QUALITY
STRATEGY
2015- 2018
SAFE CARING
RESPONSIVE
1
2
NORTH CUMBRIA QUALITY STRATEGY 2015-2018
CONTENTS
1. Introduction
Page 4
2. Our visionPage 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 qualityPage 12
8. The North Cumbria improvement way
Page 15
9. Our improvement methodology
Page 18
10. Our measurement planPage 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 NaylorDr Jeremy Rushmer
Director of Nursing & Midwifery 4
Medical Director
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
SAFE CARING
RESPONSIVE
11
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
Create a great workforce
We will meet our strategic quality needs by focusing improvement activities at five
levels within our organisation:
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
SAFE CARING
RESPONSIVE
19
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
Dedicated page on our website
Poster displays in patient areas
Annual updates through our quality account on
delivery
Our staff
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
Our
stakeholders
22
Issued formally to our key stakeholders
Annual updates through our quality account on
delivery
NORTH CUMBRIA QUALITY STRATEGY 2015-2018
SAFE CARING
RESPONSIVE
23
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