Following the example set by Dr Mark Newbold, CEO of Heart of England Foundation Trust, I have decided to do a weekly blog about my work week.  I decided to do this because I found Dr Newbold’s posts of interest, as did many others.  This sparked many suggestions on Twitter that others should do the same.

I’ve been thinking about doing this for a while but decided to take the plunge this week (12 – 16 November 2012) because I was a Reviewer for the Regulation and Quality Improvement Authority (RQIA) Review of Hospitals at Nights and Weekends and thought it would be of interest to others to learn how a review like this is conducted, and what interesting issues were discussed.

As I was helping out another organisation – RQIA – and have discussed meetings with Trust senior management teams, I decided to share what I had written with all concerned prior to publishing it which explains the slight delay.  I have also been careful not to pre-empt the content or recommendations of the report which is due for publication in early 2013.

Monday

Meeting the Team

This was the first meeting of the Review Team made up of Mr Paul Carter, Clinical Director of Surgery from Royal Liverpool, Ms Liz Coles, Senior Patient Safety Manager from GKT in London, Mr Pete Vance, Lead Nurse for Hospital 24/7 from Birmingham, and Mrs Anne Brooks, local Lay Reviewer with a teaching background who is also a carer for an elderly relative.

The meeting was opened by Dr David Stewart, RQIA Medical Director and Director of Reviews.  He started by explaining the demographics of Northern Ireland and showed the review team a map of acute hospital sites and Trust areas.

This was followed by the background to the review – why this topic was chosen for review at this time and a bit about what is currently known about hospitals out of hours including the well-publicised Dr Foster data from England which suggested an increased mortality rate for patients admitted out of hours.

Safety at Weekends and Nights (SWAN) tool & other data

We then moved on to reviewing the large amount of information collected during the data-collection phase of the review.  This data was collected through focus groups with medical staff, nursing staff, non-medical staff, senior clinicians, and managers.  There were also observation visits to all 12 acute hospitals to observe nursing handovers, critical care outreach handovers, Hospital at Night handovers, and the role of the night sisters and patient flow managers.  Each Trust had also submitted a self-assessment questionnaire based on the Safety at Weekends and Nights (SWAN) tool from the USA.

The data analysis allowed us to identify key themes and questions to be covered at the meetings with Trust teams on Tuesday, Wednesday and Thursday.  The themes identified included: leadership and organisational structure; governance; escalation policies; staffing levels; training & development of staff; hospital at night handover; measuring and monitoring outcomes; and continuous improvement.

Non-cognitive skills assessment for medical school selection

In the evening I spent 2 hours doing face-to-face coaching with a student heading for an interview at Liverpool Medical School on Wednesday.  I enjoy doing this as I meet some fantastic young people and it helps me keep up to date on the changes in selection policies for the doctors of tomorrow.  I have noticed a move towards assessing non-cognitive skills such as problem-solving, empathy, integrity, and ethics along with traditional academic criteria.

Tuesday

Hospitals at nights & weekends – challenges, initiatives & emerging issues

We had our first two meetings with trusts on Tuesday.  This involved travelling to Northern Trust headquarters in Ballymena for a morning meeting followed by Western Trust headquarters in Derry for an afternoon meeting.  RQIA had previously asked each Trust to prepare a brief presentation on challenges and initiatives to start off each meeting and this was followed by questions from the Review Team and discussion on emerging issues.

Two of the challenges facing Northern Trust are: the increasing number of acute admissions with increasing acuity and dependency of the patients admitted; and the challenge of moving to 7-day working.  It is certainly my own experience that the patients we look after in acute medicine are increasingly complex and require of a lot of work for the staff when they’re admitted.

Medics in the surgical world

Mr Paul Carter explained that in his Trust in England they are considering employing Consultant Geriatricians to look after elderly surgical patients in a similar model to that of Orthogeriatricians in Trauma and Orthopaedics.  This just shows how much things have moved on in a relatively short period.  When I was a JHO I was the medical opinion on the orthopaedic ward.  It was very stressful .

Reducing risk through standardisation

At the meeting with the Northern Trust we learned that a regional medication Kardex and regional fluid prescription and recording charts are soon to be introduced.  This should streamline training in the use of these important tools and also reduce the risk of error associated with Doctors-in-Training having to adapt to new paperwork each time they rotate to a new Trust.

Integrated health & social care

In the afternoon we visited the Western Trust at Altnagelvin Hospital where the Chief Executive, Elaine Way, explained that there was an important difference between Trusts in Northern Ireland and Trusts in England.  We have integrated health and social care here which means Trusts are responsible for acute hospitals as well as community services and social care.  This makes HSC Trusts even more complex with a range of competing priorities in a climate of limited resources.  This brings unique challenges to Chief Executives leading these large integrated health and social care organisations.

