Transforming culture in failing hospitals is possible:
Salford Royal shows that though a tall order in a cash-strapped NHS, it is possible to bring a hospital back from the brink.
This autumn the Francis report on Mid Staffs will tell us that the NHS needs to become safer and more caring even at a time when dozens of hospitals face bankruptcy. Many will clamour for more funding, but the latest figures from the Office for Budget Responsibility and the Institute for Fiscal Studies show that there is unlikely to be more money for the NHS any time in the next 10 years.
If we don't want the NHS to end up on life support, we need transformational approaches that can improve the quality and safety of care while saving money. Fortunately, answers are out there.
Eleven years ago, Salford Royal received zero stars in the Healthcare Commission's rating system. Now Salford Royal NHS foundation trust is one of England's best hospitals. It performs well on clinical measures: for instance, standardised mortality is in the top 10% nationally and hospital acquired infections have plummeted.
Efficiency has also improved: there has been a sustained reduction in the length of stay but readmission rates (which can suggest if they're discharging patients before they are ready to go home) have been stable and low. And patients love it: 98% of patients would recommend the hospital to friends and family.
What went so right? The answer is that the chief executive, David Dalton, who has been in the role for 11 years, has placed a relentless focus on safety and quality. He has done this by changing the culture of the organisation.
Clinical leadership came first. His vision for a high-performance culture placed a premium on performance and values, not reputation and time served. After planning with consultants and senior nurses, management served notice on all 20 existing clinical directors. The roles were redefined and advertised in an open internal competition.
Fascinatingly, it was a younger generation of enthusiastic consultants who stepped up to the mark. Those who were initially selected went on a competence assessment programme for nine months and the best progressed and were appointed. They have greater autonomy than their predecessors – but also greater accountability for performance and results. Success is celebrated and rewarded; poor performance is identified and rooted out.
This is realised through a performance management system borrowed from industry: GE-McKinsey's "nine-box grid" assesses performance and values – at worst you are "unsatisfactory", at best a "role model". Through this, hospital leadership has sought to introduce rewards and a "system of consequence" (ie things happen when you're not up to the job).
For example, the pay increases in the NHS contract, Agenda for Change, are often granted automatically, but at Salford they are dependent on performance and quality improvement, so you only get them if you've done mandatory training, attendance, good appraisals and so on. Additional perks and training opportunities (such as foreign study grants) have been given to the best doctors as additional incentives.
To diffuse this culture throughout such a big hospital – the organisation manages a budget of £400m and employs around 6,000 members of staff – the leadership recognised that it would have to engage frontline staff. They had to make their ambition of making care "safe, clean and personal" a shared ambition for all staff. "Ideas for change and improvement will not come from my office", Dalton told me on a visit last week, "they lie deep within the organisation".
Nurses have been collectively incentivised to work as teams. The nursing assessment and accreditation system, based on best practice at the world-leading Institute of Healthcare Improvement in America, clearly defines expectations for ward sisters. The quality of nursing care is assessed on 13 key standards and ranked, with each ward assigned a red, amber, green or blue rating. Securing a blue rating enables the ward sister to be promoted to ward matron with greater freedom, power and responsibility.
If, after support, a ward gets repeat red ratings the ward sister will be demoted. Performance against set standards – on MRSA, C-Diff, catheter associated urinary tract infections, sepsis, pressure ulcers, falls etc – is published. And standards are regularly raised. Tellingly, staff satisfaction at Salford has been the highest of any NHS Trust for the past two years.
Measuring and publishing information reinforces a culture of accountability, which in turn reinforces a culture of quality, safety and compassion. "Measurement is a vital part of improvement," says the trust's quality improvement strategy for 2011-2014. "If we do not measure then we have no way of knowing whether the changes or intended improvements that we are making have had any impact.
Measurement is also one of the key elements of a safety culture. The board and the executive are judged against the goals they set the organisation. They want Salford to be the safest organisation in the NHS as well as the first choice for patients. It is hard to think of better goals.
