Driving Quality Improvement through Difficult Times. Sir David Dalton Chief Executive

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1 Driving Quality Improvement through Difficult Times Sir David Dalton Chief Executive

2 Developments over the last 12 months Salford Royal s Journey Quality Improvement Patient Safety Reliability Culture Leadership Day Services 7 day services Provider Reform Provider Reform Integrated Care Integrated Services Standardisation Delivery at Scale

3 Where Are We Now? : Salford Royal Results Over 8 years we have achieved: In the best 10% nationally we have continued to maintain our position for risk adjusted mortality reduction in MRSA blood stream 100% infections 83% 48% reduction in clostridium difficile infections reduction in cardiac arrests reduction in grades 3 & 4 pressure 100% ulcers and 79% reduction in grade achievements: Top Best Vanguard Lead Zero 1st 4 th consecutive year in the top 3 for staff satisfaction Acute Trust nationally for patient satisfaction provider for trauma services in Greater Manchester avoidable MRSA bloodstream infection 97% of district nursing patients and 97% of hospital patient receive harm free care (as measured by the safety thermometer) compliance with correct antibiotic prescribing procedures to 96% help prevent Clostridium difficile 46% 95% site to create an Integrated Care Organisation reduction in General Surgery surgical site infections 38% reduction in Orthopaedic surgical site infections compliance with Salford Royal s Dementia & Delirium Care Bundle Trust in the North of England and second nationally to achieve CQC rating of Outstanding the highest rating possible

5 Boards Must Have Clear Goals

Lead by Example Highly Visible breaking down barriers Currency of leadership is what leaders pay attention to WalkRounds are great but they re not enough Situational Awareness to know how people and

8 Lead by Example Highly Visible breaking down barriers Currency of leadership is what leaders pay attention to WalkRounds are great but they re not enough Situational Awareness to know how people and systems operate on the shop floor If you dig a few levels down in your organisation what % of time do leaders spend on safety vs. operational pressures? Leaders need supporting at all levels particularly middle tier Accountability yes Hierarchy No Listen especially to the voices of patients and their loved ones Must be authentic humility in place of arrogance

9 Connect with Front Line - Learning Collaboratives

bedside Integrated Assessments Safer decision making Safer

11 Electronic Health Record - Improved Effectiveness Integrated with Primary Care No case notes Documentation at bedside Integrated Assessments Safer decision making Safer handover between hospital & primary care Clinical decision support tool

12 Statistical Process Control (SPC) Charts Time Sequence are you improving over time Signals indicate special cause, including: 1 point outside the +/-3 sigma line 6 consecutive rising or falling points

13 Transparency & Openness

Areas 0 + 0 29 + 0 Green Wards & Areas 32 + 0 15 + 34

14 Variation: We go looking for it SCAPE Ward and Community Status January 2010 November SCAPE Wards & Areas Green Wards & Areas Amber Wards & Areas Red Wards & Areas

15 Building workforce capability Improvement Directorate IHI Fellows (2) Lean practitioners (15) IHI Improvement coaches (10) LIPS participation in 8 programmes Clinical Leaders Programme (156) Nursing Leadership Programme (240) IHI Expert Patient Safety Training (5) Collab Learning Participation (3015) Clinical Quality Academy (72) Values Champions and staff groups (540)

16 Salford Royal s promise to our nurses: To identify and agree safe staffing standards for our community nursing services Every ward matron/manager will be supernumerary to the nursing establishment on the ward Every day-time shift will have a supernumerary shift leader The number of registered nurses per patient of 1:8 will never be breached during day-time shifts Every night-time shift will have a minimum of 3 registered nurses We will use evidence based tools to continually review and amend nurse staffing levels to meet your patients needs Your commitment to us is: to create a culture within your ward or department that delivers great teamwork in the interests of staff, patients and families

17 Duty of Candour Abandon Blame

18 Listening to Patients: What Matters Most to Me What matters most to patients at SRFT Family Pain relief Going home Manchester United matches Getting to have a coffee in the morning before being talked to by doctors

20 Having the best professionals in the world is no longer enough

21 Teamwork When most doctors get up in the morning and look for a leader they look in the mirror and see themselves Working in teams does not come easily to physicians, who still often see themselves as heroic lone healers We must reinforce our values and ensure that teamwork trumps autonomy.

