentandcarereceivedbythatindividual.
Designed for LifemilestonesrequireeachLHBtodevelopICPsforthemanagement
ofmajorchronicdiseases.
Therearemanybenefitstobegainedfromamoresystematicuseofdefined
integratedcarepathways.Theyshouldminimisevariationinclinicalpractice,
especiallyinareaswhereevidenceisclear,thoughpatientpreferencesshould
Action 9
ByApril2008developintegratedarrangementsfordealingwiththingsthatgo
wrongincludingappropriateredress.
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berespected.Theirdevelopmentcanalsohelpimprovepracticereview,team
building,andresourceuse,andsimplifystafftrainingandexplanationstopatients
concerningtheirtreatment.
Commissionerswillbeexpectedtocommissionservicesonthebasisofpathways
thatincorporateevidence-basedcross-agencyinterventionsrelevanttoachieving
theHealthcareStandards.Identificationofevidence-basedinterventionscould
beundertakencentrally,forexamplebyNPHS,andNLIAHwillsupportthe
processofimplementingcarepathways.Furtherdetailonpathwaysdevelopment
willbeissuedaspartoftheforthcomingCommissioningguidancefromthe
WelshAssemblyGovernment.
A clearer role for the publ�c and pat�ents
Toimprovethequalityofitsservicesandmoveforward,theNHSneedsto
givegoodandreliableinformationtoitsusersandpotentialusers,toseektheir
views,learnfromtheirexperiencesandtakeactionasaresult.Involvinglocal
communitiesandindividualpatientsindesigningandimprovinghealthservices
isanessentialpartofthis,asisgettingfeedbackonpatients’experiencesof
thecurrentservicesandontheperformanceofthehealthserviceingeneral.
WhileWaleshasalreadyachievedagreatdeal,thereisstillsomewaytogoin
makingtheservicetrulypatientcentred.TheNHSinWales,aswellastheother
UKcountries,performspoorlyincomparisonwithothernationswhenitcomesto
publicandpatientinvolvement(Engaging Patients in their Healthcare: How is the
UK doing relative to other countries?PickerInstituteEurope,April2006).
InWales,wehaveretainedandstrengthenedCommunityHealthCouncils,to
ensurearobustcollectivevoicefortheviewsofpatients.TheAssemblyhas
issuedguidance(Signposts; Signposts 2 and Shaping Health Services Locally)on
howtoinvolveandseekviewsofpatientsandthepublicinalltypesofsituations.
Action 10
Eachhealthcommunitytodeveloppatientpathwayslinkedtocommissioning
fortwochronicdiseasesandonementalhealthpriorityassetoutin
Designed for Life byMarch2007.ThesetobedevelopedasfullICPswithclear
performancemeasuresbyMarch2008.ThisworkwillbesupportedbyNLIAH.
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NHSmanagersmeetregularlyinthreeregionalnetworkstosharegoodpractice
andnewideas.Therearealsopatientinvolvementnetworksfordisease-specific
areas,likecancerandcardiacillnessaswellasanall-WalesPatientGroup.TheNHS
complaintsprocedurehasbeenstrengthenedandimprovedsothatcomplaints
arehandledbetterandlessonslearntwhenthingsgowrong.Inaddition,andas
indicatedinAction9,theAssemblyislookingatnewintegratedarrangementsfor
redress,incasesofharm.TheExpertPatientsProgrammehelpspeoplewithlong
termconditionstotakemorecontrolovertheirlivesandhowtheyrelatetothe
healthandsocialcareservices.
Thebuildingblocksare,therefore,allinplaceforahighqualityservicetodevelop
aroundtheexperienceofpatients.OverthenextyeartheAssemblywillbelooking
totheservicetodemonstrateimprovementsinthewayitengageswiththepublic
andpatients,tobecleareronwhatischangingasadirectresultandwhetherthis
philosophyisbeingembeddedatalllevelsinNHSorganisations.
Althoughalotofworkisalreadyhappeningatlocallevel,weneedmore
informationaboutpatients’experiencesoftheNHS,whichcanbeusedboth
nationallyandlocallytopinpointareasforimprovement.Onewayofdoingthisat
anationallevelisthroughannualpublic/patientsatisfactionsurveysandthiswill
betakenforwardoverthenextyear.Thisisalsolinkedtowiderworkbeingtaken
forwardthroughtheAssembly’sMaking the Connectionsstrategy.
