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

2. 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

3. 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

4. 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

5. 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.

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

8. 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

9. 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

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

11. 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."

12. 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.

13. How will we get there?

14. 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.

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

16. 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 ?

17. What’s in a Wordle?
Insert wordle

18. 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?

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

20. 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.

21. Learning from the Henry Ford Health System

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

23. Where are we now?

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

25. 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

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

27. “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

28. 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

29. Scotland HSMR – 9.3% reduction

30. Ayr – 9.8% reduction

31. Crosshouse - 27% reduction

32. 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

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

34. Ayr Hospital

35. 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

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

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

40. 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

41. 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)

42. 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)

43. 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

44. The stories behind the data
Andy

45. 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 ?

46. 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?

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

48. 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

49. 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

50. 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:

51. 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

52. 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

53. What do we have currently?

54. 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