QUALITY STRATEGY 2015-2018 SAFE CARING RESPONSIVE 1
2 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
CONTENTS 1. Introduction Page 4 2. Our vision Page 5 3. Our values and quality aims Page 6 4. Our key objectives for 2015-2018 Page 7 5. Making safe, caring and responsive a reality Page 9 6. How we have identified and developed our priorities? Page 10 7. Governing for quality Page 12 8. The North Cumbria improvement way Page 15 9. Our improvement methodology Page 18 10. Our measurement plan Page 20 11. Communicating our strategy Page 22 SAFE CARING RESPONSIVE 3
1. INTRODUCTION We would like to welcome our staff, patients, carers and stakeholders to our Quality Strategy. This quality strategy sets out our firm commitment to improving the quality of care for our patients and how we will make this a reality in terms of equipping our staff with the skills and tools to deliver quality patient care, every day. It is important to recognise at the outset that North Cumbria University Hospitals NHS Trust, which provides acute healthcare services for the local population of North Cumbria, has faced challenges during recent years and we have made many improvements to the safety and quality of patient care. However, we fully recognise that we still have a long way to go in some areas and this is a journey of continuous improvement that we, along with our staff are on. In 2013 the Trust was one of fourteen organisations across the NHS which was reviewed as part of the national Sir Bruce Keogh Review, for having high Hospital Standardised Mortality Rates (HSMR) for two consecutive years (2011 and 2012). Following this review the Trust was placed in Special Measures and has since implemented a range of improvements to the safety and quality of care provided. The Trust was also inspected as part of the Care Quality Commissions Chief Inspector of Hospitals programme in 2014 and we been working hard on implementing our improvement plan. This Quality Strategy has been developed within that context and reflects the journey of improvement that North Cumbria University Hospitals NHS Trust is on. Our aim is to ensure that all staff who work in our hospitals strive for excellence in all that they do and believe that the focus of the organisation is on providing safe care, which is responsive, caring and effective in terms of providing good outcomes for our patients. The objectives and commitments set out in this strategy will be reviewed on an annual basis to ensure our plans and key projects support the delivery of this strategy in practice. Gail Naylor Jeremy Rushmer Gail Naylor Director of Nursing & Midwifery Dr Jeremy Rushmer Medical Director 4 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
2. OUR VISION Our ambition is to provide local patients with the highest possible set of sustainable healthcare services by achieving our vision: To provide person centred best in class quality healthcare services. North Cumbria University Hospitals employs over 4,000 people, many of whom live in the local communities served by its hospitals in Whitehaven and Carlisle. Their development is at the heart of the Trust s success and is why we invest heavily in nurturing and empowering staff to set the quality standards within the organisation. Our aim is to ensure that staff who work in the Trust strive for excellence in all that they do and believe that the focus of the organisation is on providing safe, caring, high quality health services to those that need our care. This common goal unites all those working in the organisation, from hospital doctors to nurses, administration staff to GPs, porters to allied health professionals, to clinical managers, corporate teams and non-clinical support staff. Our vision is also aligned to the NHS definition of quality set out by Lord Darzi in 2008. Care provided by the NHS will be of a high quality if it is safe and effective, with positive patient experience. Quality is only achieved if all three of these domains are present equally and simultaneously in care delivering on just one or two in isolation is not enough. This is not always an easy task; quality can mean different things to different people. Quality is also a moving target. Continuous improvement in quality means that what is considered of an acceptable quality today may not be acceptable this time next year. To embed this across all our services our fundamental priorities as an organisation is to provide care that is SAFE, CARING AND RESPONSIVE to the needs of our patients. SAFE CARING RESPONSIVE 5
3. OUR VALUES At the heart of all our organisational strategies are our values. These are the values that we expect our staff to demonstrate every day in their working lives and what we expect patients to see and feel when they are in our care: 1. Put patients first 2. Quality and safety is at the heart of everything we do 3. Take personal responsibility and accountability 4. Everyone s contribution counts 5. Respect each other OUR QUALITY AIMS 1. To ensure that quality underpins every decision 2. To provide the safest health care services to patients and service users 3. To be recognised as a caring organisation locally, regionally and nationally 4. To ensure quality and best use of resources are not considered in isolation, but together through the concept of value 5. Ensure our services are responsive to the needs of our patients and communities 6. Attract, retain, support and train the best staff 6 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
4. OUR STRATEGIC QUALITY OBJECTIVES FOR 2015-2018 1. Deliver a year-on-year reduction in mortality metrics across all of our hospital sites. 2. Ensure that the level of preventable harm remains below the 5% national average. 3. Achieve and sustain the mandatory NHS Constitutional Standards, including Care Quality Commission Regulations. 4. Improve how we ensure we evidence delivery of care in accordance with best practice and nationally recognised outcomes across our services. 5. Achieve and maintain and where possible exceed our top decile position for patient and staff experience. 6. Continue to improve our safety culture and develop a learning organisation. SAFE CARING RESPONSIVE 7