23 Accountability Extends to behaviour Respectful To colleagues, through teamwork To patients and customers, putting their interests before their own To the organisation, observing policies and procedures Accountable Have high standards of integrity and honesty Are open to change Use evidence of best practice Focus on the needs of patients Contribute to Safe, Clean, Personal care Provide care and services which are effective and reliable Provide services efficiently and without waste Continuous improvement Motivated to find solutions to problems Have a spirit of energy Are resourceful and can do Are comfortable with change

24 Connecting the Individual to their contribution to the Annual Plan Avoid a disconnected hierarchy

27 Salford Royal s Leadership Model Leaders at all levels are crucial in creating the culture of care and compassion at Salford Royal. Today s effective leaders demonstrate their leadership by: Clarity of Purpose Aims & Values What, how much, when Assess & Measure Mindset Seek High Reliability Deep staff engagement Openness & Transparency Teamwork trumps hierarchy Behaviours Hear Patient voice & listen to Staff Visibility and Authenticity Signal Generator Defer to expertise Assessment and Feedback Adopt a coaching approach

28 Standardisation at Scale - will it deliver better care? Sir David Dalton

29 The Challenge better lower cost Safer Care Prevention Creating Value Supporting Staff Safeguarding Succeeding in a competitive environment with less money high quality services with less money Access Improving Health Improving Outcomes Reducing Inequalities

30 30 Dalton Review

31 New Models and Shapes Emerging Tertiary Complex Secondary Single Shared Services (JV) DGH/ Individual Locality City/County Secondary Area Merger Region Intermed. Care JV Accountable Care Intermediate Group/ Chain Organisations Home Care

32 Successful and ambitious organisations produce an enterprise strategy and they develop a standard operating model capable of transfer of replication to another organisation or wider system.

SCALE 20% improvement in operational efficiency by 2020 Operational excellence at scale Key result areas Reduce costs of workforce, consumables and equipment Reduce length of stay; admissions, beds

33 SCALE 20% improvement in operational efficiency by 2020 Operational excellence at scale Key result areas Reduce costs of workforce, consumables and equipment Reduce length of stay; admissions, beds and facilities Avoid admissions and enable early discharge Reduce corporate overheads Key actions Dynamic matching of workforce, equipment and facilities to demand through predictive modelling and enterprise wide control Standardisation of: - Care pathways - Staffing deployment - Product lines - Improvement methods Standardise organisation form: - ACO - Single shared acute clinical service - Back office - Industry partnerships Standardise leadership and management systems: - Staff consent - Deep engagement - Accountability & contribution

34 The Organisation Care Model Personalised, preventative, effective care management The new care model : Outcomes and key innovations What this looks like when deployed Tech and care innovation Integrated informatics 20% Improvement in efficiency Efficient deployment of resources based on prediction and standardisation Enterprise wide capacity utilisation...population level risk assessment to develop new care models and incentive systems (ACO)...care models that focus on personalised care based on risk assessment and proactive outreach preventing hospital admissions and enabling early discharge...single shared acute clinical services providing quality assured and sustainable services...integrated informatics including connection to internet of things...integrated command centre that maximises capacity utilisation ensuring right care, right place, right time

35 New Integrated Care Organisation Hospital Mental Health Community THE PATIENT Social Services Domiciliary Primary Care

Identify, Stratify and Engage Using digitisation as a care service Analytics that enable proactively management of patients across the continuum of care

36 Identify, Stratify and Engage Using digitisation as a care service Analytics that enable proactively management of patients across the continuum of care Overdue for healthcheck Type II diabetes HCP dashboard and task list: Directing outreach into patients homes to prevent admissions Early stage heart failure COPD

Evidence Based Care Standards And Digitised Workflow Innovation Moving

evidence into clinical workflow; making the right thing to do, the easy

37 Evidence Based Care Standards And Digitised Workflow Innovation Moving Knowledge into practice; systematically and reliably; hard-wiring evidence into clinical workflow; making the right thing to do, the easy thing to do; embedding SOPs. SRFT has reduced cardiac arrests, saving 700k p.a. on the rapid response team alone SRFTs current performance on pressure ulcers is saving 637k p.a. on a base line of 2011/12. US Teaching Hospital

38 Predictive Demand Modelling Intelligent design & performance management

39 Dynamic Matching of Resources to Demand New Zealand nurse staffing model

40 Enterprise-wide Capacity Optimisation Predictive demand modelling and dynamic resource allocation 10% productivity improvement

41 The Diagnosis The variation in clinical practice and operations that exists today causes significant inefficiency There are too many decision makers; too little shared information and not enough engagement of the front line The prevailing leadership style,and the culture it develops, inhibits achievement of reliability and excellence Fragmented provider landscape prevents investment in new solutions as economies of scale are not realised;

