leadership for compassion and safety julie moore ceo university hospitals birmingham nhs foundation...
TRANSCRIPT
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
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
• 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?
Experience
Outcome
Efficiency/costs
Quality triangle: 2004
• Mid Staffs• Money prioritised
Experience
Outcome
Efficiency/costs
Quality triangle - 2008
• Friends and Family• Example
Experience
Outcome
Efficiency
Quality triangle – UHB
• What measures?
Experience
Outcome
Efficiency
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• 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• 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
“Unimportant” Errors?
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• 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?
• 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• 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
• Reduce errors
• Increase speed
• Increase efficiency
• Compare
Systems at UHB
• Patient based system - PICS• Internal informatics dashboards• External informatics suite
• PICS – Prescribing– Information– Communication – System
• Decision-support prescribing• Observations and assessments• Test results• Order Comms
PICS
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
• Every interaction logged• Live information• Information by
– Specialty– Ward– Clinician
• Clinical dashboards
Clinical dashboard
Medicines management
Missed doses by ward
Missed doses by individual
Having a system is not enough
• It’s how you use it• Like any piece of kit
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
• 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 accountabilityCEO RCA meetings
The outcome?
External ComparatorsOmitted doses: Non antibiotics
0.00
10.00
20.00
30.00
Apr-1
0
Jun-
10
Aug-1
0
Oct-10
Dec-1
0
Feb-1
1
Per
cen
tag
e
UHB (PICs)
System A
System B
Currentperformance
0.00
4.00
8.00
12.00
16.00
Apr-1
0
Jun-
10
Aug-1
0
Oct-10
Dec-1
0
Feb-1
1
Per
cent
age
UHB (PICs)
System A
System B
External ComparatorsOmitted doses: Antibiotics
now
So what?
• Could just be spending more on drugs
UHB vs England Mortality
Mar
-08
Jun-0
8
Sep-0
8
Dec-0
8
Mar
-09
Jun-0
9
Sep-0
9
Dec-0
9
Mar
-10
Jun-1
0
Sep-1
0
Dec-1
0-10.00
-5.00
0.00
5.00
f(x) = − 0.0106028164682901 x + 419.228984156645f(x) = − 0.00053184962875465 x + 21.4188602018702f(x) = − 0.000610440655983615 x + 24.5029239998436
UHBLinear (UHB)England no UHBLinear (England no UHB)EnglandLinear (England)
De
ath
s /
10
00
dis
ch
arg
es
IN PRESS. J R Soc Med
Mortality and missed plusNon Charted antibiotics
-12.00
-7.00
-2.00
3.00
Mar
-08
May
-08
Jul-0
8
Sep-0
8
Nov-0
8
Jan-0
9
Mar
-09
May
-09
Jul-0
9
Sep-0
9
Nov-0
9
Jan-1
0
Mar
-10
May
-10
Jul-1
0
Sep-1
0
Nov-1
0
Jan-1
1
De
ath
s p
er
10
00
ad
mis
sio
ns
6.00%
10.00%
14.00%
UHB relative
Rest of England relative
missed Abs plus NC abs
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
• 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
75.00%
80.00%
85.00%
90.00%
95.00%
100.00%
3 YearsApr 06 -Mar 09
Last Year0809
Apr - Jul09
Last 3Months
Betablockers onoperation day
ACE Inhibitor
Antiplatlet
Statin
Information Enables Clinicians
3 Year CABG survival
Post Intervention
Pre Intervention
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
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 patients
• Live feedback• Outpatients system
– myhealth@qehb
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 patients
• Live feedback• Outpatients system
– myhealth@qehb• Inpatients system
– mystay@qehb
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......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 of quality of care in all we do• Emphasis on what is important for patient care• Is it working?
Cultural shift?Non charting
Hospital moves
Agency
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• 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
• 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
• 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
• 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
• 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
• 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