8 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
5. MAKING SAFE, CARING AND RESPONSIVE A REALITY Through our strategic objectives for quality we will set out our priorities each year, which will allow us to build on our progress year on year. The goals we have identified for the next two years to support the delivery of our strategy are outlined below: SAFE Doing the right things in line with best practice Saving more lives and preventing harm Guaranteeing safe levels of staff with the right skills Sharing learning from errors and our experiences CARING Caring for our patients like we would for our families Ensuring privacy and dignity Listening and acting on concerns Prioritising care for frail older people with our partners RESPONSIVE Providing the right care in the right place at the right time Keeping patients and their carers well informed Delivering care in a timely manner SAFE CARING RESPONSIVE 9
6. HOW WE HAVE IDENTIFIED AND DEVELOPED OUR PRIORITIES It is important to outline as part of this strategy how we have identified and developed our priorities that form the basis of our quality strategy. Our staff One of the consistent messages from our staff is the need to ensure we have the right staffing levels with the right skills. This relates to nursing, medical, clinical support and non-clinical/administrative roles. Ensuring we have the right staff in place is fundamental to ensuring we deliver safe care for our patients. Creating a safer culture for our staff to work in through providing an environment where we learn from mistakes and errors and have a zero tolerance to patient harm is equally important. Improving the levels of our staff satisfaction and making our organisation a good place to work also goes hand in hand with the experiences of our patients. Our patients and carers The feedback from our patient experience data, complaints and patient surveys has a consistent theme in relation to compassion. Our Nursing and Midwifery Strategy sets out our absolute commitment to delivering care with compassion for every patient, every day. The serious incidents we have had during the last two years, where patients have suffered harm whilst in our care is a key area of focus for us in ensuring that the sickest patients and those patients who may deteriorate are identified and escalated as part of their overall plan of care. It is also important to recognise that our patients expect us to be able to measure the effectiveness of the care we give in accordance with the recognised standards, which will be key to what we measure to improve across our services. Our partners and stakeholders Meeting national standards and ensuring the care we give is responsive is a key priority for our commissioners. This includes emergency care but also patients who require planned surgery. Demonstrating value for money and meeting best practice standards is core part of our quality strategy. Responding to national drivers which will impact on the delivery of our services is also key, for example developing plans to achieve 7 day working for emergency care. Finally, we fully recognise that we have an ageing population and feedback received from our patient representatives and external partners identifies that we need to continue to work with health and social care partners on care of our frail elderly patients. 10 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
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7. GOVERNING FOR QUALITY It is not enough to simply set out our aims and priorities for quality. We must be clear on how our systems and processes across the organisation will support the delivery of this strategy in practice from board to ward. Quality and the behaviours we expect go hand in hand with the behaviours we instil and develop at the Trust Board and what our staff instil directly with the patients we care for. It is important that our responsibilities for quality are explicit. The Trust Board s responsibilities for quality are threefold: to ensure as a minimum that the essential standards of quality and safety are being met by every service that the organisation delivers to ensure that the organisation is striving for continuous quality improvement and excellence in every service; and to ensure that every member of staff is motivated and enabled to deliver our quality aims. It is also the responsibility of the board to create a culture within the organisation that enables clinicians and clinical teams to work at their best, and to have arrangements in place for measuring and monitoring quality and escalating issues including, where needed, to the board. The Trust has a safety and quality committee which plays a key role in overseeing quality issues and providing the board with assurance. This committee is chaired by a Non-Executive Director and includes membership from a number of the Executive Directors and the Clinical Business Unit teams. Quality governance is also the combination of structures and processes at and below board level which lead on Trust-wide quality performance including: Ensuring required standards are achieved Investigating and taking action on sub-standard performance Identifying and managing risks to quality of care Planning and driving continuous improvement Identifying, sharing and ensuring delivery of best-practice 12 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
