Fiona McQueen Executive Nurse Director The Quality Agenda Fiona McQueen Executive Nurse Director

What is world class healthcare? Where are we now? Where do we want to be 2 years 5 years 20 years Call to action for the journey

Cabinet Secretary NHSScotland Healthcare Quality Strategy At its heart is a simple but very ambitious aim: “To make the NHS in Scotland a world leader in the quality of health care services that it delivers.” “That aim is not just good for patients, it is also right for staff.” Scottish Parliament, Debate 13 May 2010

Quality Strategy built on people’s priorities •Caring and Compassionate health services •Collaborating with patients and everyone working for and with NHSScotland •providing a Clean and safe care environment •improved access and Continuity of care •Confidence and trust in healthcare services •delivering Clinical excellence

Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Safe Quality Effective Person Centred Quality occurs more frequently when the three ambitions are delivered together

Aim Primary Driver Secondary Driver Everyone gets the best start in life and is able to live a longer healthier life at home or in the community . Healthcare is safe for every person every time and every experience of healthcare will be positive, delivered by staff who feel supported and engaged. Leadership – executive leaders demonstrate that everything in the culture is patient focused Nothing about me without me Healthcare systems deliver reliable, quality care The care team installs confidence by providing collaborative, evidence based care Patients get the outcomes of care they expect The Care Experience of patients and their families is improved Partnership working with communities served as equal partners Asset based service redesign Services reflect an asset based approach (place-based, relationship-based, citizen-led and promote social justice/equality) Outcomes based commissioning All services are co-produced Hospital Standardised Mortality Ratio are best in class for Scotland Clinicians review all unexpected deaths as a matter of routine and continuously learn and make improvement There are no needless deaths No patient is subjected to needles harm due to unreliable systems and or processes Any episode of harm is reviewed as a matter of routine and continuously learn and make improvements There is no needless harm Staff are recruited for values Staff governance standards are adhered to consistently An asset based approach to staff well-being is taken Compassionate communication and teamwork are essential competencies ‘One set of rules’ for all Community benefit in all employee contracts Staff experience and well being is improved

World Class Healthcare The people of Ayrshire and Arran have the best possible start and live longer healthier lives in settings of their choice whenever possible. Care is co-produced to deliver no needless waits There are no needless deaths There is no needless harm Every experience of Healthcare is positive All staff who deliver healthcare feel supported engaged and valued

Do you agree? Take 10 minutes to discuss at your tables Is this what world class healthcare looks like? Tell us what is missing

High performing organisations Culture and leadership focus – high value organisations define and relentlessly and consistently demonstrates values Specification and planning: high-value organisations base operational and core clinical decisions on explicit criteria and organise effectively Infrastructure design: High-value organisations create highly effective teams at the micro level, to meet the needs of patient and families. For example, Dartmouth's Spine Center uses a detailed intake assessment—which includes a survey, visual aids, and shared decision making—to triage patients based on the likelihood that they will achieve better outcomes with medical or surgical care. Within those microsystems, tasks are allocated to clinical team members based on skill and training, and assistive personnel is provided with all necessary resources through careful information and equipment supply chain design. According to Bohmer, microsystem design represents "an important shift away from general-services-organization designs that use a single platform to meet the needs of many different patient groups."

High performing organisations Measurement and oversight: High-value organisations use measurements of clinical operations for internal process monitoring to drive improvement. Staff focus - high value organisations ensure staff involvement and ownership The learning organisation: high value organisations examine positive and negative deviations in care and outcomes, using the information create common tools to improve outcomes.

How will we get there?

Culture Your culture is an outcome of the way employees behave. So how are we encouraging our employees to behave? Lived values = positive behaviours Relentless modelling of positive behaviours delivers positive attitudes.

Team work Efficiency Equality Excellence Care Improvement Current values Team work Efficiency Equality Excellence Care Improvement

What behaviours are required to build a culture of excellence? Select your top five behaviours from the cards at your table. As a board what is your role in the delivery of ‘lived’ values to improve culture ?

What’s in a Wordle? Insert wordle

What’s in a Wordle? Does this Wordle capture our ambitions? How should we promote these behaviours? What should be the consequence for those who don’t adhere to them?

What we think we “know” •Better quality costs more money •If you want to ― get “Safe Care” it will cost MUCH more money

Now here is the “truth” Good quality care costs LESS than poor quality care Safe, harm-free care SAVES Money. It costs less to provide, and avoids costs of correction.

Learning from the Henry Ford Health System

So, where to focus our efforts? Harm Free Care ? Safe care Unsafe care

Where are we now?

