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Delivering Improvement in Practice NHS Providers Governance Conference 7 July 2016 Sir Mike Aaronson Chairman, Frimley Health NHS Foundation Trust 2006-2016
Frimley Health FT
Turnover £600m 8,200 staff: 410 consultants 400 junior doctors 3,500 nurses & midwives
Ministry of Defence Unit
Activity: 230k A&E – 4th largest activity in England 80k Emergency Admissions 20k Inpatient - elective 78k Day Cases 800k Outpatients 10k Births
Comprises: Frimley Park Hospital Heatherwood Hospital Wexham Park Hospital
Provides specialist services: Vascular Heart Attack Stroke Plastics Cystic Fibrosis
CQC Rating: Frimley – Outstanding (Sept 14) Heatherwood – Good (Feb 14) Wexham – Inadequate (Feb 14)
FPHFT Acquisition of HWPFT
• 1 October 2014 (18 month process)
• Substantial financial support from DH (capital and revenue)
• Regulatory encouragement and political support
• Willing partner in HWP Board
• No major competition issues
• FPH Board in strong position to insist on terms
Critical Success Factors
• Leadership (executive and clinical)
• Emphasis on Values
• No compromise on bad behaviour
• Recognition of Staff
• Communication
• Honesty
• Hard work
Frimley Health – Leadership
Frimley Park Director of Operations
Deputy Director of Nursing Deputy Medical Director
Wexham Park Director of Operations
Deputy Director of Nursing Deputy Medical Director
Chief Executive
(and Execs)
Chiefs of Service
Orthopaedics & Plastics
General Surgery & Urology
Emergency Department
Obstetrics & Gynaecology
Anaesthetics, ITU, Theatres
Head of Nursing Associate Director
Associate Director Head of Nursing
Associate Director WPH Associate Director FPH
Head of Nursing Specialist Surgery
Medicine
Paediatrics
Head of Nursing
Head of Nursing
Radiology
Pathology & SPS
Associate Director
Associate Director
Head of Midwifery
Head of Nursing
Head of Nursing
Frimley Health Wexham Park - Objectives
Improve governance, quality and
safety Financial recovery
Improve the infrastructure
Raise and sustain
performance
Get the culture right
Getting the culture right Positive values and behaviours
“We are committed to excellence in
everything we do, striving to be one of
the best acute trusts in the
country.”
“We are working together as one
team dedicated to meeting patient
needs.”
“We are facing the future, continuously
improving our performance and
adapting services to meet demand”
Getting the culture right Frimley Health - Values
Committed To Excellence ✔ We make safety and quality a
priority for ourselves and others
✔ We go the extra mile
✔ We set ambitious goals for ourselves
✔ We strive to achieve our goals consistently to the highest possible
quality standard, getting the basics
right every time
✔ We have a positive attitude
✔ We deliver what we promise
✔ We work hard to solve problems if
things go wrong and make them right
✔ We take responsibility for our own
performance and for bringing our
values to life
Working Together
✔ We are friendly, welcoming,
courteous and caring
✔ We act fairly and compassionately
✔ We are open, honest and candid
with others
✔ We treat other people as
individuals and respond to their needs
✔ We respect others’ privacy and dignity
✔ We listen and ensure we understand
✔ We encourage and support colleagues
✔ We work as part of one team with
colleagues within and outside the
Trust in support of patient needs
Facing The Future
✔ We challenge poor performance
in others and expect to be
challenged if our own performance
is poor
✔ We are open to developing
ourselves and to constructive
feedback
✔ We change things for the better
✔ We make best use of public money
by being as efficient as possible
✔ We engage with others to improve
how things are done
✔ We speak up if things could be done
in a better way
✔ We see change as an opportunity not
as a problem
We are committed to excellence in everything we do, striving to be one of the best acute trusts in the country.
We are working together as one team dedicated to meeting patient needs.
We are facing the future, continuously improving our performance and adapting services to meet demand.
All appraisals including “living“ the values
Getting the culture right
What are we proud of?
Living the values
Leadership development and team approach
Listening Into Action
Long service and recognition awards
Intolerance of dysfunctional behaviour
Ward staffing: 1:8 days – 85%
1.10 nights – 95%
31 students recruited for WPH – last year 2
Less bullying
FFT scores as place to work 40% to 57%
FFT scores as place to be treated 45% to 69%
Welcoming a speaking up approach
No agency staff in maternity since April
Public engagement & encouraging feedback
Compliant
We want staff to work “FOR” Wexham not “AT” Wexham
What can we do better?
Supporting the junior doctors
Focus on retention initiatives
7 day consultant service for emergencies & very sick patients
Turnover 14% (20% nursing)
Reduce reliance on agency staff – nursing 270 vacancies – 1250 wte (100 nurses pre employment checks), therapy and radiography vacancies
Bringing good governance at the heart of patient care What have we done so far
Quality Assurance Committee – Board Committee
Wexham Quality Committee – CQC Requirement notices
Pan Trust Clinical Governance Committee – spread good practice
Patient Safety Committee
Mortality and Morbidity Committee
Speciality dashboards
Audit
Cancer steering group
Trust wide Control of Infection and Drugs and Therapeutics committees
What has improved?