Ensuring required quality standards are achieved Individuals working in clinical teams providing NHS services are at the frontline of ensuring quality of care to patients. Many of these frontline staff work within a framework of professional regulation that makes them personally accountable for the quality and safety of care they provide to individual patients. A strong organisational and management commitment through our Business Units and Corporate services is also implied; quality and safety need to be taken seriously at every level of the organisation and recognised as everyone s business. Each clinical business unit is responsible for ensuring at specialty level that priorities have been identified to raise standards of care for specific conditions or pathways of care. This includes the compliance with recognised best practice, for example NICE. As part of our quality strategy our ambition is to develop greater rigour on the specialty level reviews of quality during the next two years. This will initially be focused on areas of concern or underperformance from a safety and quality perspective. Following the CQC Chief Inspector of Hospitals inspection in 2014, the Trust has significantly developed its internal mock inspection programme, which will continue to form part of our internal monitoring systems to ensure key standards of quality, safety and patient experience are being delivered in practice. This will become a core component of our internal compliance monitoring systems during the next two years. Investigating and taking action on sub-standard performance The Trust produces a core performance report on the delivery of the NHS constitutional standards. In addition to this there is a specific safety and quality report which reviews a range of metrics including patient experience and clinical effectiveness and safety. The report also provides numbers of complaints, incidents and associated trends. Compliance with the CQC regulatory standards and the Intelligent Monitoring Reports are a core part of the Trust's safety and quality report. The board takes action following review of quality information as appropriate in order to ensure pace and focus is applied to the areas requiring improvement. The Trust has a weekly Safety Panel which is chaired by the Executive Director for Clinical Governance (Director of Nursing and Midwifery). The role of the Safety Panels is to ensure that robust investigations are carried out into serious incidents. This includes ensuring investigations have a clear root cause identified and contributory factors assessed as well as timely implementation of action plans to ensure changes to practice to improve patient safety are embedded. The Safety Panel also review all serious complaints (risk graded as high) to ensure correct escalation of concerns and any patterns in serious concerns raised from patients. SAFE CARING RESPONSIVE 13
The outcomes from the weekly reviews of all patient deaths and the alerts from Dr Foster are also reviewed monthly by the Safety Panel. The Safety Panel provides a monthly report to the Safety and Quality Committee on the outputs of the weekly meetings. In 2012/13 North Cumbria adopted the well-established Northumbria patient experience programme. Stakeholder feedback from staff and patients is followed up as appropriate for example if a domain average of a ward falls below 90%, training and support from the Patient Experience team is provided to the ward. Identifying and managing risks to quality of care The process in place for the identification, assessment and management of risks is fundamental to the delivery of safe, quality care. The Trust has in place a systematic approach to risk management which ensures the identification and escalation of both operational risks and strategic risks which directly impact on the delivery of the Trusts strategic objectives. The Trust Board has a clear statement on its risk appetite the Trust recognises that its fundamental purpose is to ensure patients are treated and cared for safely and that we do not cause any harm to patients whilst in our care. As such, the Trust will not accept risks that impact on its fundamental purpose. The Trust board receives a quarterly risk management report on the highest scoring operational risks and the strategic risks affecting the delivery of the organisations objectives. The Board are supported by the Risk and Assurance Committee, which is chaired by a Non-Executive Director to provide additional assurance to the Trust Board on the risks being scrutinised and the assurances on the mitigation plans in place across the clinical business units. It has been well documented during the last 12 months that organisations should have robust systems in place to assess the risks and quality of care provided linked to safe nurse staffing levels. We have identified safe staffing as being one of our key priorities. A specific report on ward quality indicators and staffing levels is in place which will be developed further during year one of our quality strategy in order to provide greater clarity on quality indicators, harm and staffing levels per ward area. Significant service redesign issues that potentially could impact on the quality of service provision are discussed at the board. Clinicians and managerial leaders are fully engaged in the development and delivery of their Business Unit Plans, including service development, cost improvement plans (CIP) and other initiatives. A refreshed CIP process and documentation including Director-level clinical scrutiny and sign off is now in place. If the Board deem that there may be a quality or safety risk within a particular service or area, the Trust requests external reviews to validate internal findings. Formal reports / recommendations from the reviews are shared with board and any required action plans are also shared and monitored accordingly. 14 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