Safe, Effective and Person Centred Leadership Critical Care General Ward Peri-operative Medicines Management Maternity Mental Health Primary Care Sepsis VTE collaborative

Outcome aims Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction

Hospital Standardised Mortality Rates (all patients) -2007/08

“When something goes wrong it is how the organisation acts that redefines and reshapes the culture.” Jeanette Clough, President & Chief Executive Officer Mount Auburn Hospital, Boston, MA, USA

What did we find? Failures Identification of sick patients Clinical Observation Variation in Record Keeping Need for Palliative and End of Life Care Coding Unreliable and Variable Care Clinical Escalation Failure to Rescue DNA CPR Infection and Falls Failures Identification of sick patients Planning and execution of care and treatment Rescue of deteriorating patients

Scotland HSMR – 9.3% reduction

Ayr – 9.8% reduction

Crosshouse - 27% reduction

Improvement methodology SPSP tools and methods to support implementation of improved practices Plan-Do-Study–Act (PDSA) cycles to develop improvements in clinical practice Engaging all staff to ensure ownership of new ways of working

Teams must own the processes to achieve improvement Improvement Experts Involvement Spread Sustain Plan, do, study, act Improvement

Ayr Hospital

General ward spread Back to Basics programme spread across Crosshouse. - completed in all in-patient areas. All wards monitoring and measuring MEWS, Safety Brief and SBAR plus all other GW measures Improvement programme spreading at Ayr – 6 wards complete and monitoring and measuring compliance with all BTB /General Ward measures. Spread to continue through to March 2013

Scottish VAP rate (per thousand ventilator days) 61% reduction 9.11 3.54

Percentage compliance with surgical briefing 94% 20% improvement 74%

Spread of work in theatres Percent of patients who have peri-operative briefing. Excellent compliance across all theatres in surgical pause and briefing prior to surgery

Person centred – some examples of the good 92% of in-patients said they were treated with dignity and respect (2011 n=3600) 90% of patients rate the overall care experience received from their GP Surgery as positive (2012 n=8672) Patients rate the quality of consultation with many doctors, nurses and AHP’s highly (CARE measure mean score 45/50 – mean score normative data 43/50)

Person centred – some examples of the not so good 40% of all the formal complaints are customer service related (i.e. communication, attitude, courtesy, respect) Overall customer service satisfaction rating to be 56.3% positive (2011 n= 752 staff and patients) 47% of patients were not told how long they would have to wait in A&E (2011 n=3600) 22% of patients were unable to book a GP appointment 3 or more days in advance (2012 n=8672)

Immediate interventions to support improvements in Patient Centred Care Quality of Consultation - Use of the CARE measure Customer Care Commitments Caring Behaviours Assurance System (CBAS) ‘Teach back’ approach to improving communication with patients Better Together Programme Improving Patient and family involvement in care Developing volunteer opportunities Developing Co-production approaches

The stories behind the data Andy

As a Board Member, do you know the names of the people who have been harmed or killed in your hospitals and healthcare systems because of unsafe, unreliable systems ?

As a Board Member, do you know how many clinicians have been damaged as a result of unreliable or unsafe systems and processes of care?

What approach would you want the Board to take if it was your mother, father, partner, child ?

What assurance does the Board need that we are providing world class health services and that we are learning from events. Discuss at your table and agree the top 2 things that would provide you with assurance

Ah … but! Safety improvement excellent in pilot sites Person centred care excellent in some areas Spread taking for all taking longer than we need to drive improvement New commitment to - 20% reduction in Mortality - 95% patients receive harm free care - Improved person centred care Capacity and capability building is required to enable change and improvement

Capability and capacity Capability – the people have the confidence and the knowledge and skills to lead the change. Capacity – having the right number and level of people who are actively engaged and able to take action. Helen Bevan, Journal of Research Nursing 2010; 15: 139-148

Take 10 minutes at your table to discuss … How the organisation can build the capacity and capability necessary to drive quality improvement at pace and scale

What skills are needed? Many People Few People A key operating assumption of building capacity is that different groups of people will have different levels of need for Improvement knowledge and skill. Change agents Middle Manager Level All staff Operational Leaders Experts Our approach will be to make sure that each group receives the knowledge and skill sets they need when they need them and in the appropriate amounts Deep Knowledge Shared Knowledge Continuum of Improvement Knowledge and Skills

What do we have currently?

What next? Take five minutes at your table to discuss as a Board Member what you will personally do to drive or promote the Quality Agenda