Clinical Systems Improvement
in NHS Hospital Trustsand their PCTs
- a snapshot of current practice
Mr Paul Walley
Ms Juliet Rayment
Prof. Matthew Cooke
October 2006
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Commissioned by the NHS Institute for Innovation and Improvement
Executive Summary
Introduction
This report summarises the findings of a survey of Hospital Trusts and their PCTs in England,
based on a limited qualitative semi-structured interview based study. The survey assesses the
level of use of evidence-based operations management techniques, Clinical Systems
Improvement (CSI). Sites were chosen using a stratified sampling method based around
length of stay for two common treatments, to obtain a sample of organisations representative
of medium-sized or large Trusts in England. 19 Trusts and 10 PCTs participated in the
survey, which in most cases involved a semi-structured telephone interview with one senior
manager with local responsibility for process improvement or performance management.
Key Findings in Acute Trusts and PCTs
Neither Acute trusts nor PCTs studied have clinical systems improvement culture or
techniques embedded in their organisations.
Strategy and improvement are poorly linked in most organisations
Financial pressures and targets are the main drivers of strategy. Improvement therefore
focuses on cost saving rather than quality. In PCTs there is also strong focus on
keeping people in the community.
Foundation trusts exhibit the greatest freedom in developing their own strategies
There appears to be goodwill in working between Acute trusts and PCTs but these
relationship are mostly based on specific projects. PCTs view the relationship more
optimistically.
The infrastructure for improvement is highly variable with only top performers having
it embedded in the organisation and their staff. Many organisations in both Acute
Trusts and PCTs have a service improvement team but this is often small
Most service improvement is very focussed and tends to look at areas where there are
targets
Use of CSI tools and techniques (e.g. PDSA, process mapping, SPC, lean thinking,
theory of constraints, capacity and demand management) is highly variable and is
mostly project based but increasing use of SPC in routine reporting was seen in PCTs
The best performers seem to exhibit the following characteristics;
oStrong leadership that is able to implement difficult and sensitive change
oSenior managers with a high level of awareness of the process and systems
issues that they face
oA workforce that is receptive to new ideas or lacks “change fatigue”
oStrategies that are policy deployed, to reconcile conflicting priorities and
tensions between short and long-term improvement pressures
oA critical mass of people trained in the use of improvement tools and
techniques
oA management style that is able to harness staff-driven process improvement
Command and control styles are still common and can obstruct engagement of front
line staff in service improvement
Methods of knowledge transfer are still based on traditional techniques and rarely use
interactive learning. Both PCTs and Acute Trusts rarely mentioned staff involvement
as a means of communication.
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Key Recommendations for Acute Trusts and PCTs
The most successful Acute Trusts have clear leadership that provides a foundation for
sustainable improvement rather than crisis management. This best practice needs to be
cascaded to middle-ranked Trusts, to close the gap in practice. This may help to reinvigorate
service improvement. The top-performing Trusts have clearly demonstrated that it is possible
to develop an improvement capability that justifies the investment in people and processes
that CSI requires. Similarly PCTs have very variable practices and best practices need to be
shared.
In our opinion, the NHS Institute strategy needs to recognize that many Trusts still have the
potential to realise additional quality and productivity gains from CSI and process redesign.
Much of the work conducted by the NHS Institute should focus on this group of Trusts.
Initially we recommend that all Acute Trusts and PCTs should establish service improvement
departments with a core of CSI trained individuals to promote the techniques and help support
service improvement initiatives. Communication is key to the success of CSI; the NHS needs
to look at how it can transfer knowledge more efficiently and effectively
CSI techniques should be further adapted to the healthcare environment to promote and
facilitate their uptake
Clinicians and managers need access to CSI expertise to support their service
improvement projects
Increased awareness of CSI and its advantages is required by senior managers and policy
makers
Increased usage of CSI techniques in commissioning by PCTs may help the organisations
and also help spread the message of the advantages of this approach.
UK based case studies of successful CSI implementation are required
An educational programme in CSI should be developed for NHS clinicians and managers
to allow a continuous development of knowledge and skills from initial training to expert
status
Leadership and team working need to be incorporated in to future training
A programme to disseminate best CSI practice should be established
CSI needs more exposure in academic and health journals
Conclusion
Clinical Systems Improvement is being slowly adopted by the NHS with examples of
consequent improvement in cost, quality and timeliness of care. There is a need to develop
both local and national strategies to improve understanding of these techniques. At local level
service more training and access to experts is required. At national level appreciation of CSI
but also appreciation of the potential contradictory effects of some policy needs to be
increased.
