CitationDownload as .RIS
Emerald Group Publishing Limited
Copyright © 2008, Emerald Group Publishing Limited
In this special edition of Clinical Governance I am pleased to present papers reporting on a range of issues that are currently being addressed by the NHS Institute for Innovation and Improvement. The NHS Institute, formed in July 2005, was set up to “support the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world-class leadership” (NHS Institute website, 2007).
Bernard Crump, chief executive, poses the question “How can we make improvement happen?” (Crump, 2007) He sets out a framework of four key notions that are needed to drive change. These are: leadership; measurement and data; practical tools and processes; and relationships.
Leadership training for new managers coming in to healthcare is already a core part of the NHS Institute’s business. However, clinical leadership is a critical factor in successful improvement work, so leadership training for clinicians is an important component of a continuously improving healthcare system. Clark and Armit (2007) describe how they developed a framework for leadership competencies for doctors. This work will form the basis of training curricula at undergraduate, postgraduate, and post registration. It neatly complements the earlier work of the Medical Leaders Professional Council which developed a syllabus for clinicians who choose to take up clinical leadership (medical management) roles (Medical Leaders Professional Council, 2007). Both place emphasis on the important role doctors play in transforming services, and the need for them to develop relevant knowledge and skills.
Prof. Crump’s second driver concerns performance data and measurement. Taylor and Shouls (2007) offer an account of an extraordinary web based resource – the “No Delays Achiever”. This uses existing national data to give acute trusts and their commissioners the information they need to understand where their main delays lie, in preparation to meet the English 18 week journey time target from referral to definitive treatment. This data will help them to focus on problem specialities or procedures and even highlights individual consultants. Another section of this rich resource has an extensive catalogue of tools and guides that are effective at different stages of the patient journey.
Having the right tools and processes is the third domain. Mugglestone et al. (2007) describe a detailed process for innovation and improvement. This methodology was developed within the NHS Institute and is used by all the projects and programmes. The methodology can be adapted for programmes of improvement work anywhere in healthcare, or indeed other sectors. Pickles, Hide and Maher (2007) describe the process by which patients are involved as partners in healthcare improvement, not simply through questionnaires or focus groups, but by directly involving them in the process to truly understand their views on how to redesign services. A key innovation is the use of designers to work with patients and staff to help them to co-create new ways of organising care.
The paper by Gilligan and Walters (2007), demonstrates what can be achieved through quality improvement methods. This is a case study of a project, supported initially by the NHS Modernisation Agency, which was primarily intended to improve flow through acute beds. The flow of medical patients through beds was improved, but there was also a synchronous reduction in hospital deaths. It is difficult to see which changes made the difference – many were implemented, including the introduction of early warning scores on the wards, ALERT training and critical care outreach. However the single most striking temporal correlation was between the change in mortality and a substantial reduction of medical patients outlying on other wards.
This is not the only project that has shown success in reducing deaths in hospitals (Wright et al., 2006). The NHS Institute, working together with the Health Foundation, examined what 12 organisations have done to achieve this. We based this partly on a commissioned evaluation (Matrix, 2006), and partly on a consensus workshop with attendees from the 12 contributing organisations. The findings were clear – there is no single intervention that will reduce avoidable deaths.
The first step is to uncover local issues in order to engage the local clinicians and managers. Incident reporting is necessary but not sufficient to show what errors are occurring. Sadly it may identify as few as 6 per cent of the errors that can be uncovered through case notes review (Sari et al., 2007). The case notes review can be done more efficiently using a trigger tool – a list of items to look out for which merit further examination, such as unplanned return to theatre, or administration of vitamin K. The UK Adverse Event Trigger Tool describes the tool and how to use it (NHS Institute, 2007). Experience has shown how powerful local stories and data can be in generating a call to action.
Implementing a system to identify and retrieve the deteriorating patient was considered important by all. This reinforces similar findings from the National Reporting and Learning System (Thomson et al., 2007). The hospital staff emphasise that it has to be a complete and integrated system to be effective. This includes early warning methods and assertive communication tools for nurses to call support. It also needs someone with appropriate skill, such as critical care outreach nurse or team, to respond quickly to the call. There were numerous other interventions, many based on the reliable implementation of care bundles, for example in theatre to reduce surgical site infections, in intensive care to reduce ventilator associated pneumonia and central line associated bacteraemia.
The interventions are only one component for a hospital to reduce mortality and improve safety. Building a safety culture can only be achieved through committed leadership at every level, but especially at board level. Hence we have published guides for leaders: Medical Directors Drive Improvement, and Chief Executives Lead the Way (NHS Institute, 2007). The Health Foundation has also assessed their four first wave sites for the “Safer Patients Initiative” and emphasise the importance of team working and shared leadership (The Health Foundation, 2007).
Bernard Crump’s paper refers to many more contributions the NHS Institute is making to help the NHS to improve healthcare through a range of initiatives, based on this framework. I urge you to visit the web site (www.institute.nhs.uk) where all the NHS Institute’s publications on reducing mortality and all other programmes can be found.
Hugh RogersGuest Editor
(The Health Foundation (2007), “Better team working for a safer hospital”, available at: www.health.org.uk/publications/briefings/better_team_working.html
Matrix research and consultancy (2006), “Scoping of evidence in relation to interventions to reduce avoidable mortality”, available at:www.institute.nhs.uk/safer_care/safer_care/reducing_avoidable_deaths_in_hospital.html
Medical Leaders Professional Council (2007), A Syllabus for Doctors in Management and Leadership Positions in Healthcare, British Association of Medical Managers, Stockport
NHS Institute (2007), “Reducing avoidable deaths in hospital”, available at:www.institute.nhs.uk/safer_care/safe_care/reducing_avoidable_deaths_in_hospital.html
NHS Institute web site (2007), available at: www.institute.nhs.uk
Sari, B.A., Sheldon, T.A., Cracknel, A. and Turnbull, A. (2007), “Sensitivity of routine system for reporting patient safety”, BMJ, Vol. 334, pp. 79–81
Thomson, R., Luettel, D., Healey, F. and Scobie, S. (2007), “Safer care for the acutely ill patient: learning from serious incidents”, National Patient Safety Agency, London
Wright, J., Dugdale, B., Hammond, I., Jarman, B., Neary, M., Newton, D., Patterson, C., Russon, L., Stanley, P., Stephens, R. and Warren, E. (2006), “Learning from death: a hospital mortality reduction programme”, J R Soc Med, Vol. 99 No. 6, pp. 303–8