We published Driving Improvement in eight NHS trusts in June 2017. It told the story of how Cambridge University Hospitals NHS Foundation Trust moved from being in special measures in 2015 to a good rating in 2017.
Since then, the trust has maintained its good rating overall while facing a 10 per cent increase in non-elective activity. At the same time, it achieved outstanding for well-led. And its End of Life Service has an overall outstanding rating.
Leadership
Chief executive Roland Sinker understood that good leadership was key to improvement. That’s helped by having a stable executive team. And board members take responsibility for different programmes of work.
The introduction of a senior leadership programme underlined the importance of leadership. The King’s Fund, Judge Business School and Cambridge University Health Partners provided the programme. Aimed at middle tier managers who report to directors, 300 people have been through it. Topics covered include:
- the broader NHS context
- the organisation’s culture
- individuals’ roles in moving the organisation forward
Similar programmes are offered to matrons and senior doctors.
Chief Nurse Lorraine Szeremeta says: to reinforce the role of individuals, the trust is moving away from a rigid decision-making hierarchy. Decision making groups now have a wider staff representation, including student nurses. It’s also looking at introducing small shared governance councils. These will allow staff at lower levels to make decisions.
Quality improvement
Clinical director for improvement, Fay Gilder, is a consultant anaesthetist. Two years ago, Fay says, the trust board decided to highlight improvement as a way forward for sustainability in the trust and local system. Ewen Cameron is director of improvement and transformation. Ewen comments that it was important to show how improvement is about delivering better care. It's not only about money. “In many cases, delivering the best care is not the most expensive way”, he says. To emphasise the point, the former Financial Steering Group became the Improvement Steering Group. Every monthly meeting of the group starts with an improvement story. Having a doctor in a lead corporate improvement role underlines this shift of emphasis from finance.
The trust's approach to quality improvement is to optimise an improvement culture. And staff are given the skills to deliver improvement. Ewen says the aim is to embed QI across the organisation in the next 5 to 10 years. “Non-clinical areas are as important as the clinical ones”.
The trust will be appointing an external partner. They'll work with the organisation as it takes an improvement culture forward. As Fay says: this will help get to a culture where “everyone who comes to work can improve the work and enables us to harness the power of all of our staff”. That underlines a culture that’s moved away from command and control. Now everyone can contribute to improvement.
Improvement is being delivered on ‘the shop floor’. Encouraged by a central improvement and transformation team acting as facilitator and coach. And for Ewen, the focus of improvement is on the combination of outcomes, experience for patients and staff, and value.
Early priorities for the improvement work focus on the trust’s strategic objectives:
- improving patient pathways
- strengthening the organisation
- working with its communities
- contributing regionally, nationally and internationally
One of the priority areas is patient flow. The trust worked with wards to find the most efficient ways patients can move through the hospital. The trust has been using NHSI’s SAFER tool. Ward leaders work with staff on different approaches. For example on a neurology ward the neurosurgeons introduced a ‘grand round’. Every patient is seen in the morning, facilitating better flow. In another example, physiotherapists reviewed how they were documenting care. This resulted in savings of 1.5 hours a day. The trust is now looking to see how it can scale that work up across the organisation.
Specialties are also considering ways to reduce the number of patients seen in outpatients. For example, the trust is talking with patients about diabetes and oncology clinics. Some clinics could be delivered to groups of patients at the same time instead of one-to-one.
Giles Thorpe is Deputy Chief Nurse at the trust. He says sustaining and improving goes back to the culture of the organisation. It's “the collective energy of the staff who want to continue to deliver better care”.
Assurance
Effective risk management is one of the keys to improvement. Auditors have commended the trust for its risk management practice. Giles says the leadership team is focused on risk. Leaders have “intelligent conversations about controls and assurances. We look at what we are doing to manage risk and welcome staff across the organisation to raise risks. There are conversations and challenges so that if the risk is escalated there is a level of assurance that everything that can be done, has been done.” Every six months there’s a deep dive into corporate risks to test the assurances and controls. “We risk assess our own risks”, as Giles puts it.
The trust has refined guidance and protocols on risk. And it’s near to completing the quality assurance on all the risks in the organisation. This process identifies risk owners and risk lead, while “making sure risk registers are not ‘car parks’”.
‘After action reviews’ bring teams together with an independent facilitator. After positive or negative events, they learn together safely. Initiatives such as this contribute to teams being more cohesive. People feel more able to speak up and work together to find ways to improve.
