David Fillingham

1. David Fillingham Chief Executive, AQuA

2. Success in Leading Change:Can we get Better Quality Healthcareat a Lower Cost? • David Fillingham • Chief Executive, AQuA • October 2011

3. Harry’s Story • 72 years old, Parkinson’s sufferer, chest problems • Bank Holiday weekend admission • Delay to senior review • Lost Parkinson’s medication • Confusion regarding x-ray test • Central line infection • Poorly co-ordinated discharge process • Length of stay 21 days • Subsequent complaints process

4. Avoidable cost to the NHS • Cost to Harry and his family • = estimated £12,000 • = incalculable

5. A small, non representative study

6. Question 1 Do you believe that it’s possible to deliver better quality safer care at a lower cost? (a) Yes (b) No (c) Not sure

7. Question 2 Consider the savings plans you know about in your own organisation. Will their impact on safety and quality be: (a) Make it worse (b) Neutral (c) Make it better

8. Question 3 So… what are you going to do about it?

9. Does improving quality save money? • Making the Business Case • case example: Royal Bolton Hospital • AQuA’s Approach • The job of leaders: better care at lower cost • What about the cynics?

11. Strong evidence of considerable volume of adverse events and poor quality • Significant potential for savings • Much less evidence on actual links between savings and costs • There are very few robust research studies showing the impact of quality improvement interventions on costs (Ovretveit, 2009)

12. Evidence for cost increases linked to poor quality • Overuse and underuse • Hospital acquired infections • Achieve drug costs • Complications in surgery • “failure to rescue” • Misdiagnosis or maltreatment through poor communication or co-ordination (Ovretveit, 2009)

13. UK Estimates • Hospital Acquired Infections - £1.0 bn a year • 25% of radiological procedures are unnecessary • One patient fall causing a fractured neck of femur = £11,452 • Pressure ulcers is 4-10% of in-patient admissions - … estimated £1m per 600 beds per year • Cost of adverse drug events £6.6 bn (Ovretveit, 2009)

14. QIPP Safe Care: Safety Express Targets £225m of taxpayer savings by reducing Falls, VTEs, Pressure Ulcer, Catheter Acquired UTIs But acknowledges: • Poor understanding of cost versus quality relationship • Extrapolation from small research studies • Incomplete data sets • Methodological initiatives

15. Why is this? • Improvements have (rightly) focussed on safety and quality more than costs • Payment by results incentivise activity not quality • Providers who reduce length of stay through quality improvement earn more through extra activity than capacity reduction • We haven’t engaged our finance colleagues (with notable exceptions) in the debate

16. Making the Business Case for Quality

17. Making the Case for Quality: a case example Royal Bolton Hospital

18. Quality as the Business Strategy No defects/best experience No avoidable deaths or harm Improved Health Best Possible Care Joy and Pride Value for Money Highest Morale No waste

19. Characteristics • Aim is to create a system for Improvement • Based on “lean” principles, creatively adapted for the NHS • At heart of our Business Plan – drives safety, quality and productivity • Comprises tools, methods, management system and leadership • Seeks to engage all staff in a long term cultural transformation

20. : Some Results - 2005 – 2011 • Improved Mortality and Productivity • Ophthalmology one stop shop – patients visits 50% • Pathology – test turnarounds from x3 to x10 quicker; 40% floor space savings • Radiology, audiology, therapies and other clinical support services redesigned into the flow • Laundry, finance, estates and others – six figure cost savings • 33% staff involved in week long improvement and 80% in the BICs Academy • 2010/11 BICs contributed to £1.5m cost savings and 23% fall in overall hospital mortality

21. The Bolton Improving Care System Understanding Value Learning To See Improving Health Best Possible Care Value for Money Joy and Pride in Work Delivering Benefit Redesigning Care

22. Due to their improvement work since April 2009 the respiratory team have: • Reduced inpatient mortality by 20% • Increased discharges by 25% • Reduced readmissions from 9.5% to 8.5% • Reduced length of stay by >1day • Reduction in complaints Respiratory Team “I knew change was possible and we’d make some improvements, but I didn’t imagine we’d make as many as we have and it gives you the courage to go further and make even more changes” Dr Brian Bradley, Respiratory Consultant 2010 22