Monitor targets delivered Q1 & Q2 15/16
Identification of SIRIs
MDTs more effective
Stronger focus on outcomes (CRAB - cardiac arrest, pneumonia, AKI - hydration)
Consultant delivered services – weekends and new medical and plastics models – 16 new consultants
More transparency with consultant job plans
Radiology out of hours and open access for GP referrals
Duty of candour – openness and transparency
New serious incident process
WHO checklist
Safeguarding and DOLS
Falls & pressure sores
DNA CPR
Control of infection
Sepsis
Acute kidney injury
Deteriorating patient
Mandatory training
MDT working
Structured handover
Creating a learning environment
Structured approach to audit
Learning from incidents, especially SIRI and never events
Encourage more incident reporting
Supporting staff when things go wrong
Impact
Better than average mortality – SHMI 86
Harm reduced
Surgical complication rate better than expected
Keeping our patients safe
Getting the quality right for patients
What are we proud of?
Strengthening the culture- getting the basics right
Values based customer care programme - 348 leaders
Improved access times
Released more time to care
Being more proactive and open
Cleanliness
Valuing unregistered staff
Support at mealtimes
Patient Friends and Family test improving – 93%
What can we do better?
Noise at night
Dementia
Discharge process
Involving patients and carers
Antibiotic policy
Learning disabilities
Patient moves
Frimley Health performance – top quartile
2014/15 2015/16
Q3 Q4 Q1 Q2
4 Hours X X
18 Weeks X X
C.Diff Cancer
2 week rule Cancer
31 day standard Cancer
62 day treatment X X
Estates – improving the infrastructure
What have we done so far? Roof and floor repairs 2nd Cath lab - Wexham Improved security of Wexham at night Improved way finding – all sites Improved the responsiveness of estates department – toolbox meeting – 50% of urgent requests done on the day Approved 500 additional car parking spaces Point of care - ED
Estates – improving the infrastructure
Wexham
Paediatric Critical Care Unit 5 inpatient beds Separate parents room with en-suite
£1.25m
Second CT scanner and replace existing New X-Ray rooms C arm
£2.5m
New Teenage Unit
Estates – improving the infrastructure What we are working on – development control plan
Wexham
£45m investment
Short stay beds – 72 hours
Ambulatory care assessment
unit – multi speciality – 12 hours
New emergency department –
4 hours
Redevelopment of maternity - £10m
En suites in all delivery rooms including Midwifery Led Unit
New bereavement suite with discreet access.
Separate maternity and gynaecology outpatient waiting areas
Improved outpatient consulting and waiting area in outpatients
Fully equipped Gynaecology procedure rooms for Colposcopy/ early pregnancy and urodynamic
Estates – improving the infrastructure
Estates – improving the infrastructure
New Heatherwood Hospital 6 operating theatres 48 beds 16 day case beds Outpatients Diagnostics Will move some additional activity from Frimley Need to sell part of the site to generate the funding
£63m
Securing financial balance £600m turnover
2015/16 - £14m deficit Need to save £26m per annum
How? Reduction in agency cost Productivity – output per head needs to improve New Heatherwood needs to make a surplus Better purchasing Improved discharge process
CQC Requirement Notices February 2014 inspection
Notice Action
Governance process New governance structure. Quality Committee, M&M Committee and CRAB, speciality dashboards
Staffing vacancies 270 vacancies of 1250 ward establishment , 100 nurses going
through pre-employment checks
Access times Delivered Monitor standards for Q1 and Q2
Patient safety Embedding key standards
Culture “Can do attitude”- Frimley Health values and behaviours
Deteriorating patient Outreach consultant 8am – 6pm
24/7 Outreach nurse – plus resus team 8am to 8pm Mon - Fri
Cancer pathways and MDT working MDTs functional and improved pathways
Critical care capacity Transfers out - 2 for Q1 and 0 for Q2 – Establish Medical HDU
WHO checklist 96.7% compliant
Bookings and cancellations No capacity list – reduced from 10k to 300 – 100 one week
beyond target follow up date
Responsiveness of complaints and patient feedback
200 Complaints backlog eliminated. Wexham Park complaints have reduced from 50 per month to 33.
Patient environment £130m of investment secured
Improved maintenance turnaround times
Wexham Park – FHFT Key priorities
Top performing District General Hospital
Cancer – onsite radiotherapy
7 day consultant delivered service
£130m investment in estate. New ED and assessment area, upgrade maternity,
radiology
Heart attack centre
Provide HDU capacity for medicine
New models of care for frail elderly
Secure additional elective activity
Slough +16% Chiltern +20% Windsor +9%
Children – HDU teenage unit
Building a reputation for quality
Eliminate the deficit
Wexham Park Hospital Today
Better place to receive
care
Inspiring staff to care and lead
Bedding in the new
governance arrangements
Stronger focus on clinical outcomes
Reduced harm events
Better place to work
Improved and sustained
performance
Deficit support package has resulted in more
focus on quality
Learning from complaints and
incidents
Clean
Working with Commissioners to redesign and improve care
Strengthened culture - Alignment of purpose - Rebuilding confidence
and self belief
Reflections as Chairman
• Put patients at the centre of thinking and decision-making
– only ‘tick the box’ after this, not the other way round
• Understand and support the role of the chief executive
– leave the long screwdriver at home
• Assert the independence of the Board
– innovation and improvement takes courage; risk needs to be rewarded