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Contents
Executive Summary…………………………………………………………...2
1. Introduction ……………………………..……………………………… 6
2. Research Methods………………………………………………………. 9
3. Results from Acute Trusts………………………………….…… ……..11
3.1 The current improvement focus of the Trusts......................…..…11
3.2 The impact of Trust strategy on improvement………………..… 13
3.3 The role of the PCT in directing or engaging in improvement
with the Trust…………………………………………………….14
3.4 The structure of service improvement in Trusts………………... 17
3.5 The types of service improvement projects implemented….……19
3.6 CSI tools and techniques used by the Trust………………. …….20
3.6.1 Process Mapping………………………………………… 21
3.6.2 Plan, Do, Study, Act………………………………………22
3.6.3 Queue management………………………………….……22
3.6.4 Understanding Demand…………………………….…….23
3.6.5 Statistical Process Control……………..………….......…24
3.6.6 Lean Thinking and Theory of Constraints..………............24
3.7 Management style………………………………………….……25
3.8 Spreading best practice and internal communications……….…28
3.9 The benefits of CSI working………………………………..…..29
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4. PCT Results…………………………………………………………….32
4.1 PCT Improvement Focus………………………………………...32
4.2 Strategy and Improvement…………………………………….....34
4.3 Joint Working………………………………………………….....34
4.4 The Structure of Service Improvement…………………………..37
4.5 Use of CSI Tools………………………………………………....38
4.6 Communication…………………………………………………..41
4.7 Benefits of CSI…………………………………………………...42
5 Conclusions……………………………………………………………..44
6. Limitations of the study…………………………………………………47
7. Recommendations………………………………………………………48
Future CSI Training and Development needs……………………49
Funding…………………………………………………………..51
8. Appendices……………………………………………………………...52
8.1 Appendix A: Acute Trust interview question guide………….….53
8.2 Appendix B: PCT interview question guide……………………..62
References……………………………………………………………....65
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1. Introduction
In a May 2005 report, the NHS Chief Executive stated that “service redesign and innovation
is now widespread”I, is “starting to take effect” and that he was “seeing good examples of
local innovation and leadership”. In December 2005II he re-iterated “how important it is to
innovate and to reform the system” and stated an aim to “make innovation more widespread
and support this for the future”. This report focussed on new systems and benchmarking
rather than infrastructure to support improvement and embed it in the system as a
methodology for improving quality and productivity.
Recent events in the NHS have highlighted the large increase in income with relatively small
increases in productivity. Whilst waiting times are decreasing, there are still marked
inefficiencies in health delivery internationally e.g.
Most developed countries report that one in ten patients will suffer harm whilst
in hospital. 50% of these patient safety incidents could be avoided if lessons
had been learnt from previous incidents. Poor communication of learning is a
major problem. [NAO reportIII]
A recent report by REFORMIV highlighted the negative effects of centralised
medical manpower planning, a focus on quantity rather than quality and a total
lack of regard of cost and economics. It criticisms are of waste such as the high
levels of sickness absence and low morale compared to other sectors.
A Kings fund report has highlighted the lack of change in working practices
associated with the extra expenditure on the new consultant contractV
A large study in US healthcareVI concluded that the “defect rate” in the
technical quality of American healthcare is approximately 45%
High rates of patients not attending appointments
Cancellations of operations
Widespread duplication across organisational boundaries
But many examples of improved efficiency have also been cited
Reducing spending on agency staff saving £78milion
The effects of the GershonVII report, resulting in savings of £1.7bn through
initiatives such as reducing the average hospital length of stay;cutting
treatment costs; increasing day cases; improving proactive care of patients;
reducing levels of staff sickness and renegotiating national procurement
contracts.
Clinical Systems Improvement (CSI) is evidence based operations management for
healthcare. The techniques used have been implemented in manufacturing and service
industries for many years and have been one of the most important factors in improving
productivity. Small pockets of CSI implementation are known to have occurred in the NHS
and have resulted in similar benefits, but the uptake across the whole NHS is unknown. If CSI
was adopted across the whole NHS then it is likely billions of pounds of benefitsVIII and major
quality improvement could be realised.
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CSI teaching aimsIX to enable staff to:
Understand the relationship between strategy formulation and continuous
improvement activity;
Understand how they can help devise consistent performance measures that
support sustainable improvement;
Enhance quality measurement and improvement systems;
Facilitate the design of new service processes;
Create a vision for incremental redesign activity;
Consolidate a process-based view of healthcare delivery;
Help develop more effective medium-term capacity plans;
Educate others in the basics of CSI techniques.
Clinical Systems Improvement (CSI) can be described as evidence–based operations
management for healthcare. This term is used to describe a body of knowledge adapted from
systems engineering, psychology and other disciplines to improve health systems and clinical
processes at the heart of service delivery.
CSI encompasses generic improvement methods, such as lean thinking, six sigma, theory of
constraints, reliability and safety engineering, as well as context specific improvement
knowledge such as reducing hospital mortality, improving emergency flows in hospitals, and
increasing productivity on wards and elsewhere.
The concept of Clinical Systems Improvement was developed by the Improvement
Partnership for Hospitals (IPH) as a major component of the learning programme. It built on
pioneering work of Modernisation Agency programmes such as the Cancer Service
Collaborative and Emergency Services Collaborative. CSI was seen as the strategy for
improving performance at clinical team or ‘micro-system’ level, and IPH also contained a
major Organisation Development strategy to help create a receptive context within
organisations (Figure 1: The IPH approach).
A Learning Programme was a substantial element of IPH, and as an important component of
this Learning Programme, staff from the Medical and Business schools in Warwick
University were commissioned to develop and run a 5 day training programme for
Improvement Leaders. 9 courses were run, each with 30 participants, over a period of almost
2 years. Most of the 270 participants were staff from acute trusts, but some SHA staff and
national improvement leaders also attended.