42 Our Solution A group that delivers ACO types of operating at locality level with a single service model for acute clinical care covering a 2m population A standard operating model that provides digitised information from patient onwards; hardwires decision support systems into workflow and optimises capacity utilisation Leadership and governance that will instil a culture to fully exploit opportunities provided by the standard operating model and SRFT s QI capability Back office and corporate functions operated at scale Partner with global leaders to bring expertise, investment and leverage A major innovation to consolidation in the UK not the usual M&A

43 The Group s Vision Our bold vision is to establish a healthcare group that will deliver accelerated improvements in patient outcomes and productivity = Better care at lower cost We will achieve this by: Building on the assets to develop a standard operating model that will: Use information repositories to remove unwarranted variation and address fragmentation of patient pathways, by: Standardising the patient pathways Standardising operational system and processes Developing a groundbreaking proof of concept that utilises standardised care pathways and predictive modelling to dynamically match resource deployment to demand (including workforce & consumables) Developing standardised care models, which are capable of replication into other localities of the Group, to include: A vertically integrated health and social care service in each locality in the Group Single-shared clinical services across operating entities of the Group A single set of corporate services operating across the Group Our aim is to improve operational efficiency by 20%

44 The Standard Operating Model The What Standardise the care model Standardise patient pathways Standardise interoperability and informatics Standardise resource deployment (staffing, facilities and equipment) Standardise product lines Standardise back office The How Identify, stratify and engage patients. Connect them (technology) and integrate the data (health integration engine) Enable MDTs to set standards that incorporate latest evidence Incorporate into workflows supported by digitisation and decision support that create SOPs Fast feedback loop to MDT enabling them gauge performance against SOPs Forecast demand through predictive modelling (patients and procurement needs) Dynamically match demand with resources to optimise efficiency Lift and shift to each unit in the group one off development, local customisation, benefits at scale

45 Technology

46 Scale Group of hospitals Single shared services Standardised Operating Systems

47 How will we know if this has worked? So what might a typical general hospital look like in five years time? Federated Back Office With 10 other Providers?Management Contract, or Organisational Chain Single Shared Surgical Service with 2 other Providers serving 1m population Integrated Care Models for Long term conditions and Urgent Care Service Line Contract for Specialist Services with Specialist Providers 47 Dalton Review

48 Enterprise-wide Capacity Optimisation Predictive demand modelling and dynamic resource allocation 10% productivity improvement

49 Delivering Scale- Leadership Model Leaders at all levels are crucial in creating the culture which can deliver the change they wish to see. Effective leaders in a Group will demonstrate their leadership by: Clarity of Purpose Aims & Values Standards Based What, how much, when Assess & Measure Behaviours Hear Patient voice & listen to Staff Visibility and Authenticity Signal Generator Defer to expertise Mindset Reliability Deep staff engagement Openness & Transparency Teamwork trumps hierarchy Encourage collective solutions Build relationships Challenge inappropriate behaviour

50 Summary Don t tolerate variation high reliability is crucial Integration both vertical and horizontal is crucial Share back office functions 240 organisations is an unsustainable overhead and impedes improvement Rapid introduction of EPR is crucial the data is the future Standardised operating systems/models Create standardised pathways and order sets Just-in-time procurement and workforce deployment Utilise the technology solutions available from industry Get a better return from assets substitute hospital based care BUT without the right culture & leadership there will be no success 50

51 51 Ian s slides

The components of our Transformation Programme Section 1: Summary Value Proposition Standards We will adopt evidence based standards & gain agreement across all stakeholders.

Staff and patients will have access to technology that transforms the delivery of right care, right time, right place Digital Health Enterprise Outcome focussed : Transformed Acute Hospital

52 The components of our Transformation Programme Section 1: Summary Value Proposition Standards We will adopt evidence based standards & gain agreement across all stakeholders. Group for speed to value Transformed Acute Hospital Leadership and staff engagement We will develop a culture that enables staff to be the best they can be Technology : The Digital Health Enterprise Staff and patients will have access to technology that transforms the delivery of right care, right time, right place Digital Health Enterprise Outcome focussed : Transformed Acute Hospital Performance will be measured and rewarded by delivering what really matters to patients, not just process measures Group to scale & speed to value We will have the scale to develop and deploy at pace innovations and best practice, we will leverage scarce clinical & managerial talent, and rationalise estate 52

Leadership. David Dalton Chief Executive

Leadership. David Dalton Chief Executive Leadership David Dalton Chief Executive Effective Modern Leadership Leaders at all levels are crucial in creating the culture of care and compassion in the NHS. Today s effective leaders in the NHS demonstrate