Quality improvement: the ‘Northumbria Way’
In healthcare, we often seek to understand what ‘good looks like’ – but what does ‘outstanding’ look like? Louise Frampton speaks to the Northumbria Healthcare NHS Foundation Trust about quality improvement initiatives.
In healthcare, we often seek to understand what ‘good looks like’ – but what does ‘outstanding’ look like? Louise Frampton speaks to the Northumbria Healthcare NHS Foundation Trust about the quality improvement initiatives that have helped sustain top ratings in evaluations by staff, patients and the CQC.
The Health Foundation points out that most NHS Trusts that have an outstanding CQC rating have implemented an ‘organisational approach to improvement’.1 This is defined as embedding “a culture of continuous improvement and learning across an organisation, along with the means to make it a reality, with a view to delivering sustained improvements in the quality and experience of care.”
The Health Foundation states that this requires several key elements:
- Leadership and governance – visible and focused leadership at board level accompanied by effective governance and management processes that ensure all improvement activities are aligned with the organisation’s vision.
- Infrastructure and resources – a management system and infrastructure capable of providing teams with the data, equipment, resources and permission needed to plan and deliver sustained improvement.
- Skills and workforce – a programme to build the skills and capability of staff across the organisation to lead and facilitate improvement work, such as expertise in quality improvement approaches and tools.
- Culture and environment – the presence of a supportive, collaborative and inclusive workplace culture and a learning climate in which teams have time and space for reflective thinking and feel psychologically safe to raise concerns and try out new ideas and approaches.
In seeking to describe “what good looks like”, the Health Foundation highlighted the Northumbria Healthcare NHS Foundation Trust as an exemplar organisation.
The Northumbria Healthcare NHS Foundation Trust provides healthcare services to the more than 500,000 people living in Northumberland and North Tyneside. Staff consistently rate the Trust as one of the best places to work in the NHS and it has been rated by the CQC as ‘outstanding’ twice in succession.
Maternity services in particular were singled out by the CQC for extensive praise not only for their improvements and overall performance, but for being committed to the Trust’s vision, for embedding change and for their commitment to on-going training. The Trust’s work to reduce falls, improve stroke outcomes and academic respiratory (COPD) programme was also noted for outstanding practice.
Commenting on the rating, chief executive, Sir James Mackey, said: “The NHS has undoubtedly become more challenging in the four years since our last inspection and it is credit to everyone’s hard work and dedication that we have remained at the pinnacle of healthcare in this country, while maintaining strong performance and financial resilience.
“Despite this rating, and the many other accolades we have been awarded over the years, we will never rest up on our vision to continuous improvement – what we call ‘The Northumbria Way’. While being rated ‘outstanding’ is fantastic – and it is only right that we take this opportunity to celebrate that – we know we must always do more to ensure every single one of our patients, and their families, have an even better experience of our care and our staff have the support they need to deliver this.”
While many Trusts have struggled to sustain their ratings during a period of financial and staffing pressures, Northumbria has consistently bucked the trend and continued to secure top ratings. So, how has the Trust continued to deliver this high performance, despite experiencing the same challenges and pressures faced by hospitals across the UK? Furthermore, what can other Trusts learn from their example?
‘The Northumbria Way’
Birju Bartoli, the executive director of performance and improvement, at the Trust, revealed that significant organisational changes were being navigated during the CQC inspection period, in addition to the financial and staffing pressures encountered across all NHS Trusts at this time.
“When CQQ first visited, we had just opened England’s first purpose-built specialist emergency care hospital, moving emergency services away from three district hospitals. Since then, we have been in a process of continuous improvement in terms of patient flows. We have undertaken reconfiguration, looked at new ways of working, then continued to evaluate where we need to go next – in terms of organisation, service and staff levels,” commented Bartoli.
Central to the Trust’s improvement efforts is an extensive real-time patient experience programme. An independent team are tasked with asking a series of evidence-based, structured questions, coupled with ‘freenarrative’ from patients. This information is fed back to ward teams within 48 hours of collection.
“This can drive real time improvement – you can solve any issues straight away, rather than a patient going on to make a complaint. This happens across all of our sites. Our ward teams place a lot of value on the results – everyone is looking for the perfect 10 score,” Bartoli explained.
Patients are also sent a ‘Two Minutes of Your Time’ survey, after they have been discharged from hospital. “There is evidence to suggest that if you are unhappy about your care it is likely to be two weeks after your discharge, so we ask about their care at this time,” continued Bartoli.
This is benchmarked and shared across all departments, fostering a “healthy competition” between wards.
