Quality improvement in action

‘Working in the emerging field of quality improvement, and using our independence and investments judiciously, we are fostering the drive for excellence in patient care.’

The Health Foundation’s goal to improve the quality of health and healthcare is an ambitious one. The sheer complexity of healthcare systems can frustrate the best intentions to provide safe, effective and responsive patient care. As we begin to appreciate fully the extent of suboptimal healthcare, adverse incidents and harm to patients, so the gaps between what we know to be the best care and what patients routinely receive become more apparent. The Health Foundation has taken up the challenge of addressing these problems. Working in the emerging field of quality improvement, and using our independence and investments judiciously, we are fostering the drive for excellence in patient care.

Our portfolio of programmes demonstrates how tackling problems in healthcare quality requires focus, outstanding leadership and partnership. These requirements are being deployed by the teams of professionals working to great effect in both our hospital-based Safer Patients Initiative in the UK and our newly launched programme to improve the quality of healthcare for mothers and babies in Malawi. Though early days, both programmes are already showing encouraging signs that tangible benefits will accrue for patients. These programmes demonstrate the importance of bringing together the best combination of local, national and international expertise. The Health Foundation’s support is not just about funding, but about enabling these strategic partnerships to form and flourish.

With mounting financial pressures in the health service and demands for better value for money, bridging the gap between what we know to be the best patient care and current clinical practice is increasingly important. Through our Engaging with Quality Initiative, we are working with Royal Colleges and other professional bodies to support projects that directly engage clinicians in quality improvement.

The methods developed by these projects will further the adoption of national guidelines and service frameworks, leading to better performance of the health service overall.

We are privileged to work with healthcare professionals of the highest calibre. Through our investment in people, such as those in receipt of our leadership awards, and with the expert help of our technical suppliers and advisers, we are creating a dynamic network of people interested in and knowledgeable about quality improvement.

Improving healthcare quality requires broad thinking and a sound research base. The Health Foundation is searching globally for solutions and continues to commit significant resources towards researching the best policies and practices for better patient care. One of this year’s highlights was a meeting we convened to exchange expertise across Europe. In addition, our international research partnership, the Quest for Quality and Improved Performance (QQUIP), is beginning to bear fruit by providing informed and objective monitoring of quality across the NHS.

Having completed only the first year of a five-year strategy, we believe the breadth and scope of our activities have been truly impressive. Our reach and influence are expanding beyond our initial expectations. We have learnt already that improving healthcare quality requires the freedom to innovate, time, money and the motivation and skills to take concerted action. Our work would fall short of expectations without the dedication and imagination of our staff, the enlightened stewardship of our board of governors and the partnership of our many technical experts and professional associates. We are especially grateful to those who have advised us on our programme development and who support the spread and uptake of our work. The true test of our collective impact will be real progress towards safer, more effective and responsive patient care.

Stephen Thornton, chief executive, and Vin McLoughlin, director of programmes and policy, discuss how The Health Foundation is using its independence and resources to mprove the quality of healthcare in the UK.

Since its launch just three years ago, The Health Foundation has been developing its own distinctive way of working to enable it to achieve its aim of improving health and the quality of healthcare in the UK. We asked Stephen Thornton, chief executive, and Vin McLoughlin, director of programmes and policy, to tell us more.

Stephen Thornton (ST) The Health Foundation’s unique contribution to UK healthcare stems from our independence as a charitable foundation. That independence enables us to use our resources in a targeted manner.

Vin McLoughlin (VM) Combining our independence and resources enables the Foundation to be and to create something different. I see our role as bridging the gaps between policy, practice and research – we draw on existing research and employ a variety of methods to test out new ways of delivering healthcare services and use the evidence generated from our work, alongside that of others, to influence policy for the future.

ST There are also real connections between all those areas. We work with people from across all fields: some from a policy background, some from research and others from the front line. We bring people from these very diverse parts of the healthcare system together to talk, listen, discuss and learn. As someone told me recently, being involved in our work enables people to meet those whose names or work they know, but whom they wouldn’t otherwise have met. That brokerage role really matters.

VM There’s an international perspective to our work too, where we collaborate with leaders in healthcare quality from around the world.

ST There’s still much more that we can learn from healthcare systems overseas in developing policy in the UK. We see ourselves helping to provide those kinds of links.