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This survey was commissioned by the NHS Institute for Innovation and Improvement (The
NHS Institute) to provide a snapshot of current practices within the NHS in England (in this
case, looking at Acute and Primary Care Trusts). The following aims and objectives were set:
Aims
1. To understand current capabilities of acute and primary care trusts in clinical systems
improvement
2. To inform a strategy for enhancing the CSI capability in the NHS in both service
provision and in commissioning
Objectives
To assess for each NHS organisation studied
1. The focus of the organisation
2. The use of service improvement techniques and tools
3. The service improvement structures
4. The role of management in service improvement
5. The types of SI projects undertaken
6. Methods of spreading knowledge
7. Achievements of service improvement
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2. Research Methods
A stratified sample was produced using a list of Acute Trusts, graded by length of stay as a
proxy for Trust performance, for UTI and hip replacement as examples of medical and
surgical streams (data from Dr Foster), so as to obtain a sample representative of all Acute
Trusts.
After listing Trusts in ascending length of stay, every 15th Trust was selected down the list,
discarding those Trusts with a significantly low procedure rate and replacing them with the
following Trust in the list. This ensured that the sample contained a representative sample of
high and low performing Trusts. Trusts were placed in alphabetical order within each stream
and every other corresponding local PCT was chosen down the list giving a total sample of 22
Acute Trusts and 11 PCTs. One PCT and three Acute Trusts were not available to participate.
Each Trust was contacted through the Director of Operations or equivalent for Acute Trusts
and Head of Commissioning or equivalent for PCTs with the option to refer to a more
appropriate respondent within the Trust. Although the title of the individual varied, we always
requested to interview the individual with Trust wide responsibility for service improvement.
The timescale of the project prevented cross tabulation within organisations by undertaking
multiple interviews. Semi-structured interviews were carried out over the phone with the
following people and tape recorded with permission: The structure of the interviews is
enclosed as Appendices A (Acute Trust) and B (Primary Care Trust)
Acute Trusts
Director of Service Improvement/SI Manager 7
Director of Operations or equivalent 5
Director of Performance or equivalent 4
Director of Planning or equivalent 2
Chief Executive 1
TOTAL TRUSTS 19
Response rate 19/22 (86%)
PCTs
Director of Service Improvement 3
Director of Commissioning and/or Modernisation/Planning 3
Director of Service 2
Director of Policy and Redesign 1
Chief Executive 1
TOTAL 10
Response rate = 10/11 (91%)
All participants were informed of the steps taken to ensure confidentiality and were given the
opportunity to ask questions. The interview was semi-structured based on a questioning
schedule (Appendix A&B). This schedule was developed by the research team in conjunction
with the service transformation team of the NHS institute for Innovation and Improvement.
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All interviews started with open questions to allow the interviewee to freely express their
views. Closed questions were only utilised to clarify specific areas that were not answered in
the open discussions. All interviews were transcribed. Thematic analysis of the data according
to assigned criteria and a four-point maturity scale was undertaken. This scale was based on
the framework:
1 Minimal uptake
2 Some uptake within the organisation
3 Localised to parts of the organisation
4 Systematised across the organisation
The exact nature of the score was modified according to the question and is described with
each table. The maturity was assessed by one of the authors for each organisation.
Interviewees were asked questions about the following topics:
1 The Current improvement focus of the Trust
2 Impact of Trust strategy on improvement
3 The Role of the PCT in directing or engaging in improvement with the Trust
4 The Structure of service improvement in Trust
5 The types of service improvement projects implemented
6 CSI tools and techniques used by the Trust
7 Management style
8 Spreading best practice/internal communications
9 Examples of Benefits of CSI
10 Messages to the NHS Institute
PCTs were asked similar questions, but with attention paid to their possible dual roles of
commissioners of care from Hospital Trusts and as providers of care within communities.
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3. Results from Acute Trusts
3.1 The current improvement focus of the Trusts
Table 3.1 below details the main focus of improvement effort at each of the Hospital Trusts in
the survey using the maturity scale:
Scale 1 No mention or engagement in this improvement priority at a strategy level
2 Some mention but not the main focus of improvement
3 A key element of the improvement focus
4 The dominant and most important improvement objective
Table 3.1 The Improvement Focus of Hospital Trusts
Trust Govt.
Targets in
general
18-week
target Financial
stability “Hotspots”
e.g.
diagnostics
Other/Notes
11 1 4 1 PFI
24 2 1 3 A&E/diagnostics
33 1 2 1 Managing public
expectation
44 2 2 2 None
54 1 1 2 PbR/LoS
62 1 4 1 Turnaround team in
71 1 4 1 3 sites, 2 underperforming
81 1 3 3 PbR/Tariff
92 2 4 1 Labour cost, HR Focus
10 1 2 1 1 PFI
11 1 1 4 1 Labour cost
12 4 1 3 1 PFI
13 1 1 4 3
14 1 1 4 1 Focus on finance
15 1 3 1 4
16 4 2 1 3
17 1 4 1 1
18 2 2 4 3 (A&E) Trust in real trouble
19 1 1 4 1 Rural Trust spread thinly
Inevitably, partly due to the timing of the survey at the end of the financial year and in view
of recent highly publicised events relating to the NHS overspend for the financial year, many
respondents stated that the main improvement focus concerned the Trust’s financial situation.
Two Trusts were subject to a recovery team, with a further one awaiting recovery.
The biggie for us is the financial challenges that we are facing here (in the
future).[10]
Finance, finance, finance, finance. [19]
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“The financial pressures are not just within our trust they are across the whole health
community.” [11]
Payment by results (PBR) and the tariff system got some blame for the financial situation.
Trusts were finding it quite difficult to adapt to the new approach.