Additionally,patientscanonlybecomeproperlyinvolvedifthereisamore
focusedattempttoexplaintothemwhatishappeningtohealthcareservicesmore
generally,andiftheyfeelmoreinvolvedandempoweredinrespectoftheirown
individualhealthcare.AllNHSorganisationsinWalesnowproducetheirown
guidestolocalhealthservices.TheInformingHealthcareProgramme,theNational
LeadershipandInnovationsAgencyforHealthcare,theWalesCentreforHealth
andothersarealltakingforwardinitiativestoimprovepatientempowerment,
andthequalityandavailabilityofinformation.TheFacultyforHealthcare
QualityImprovement(action4)willplayanimportantroleinbringingallofthese
strandstogetherintoacoherentwholeandmakingsurethattherearecontinual
improvements.
Further,theHealthcareStandardswillbethemeansthroughwhichthepubliccan
seewhatservicesshouldlooklikeandHealthcareInspectorateWaleswillmeasure
whetherprogressisbeingmadeacrossorganisations.
��
Providinghighlevelsofcustomerservice,learninglessonsfromwhenthingsgo
wrongandmakingpeoplefeelinvolvedisacomplexandcross-organisational
activity.Itisnotsomeoneelse’sjobtodothis–itiseveryone’sjob-anditneeds
thehighestlevelsupporttomakethechangesthatarenecessary.Wewillbe
lookingtoBoardDirectorstodemonstrateclearactionandcommitmenttothis
andwewillofferfurthersupportindevelopingthisarea.
An eas�er task for healthcare staff
Manystaffarealreadydeeplyengagedwiththequalityagenda.Toenablethem
todomore,thereneedstobemoreattentiontoskilldevelopment,feedbackand
easeofaccesstoinformation,andareductioninunnecessarywork.
Toachievethis,therewillbeastrongemphasisonengagingfrontlinestaffin
qualityimprovementactivitieslocallyandasubstantialextensionoftrainingin
qualityimprovementandpatientsafetyacrossWales.Thiswilldrawonexisting
experienceandsuccessfulinitiativessuchastheSaferPatientInitiativework
inConwyandDenbighshireNHSTrustandtheNationalPatientSafetyAgency
’CleanYourHands’campaign.
Action 11
By2008considerhowbesttoinitiateacomprehensiveannualsurveyof
public/patient’ssatisfactionwithhealthcare.
Action 12
By2008considerhowbesttosupportandstrengthenBoard-level
commitmenttocustomerservice,andpublicandpatientinvolvementacross
theirorganisationsandtodeliverchangesasaresult.
Action 13
ByMarch2008havecompletedananalysisofthequalityandsafety
improvementskillstrainingneedsinthenationalhealthcareworkforceand
haveastrategyforaddressingthegap.
�0
Throughclosecollaborationwiththe Informing Healthcarestrategy,keyareas
ofinformationprovisionanddecisionsupportforbothpatientsandhealthcare
workerswillbeaddressed.
Action 14
ByMarch2007haveclearlinkagesdevelopedbetweentheInforming
Healthcarestrategyandthenationalqualitystrategysuchthattimetablesare
identifiedforpatientandprofessionaldecisionsupport,professionalCPD
supportandeasilyaccessiblerelevanthealthcareinformation.
…Increase the influence of the public and users on care
��
Conclus�ons
Theactionswehaveoutlinedaddressthemajorchallengestodeliveringthe
highestqualityservice.Together,theywilllaythefoundationsforaradical
improvementinthequalityofourhealthcareservices,andsetthecoursetocreate
ahighperformancehealthcaresystem.
Achallengingagendahasbeensetout,withsimple,connected,radicalideason
howbesttomoveforward.ThereiscertainlyawillamongstaffacrosstheNHS
toengageinhealthcareimprovement,andtogetherwecancreateanational
momentumtodeliverandmakethehealthcareofWalesamongstthebestin
theworld.