“Staff really wanted this and have pushed for it. But, as an organisation, we also really listen to the results and the Governors use it as an indicator to complement external audit. External, nationwide surveys, such as the Maternity Survey, may only be performed once a year, which can mask the true picture for an organisation. Our survey is performed on a regular basis, so any issues are picked up and dealt with sooner,” commented Bartoli.
The Trust has also scored the highest nationally in the NHS Staff Survey for equality, diversity and inclusion, health and wellbeing and morale. The staff survey, completed by all NHS Trusts in England, focuses on 11 themes and provides a detailed insight into how staff feel about culture, their wellbeing, levels of engagement and motivation, equality, diversity and inclusion, safety and quality of care.
Northumbria is ranked first among acute and community Trusts and joint top alongside Cambridgeshire Community Services, Liverpool Heart and Chest Hospital and Kent Community Health NHS Trusts.
76% of staff completed the national survey, achieving the best response rate in the country – the average response rate is 45%.
The Trust has scored best in the following seven areas compared to all acute and community Trusts:
- Equality, diversity and inclusion
- Positive action on health and wellbeing
- Quality of care
- Safety culture
- Staff engagement
- Team working
Sir James Mackey commented: “These staff results, along with some recent excellent performance ratings, clearly demonstrate that our staff, service users and the patients we treat and care for are at the core of all we do.
“How happy and satisfied staff are in their work directly links to the quality of patient care – 90% of our staff believe that our number one focus is on patient care.
“We know there is never room for complacency and always room for improvement. The ‘Northumbria Way’ ethos embodies being driven and continually pushing boundaries and striving for excellence, despite the challenges we face.”
Ann Stringer, executive director of human resources and organisational development at Northumbria Healthcare, said: “We are so very proud of these results and every single colleague should also be proud of their contribution to being ranked top in the country.
“Our staff experience programme, which was launched last year and is based on previous staff feedback, has enabled us to engage with staff on a wide range of topics and provided a wealth of information.
“This insight gives us the opportunity to improve relationships, on all levels, and to evolve our work to support their short and long-term wellbeing in a focussed and meaningful way. We are confident that this will help staff to feel even more happy and engaged in their work.”
The real-time staff experience programme is now in its second year, providing the Trust with a base line to measure performance.
“We are continually trying to make a difference,” commented Bartoli. “If you have happy staff, the evidence-base shows that you are likely to have a great patient experience. It always comes back down to the patient, but it is about putting patients and staff at the centre of everything we do. It is about not standing still and not accepting mediocre. This is not motivated by driving the CQC ratings; it is the culture of the organisation,” she continued.
The survey data can be focussed on site level, professional group level or even targeted at a subject area – for example, health and wellbeing.
“Staff are encouraged to identify how they can take ownership of the things they want to change – to establish how they can be empowered to fix it and push for improvement. It is important that this is an equal relationship – it is not simply about staff telling management everything that is wrong and management then going away to fix it; teams are asked what improvements they want to make to think about what they can do to address the issue,” Bartoli explained
The Big Room: improving flow
Northumbria has also been undertaking quality improvement work on emergency department ‘flow’, appointing trainers as part of the ‘Sheffield flow programme’, with the aim of preventing overcrowding and ensuring patients are seen in a timely way.
The Flow Coaching Academy is an award-winning initiative pioneered by the Sheffield Teaching Hospitals NHS Foundation Trust. Initially a group of staff receive specialist quality improvement training at the Flow Coaching Academy. Once trained, the coaches set up a ‘Big Room’ back at their hospital to guide staff from across a pathway through assessment, diagnosis, aim setting and testing prior to implementation of new models of care delivery.
Each one hour ‘Big Room’ starts with a short patient story to ensure the patient perspective remains central to the improvement process. The ‘Big room’ concept was taken from an initiative used by car manufacturer Toyota.
Obeya (which translates roughly as ‘Big Room’) is a space where Toyota brings together all the different stakeholders involved in developing a new car to share the prototyping process enabling them to overcome complexity. Everybody’s opinions are valued, and everyone is equal in the ‘big room’.
The methodology has been adapted to the healthcare setting and Northumbria is now bringing people together through the ‘Big Room’ approach to look at how flow can be improved throughout the patient pathway. To date, the Trust has coached its third cohort as part of the programme.
The methodology has also been used successfully to drive improvement in day case surgery and sepsis compliance.
“The key to improvement is not standing still,” commented Bartoli. She emphasised the need to re-evaluate the changes put in place and to continue to map the processes that are no longer adding value.