An accreditation programme is being introduced for the trust’s wards and departments. Staff will be encouraged to own their data. Using feedback from patients and their own teams, as well as external review, to work on improvement projects at local level. Wards will be rated on their outcomes, along with their patient and staff experience. They'll be supported to reduce variation and continuously improve.
The trust is changing how it measures improvement from RAG ratings. It now uses statistical process control (SPC) data for improvement. SPCs show where things may be moving off track, allowing for more timely intervention. Giles Thorpe says this has “given us a completely different view about what’s going on in the organisation and allowed us to identify where things are starting to go slightly off track and take action quite quickly”. SPC charts help identify what good looks like over time, and where improvements can be made.
Giles says the trust has been focusing on early warning signs from a variety of metrics. Safety data, audit results or experience feedback are triangulated to see where to look deeper.
The trust has also worked with the THIS Institute. This helps understand how staff are feeling about their role in improvement. An event with ward improvement teams found that staff felt listened to and able to own their improvements.
Recruitment and retention
In common with most trusts, the trust has faced problems in recruiting nursing staff. It has reduced the vacancy rate from about 20 per cent to about seven per cent. This was achieved through initiatives, including overseas recruitment. Easing pressures on staff also helps retention rates.
Alongside traditional recruitment work, the trust has invested in a programme for up to 100 nursing apprentices a year. These are mostly people recruited from within the organisation, mainly current healthcare assistants. This has helped overcome the difficulty of attracting people to the area. It has high accommodation costs and they already live locally. It has also been considering the role of nursing associates in the trust. It plans to train 25 nursing associates a year in the nursing associate apprenticeship programme.
But Chief Nurse Lorraine Szeremeta recognises that staffing is a system-wide issue. She's working with system partners to explore what the workforce of the future should look like. That includes working with other chief nurses to consider innovative pathways. For example, incorporating skills training in areas such as mental health and physiotherapy. All partners in the system have guaranteed to employ successful students trained within the system.
Lorraine is also considering working with social care. She's looking at how the trust can use skills from acute nurses in nursing homes and primary care. “It’s about understanding each other and the skills they have in nursing homes. What can we do as a system to train staff in the system to stop people being admitted unnecessarily to hospital?”
The trust’s HR team recognised the time it takes to recruit was adding to recruitment problems. Together with the improvement and transformation team, it redesigned the recruitment process. Halving the time taken has improved the experience of people applying. And it gets people into post faster - improving team morale. The trust also supports and prepares nurses recruited from overseas for their Objective Structured Clinical Examination (OSCE), and for getting their personal registration number (PIN).
Importance of system working
Trust leaders acknowledge that sustaining and improving services ultimately depends on the trust being an active and influential partner in the local system. The chief executive and chair are committed to the vision of an integrated care system. They take leading roles in the STP. Ewen Cameron points to the fact that patients ‘flow’ through the system. If it is a poorly functioning system, all the organisations involved are affected. For the trust, that means more patients coming to hospital and the need to integrate more people back to the community.
Improvement in action
The trust's electronic patient record (EPR) system is an example of significant improvement. Using the EPR (Epic) helped embed work that had been in progress. The trust says use of the EPR has contributed an improved performance in relation to sepsis. Epic identified sepsis management as a priority. The trust carried out multidisciplinary work to describe the ideal clinical pathway. Epic then identified patients with possible sepsis - prompting best practice care. As a result, the trust says there are 64 fewer deaths from sepsis a year. All monitoring equipment in critical care and theatres is now interfaced with Epic. Nurses no longer need to input data - freeing up around 102 nurses’ worth of time for clinical care.
Linked to Epic is My Chart. Patients have personalised and secure online access to portions of their medical records. It helps them to manage and receive information on their health. Thousands of patients have signed up to My Chart.
The trust increasingly involves patients in co-producing service improvements. For example, paediatric patients helped redesign the paediatric A&E waiting room. Oncology patients have been involved in the improvements in cancer care. And patients and carers have supported the development of a ‘carers passport’ The passport helps identify carers so staff know they can work with them. This supports a positive patient and carer experience. “Our ambition is to have patients as partners in improvements as standard”, says Giles Thorpe.
To help mitigate winter pressures, the trust introduced point of care testing for flu and other respiratory conditions. And it created step-down wards for patients with the same infections. Despite the increase in cases last year, there was a significant reduction in infections in hospital.
Leaders are determined for the focus on improvement to continue despite the pressures. “Operational pressures can paralyse organisations, but improvement can’t stop in winter months”, says Chief Nurse Lorraine Szeremeta. “The challenge for the whole NHS is to be less reactive and focus on continuously looking to improve”.