For further �nformat�on or comments contact:
WendyChatham
Director
Quality,StandardsandSafetyImprovementDirectorate
DepartmentofHealthandSocialServices
WelshAssemblyGovernment
CathaysPark
Cardiff
CF103NQ
Email:wendy.chatham@wales.gsi.gov.uk
Telephone:02920801147
��
Append�x �
Summary of Act�ons
Action 1
DraftguidancecoveringHealthcareStandardsassessmentcriteriaand
theassessmentprocesswillbepublishedforfullpublicconsultationin
October2006withaviewtothesystembeinginplaceforthebeginningof
the2007-08financialyear.
Action 2
ByMarch2008identifyandbegincollectionofthehighlevelindicators
thatwillhelpustoassessthequalityoftheNHSandthatwillfigurein
reportsonitsperformance.Thekeymeasureswillberuninshadowform
through2008/9.
Action 3
BySeptember2007,todevelopanapproachtoassessandquantifythe
effectofintroducingpotentiallifesavinginterventionsatanationallevel
Action 4
ByMarch2007developandlaunchtheFacultyforHealthcareQuality
Improvementtosharelearning,facilitateengagementandenthusiasmfor
qualityandsafetyimprovement
Action 5
Subjecttotheoutcomeofthepublichealthfunctionalreview,byMarch
2007establishanationalQualityImprovementBoardtoensurean
integratedapproachtoqualityandsafetyimprovementactivitiesand
clarifyrolesandresponsibilities.
��
Action 6
ByMarch2008haveidentifiedprogrammestospreadQualityImprovement
learningincollaborationwithleadersintheimprovementfieldforexample
theInstituteforHealthImprovement,theHealthFoundation,National
PatientSafetyAgency,NLIAH,andtheDSU.
Action 7
ByMarch2008reviewalltargetsforhealthserviceswithaviewtoensuring
thattheysupportthedevelopmentanddeliveryofbalanced,integrated,
highqualityservices.
Action 8
ByMarch2008establishastrategyforBoardengagementinsafetyand
quality,withallTrustandLHBBoardsdemonstratingengagementwith
qualitythroughtheBoardagenda.
Action 9
ByApril2008developintegratedarrangementsfordealingwiththingsthat
gowrongincludingappropriateredress.
Action 10
Eachhealthcommunitytodeveloppatientpathwayslinkedto
commissioningfortwochronicdiseasesandonementalhealthpriorityas
setoutinDesignedforLifebyMarch2007.Thesetobedevelopedasfull
ICPswithclearperformancemeasuresbyMarch2008.Thisworkwillbe
supportedbyNLIAH
Action 11
By2008considerhowbesttoinitiateacomprehensiveannualsurveyof
public/patient’ssatisfactionwithhealthcare
��
Action 12
By2008considerhowbesttosupportandstrengthenBoard-level
commitmenttocustomerservice,andpublicandpatientinvolvement
acrosstheirorganisationsandtodeliverchangesasaresult.
Action 13
ByMarch2008havecompletedananalysisofthequalityandsafety
improvementskillstrainingneedsinthenationalhealthcareworkforceand
haveastrategyforaddressingthegap.
Action 14
ByMarch2007haveclearlinkagesdevelopedbetweentheInforming
Healthcarestrategyandthenationalqualitystrategysuchthattimetables
areidentifiedforpatientandprofessionaldecisionsupport,professional
CPDsupportandeasilyaccessiblerelevanthealthcareinformation.
��
Append�x �
Acknowledgements
ThispaperreflectsthehardworkbyallmembersoftheQuIPworkinggroup:
WendyChatham - Chair-Director,Quality,StandardsandSafety
ImprovementDirectorate,WelshAssemblyGovernment
JonathonGray - WalesCentreforHealth
PaulTromans - RegionalDirector,NPHS
AlanWillson - DirectorofServiceDevelopment,NLIAH
DavidGozzard - MedicalDirector,Conwy&DenbighshireNHSTrust
PeterJohns - Director,TheBoardofCommunityHealthCouncils
inWales
MikePonton - Director,WelshNHSConfederation
MartinMurphy - ClinicalDirector,InformingHealthcare
ChrisRiley - StrategicPlanning&PrioritiesTeam,
WelshAssemblyGovernment
JanAttwell-Thomas - HeadofCGSDU&SpecialistAdvisor,
WelshAssemblyGovernment
KenAlexander - BranchHead,Quality&SafetyImprovementBranch,
WelshAssemblyGovernment
PatVernon - BranchHead,Public&PatientInvolvementBranch,
WelshAssemblyGovernment
CarlEley - BranchHead,HealthcareStandardsBranch,
WelshAssemblyGovernment
JoMenzies - WalesCentreforHealth
JoBinding - QSSID,WelshAssemblyGovernment
WithparticularthankstoJonathonGray,WalesCentreforHealthas
ProjectManager
��
Thisworkhasalsobeeninformedbyextensivereferencetotheworkofcolleagues
withintheIHI,andtheirpublications.WiththankstoJimReinertsenforsharinghis
draftsofpreviousworkandhisgenerousagreementthatwecouldusethistohelp
usframeourworkinWales.
