Disinvesting in Harm

Transcription

1 Disinvesting in Harm Dr P Umesh Prabhu FRCPCH Consultant Paediatrician ( ) Clinical Director ( ) Medical Director of Bury NHS Trust ( ) Board Member of NPSA ( ) NCAS Adviser Since 2003 Clinical Adviser to the Health care Commission Medical Director of Wrightington, Wigan and Leigh Foundation Trust

2 What I am going to talk Investing in safety and quality of care Getting the basics right Avoiding harm Learning from mistakes Holding people to account Value based leadership and our success

3 Please Feel Free To Follow Me Twitter ID Twitter fans Please feel free to Tweet

4 One Message for you to take home Good quality is not cheap but poor quality is very costly and causes lot of human tragedies!

5 Second Message Most harms to our patients have nothing to do with money but getting the basics right. Culture, leadership, staff engagement, patient engagement, governance and staff empowerment right Holding people to account early Nip it in the bud!

6 Examples Elderly patient who fell and fractured her neck of femur in our Trust Perforation in a young man Katie Davies 21 year old who was found dead!

7 Some True Stories for you (Not in our Trust) Consultant Ophthalmologist Consultant Paediatrician Bullying Surgeon Consultant Anaesthetist

8 My Question Who is responsible for these tragedies? Why do we tolerate poor behaviour and poor care for so long? Where is the leadership? Where is the governance?

9 NHS I am (was) very proud of our NHS It is a great Institution Vast majority care is of high quality Vast majority doctors and other staff work hard providing the best care Each year 360 Million patients are seen by 1.3 Million staff working in the NHS

10 But. Each year 20,000 patients die 55,000 patients suffer more than 6 months or permanently disabled due to medical errors! In ,000 doctors were referred to GMC 1000 Doctors are referred to NCAS Vast majority of these tragedies are preventable!

11 Wrightington Wigan And Leigh FT I joined as MD in 2010 Today we are the 2 nd best Trust in the North-West 5 th best in the whole of North 450 less patients die each year All 22 Quality measurements have improved

12 Wrightington Wigan And Leigh FT 90% reduction in harm MRSA, C. Dif, Pressure Ulcers, Serious Falls Got 220 patient safety champions Got 15 Awards Staff feedback Top 20% (from bottom 20%) Get many invitations to speak and share Love my life Feel there is a purpose in my life

13 Performance Results A&E Performance 95.1% Top 20% 18 Weeks RTT 97.2% Top 10% Cancer Wait 98.4% Top 10% Monitor Risk Rating 4 Top 20% Monitor compliance score 0 Top 10% PLACE Score % Top 5% Safety Thermometer 96.1% Top 10% Staff Engagement Score 14/141 Top 10%

14 Quality and Safety Results HSMR (not rebased) % Change % Deaths in Hospital % MRSA % C. Dif % Pressure Ulcers (Grade >2) % Serious Falls % Total Harm %

15 How Did We Do That?

16 Success Success is rarely due to one or two individuals but success is when the whole team works towards a common purpose Our Values

17 Mr Andrew Foster Amazing CEO

18 The Reason for our Success 1. Our Values 2. Value Based Leaders 3. Our Culture 4. Our Governance 5. Excellent Staff Engagement 6. Patient Engagement 7. Patient Safety Champions 8. Our Wonderful Staff 9. Our Excellent Relation with CCG, GPs and Social Services 10. Positive Energy

19 Why Values are Important Living a life driven by purpose is much more meaningful and rewarding than meandering through life without direction

20 ST05_Mar12

21 Our Values Patients at the Heart of Everything We Do

22 WWLFT Values Patients at the heart of everything we do Happy staff Happy patients Our Duty of Candour We have Fair and Open culture, Supportive and Learning Culture and not blame, humiliation, punishment or discipline (unless a must) Managers and Leaders job is to make staff job easy

23 WWLFT Values NHS must be for the patients with the patients and by the patients It is patients who got to live with the consequences of our decision, surgeries we carry out, medicine we give and rarely mistakes we make They have the ultimate say and they are not simply equal partners but major stake holders

24 Patient Safety - Our Values Patient safety and quality of care is not for compromise No patient or staff should suffer because of our poor systems and processes. They are ours So we own them Collectively we are responsible for them

25 Happy Staff Happy Patients For our staff to provide good care we must care for our staff We must make sure our staff feel valued and integral part of the organisation Staff engagement is the key to our success Important All Staff Our staff will make mistakes and our duty is to learn from them and not to discipline staff

26 Happy Staff Happy Patients Everyone wants to succeed and success is contagious When all our staff do well all our patients are happy

27 Our Values Patient safety and staff well-being is everyone s responsibility When it comes to patient safety and staff wellbeing, no one is untouchable and that includes the Board We accept everyone makes mistakes and our aim is to work with our staff and to prevent them and also to learn from any mistakes.

28 Trust Must Do Well Value 3 We must do well to do good and we must do good to do well

29 Values Putting people in the right jobs is one of the most important jobs of the leader and manager In such a culture diversity thrives

30 We Value Diversity Diverse groups of people are more innovative than homogenous groups But we don t appoint diverse people to prove our values (tokenism, cronyism Bad for NHS bad for the society) We appoint right people who will uphold our values and diversity reflects our values We also give feedback to all leaders & managers 360 feedback

31 Governance We have robust governance Weekly Executive Review meetings Divisional Governance meetings Departmental governance meetings My own meetings with CD once a year My annual performance of Clinical Directors

32 Some of the things patients and families told me in my Trust Wife told me Dr Prabhu, my husband died in your hospital, he was only 53 years old and died of cancer. You could not prevent him from dying but why he had to die with severe pain for 2 days Pain killers were not given!

33 4 Families Dr Prabhu, your doctors decided not to resuscitate my mother/father but why they did not tell any one of us? Why we had to find out about it after the death? If only I knew my mum was dying I would have spent more time with her and would have cooked some nice food for her

34 One More Patient Dr Prabhu, your junior doctor discharged me from out patient clinic He missed my cancer Ultrasound showed something in my scan Now 9 months on I am dying of cancer why?

35 Others Patient safety champions 220 of them Staff Engagement and pulse check Internal Inspections Weekly Death audit Trust Dashboard

36 We are not perfect We still get 6000 Incidents We had 5 Never Events in the last 4 years Still get 400 Complaints 70 Medico-legal cases 20 SUIs We still have long way to go

37 My Dream My Vision To make WWLFT the best Trust in the country Where every patient says; This is my hospital and I am looked after well by kind and caring staff Where every staff says; This is my hospital and I am looked after well and I am proud to work here

38 Patient Safety Patient safety should matter to us Quality of care should matter to us Ask yourself why did you become a doctor or a nurse? To make a fellow human being better!

39 My Final Messages to All of You Don t blame the system, we are all integral part of the system we blame, be the system or become the system and change it Gandhi We can ignore anything but we can t ignore patient safety and staff well-being For all so called leaders Have you defined your values? Have you asked your staff whether you live and breath your values?

40 My Sincere Request to all of you NHS Belongs to us It is a great Institution Let us not leave it to the politicians to sort it out We as doctors, nurses and clinicians must take on leadership Value based leadership is the key Master the art of leadership Be a good leader

41 If not already one day we will be patients of our NHS!

42 Finally Investing in quality and safety is simple Get the basics right Right values Right culture Right leaders Staff and patient engagement Your governance Evidence to support that you got these right