healthcare quality improvement plan - nhs wales · the healthcare quality improvement plan sets out...

Healthcare Quality Improvement Plan

Designed to Deliver

November 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:[email protected]

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,


JanAttwell-Thomas - HeadofCGSDU&SpecialistAdvisor,


KenAlexander - BranchHead,Quality&SafetyImprovementBranch,


PatVernon - BranchHead,Public&PatientInvolvementBranch,


CarlEley - BranchHead,HealthcareStandardsBranch,


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,


RonanLyons - HeadofInformation,NPHS

StephenThornton - ChiefExecutive,TheHealthFoundation

GordonMcKenzie - HeadofInformationServicesDivision,


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,


AndreaThomas - NursingOfficer,OfficeoftheChiefNursingOfficer


JonathonDavies - DeputyChiefExecutive,CardiffandValeNHSTrust

StephenHunter - MedicalDirector,GwentHealthcareNHSTrust

AllisonWilliams - ChiefExecutive,Ceredigion&MidWalesNHSTrust

ChristineMiles - Director,Delivery&SupportUnit,


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,


GwynThomas - ProgrammeDirector,InformingHealthcare

GeraintMartin - HeadofStrategy,WelshAssemblyGovernment

ChrisLines - NPHS

CarlJames - BranchHead,PerformanceManagementPolicy

Development,WelshAssemblyGovernment

ManselAylward - Chair,WalesCentreforHealth

NurseDirectors - RegionalOffices,WelshAssemblyGovernment

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