All single room hospitals – the challenges

The Western Trust is the first in Northern Ireland to have a new all-single-rooms hospital – the Southwest Acute Hospital in Enniskillen.  We heard about the advantages this brings for managing patient flow, infection control, peace and quiet for patients at night, and privacy and dignity.  But it has also brought new challenges, some patients find it too quiet or lonely, more nurses are needed to look after the same number of patients, and the design of the hospital means more time spent walking between areas.  These will be important learning points for other Trusts in NI and wider afield when planning the construction of new hospitals.

Wednesday

On Wednesday morning we visited the South Eastern Trust HQ at the Ulster Hospital.  Again the challenge of caring for an increased number of patients with increased acuity and increased dependency was discussed.

The effect of environment & resources on performance of the team

The Hospital at Night project co-ordinator explained that handovers were impacted when the handover venue was lost and so a new venue was quickly found.  This indicates the importance of the right environment and resources to getting the right performance for handovers and makes a lot of sense to me.  The environment we work in definitely affects our feelings and attitudes and the way we work.

How can we communicate the good news stories in healthcare

Mrs Anne Brooks, the RQIA lay reviewer posed the question.  How can Trusts communicate all of the good news and positive stories about healthcare in the face of press and media appetite for negative stories?  This was an interesting question to which there appears to be no easy answers.

The function of the NI healthcare regulator

I had a very interesting discussion with the RQIA Medical Director on the drive to Craigavon Hospital.  He explained the remit of RQIA and the legislation behind their regulatory function.  They have a programme of themed reviews but can also be asked to carry out ad hoc reviews into particular issues when they arise, such as the recent review into the pseudomonas outbreaks in Northern Ireland.  He also explained the process of compiling and writing the reports which are sent to organisations for factually accuracy checking and then to the Department of Health, Social Services and Public Safety for consideration before being published.

Hospitals – primarily out-of-hours facilities?

In the afternoon we met with the Southern Trust at Craigavon Hospital.  The Trust started by pointing out that 9 – 5 on Monday – Friday represents just 24% of the week and that a significant focus is required on the other 76% when there is a lower number of staff on duty and a lower number of resident medical staff.  This is a statistic I have quoted in the past when trying to convince people that it’s important to pay attention to what happens in hospitals out of hours.  I’m glad to see this issue moving rapidly up the healthcare agenda.

Leveraging technology

The Southern Trust has also made significant use of technology to overcome the geographical challenges facing them, including the use of a tele-presence robot in the HDU at Daisy Hill hospital and a dispensing robot in pharmacy at Craigavon Hospital.

Breaking down hierarchies, culture, and escalation

Another important topic discussed was how to break down hierarchies to create a culture where junior staff feel able to escalate situations to senior decision makers.  Craigavon and Daisy Hill Hospitals have established systems whereby the senior decision makers pro-actively institute regular contact with juniors after handover meetings and this seems to be working well.  This is certainly an important issue as many investigations into serious adverse incidents have found barriers to escalation and hierarchies to be part of the problem.

Communicating with the media

On Wednesday evening the review team met the RQIA Chief Executive for dinner.  We had an interesting discussion about the challenges of communicating with and through the media.  They are taking an increasing interest in healthcare which provides an important opportunity for scrutiny and public accountability.

Thursday

Mind-boggling sums of money

The meeting with Belfast Trust on Thursday morning began with some fascinating statistics to give us an idea of the size and scale of the organisation.  Belfast Trust has a turnover of approximately £1.2bn per year.  A mind-boggling sum of money.  Approximately 42% of this budget is spent on acute care.

Moving from a focus on beds & buildings to a focus on patients & pathways

The Medical Director, Dr Tony Stevens told us of the infrastructure challenges and trying to move from a focus on beds and buildings to a focus on patients and pathways.  This is another new concept as we try to modernise our healthcare system.

The challenges of moving to 7-day working

Dr Stevens also cited the challenge of moving to 7-day working and I know that this is going to be one of the big changes in how our healthcare system works.  The challenge will be changing the culture for many staff who are used to working Monday to Friday.  Financing 7-day working will also be a challenge – adding 2 days to the normal working week represents a 20% increase and many staff contracts provide enhancements for out-of-hours and weekend working.

After the Belfast Trust meeting we returned to the RQIA office to start synthesising all of the information collected during the review and distilling the key recommendations and examples of good practice.

Friday

Patient experience at nights & weekends

On Friday morning we reconvened to work on recommendations for the report.  One of the topics covered was patient experience out-of-hours and there was much spirited discussion about how we can measure and improve the patient experience.  There is a need to focus on a patient-centred approach – thinking about the needs and wants of the patient and how to deliver a service that meets these rather than working within rigid professional and organisational boundaries.

From ward to board and board to ward

Another fascinating discussion was around how the Boards of organisations can identify key priorities and decide what to pay attention to and dedicate resources to.  And also how boards can measure and monitor what is happening in their large, complex organisations to assure themselves that the organisation is delivering safe, effective, quality care.  I expect this will be an on-going challenge that Boards are always striving to improve.  There is no finish line.