“We’re finding it very different since we’ve been on PBR.” [5]
The pressures to improve come from all the national policies that are in place so
everything to do with tariff and Payment by Results means that we’ve got to improve
our services to make sure that we’re operating at or below tariff …we’ve got to be the
hospital of choice [8]
“We’re basically looking at performance against tariff in specialties and then
targeting specialties where they’re significantly over on the tariff.” [5]
The main criticism was that the tariff system is relatively crude, with “easy” and “difficult”
cases sometimes attracting the same payment. There was some recognition that the financial
pressures were a distraction and tended to discourage sustainable process improvement:
“I think it would probably be fair to say that a lot of the emphasis so far has been on
what I would describe as ‘slash and burn’” [19]
One Trust without financial pressures saw how this allowed other improvement activity to
take place:
“I suppose it is slightly different here with it being a relatively solvent hospital – so
that takes the pressure of that so you are touching on other hot spots. [15]”
Many other Trusts identified Government Targets as the main improvement focus. There was
general frustration with the need to achieve targets or other interventions and they were
clearly regarded by some as acting against Trusts’ and patients’ best interests:
“The organisation was…very distracted from the delivering for patients.” [6]
“How do you actually get the resource and the time to change things while you’re
trying to deliver targets at the same time? [16]”
In particular, the emergency care target was one repeatedly mentioned as a cause for concern:
“Emergency care that’s just by far the biggest absolute massive red light, [the] entire
executive team [is] involved almost on a daily basis and I certainly am. [18]
“The biggest one is the emergency bed pressures where we are still struggling with the
4 hour target”. [2]
Again, there was frustration with the imposition of the target and a lack of perception of value
of the purpose of the target:
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“We do have to question that the amount of time and energy that goes into chasing this
one area of performance [the four-hour wait] is substantial and it is still a struggle for
us. So despite the very close attention that gets paid to it then we are still struggling
with it, fundamentally something is not quite right. [9]”
However, there was increasing recognition that the problems seen in achieving the target was
down to system behaviour, rather than A&E performance:
“In terms of the last couple of months performance around A&E that maybe we just
have not got our systems set up right here.” [9]
“Due to big capacity, often having no empty beds and patients in A&E needing
admission. Deep pressure there around managing discharge and managing patient
flows in general.” [2]
Few interviewees stated a strategic vision as driving the improvement. Instead, where Trusts
were not tackling finance or targets, interviewees selected “hotspots” as improvement themes.
For example:
“The two top priorities for redesign are now CT and social service discharge.” [2]
The overall impression was that finance, targets and specific problems led to fire-fighting
individual issues rather than focussing on a longer term strategy. This has led to patchy use of
service improvement within organisations.
3.2 The impact of Trust strategy on improvement
There was very little evidence of policy deployment of strategy. Instead, improvement was
either thematic (i.e. focusing on national initiatives such as cancer or radiology) or was driven
by the Government Agenda. Even the most ambitious Trusts couched their improvement
strategy relative to Government targets:
“As an organisation we have an ethos that we will do better than the national
targets”. [5]
The quest for Foundation status emerged as the other agenda-driven link between strategy and
improvement. Some managers used the Foundation Trust checklist as a guide for
improvement, something that was seen as a good approach:
“The rigor associated with the FT application has really forced us to look at our
activity and expenditure.” [9]
However, some Trusts appeared to have considered the links between strategy, policy and
care:
“[The Trust] has an over all strategy and a vision for the next five years”. [10]
I did a number of seminar things about six months ago which were all about trying to make
sense of the world. And getting people across the organisation to understand the strategic
context that we were operating within. And understand the policy reform agenda and to try
and make some linkages where linkages clearly did not exist. [3]
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Other linkages were either ad hoc or came from initiatives:
“Our Chief Executive does corporate objectives and service improvement is in every
manager’s objective and we expect to see a lead in all our directorates in service
improvement.” [5]
“So I have all my managers that will be looking at service improvement and new ways
of working looking at the ten high impact changes.” [10]
Table 3.2 identifies the qualitative links between Organisation Strategy and Improvement.
Table 3.2 Strategy and Improvement
Trust Comments on Strategy
1Strategy dominated by PFI. Improvement driven by need for profitability.
2Strategy driven by a few key people. Trust engaged in large-scale redesign.
3Clear understanding of wider strategic context; currently working on
understanding links between this and provision of care.
4Major improvement projects are policy deployed. CI just happens.
5Strategy mainly about Govt. targets
6Trust strategy driven by improvement activity which is thoroughly embedded
7Major improvement project structured around 5 work streams linked to strategy
8Improvement strategy based around national themes, Cancer, A&E, ISIP
9Improvement projects around national themes
10 No comments recorded
11 Improvement driven by internal “recovery team”
12 PFI is driving new models of care with elective specialities as the focus
13 Board-driven improvement around high improvement potential (high cost)
process streams
14 Dominated by cost-saving measures, particularly from PCT
15 Board-driven themes
16 Improvement driven by Foundation Trust diagnostic tool
17 Links between current ad hoc approach and strategy being developed
18 One of the country’s worst performers with brand new board to turn it around
19 Severe financial difficulty is threatening service improvement activity and jobs
The role of an organisation wide strategy appears limited. National priorities seem to
dominate the planning process rather than having a higher level strategy for the organisation
which independently also achieves national priorities and targets as well as local priorities.
3.3 The role of the PCT in directing or engaging in improvement with the
Trusts
Interviewees from Trusts were asked about the relationship between the Trust and one of the
local PCTs. Table 3.3 records the opinions of Trust staff on the level of joint working with
the PCT to effect improvement to the delivery of hospital-based care and related community
support.