Setting improvement priorities
Each year, Northumbria prioritises a number of areas to improve the safety and quality of its care. For 2020, these priorities include:
- Deteriorating patient
- Staff experience
- Every contact counts
The Northumbria Healthcare NHS Foundation Trust has also adopted a zero-tolerance approach to infections and has received widespread recognition for its consistent efforts in reducing surgeryrelated infections. The work of the Quality Improvement in Surgical Teams (QIST) initiative has shared the Trust’s improvement strategies across UK theatre teams, with a number of successful conferences held to highlight best practice and exchange knowledge across the NHS.
The Trust is taking a variety of actions to ensure the patient’s condition is ‘optimised’ prior to surgery and to help reduce their risk of infection – from optimising patient warming to tackling obesity and smoking.
“The Trust also now checks every patient for diabetes,” commented Professor Mike Reed, a consultant trauma and orthopaedic surgeon for Northumbria Healthcare NHS Foundation Trust. “This is a key area that can be addressed to improve surgical site infection prevention, along with optimisation of diet, and we now check albumin levels and make dietician referrals if appropriate.”
Northumbria has also been part of a large collaborative project, which has included the training of other Trusts in the pre-screening and decolonisation of patients, using body wash and nasal gel treatments, to reduce infection rates from MSSA, following joint replacement surgery.
This work was named infection prevention and control initiative of the year at the 2019 HSJ Patient Safety Awards. In addition to the focus on MSSA, the project is evaluating the introduction of screening for anaemia and treating patients with iron before their surgery
Prof Reed said: “We know from the work we have already undertaken within our own organisation that there are many benefits for patients including reduced infections and blood transfusions, fewer critical care admissions, shorter stays in hospital and fewer re-admissions.”
The Anaemia & MSSA Collaborative project has received £1.5M in funding from the Northumbria NHS Vanguard, NHS Improvement, and industry (Vifor and Schülke), with independent evaluation by the University of York Trials Unit.
In addition to being named ‘patient safety organisation of the year’ at the HSJ Patient Safety Awards, the Trust has led the development of some key initiatives that are gaining interest from hospitals across the UK. The Matron and nurses in the falls team at Northumbria Healthcare NHS Foundation Trust have sought to address variation in the practice of observation for patients who may be at risk of falling, for example.
The matron, in collaboration with the nursing team, developed a new system of observation – known as the ‘Avoiding Falls Level of Observation Assessment Tool’ (AFLOAT). The aim was to reduce risk, improve patient safety and improve patient outcomes and experience.
Nurses from across the wards identified which patients required enhanced observations to reduce the risk of falls, enabling the falls team to learn from the experience of the staff on the wards caring for the patients. Identified risk factors included: confusion, being unsteady on their feet, a previous history of falls (including in hospital) or had postural hypotension.
The falls team developed an initial clinical assessment tool, which they piloted in areas of the hospital identified as having a high number of patients at risk. The nurses on the ward trialled the tool and provided feedback to the falls team where they felt there could be improvements.
The final version has now been implemented and was highlighted as an example of excellence by the CQC in its most recent evaluation of the Trust’s performance.
According to Bartoli, the Trust also demonstrates an open, learning culture, when it comes to dealing with Never Events.
“Nothing is hidden. If we know about it, we can do something about it and prevent it from happening in the future. An open culture is instilled across the Trust – we look at the root cause of incidents and safety panels work with those involved in a nonpunitive manner to understand how what lessons can be learnt,” she commented.
Clinical engagement is key
Ultimately, successful improvement initiatives are rarely driven from the top down, as Bartoli points out: “Improvement is about asking clinical teams what they want to change, then knowing how the system and process works,” she concluded. “It requires engagement at the ‘shop floor’ level and understanding how teams work. Our approach is to identify a problem and say: ‘how are we going to fix it?’ Over the years, Northumbria has had a stable leadership, so this has continued to be the culture within our organisation.”
As well as ensuring that there is a common way of working across the Trust, and that an improvement ethos is shared by clinical and non-clinical staff, Northumbria has sought to build the capability to drive change across service and organisational boundaries. Whether reducing falls, tackling surgical site infection, or screening for anaemia, the Trust has looked beyond its walls to share knowledge and best practice to the benefit of patients throughout the NHS.
The Trust is continuously working to ensure that the care that it delivers is outstanding – but it is also working to ensure that others are too.
References 1 Jones, B, Horton, T & Warburton, W, ‘The improvement journey: Why organisation-wide improvement in health care matters, and how to get started’, Health Foundation, 2019