VM When we talk about quality improvement, we use the Institute of Medicine’s definition of quality: ‘increasing the likelihood of reaching desired health outcomes, consistent with current professional knowledge’. Our work is not primarily about developing new cures and treatments – we recognise that many others fund this – but rather it is about closing the gap between what we know to be the best care and what patients routinely receive. For us, that means care that is safe, effective and responsive to patients’ needs.

ST We are employing a number of different approaches to help us achieve our goal. For example, we are using research generated through our Quest for Quality and Improved Performance (QQUIP) initiative to provide a theoretical grounding for our work and to investigate which interventions really work to improve the quality and performance of healthcare. We are offering unique learning and development opportunities to the rising stars working in every aspect of healthcare so that they can go on to lead positive changes in healthcare. We are also making a practical difference to the quality of healthcare by supporting large-scale, sustainable and ‘spreadable’ projects, working at multiple levels throughout the healthcare system. We’re not about simply funding projects that make a big impact initially, but then stop once we’ve left. What we’re interested in is making systematic and sustained changes that we can measure and document.

VM We’re very selective about the work we support. Our unique approach is to provide more than just financial assistance. Those we work with receive a whole package of support including evaluative tools, leadership training and access to networks. Evaluation has a vital role to play. Before our projects even start, we evaluate: why this project, to what end, what evidence base do we need to build, and how will the findings be applied? We also evaluate throughout the project – and beyond – to ensure that we are contributing to the evidence base for quality and performance improvement. The ultimate test we apply to everything we support is: what happens for patients?

ST We’re also clear about how important it is to work with the right technical experts, sourced from around the world – again, the global perspective.

VM When we look back in ten years’ time, we will judge our success on whether we’ve made a difference to the provision of services.

ST And those changes will have been in place for some time, embedded as ‘the way we do things round here’ – not just a short-term project driven by charismatic individuals. The changes will be embedded across institutions and also, I hope, across whole systems. We’ll also be making insightful contributions to healthcare policy, based on the evidence generated through our programmes, and enabling a voice for those we’ve supported who are working at the front line of healthcare.

How a £4.3 million initiative is improving atient safety in UK hospitals

Going to hospital can be a worrying experience for many people. With advances in modern medicine, few people expect mistakes or errors to creep into a system designed to help them get better. However, across the globe, approximately one in ten hospital patients experiences unnecessary harm or suffering due to errors in the care they receive.

In 2004, The Health Foundation launched a £4.3 million, four-year initiative specifically aimed at making hospital care safer and reducing the risk of mistakes occurring. Almost two years into the initiative, the results are impressive and show there are proven steps that can be taken to improve safety in hospitals.

Ambitious goals, significant early results

Hospital care is inherently complex. Many people are involved in delivering care to patients using a wide range of different systems. There is a wealth of literature telling us what works in theory to improve patient safety, so why isn’t the safety record better?

The simple answer is that for hospital staff, especially now they are grappling with financial and management demands, it can be difficult to retain a focus on safety.

With this in mind, the Safer Patients Initiative is providing four hospital sites with the resources and technical expertise needed to change the way care is provided so that mistakes (known as ‘adverse events’) are harder to make.

Conwy and Denbighshire NHS Trust (Wales), Down Lisburn Health and Social Services Trust (Northern Ireland), Luton and Dunstable Hospital NHS Trust (England) and NHS Tayside (Scotland) were selected through a UK-wide competition and began their work in early 2005. Their ambitious aim is to reduce adverse events in their hospitals by 50 per cent by October 2006. Early results are impressive and suggest that adverse event rates are falling, as well as the number of patient deaths.

The four hospital sites are testing what works to improve safety in three settings: on the wards; before, during and after operations; and in critical care. In each of these settings, staff are working with The Health Foundation and experts from the US-based Institute for Healthcare Improvement (IHI) on ways to improve infection control, the management of drugs, and communication between teams of staff and between staff and patients.

Highlights from the results so far include reductions in surgical infection rates. Conwy and Denbighshire has seen infection rates following orthopaedic surgery bottom out at around 0 per cent after peaking at 7 per cent. In addition, hand-washing compliance rates on the general wards of all the Safer Patients Initiative hospitals are over 80 per cent.