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Table 3.3 Trust and PCT levels of Joint Working
Key 1 Joint working on required areas only
2 Specific projects
3 Work together
4 Plan together
Trust Score Comments
11 Not joint working
21 Trust excluded from local transformation board as FT; difficult relationship.
32 Working with PCT on integrating strategy but not an harmonious
relationship.
41 Mainly annual planning process
51 Mainly national targets
63 Recent change to joint working and planning in several areas
71 Tend to set up separate projects, keeping in community
81 Target orientated
91 Target and keeping out of secondary care
10 2 Admissions avoidance
11 1 Avoiding admission. Question not asked specifically
12 2 Lot of joint projects
13 1 Given plans not jointly developed
14 3 PCT financially stretched – work closely to manage finance
15 2 Mostly target but some admission avoidance joint working
16 1 Performance management
17 1 Target orientated
18 2 Develop whole system maps but focussed on trouble areas
19 1 Performance management style
The vast majority of acute Trusts consider that PCTs are only involved in service
improvement in areas related to targets or financial savings.
“[The PCT] will put pressure on in terms of meeting targets so for example when we
breach the four hour A&E target because that’s part of their old star rating with their,
you know, the new Health check ratings, they get penalised for that as well; so where
it directly impacts on them as an organisation relating to targets then yes pressure
will be put upon us on that but other things generally not”. [8]
“I think the PCTs generally are feeling under some pressure in terms of what money
they have actually got to commission. What they can reasonably do. And I guess we
are just in the annual cycle of can we drive more out of the acute sector, we are
working at full pelt”. [9]
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Relationships were also affected by the financial state of either party:
We have just heard that our PCTs have run out of money so they stopped
commissioning elective work in January – theatres are empty and people are
twiddling their thumbs for two months – what the hell is that all about? [3]
There was little mention of PCTs encouraging service improvement approaches within acute
Trusts. Trust managers did not perceive PCTs as capable or willing to deliver the required
system changes:
“[The PCT] just take the traditional [approach] – your problem you do something about it”.
[15]
“They do not have a strategy to reshape the system”. [19]
“hands off”. [18]
“In terms of improvement work … there is quite little collaborative improvement
work”. [2]
“There is no direct involvement of the PCT as a consequence of the Foundation
status”. [4]
There were a few exceptions to this, where some collaborative working was reported:
“We are working very closely with our local Primary Care Trust and also other local
trusts to redesign care pathways and redesign how care is provided”. [11]
“We’re doing things like we have a massive workshop next Saturday with all our
partners”. [18]
“We have been talking to our PCTs…because we have seen an increase in referrals
when … should have been seeing … a reduction. [9]
The above comments show the transactional nature of the existing relationship. The two
organisations generally communicated for two main reasons: to negotiate contracts and to
highlight real problem areas requiring attention:
“In admission avoidance and dealing with appropriate admissions rather than just
bringing patients in”. [10]
Many feel that PCTs are working more along a performance management route than via
service improvement. Some work is apparent around avoiding hospital admissions but the
driver appears to be financial saving rather than added value and quality. Organisations who
have reached rock bottom have had the opportunity to change their relationships with PCTs
but are in the early stages of this change.
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3.4 The structure of service improvement in Trusts
Interviewees were asked how service improvement roles fitted into the Trust organisation
structure. Table 3.4 summarises these findings:
Table 3.4 Service Improvement Structure
Key 1 None
2 Service improvement activity performed by individuals
3 Dedicated Service Improvement team
4 Embedded process
Trust Score Notes
13
23 Very small team
32-3 Very small team – wide network and improvement well integrated
43
53 1 WTE - others work as a consultancy team though retain line roles
63-4 Undergoing transformation of all activity through turnaround team
73
83 Team currently undergoing restructuring
93
10 2
11 1 Lack of resources - awaiting turnaround team
12 2
13 3-4 Moving towards embedding improvement activity
14 2 Team in transition – numbers shrinking
15 3
16 3
17 2
18 4
19 3 Service Improvement seen as dispensable - currently facing job cuts
Few Trusts reported no improvement structure at all, but it was worrying that two Trusts
stated that the costs of improvement could not be afforded. Trusts that lacked the financial
resources to sustain a team, considered them dispensable in times of crisis. In those Trusts
which had not yet been ‘turned around’, resources were currently used for fire-fighting which
withdrew capacity from any kind of improvement activity or planning:
“I have got remnants of [a service improvement team] … it’s probably going to not
exist at all after this afternoon’s executive board because we’re going into head count
reduction mode again.” [19]
“We don’t have anybody and we don’t have any money to do it.” [11]
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Most trusts studied had a small dedicated Service Improvement team which reported to the
Director of Operations or equivalent. The work conducted was planned on an ad hoc basis,
rather than it being part of an improvement strategy:
“We’ve got lots of individuals on different projects”. [5]
“We’ve got lots of sort of individuals running projects but they weren’t connecting, so
we needed to find a way to pool it together”. [5]
“We’ve pulled them together and we call them the clinical redesign group and they
work as a collective… almost as a consultancy within the organisation”. [5]
Where there was a lack of a dedicated team, this was mostly a strategic measure which
encouraged the embedding of improvement activity throughout the Trust.