23. Royal Bolton Hospital • BICs underpinned quality gains and financial savings • Strong Board level and clinical engagement • Biggest wastes and avoidable harms lie in preventable ill health and avoidable hospitalisation • Critical to planned development of “provider alliance” with community services, GPs, social care • Next step is using lean across the whole health and social care system

24. AQuA • AQuA has been established as a membership organisation through the active leadership of North West CEOs • It also aims to improve Quality and reduce costs • Results are already being delivered: • Stroke 90:10 driving up compliance with Sentinel Audit > 90% • AQ improving outcomes and productivity for five conditions • Safety Networks – improvements in falls, pressure ulcers and VTEs • Mortality Collaborative – reducing standard mortality rates in 9 Trusts with highest rates

25. Harm free care Improved care for patients with long term conditions Shared decision making The continual elimination of waste AQuA Priorities 2011/12

27. Original AQ measure sets (1) • Hip and knee replacement • Prophylactic antibiotic received within one hour prior to surgical incision • Prophylactic antibiotic selection for surgical patients • Prophylactic antibiotics discontinued within 24 hours after surgery end time • Recommended Venous Thromboembolism prophylaxis ordered • Appropriate Venous Thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery • Community-acquired pneumonia (CAP) • Percentage of patients who received an oxygenation assessment within 24 hours prior to or after hospital arrival • Initial antibiotic selection • Initial antibiotic consistent with current recommendations - ICU • Initial antibiotic consistent with current recommendations - Non ICU • Blood culture collected prior to first antibiotic administration • Antibiotic timing, percentage of pneumonia patients who received first dose of antibiotics within six hours after hospital arrival • Smoking cessation advice/counseling

28. Original AQ measure sets (2) • Coronary artery bypass graft (CABG) • Aspirin prescribed at discharge • Prophylactic antibiotic received within one hour prior to surgical incision • Prophylactic antibiotic selection for surgical patients • Prophylactic antibiotics discontinued within 48 hours after surgery end time • Inpatient mortality rate • Heart failure (HF) • Left Ventricular Systolic (LVS) assessment • Detailed discharge instructions • ACEI or ARB for LVSD • Smoking cessation advice/counseling Acute myocardial infarction (AMI) • Aspirin at arrival • Aspirin prescribed at discharge • ACE or ARB for LVSD • Smoking cessation advice/counseling • Beta blocker at arrival • Beta blocker prescribed at discharge • Thrombolytic received within 30 minutes of hospital arrival • PCI received within 90 minutes of hospital arrival • Inpatient mortality rate

29. Composite Process Score Performance ImprovementPreliminary Data October 2008 – September 2010 Composite Process Scores Quarters

31. The Collaborative Rate of Improvement – Dr Foster

32. AQuA’s Model of Spread Evidence and Intelligence Change Champions and Communities of Practice Incentives Robust Improvement Methods Peer to Peer Learning

33. The job of leaders: better care at lower cost • Building a vision of a better service (quality and cost = value) • Engaging all staff, patients and stakeholders in the improvement effort • Personally mastering improvement know how – hands on approach • Building a system for continuing improvement • Overcoming opposition and setbacks

34. What about the cynics?

35. Fillingham’s Motivational Matrix Enthusiastic Pragmatist Naïve Idealist Positive Outlook on Life Disillusioned Sceptic Embittered Cynic Negative High Low Grip on Reality

36. Converting the Sceptics • Make it specific to ‘my’ service • Use rigorous improvement methods • Robust and convincing data • Hands on experience… rapid improvement weeks • Reinforce through changed management system and leadership style

37. “Men wanted for hazardous journey. Small wages, bitter cold, long months of complete darkness, constant danger. Safe return doubtful. Honour and recognition in case of success.” Quoted in “Shackleton’s Way” by Morrell and Capparell

38. “The names of the patients whose lives we have saved can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended, which without our work, would never have been.” Don Berwick, IHI