Nick Seddon is deputy director of the independent thinktank Reform Guardian Professional
This autumn the Francis report on Mid Staffs will tell us that the NHS needs to become safer and more caring even at a time when dozens of hospitals face bankruptcy. Many will clamour for more funding, but the latest figures from the Office for Budget Responsibility and the Institute for Fiscal Studies show that there is unlikely to be more money for the NHS any time in the next 10 years.
If we don't want the NHS to end up on life support, we need transformational approaches that can improve the quality and safety of care while saving money. Fortunately, answers are out there.
Eleven years ago, Salford Royal received zero stars in the Healthcare Commission's rating system. Now Salford Royal NHS foundation trust is one of England's best hospitals. It performs well on clinical measures: for instance, standardised mortality is in the top 10% nationally and hospital acquired infections have plummeted.
Efficiency has also improved: there has been a sustained reduction in the length of stay but readmission rates (which can suggest if they're discharging patients before they are ready to go home) have been stable and low. And patients love it: 98% of patients would recommend the hospital to friends and family.
What went so right? The answer is that the chief executive, David Dalton, who has been in the role for 11 years, has placed a relentless focus on safety and quality. He has done this by changing the culture of the organisation.
Clinical leadership came first. His vision for a high-performance culture placed a premium on performance and values, not reputation and time served. After planning with consultants and senior nurses, management served notice on all 20 existing clinical directors. The roles were redefined and advertised in an open internal competition.
Fascinatingly, it was a younger generation of enthusiastic consultants who stepped up to the mark. Those who were initially selected went on a competence assessment programme for nine months and the best progressed and were appointed. They have greater autonomy than their predecessors – but also greater accountability for performance and results. Success is celebrated and rewarded; poor performance is identified and rooted out.
This is realised through a performance management system borrowed from industry: GE-McKinsey's "nine-box grid" assesses performance and values – at worst you are "unsatisfactory", at best a "role model". Through this, hospital leadership has sought to introduce rewards and a "system of consequence" (ie things happen when you're not up to the job).
For example, the pay increases in the NHS contract, Agenda for Change, are often granted automatically, but at Salford they are dependent on performance and quality improvement, so you only get them if you've done mandatory training, attendance, good appraisals and so on. Additional perks and training opportunities (such as foreign study grants) have been given to the best doctors as additional incentives.
To diffuse this culture throughout such a big hospital – the organisation manages a budget of £400m and employs around 6,000 members of staff – the leadership recognised that it would have to engage frontline staff. They had to make their ambition of making care "safe, clean and personal" a shared ambition for all staff. "Ideas for change and improvement will not come from my office", Dalton told me on a visit last week, "they lie deep within the organisation".
Nurses have been collectively incentivised to work as teams. The nursing assessment and accreditation system, based on best practice at the world-leading Institute of Healthcare Improvement in America, clearly defines expectations for ward sisters. The quality of nursing care is assessed on 13 key standards and ranked, with each ward assigned a red, amber, green or blue rating. Securing a blue rating enables the ward sister to be promoted to ward matron with greater freedom, power and responsibility.
If, after support, a ward gets repeat red ratings the ward sister will be demoted. Performance against set standards – on MRSA, C-Diff, catheter associated urinary tract infections, sepsis, pressure ulcers, falls etc – is published. And standards are regularly raised. Tellingly, staff satisfaction at Salford has been the highest of any NHS Trust for the past two years.
Measuring and publishing information reinforces a culture of accountability, which in turn reinforces a culture of quality, safety and compassion. "Measurement is a vital part of improvement," says the trust's quality improvement strategy for 2011-2014. "If we do not measure then we have no way of knowing whether the changes or intended improvements that we are making have had any impact.
Measurement is also one of the key elements of a safety culture. The board and the executive are judged against the goals they set the organisation. They want Salford to be the safest organisation in the NHS as well as the first choice for patients. It is hard to think of better goals.
Nick Seddon is deputy director of the independent thinktank Reform Guardian Professional
No comments:
Post a Comment