“Unless you mainstream service improvement you don’t actually integrate the
change”. [18]
“What we’re trying to do … is to get it embedded into the core working of
operations”. [13]
“I have a quite a strong belief that … your management role … involves quality i.e.
quality, service improvement etc … and it’s a belief for most of us in the organisation
is you don’t achieve sustained change unless its part of the ongoing management
team”. [18]
Successful improvement activity without a dedicated team was dependent upon strong
leadership from Executives, and the development of a climate in which individual clinicians
and managers took collective responsibility for continuous improvement. This was most
apparent in those Trusts being run by knowledgeable turnaround teams with a strong vision
for the future:
“Well, while we have this Chief Exec it is embedded as part of the philosophy of the
organisation”. [14]
“I am welcomed into everything and I’m invited into everything so… ‘We’ve got a
problem with readmission rates, can you come and help us, see what we’ve got to do?
... So I just feel that because I’m invited in all the time to help out with things that
that’s kind of an understanding that what we’re trying to do”. [8]
“I wouldn’t say people necessarily would equate some of the improvement with
service improvement. I know that might sound a funny statement. I think that some
people do see … that [as] their day job and I think that’s great.” [17]
The role of service improvement teams is highly variable and was often relying on a few
individuals.
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3.5 The types of service improvement projects implemented
Table 3.5 shows the examples given by Trusts of their current foci in service improvement
activity. Questions on current improvement work were designed to expose whether or not
improvement was driven by targets, mainly consisted of small scale projects in priority areas
or included wider, system-based continuous improvement activity.
Table 3.5 Trust Focus for Service Improvement and Examples of Current Projects
Trust Notes
1Projects based around targets; attempts made to sustain improvement.
2Ultrasound, COPD admissions, reducing length of stay.
3Care pathway development; pathology – use of Lean with LTCs
4Focus on completing projects – project based improvement.
5Wide-scale skilling up of all staff in improvement tools and techniques.
6Wide reaching structural overhaul – systemic improvement creating a culture
of continuous improvement.
7Focus on length of stay, diagnostics, theatre utilisation, outpatients, cancer.
8Cross-divisional work on elective care pathway involving almost all
departments; choose and book etc.
9Projects are target focussed e.g. 18 weeks; but also cross-functional work
along pathways, theatre use, outpatients etc.
10 Pre-op patient pathway; orthopaedics
11 Lots of work on length of stay and emergency pathways. Emphasis on patient
flow through whole organisation but generally project-based work without
significant continuous improvement.
12 Some very specific projects but also improvement across local health
economy.
13 Service improvement is both target and quality focussed.
14 Excellent improvement leadership in financially challenged environment.
Work on pathways and LoS reduction.
15 Acknowledgement of benefits of continuous improvement including early
implementation of Lean.
16 Lots of work on length of stay with an emphasis on redesigning process to
meet targets.
17 Length of stay reduction. Improvement leadership is in transition – moving
to a more systemic approach including enthusiasm for Lean.
18 Significant changes in improvement activity since turnaround began.
Proactive management of targets etc.
19 Patient pathway redesign including modelling and forecasting. Continuous
improvement is not sustained.
Almost all Trusts demonstrated both project-based work and some commitment to
cross-functional improvement activity, although continuous improvement was generally not
well sustained. Projects were commonly driven by targets and constituted one-off
improvement processes with less provision for developing continuous improvement
capabilities within clinical teams. The main examples of integrated projects were in Trusts
with recovery plans or new senior management teams, brought in to turn around bad
situations. These Trusts had the most ambitious improvement plans, but with the least
evidence of achievement as yet due to the ongoing nature of the work.
Page 20 of 65
3.6 CSI tools and techniques used by the Trust
All interviewees were asked about their use of the following CSI tools; responses are
tabulated in table 3.6:
Process Mapping
PDSA (plan, do, study, act)
Statistical Process Control
Lean Thinking
Theory of Constraints
Demand Pooling and Queue theory
Measurement of referral demand
Table 3.6 Levels of use of CSI Tools
Key 1 No use recorded/little use
2 Awareness and partial use
3 Good levels of use
4 Extensive use, probably at top of national practice standards
Trust Process
Mapping PDSA SPC Lean TOC Queue
theory Demand
Measures
13 2 2 2 2 1 1
23 2 3 2 2 3 3
32 2 2 2 1 1 1
43 3 3 2 4 3 3
53 2 3-4 1 2 4 3
63 2 1 1 1 1 1
72 2 2 1 1 2 1
82 2 2+ 2 1 3 3
91 1 1 1 1 1 1
10 2 1 2 1 1 1 1
11 3 2 2 1 1 3 2
12 2 2 2 1 1 3 3
13 2 2 2 2 1 3 2
14 3 3 3 3 3 3 2
15 3 2 2 1 1 2 1
16 3 1 3 1 1 3 2
17 3 2 2 2 1 3 2
18 1 1 1 1 1 1 1
19 3 2 2 2 1 1 1
Page 21 of 65
Figure 3.6 Radar chart demonstrates the average usage score of selected CSI tools:
3.6.1 Process Mapping
Process mapping is a technique of describing processes in terms of how activities within a
process relate to each other, identifying different types of activities and the flow of materials
or people or information through that process. Having drawn the map each activity can then
be challenged in an attempt to improve the process.