Thisdocumentalsoincludesthoughtsandideasstimulated,synthesizedfromand
borrowedfromexperiencesinrelationto:
- Plannedcareinnovationcommunity.
- TheworkofthemanyexcellentHealthFoundation,MerckandHarkness
FellowsatIHI
- TheP2PursuingPerfectionworkinUSandEurope
- WhitePaper:TheIHILeadershipModel(Reinertsen,Bisognano,Nolan,
Provost,Rupp:October2002)
- TheoryofLeadershipforTransformation(Reinertsen:March2004)
- LeadingforImprovement:LearningfromthePursuingPerfectionhealth
andsocialcarecommunities(BibbyandGarrett,March2004)
- CommunicationsandconversationswithIHIcolleaguesDonBerwick,
MaureenBisognano,PennyCarver,RashadMassoudandmanyothers.
- DiscussionswiththemanyexpertsinWales,butparticularthanksto
GeraintMartin,DavidSalter,JanWilliams,CerilanRogers,ManselAylward
andDavidSeal
- DiscussionswithcolleaguesatHealthFoundation,inparticularStephen
Thornton
- Multipledocumentsandcommunicationsaboutongoingworkforspecific
improvementteams
��
Otherswhohavecontributed:
JohnHill-Tout - JointDirector,DirectorateofPerformance&Operations,
WelshAssemblyGovernment
RonanLyons - HeadofInformation,NPHS
StephenThornton - ChiefExecutive,TheHealthFoundation
GordonMcKenzie - HeadofInformationServicesDivision,
WelshAssemblyGovernment
JohnWynOwen - Personalcontact
BeverleaFrowen - HeadofHealth,SocialService&Wellbeing,WLGA
CarolHaraden - VicePresident,InstituteofHealthcareImprovement
DeeJones - ResearchFellow,UniversityofWalesBangor
FionaPeel - Chair,CancerServicesCo-ordinatingGroup
MarcusLongley - AssociateDirector,WelshInstituteforHealthand
SocialCare
AnneEvans - MedicalDirector,RhonddaCynonTaffLHB
DeniseRichards - NursingOfficer,OfficeoftheChiefNursingOfficer,
WelshAssemblyGovernment
AndreaThomas - NursingOfficer,OfficeoftheChiefNursingOfficer
WelshAssemblyGovernment
JonathonDavies - DeputyChiefExecutive,CardiffandValeNHSTrust
StephenHunter - MedicalDirector,GwentHealthcareNHSTrust
AllisonWilliams - ChiefExecutive,Ceredigion&MidWalesNHSTrust
ChristineMiles - Director,Delivery&SupportUnit,
WelshAssemblyGovernment
HefinJones - Chair,WelshMedicalCommittee
PeterHigson - ChiefExecutive,HealthcareInspectorateWales
JohnBullivant - NHSClinicalGovernanceSupportTeam,England
PeterHalligan - SeniorResearchFellow,CardiffUniversity
SharonHopkins - NLIAH
��
JohnWilliams - Director,Research&Development–Health&Social
Care,WelshAssemblyGovernment
GeoffLang - ChiefExecutive,WrexhamLocalHealthBoard
PeterFarley - ActingHead,PublicHealthProtectionDivision,
WelshAssemblyGovernment
GwynThomas - ProgrammeDirector,InformingHealthcare
GeraintMartin - HeadofStrategy,WelshAssemblyGovernment
ChrisLines - NPHS
CarlJames - BranchHead,PerformanceManagementPolicy
Development,WelshAssemblyGovernment
ManselAylward - Chair,WalesCentreforHealth
NurseDirectors - RegionalOffices,WelshAssemblyGovernment
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