Drugs are also being managed more effectively, reducing the number of medication errors that currently harm patients. Patients at Down Lisburn taking anti-coagulant medication to thin their blood used to experience ten adverse events per 1,000 doses; the figure is now fewer than four.

Patients are getting involved too. Luton and Dunstable has set up the first web-based scheme in England that allows members of the public to suggest ways of making their hospital safer.

Building a safety culture

The Safer Patients Initiative sites are finding that the hospital data collected to meet government performance targets are insufficient for improving safety. Data need to be gathered in a way that is useful to clinical teams. Front-line staff also need instant access to data. Equally, the importance of an open and blame-free culture cannot be underestimated. Dr Gillian Hastings, assistant director at The Health Foundation, says: ‘Learning from past events when things have gone wrong is just as important as acknowledging success.’

At the heart of the initiative is the need for hospital leaders to put patient safety at the top of their agendas. The chief executives of the four sites demonstrate their commitment by conducting weekly walk-arounds with their clinical teams and responding to any issues raised within 72 hours.

Alan Finn, director of nursing and acute services at Down Lisburn, sums up the culture shift the Safer Patients Initiative has brought about: ‘It’s more than an initiative; it’s become a way of life. People are thinking of safety now as a priority and it’s not an ad hoc thing, it’s a structured way of thinking.’

Dr Jonathon Gray, director of health improvement at the Wales Centre for Health, talks about his year as a Quality Improvement Fellow

Through the Quality Improvement Fellowships scheme, delivered in partnership with the US-based Institute for Healthcare Improvement, senior clinical leaders are learning the tools and techniques of quality improvement.

Dr Jonathon Gray was a consultant and senior lecturer in medical genetics at Cardiff and Vale NHS Trust before he was awarded a Quality Improvement Fellowship. He explains what he did during his transformative year in the USA.

How did you spend your time on the fellowship?

I spent the first nine months based in the offices of the Institute for Healthcare Improvement (IHI), near Boston. It’s a small, flexible and energetic organisation with a real ‘can do, will do’ attitude. The time I spent there was inspirational – full of things they should have taught us at medical school. It was hands-on and pragmatic, using IHI methodologies for quality improvement. It was fantastic to be able to spend time with people who have the personalities and experience that allow them to influence change.

During the final three months, I was taught in a more traditional academic way at Harvard School of Public Health. The programme included a seven-week intensive clinical effectiveness course which was of immense value.

You learnt a lot about quality improvement – why was this so important?

In the past, even though I recognised quality when I saw it, I was unable to define it. Now I have been able to create a framework in which to understand and discuss it and this has given me a strong sense of what makes a quality healthcare system. I have learnt that an important aspect of quality improvement is about making small changes – if you see a problem make a small change and, if it brings benefits, make another and build on it. It is what is called a PDSA cycle – plan, do, study, act. I have also learnt from IHI that to live and work in the world of quality improvement means talking about the psychological aspects of change – some might say the softer elements of team, individual and organisational change.

Has being exposed to the US healthcare system brought you any new perspectives about the NHS?

Now that I have a strong sense of what makes a quality healthcare system, it makes me even more proud of the NHS. But I am aware that while we have people working incredibly hard, we do not give them a framework to understand what they do really well and the areas in which they can improve. For me, quality is about a framework that resonates at the front line and with the patient.

My ambition is to bring a more rounded picture of quality, identify ways of measuring it and help clinical staff understand that recognising there is room for improvement is not a bad thing.

Which key elements of learning have you brought back to the UK?

I came away with two simple rules which I am trying to follow. The first is to maintain enthusiasm in myself and bring it to others, despite the difficulties when daily problems hit you, particularly at the front line. Keeping in regular contact with the inspirational people I met in the USA is really useful for helping refuel my enthusiasm when I need it. The second rule is to take risks and chances, to step outside your comfort zone, as so many people at IHI do. So while I aim to maintain some clinical practice, I also want to introduce successful systems from industry, whether it be from the aircraft industry or Toyota production systems, and to advocate for these in healthcare.

What are your aims for the future?

In the short term I want to show that we can make a positive difference in the small but very important healthcare system for three million people in Wales. I am currently on secondment to the government in Wales to try to influence change centrally by identifying a high-level system to measure quality. In five to ten years’ time I would love my career to be driven by the continued learning from North America and Europe, bringing their strengths into the UK healthcare system.