Process mapping was the main tool used by Trusts, and the value of the technique was
understood by many. People often saw the team-working and involvement benefits as well as
the analytical properties:
“We like process mapping… it’s a good tool to bring people to talk about the
services”. [5]
“[When process mapping] you can see almost immediately when you start to look at
‘why does it take that long?’”. [9]
In most of the Trusts sampled, only the patient pathways that were part of collaborative
programmes such as Cancer, ESC and IPH have been mapped to any great extent:
“Process mapping … say 50% of the high volume ones. The … more difficult ones –
no they’ve not been done”. [5]
“We did a lot of mapping around scheduled care and journeys through from wards
through to theatre.” [12]
Few people interviewed had used process maps as a communication tool or part of real
continuous improvement. The following comment sums up what many have done:
0.0
1.0
2.0
3.0
4.0
5.0
Joint working
Service Improvement structure
Process Mapping
PDSA
SPC
Lean
TOC
Queue theory
Demand Measures
Management style
Projects
Page 22 of 65
“[Process maps] We keep them filed away.” [10]
One of the issues that may affect their use in the future concerns the fatigue of going over the
same mapping processes repeatedly over time:
I went to see the people to say ‘Who would you like to go along to be involved in the
[process] map?’ and it was ‘Oh we’ve done that before. Do we have to do it again?’
[17]
Overall, it is clear that few of the Acute Trusts interviewed use process maps fully, in a
sophisticated way. However, most trusts studied have found some value in the tool,
especially to create a process-based view of the healthcare system, although process maps
were often limited to individual departments with no mention made of value stream mapping.
3.6.2 Plan, Do, Study, Act
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change - by planning it,
trying it, observing the consequences, and then acting on what is learned from those
consequences. The PDSA model thrives on trial and error. This challenges the traditional
approach in healthcare of detailed planning over a long time period to introduce major
change that is safe, with the risk of excessive risk aversion.
The improvement methodology PDSA has not been embedded in most of the Trusts
interviewed. It is clearly seen as a collaborative tool, for use in programmes. The influence
of the collaborative programmes was clear from the interviews:
“It’s been a big feature of the cancer stuff ... The cancer lead manager’s been really
pushing that.” [5]
The following two quotes sum up the current situation regarding the use of PDSA:
“We have done in the past but we’re not at the moment … We haven’t got anyone to
use them. [19]
“We use[d] those [PDSA cycles] a lot around the emergency care calamities. Not so
much recently but we have done in the past. [11]
The use of PDSAs was associated by many interviewees with the Modernisation Agency
collaborative events and it seems to have decreased since then.
3.6.3 Queue management
There was a lot of evidence of the influence of the Capacity and Demand training on Trust
practices. The top-performing sites had made good progress towards implementation of
queue reduction, especially for out-patient work:
Page 23 of 65
“We virtually stopped a few years ago having referrals to particular consultants and
in many areas referrals come in and are organised according to the shortest waiting
lists.” [12]
“Yes, we’ve got some of the best waiting times in the country, so I think actually you
could actually learn quite a lot from what we do, so … I think you’d be hard pressed
to find something we don’t do. I won’t say that we do it everywhere with everybody
because we don’t, but I’d say 80% of our waiting list practice is exemplar.” [5]
A number of respondents saw a tension between the capacity and demand work and the new
developments through the patient choice agenda:
There’s lots of pooling done but that doesn’t fit comfortably with choose and book.…
When a patient is choosing to come somewhere its generally because they’re choosing
the place and the consultants so when you then say but actually we’re going to put you
in a pool and somebody else will treat you it doesn’t sit very comfortably at all. [8]
We have lots of pooled service clinics like a hernia clinic, a breast clinic, but we also
have… and this has been an active decision as an organisation, we also have named
consultant clinics and we’ve had to do that … our local GPs are kind of insistent on
that, so we try and do a combination of both and so far that’s working for us. [5]
There appears to be a misunderstanding of how Choose and Book, choice, pooling and
capacity and demand can work together. There was no mention of the differentiation between
the choices available, e.g. the hospital, the consultant, the time. For example, for high volume
conditions it is likely that a wider choice will exist and that choice between pools of
consultants who are equally skilled will be possible.
3.6.4 Understanding Demand
Balancing capacity and demand is a fundamental step in achieving optimal flow in a system.
It has been recommended in several situations in the NHS for many years (e.g. matching A&E
staffing levels with patient attendances was recommended by the Audit Commission in 1996X)
There was less understanding of demand patterns and the lack of working with PCTs was
evident, for example,
“We’ve not done enough on GP referral patterns…”[5]
Page 24 of 65
3.6.5 Statistical Process Control
SPC is recognised as a useful technique in healthcare process analysis but has been slow to
be adopted. This may be for many reasons, including its lack of uptake in the specialty of
medical statistics, a reluctance to accept industrial techniques and a reluctance to face the
resulting challengesXI
Overall, the use of SPC was patchy. Some Trusts used it extensively, where local experts had
championed the approach. In other cases, collaborative programmes had been the vehicle by
which SPC was introduced:
“We’ve used it [SPC] ad hoc. It was one of the things that the Emergency
Collaborative brought with them”. [5]
There were mixed reactions from Trust staff to the use of SPC. The popularity was
influenced by the impact it had on local decisions:
“SPC is used extensively within PDSAs and for analysis of system behaviour. There is
some resistance from clinicians where the SPC gives awkward answers.” [4]
Where SPC was used, its unbiased interpretation was valued, even where it sometimes
provided unexpected results:
“She was going to use statistical process control to prove him wrong and actually he
was right”. [5]
3.6.6 Lean Thinking and Theory of Constraints
Lean Thinking is an approach to Operations Management that emphasises the continual
elimination of waste of all types, including an overall philosophy of approach to achieving
this.
