We published Driving Improvement in eight NHS trusts in June 2017. It told the story of how East Lancashire Hospitals NHS Trust moved from being in special measures in 2013 to a good rating in 2015.
Since then, it has faced increased demand and increased pressures. And the trust maintained its good rating.
According to chief executive Kevin McGee, sustaining ‘good’ and achieving continuous improvement has been through “lots of hard work and focus. Two things have been at the heart of what we’ve tried to do. One has been a systematic approach to quality improvement driven by the use of data to really understand the business and to forecast and predict.”
“The second is a relentless focus on the fact that everything starts and finishes with staff. Whatever we do we always start by asking how will this improve the health and wellbeing of staff, how will it improve the daily working environment, how do we support staff?”.
Quality improvement
The trust has been part of the national Vital Signs improvement programme for the NHS. And it has continued and embedded initiatives, such as the Nursing Assessment Framework. This has all helped it achieve a good rating.
Kevin Moynes is Director of Human Resources and Organisational Development. Vital Signs, says Kevin, is a clinically led improvement method. It helps the trust understand where its problem areas are. And the trust can address those problems promptly. It also supports improvement. For example through analysing and making changes to pathways such as the frailty pathway. Vital Signs tracks performance using statistical process control (SPC) charts. Kevin says SPC is changing the way the trust looks at things. For example, the charts allow the trust to understand normal variation. And they show the impact of changes or where to make adjustments.
Christine Pearson is Director of Nursing. Christine is confident the focus on continuous improvement has raised quality across the trust. “I have assurance from inside the organisation that the two services that were rated requires improvement [in 2014] – outpatients at the Royal Blackburn Hospital and maternity at the Blackburn Birth Centre - are now considered to be outstanding. We would want them to be inspected!”
Assurance
Christine introduced the Nursing Assessment Framework in 2015 to tackle variability of care on the trust’s wards. Using a method based on CQC's, a panel of staff visit wards and give them a red, amber or green rating. Wards that achieve three greens in a row can apply for ‘silver status’. Over the past five years all wards have been assessed. Recently Christine reported that for the first time no wards had a red rating. The programme is now being rolled out to community teams.
She says the programme has to be continuous, with wards being re-visited: “even outstanding hospitals have ‘worry wards’”. And wards that improve to green can slip back if the pressure to sustain and improve lets up. Non-executive directors also take part in ‘quality walk rounds’. And every six months members of the public and Healthwatch carry out quality visits to wards. These people could be from groups such as the local public participation group.
Other clinicians and teams have asked Christine how to make this a multi-disciplinary approach. And medical teams are now more involved with nursing teams in pushing for silver status.
Staff engagement
Staff hold the keys to improvement: having the appropriate staff and staff who are supported and listened to. “The continuation and evolution to the next stage is based on and driven by staff, says Kevin McGee”.
Kevin Moynes emphasises the importance of staff engagement and support for staff. These have a bearing both on improvement and on staff retention - vitally important when all trusts are struggling to recruit. “The more engaged staff are, the better patient care is”, he adds.
Support includes initiatives such as providing theatre staff with head and neck massages. There's a programme of physical and mental wellbeing, including Zumba classes. The trust has an Amazon locker, so staff can pick up parcels at work. And staff can do their laundry on site. These all help to improve the wellbeing of staff. The trust has a strong and well-resourced staff engagement team.
It's also, says Kevin McGee, about trying to “do the right things” as opposed to “expedient things” at a time when the NHS is under such pressure. “If there are pressures and we need to do different things and invest in staff and support staff in a different way even if it’s going to cost money, we’ll do that even if it is to the detriment of finances.”
Christine Hughes is Director of Communications and Engagement says. She says that being on the board underlines the trust's commitment to communicating and engaging with staff, people who use services and other stakeholders. “We have maintained our commitment to good two-way staff engagement. We understand that the organisation is nothing without people; we value our staff and place importance on who we recruit.” She says the focus is on promoting and protecting staff wellbeing. The trust is establishing and maintaining an open culture – a no-blame culture that encourages learning.
The emphasis on staff is reflected in the staff satisfaction survey - results improve year on year.
Leadership
Inherent in the focus on staff is the trust’s commitment to embed compassionate leadership in the organisation. “We recruit on that basis, induct on that basis, appraise on that basis and lead and manage on that basis.”
Kevin McGee points to the benefits of having a stable leadership over the past few years. But also making sure ‘stable’ doesn’t lead to staleness.
Kevin McGee and Christine Pearson stress the importance of accessible leadership in sustaining ‘good’. Leaders spend time around the hospital. Christine meets with all grades of staff regularly. She has monthly meetings with Band 7 nurses, with no agenda, enabling them to raise any issues they want to. She also holds an open session with Band 5 and 6 nurses every six months and is now looking to meet with support workers. She has an open-door policy, an approachable attitude mirrored throughout the nursing teams.
Vision
The trust’s vision is expressed as Safe, Personal and Effective care. Kevin Moynes thinks this allows the trust to hold a mirror up to itself. And it provides a clear narrative to teams about what the trust stands for. “Teams can look at something and ask, ‘does that look safe, does that look effective’?”
Christine Hughes says the vision has been “immensely successful in clarifying for people why they are here. Every single role has an impact on that commitment to safe, personal and effective care”.
Recruitment and retention
In common with many other trusts, East Lancashire does not have enough doctors and nurses. So it cannot follow the traditional hierarchy of ward-based teams. Kevin McGee says, “Teams have started to look very different and much more multi-disciplinary including allied health professionals and healthcare assistants, allowing doctors and senior nurses to focus on what only they can do and take everything else off them. It’s born out of necessity, but I think it’s the right thing to do anyway.”
The trust has also introduced a mediation service. That has resulted in a fall in the number of issues going to a grievance procedure. And to signpost a more constructive environment, the disciplinary policy is now a resolution policy.
As well as the more traditional exit interviews, HR now conducts ‘stay’ interviews with staff to help understand issues they face. It also holds ‘keep in touch’ days. Staff can work up to 10 days during maternity or adoption leave without leave or pay coming to an end.
Importance of system working
The trust plays an active role in the Healthier Lancashire and South Cumbria Integrated Care System (ICS). And more specifically Pennine Lancashire - one of five integrated care partnerships (ICPs) that make up the ICS. With the CCG accountable officer, Kevin McGee is lead for Pennine Lancashire ICP. “System support and back up is vital”, says Kevin McGee. “There are good relationships across the system, with people trying to do the right thing. When the going gets tough, you see how good it is.”
He sees effective system working as a key to the trust sustaining improvement and continuing to improve. And this makes sure people get the care they need. “The main driver of pressures in acute care is demand – demand drives need and impacts on beds and staffing. We must get hold of demand at source, in primary, community and social care.” Kevin Moynes comments that you “can’t have a perfect hospital in an imperfect system.”
Kevin Moynes says there's an ambition to put a system-wide workforce plan to the ICS. And the trust is working closely with neighbourhoods and primary care networks. Together they're trying to get social care more embedded in the system. And Kevin McGee thinks for the trust “to get to the next level, we need to invest in an electronic patient record system that works across the local system.”