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