Planning and driving continuous improvement. Quality improvement has been defined as The combined efforts of everyone - health care professionals, patients and their families, researchers, commissioners, educators - to make changes that will lead to better patient outcome, better system performance, and better professional development. (Paul Batalden and Frank Davidoff) A robust process is undertaken every year to engage with staff, public, shadow governors and stakeholders on the production of the Trust's quality accounts and this is used to feed into the Trust s forward planning. 8. THE NORTH CUMBRIA IMPROVEMENT WAY The Trust is on a significant journey of improvement across all aspects of its work, encompassing major issues of quality, safety, efficiency, and value for money as well as cost-reduction. In 2014, the Trust developed a change team to ensure there was a robust and systematic approach to change that can be embedded across the organisation. Our trust philosophy is one of everyone counts - all staff can and should be able to make a valuable contribution to improvement work; our staff are the service experts best placed to fix the problems we face. It is the responsibility of the Trust to ensure that individual members of staff and teams are supported to deliver improvements. Likewise, it is the responsibility of all staff to endeavour to make improvements, however small, as part of our routine day to day work. The Trust approach is to develop capacity, skills and capabilities in individuals and within all teams at the frontline of care delivery, sharing improvement tools and learning wherever possible to rapidly disseminate and embed positive change. To this end, staff and the wider Trust will continue to work as active participants within the Cumbria Learning & Improvement Collaborative (CLIC), which seeks to create a common culture across a network of health and social care partners by using common language and approaches, cross-agency/organisational learning and support, enabling access to training and skills development. Both internally and with partners, the Trust will learn to use a range of methodologies/ frameworks/tools for creating positive service change and resolving operational challenges. These might include simple and quick PDSA (Plan, Do, Study, Act) cycles in a small team setting as well as more sophisticated approaches, for example, value stream mapping of complex pathways which require more in-depth knowledge. SAFE CARING RESPONSIVE 15
We will meet our strategic quality needs by focusing improvement activities at five Create levels within our a organisation: great workforce Our people Firstly, all staff will be asked to incorporate the organisational values that drive this strategy within their annual performance review and learning plans. Secondly, they will be asked to evidence their participation in improvement activities, big or small, at a team or organisational level. Thirdly, we will ask staff to provide their feedback of the opportunities for improvements they see and our progress as an organisation in addressing them. Our leaders Everything we do to improve quality will be underpinned by relentless leadership and role modelling. Our intention is to build leadership at all levels and at scale, with attitudes, purpose and resilience consistent with this strategy and our overall vision. Clinical and management team leaders will see rigorous performance management linked to real consequences and staff rewards. Our care teams Our care and support teams (including wards, outpatient clinics and supporting services) will be supported through a standardised process (a Team Based Improvement Plan) to understand and measure current and future state, identify and prioritise opportunities for improvement, and then implement change. These plans may be significant stand-alone projects in their own right or quick small test cycles of change to test a great idea. Our intention is to develop leaders of change at all levels to support sustainability and spread. Our clinical pathways and supporting processes Each year we will focus on the redesign and improvement of clinical pathways or supporting processes to represent large cross system based work addressing our most important clinical priorities. These will be linked to the implementation of our clinical strategy. Our executive management team will agree these focused breakthrough pathways / quality programmes in line with our annual plan. This will allow for a rational portfolio of projects - with the scale and pace needed to achieve their aims based on three levels: 16 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
Our three levels of improvement System wide improvement programmes Executive sponsored improvement projects (linked to the delivery of our quality priorities) Front line - team based improvements Our organisational readiness to identify, share and ensure delivery of best - practice Working collaboratively within CLIC (Cumbria Learning and Improvement Collaborative) will allow us to network with other health organisations with regards to improvement and ensure we share and use the experiences and improvement techniques of others within the health economy. We will also research best practice when implementing improvement projects to ensure that the latest guidance and successful ways of working are considered when delivering change. We seek to maximise the opportunities to learn from the best NHS Trusts and international organisations to bring measurable improvement. We will actively promote good practice across the organisation learning from high performing organisations nationally and internationally. If we are to encourage innovation & collaboration for quality and if successful projects are to scale up, then we must build a system of leaders capable of rapidly recognising, translating, and locally implementing change concepts and improved designs. Our ability to support quality improvement at an individual, team and pathway level, alongside our broader maturity at an organisational level will be improved by establishing an improvement approach across the organisation where improvement is embedded within everyone s role. SAFE CARING RESPONSIVE 17