Good leadership is recognised as central to the delivery of effective healthcare, yet surprisingly little is known about the extent to which different types of leadership development contribute directly to better patient care.

Through its leadership programme, The Health Foundation is evaluating different approaches to leadership development, not only to individuals but also to multidisciplinary teams and organisations. Our aim is to build a better understanding of the most effective ways to invest in leadership development for quality improvement.

We asked people working with us in these three different aspects of our leadership programme to tell us about their experience so far.

Individuals

The Leaders for Change award scheme, delivered in partnership with Lancaster University Management School, offers health professionals the opportunity to acquire the necessary skills and knowledge to lead projects that improve the quality of local healthcare services. Debbie Smith, patient and public involvement lead for West Cheshire PCT, is one of our award holders.

Debbie’s project was to develop an evidence-based care pathway for young people with diabetes. Its remarkable success brought ‘did not attend’ rates at clinics down from 80 per cent to under 30 per cent. The model she developed is now being adapted to improve access for this age group in other clinical areas.

The theoretical grounding offered through the scheme bolstered Debbie’s confidence in her change management skills and the support she received through the programme helped her to realise her personal leadership ability.

The project broadened Debbie’s views on quality and the role of patients in improving services emerged as a new dimension. In one approach, Debbie invited young people to focus groups in a local pizza restaurant to find out how and why diabetes services were poorly suited to their lifestyles. Lessons from this helped her redesign the service to better meet their needs.

‘The Leaders for Change scheme provided a fantastic opportunity for me, both professionally and personally,’ says Debbie. ‘I have come away with a whole range of practical tools and techniques to make change happen. I am confident I will use these throughout my future career.’

Teams

Through its Shared Leadership for Change award scheme, The Health Foundation is exploring how far investing in leadership development across multidisciplinary teams produces improvements in patient care. Lothian Diabetes Services Advisory Group is one of six teams working with The Health Foundation’s expert leadership development consultants on the scheme.

‘It has been fascinating to be part of this scheme,’ says Mary Scott, manager for the Diabetes Managed Clinical Network in Lothian. ‘We have set ourselves demanding challenges. We want to see whether changing the way we work together as a team can really lead to improvements in the quality of service we offer people with diabetes.’

She believes that participating in the scheme has helped group members to examine how they work as a team, make decisions and conduct meetings. It has enabled them to be more honest with each other and challenge one another in a constructive way.

For Dr Ewan Crawford, diabetes lead for NHS Lothian’s primary care division, the scheme has offered an opportunity for the team to investigate how best to involve people with diabetes in improving services. The scheme enabled the group to agree specific goals for quality improvement. It also enabled them to build positive relationships with Lothian Health Board and the community health partnerships so that they can work towards being influential at a higher level.

‘Participating in this scheme has enabled us to pool our strengths as individuals and is helping us to develop our leadership skills as a team,’ says Ewan.

Organisations

Trusts and organisations working with us in the Safer Patients Initiative and Engaging with Quality Initiative are also receiving leadership development support to help them achieve the programmes’ ambitious goals. Down Lisburn Health and Social Services Trust is working with Carol Culshaw, one of The Health Foundation’s leadership development consultants.

On joining the initiative, Down Lisburn took on an ambitious goal to reduce adverse events in their hospitals by 50 per cent by 2006. They knew that achieving it would rely on having strong leadership throughout the organisation.

Carol worked with the trust’s senior team to devise a tailored programme of leadership development which she delivered to staff working at different levels throughout the organisation. The programme examined leadership theory and models as well as specific issues of quality, safety and openness. Psychometric tests and 360-degree feedback were used to help participants understand their own personal effectiveness. These tools helped to identify key areas for development.

Alan Finn, director of nursing and acute services, feels that Carol’s work has helped embed a culture of safety throughout the trust. For instance, action learning sets have played a vital role in helping staff look at changes, measure them and learn from them.

The real success of the initiative has been involving staff throughout the trust. As chief executive John Compton says: ‘If this succeeds, we’ll have a whole cohort of leaders prepared to stand up and challenge poor quality care, not just those at the top of the hierarchy but throughout the organisation.’