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Leadership for Compassion and Safety Julie Moore CEO University Hospitals Birmingham NHS Foundation Trust.

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Presentation on theme: "Leadership for Compassion and Safety Julie Moore CEO University Hospitals Birmingham NHS Foundation Trust."— Presentation transcript:

1 Leadership for Compassion and Safety Julie Moore CEO University Hospitals Birmingham NHS Foundation Trust

2 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

3 University Hospitals Birmingham

4 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

5 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?

6 What is Quality? Experience Outcome Efficiency/ costs

7 Quality triangle: 2004 Mid Staffs Money prioritised Experience Outcome Efficiency/ costs

8 Quality triangle - 2008 Friends and Family Example Experience Outcome Efficiency

9 Quality triangle – UHB What measures? Experience Outcome Efficiency

10 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

11 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

12 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

13 Important Errors

14 Unimportant Errors?

15 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

16 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

17 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

18 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?

19 IT to its full potential Reduce errors Increase speed Increase efficiency Compare

20 Systems at UHB Patient based system - PICS Internal informatics dashboards External informatics suite

21 PICS –Prescribing –Information –Communication –System Decision-support prescribing Observations and assessments Test results Order Comms PICS

22 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%

23 Live feedback Every interaction logged Live information Information by –Specialty –Ward –Clinician Clinical dashboards

24 Clinical dashboard

25 Medicines management

26 Missed doses by ward

27 Missed doses by individual

28 Having a system is not enough Its how you use it Like any piece of kit

29 Information is not enough IT systems dont result in change Informatics systems dont 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

30 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

31 Team accountability CEO RCA meetings

32 The outcome?

33 External Comparators Omitted doses: Non antibiotics 0.00 10.00 20.00 30.00 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Percentage UHB (PICs) System A System B Current performance

34 0.00 4.00 8.00 12.00 16.00 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Percentage UHB (PICs) System A System B External Comparators Omitted doses: Antibiotics now

35 So what? Could just be spending more on drugs

36 UHB vs England Mortality IN PRESS. J R Soc Med

37 Mortality and missed plus Non Charted antibiotics

38 Types of standards General universal standards –Bacteraemias –Drug omissions –Time from prescription to 1 st administration Specialty specific Live information enables clinicians to take action

39 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

40 Information Enables Clinicians

41 3 Year CABG survival Post Intervention Pre Intervention

42 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

43 Using IT in other ways

44 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

45 Partners with our patients Live feedback Outpatients system – myhealth@qehb

46 Partners with our patients Access records Access results Communicate with clinical team Access to correspondence Appointments and reminders Upload other info Informed patients.


48 Partners with our patients Live feedback Outpatients system – myhealth@qehb Inpatients system – mystay@qehb






54 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

55 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

56 Culture change? Culture of quality of care in all we do Emphasis on what is important for patient care Is it working?

57 Cultural shift? Non charting Hospital moves Agency

58 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

59 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

60 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

61 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

62 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

63 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

64 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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