9. OUR IMPROVEMENT METHODOLOGY We wish to ensure that quality is everybody s business wherever staff work and in whatever capacity. As part of CLIC, the Cumbria Production System provides a suite of improvement tools that are based on Toyota improvement techniques and can be used depending on the scope and context of a project. This is a standardised approach to drive improvement across the Trust but includes a wide range of different tools that can be deployed depending on the scope and context. This approach has its roots in systems thinking - the idea being that sometimes making small discreet changes can have a disproportionately large impact. The CLIC training programme will offer frontline teams a variety of training sessions that will link the acquisition of improvement skills to application in a real life work context with Director level sponsorship. The CLIC courses will cover a range of tools regarding quality improvement to help them re-design or improve the services they deliver. These improvement tools are collectively known as the Cumbria Production System. The practitioner training in the CLIC Cumbria Production System will also provide three day comprehensive training so the Trust can continue to increase the number of improvement leads/coaches within the workforce. CLIC leadership training for staff will also be delivered via the making a difference courses. The change team will use a range of improvement tools when implementing improvement projects across the Trust and will support other change leads to do the same, gradually embedding a more systematic approach to improving services throughout the organisation. Our annual Patient Safety days will be at the heart of focussing on key safety subjects and developing skills through specific workshops, linked to our improvement priorities. This will support teams to take back ideas to their clinical areas to develop locally owned and driven improvement priorities. 18 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
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10. OUR MEASUREMENT PLAN Improving how we use information is a key driver of our quality strategy, measuring to improve and becoming an information rich organisation is a key ambition. Measurement must be timely and be conducted often enough to track the statistical significance of change (i.e. to determine which trends are showing real improvements due to changing our practice/processes as compared with normal or random variations in performance over time). The metrics we use must be meaningful to both staff and patients with data generated as close to the level of each clinical team as possible (e.g. ward by ward, team by team). Measurement will first be used to demonstrate the impact of change within teams as they test improvement strategies and then continued as on-going performance measures following the implementation of successful change. In line with our commitment to transparency a small number of our most important metrics will be chosen and reported as widely as possible to both staff and patients. We want to be sure that improving quality at North Cumbria and learning about the best way to do that is not thought of as just a project or another initiative. We will use core questions which will sit at the heart of our improvement methodology: Do we know how good we are (on dimensions of quality & safety that matter to patients)? Do we know where we stand relative to the best? Do we know how much variation we have and where that variation exists? Do we know our rate of improvement over time? Board to ward Central to our measurement plan is our commitment to measure quality from board to ward. Through our strategy we commit to ensuring we have a systematic approach on measuring key quality indicators which are owned at ward level. This will include an approach to have a formal accreditation process in place for all of our wards. 20 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
Integrated information In August 2013, the Don Berwick review report into improving patient safety across the NHS was published. One of the recommendations in this report related to the use of information, including transparency and integration of information. The Berwick report illustrated the suit of indicators which organisations and Boards should look at when assessing the safety and quality of care: The perspective of patients and their families Measures of harm Measures of the reliability of critical safety processes Information on practices that encourage the monitoring of safety Information on the capacity to anticipate safety problems Information on the capacity to respond and learn from safety information Data on staf attitudes, awareness and feedback Mortality rate indicators Staffing levels Data on fundemental standards Incident reports Incident reporting levels Through our quality strategy we commit to building capability and capacity to allow integrated information on quality to become standard practice across our clinical business units and key safety and quality reports. Building a safer culture Our quality and safety culture is founded on the individual attitudes, behaviours and values of everyone in the organisation. We will recruit new staff to these values and recognise that everyone has a part to play in ensuring our services are high quality, safe and caring. These values will be made real by the behaviours that we demonstrate in our day to day practice. The chief executive and board provide clear and committed leadership, communicated through the organisation, that makes the quality of care and safety of patients and staff a priority. Our 'sign up to safety' campaign will be at the heart of our quality strategy and the priorities we set to improve the safety of patient care each year. SAFE CARING RESPONSIVE 21
11. COMMUNICATING OUR STRATEGY Our quality strategy will be promoted both internally and externally using a variety of channels which will include: Our patients and the public Our staff Our stakeholders Dedicated page on our website Poster displays in patient areas Annual updates through our quality account on delivery Dedicated page on our intranet site, with linkages to key improvement information and tools. Core part of induction for all staff. Email bulletins sharing success Safety newsletter updates Core part of staff appraisal Issued formally to our key stakeholders Annual updates through our quality account on delivery 22 NORTH CUMBRIA QUALITY STRATEGY 2015-2018
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The Cumberland Infirmary Newtown Road Carlisle Cumbria CA2 7HY 01228 523444 West Cumberland Hospital Hensingham Whitehaven Cumbria CA28 8JG 01946 693181 Penrith Birth Centre Penrith Hospital Bridge Lane Penrith CA11 8HX 01768 245555 www.ncuh.nhs.uk 24 NORTH CUMBRIA QUALITY STRATEGY 2015-2018