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Leadership for Compassion and Safety

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.

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Leadership for Compassion and Safety

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  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. Outcome Efficiency/costs Experience What is Quality?

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

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

  9. Outcome Experience Efficiency Quality triangle – UHB • What measures?

  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 • It’s how you use it • Like any piece of kit

  29. 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

  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 accountabilityCEO RCA meetings

  32. The outcome?

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

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

  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 plusNon Charted antibiotics

  38. Types of standards • General universal standards • Bacteraemias • Drug omissions • Time from prescription to 1st 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.

  47. Partners with our patients • Live feedback • Outpatients system • myhealth@qehb • Inpatients system • mystay@qehb

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