Theory of constraints is a philosophy that focuses attention on capacity constraints
(bottlenecks) in an operation.
Despite the publicity about Lean Thinking and the level of application historically via the IHI
and the collaborative programmes, there is only a level of awareness of Lean and no real
evidence of practice. Many Trusts have tentatively looked at Lean as an improvement option
and mainly failed to gain commitment:
“We talk about it but I think Lean it’s too big a culture shift for us to get to at this
moment in time”. [5]
“It’s popped up now and again but I think there’s probably a bit of cynicism [that] it’s
just another management toy.” [19]
I’ve got to get some input into the trust in terms of helping them understand what it is
and what it isn’t. [13]
Page 25 of 65
One Trust claimed to have successfully implemented the Theory of Constraints, as an
alternative approach, but people saw that the same types of issues were often being addressed:
“Theory of Constraints has caused a massive reduction in the number of outliers. [4]
“I have my own personal philosophy on Theory of Constraints and Lean Thinking and
all the rest of it, in that really they’re all the same and …they’re just focusing on
slightly different things”. [17]
Those Trusts that had used Lean tools during collaborative programmes saw difficulties in
their application. There were also worries about the acceptability of the term ‘Lean’:
“We wouldn’t say it we call it ‘Lean Thinking’ because otherwise they’d get upset
but we’re looking at how do you reduce the average length of stay, how do you get
more out of your resource.” [1]
Overall, the tools studied were not used extensively. Process mapping and PDSA were
used by many Acute trusts but not systematically throughout the organisation.
Other techniques were not widely adopted.
3.7 Management style
Interviewees were set a test question about performance target breaches (e.g. the 4-hour A&E
target) to establish the level of “command and control” management within the Trust. Table
3.7 summarises the interpretation of the answers received. It should be noted that the
mentions of A&E performance within the table reflect the nature of the question posed, as
opposed to any undue attention to this target measure specifically.
Some Trusts remain target-driven, or driven by Foundation Trust Status objectives. The
immediate implication was that management style tended to be more centralised or ‘command
and control’:
“A “command and control” situation? Yes, absolutely, and that tends to be around
the key targets”. [5]
“When things start to get a bit hairy, when we are getting away from the targets, it
tends to become more of a “command and control”. [11]
“If we have major crisis management issues, say we had six breaches…we call … a
meeting of all the people concerned with the Chief Executive and myself [18]
“[We’ve] got an escalation system within the organisation, so that once… by
Wednesday of each week, if we’ve had more than fifteen breaches I’m aware of it”.
[5]
Page 26 of 65
Table 3.7 A Summary of Trust Management Style
Key 1 Trust predominantly fire-fighting with a “command and control” management
style
2 Some effort to include appropriate teams in problem-solving initiatives
3 Significantly team-based approach to problem-solving
4 A considered response to target breaches, recognising the wider context and
closely involving teams in developing improvement strategies
Trust Score Notes
12Team based approach to long-term targets, ‘command and control’ on
targets such as A&E.
23
32/3
43
52Little support from SHA to help maintain performance. Emphasis on
“command and control” on borderline targets.
64Understanding of breaches situated within wider context; effort to engage
management with everyday activity in hospital.
72Turnaround project over the past year has shifted management style from
“command and control” to team based back to “command and control”.
83
93
10 2Hourly monitoring – combination of teamwork, resorting to “command
and control” in times of crisis
11 2/3 Predominantly team based approach with “command and control” approach
when under pressure on certain breaching targets.
12 2/3 Zero-tolerance policy on A&E breaches. Commitment to providing
resources for breach management.
13 3 Significant team work around managing relationships within A&E.
14 2/3 Team based with recognition of wider structure e.g. discharge bottle necks
in primary care etc
15 3
16 1
17 2
18 4Excellent example of best practice by new turnaround team. Hands-on
executives with open-door policy.
19 1
Poor performing Trusts were more likely to react with panic to their frequent target breaches
and often micro-managed staff, particularly in A&E, demonstrating a zero-tolerance response
to breaches.
“[A&E] is so nail biting now we are into point nought of percents so it is living
breathing those people who are doing nothing but – the managers are down there it is
performance managed hourly and that is when we’re achieving them”. [12]
“Our managing director yesterday said I don’t want 95% I want 100%... I said
yesterday, you will not get 100%”. [15]
Page 27 of 65
Those interviewed at poor performing Trusts were often critical of this approach but
considered more team-based problem solving to be a luxury that they could not afford whilst
experiencing such significant pressure to achieve financial and performance targets. The
reactive approach was very much in evidence:
“We have bed management meetings twice a day so we would clearly know if there
are any blips” [10]
Most trusts studied demonstrated some attempt to involve teams in addressing target breaches
although the level of team work was inversely proportional to the number of breaches
experienced in any period of time.
A sustained team-based approach was particularly apparent in high performing Trusts with a
history of achieving targets or those Trusts undergoing turnaround, in which a significant
change in management style had occurred over the previous few months.
“It’s…very non-hierarchal the new management, right from the Chief Executive to the
Executives and then outwards it’s very non-hierarchal. The Chief Executive’s got a
very much an open door policy, will go and talk to everybody involved not just the
senior team if you see what I mean”. [18]
“What happened in the past was that any time there were breaches everybody was
panicking, so the first thing to say is it’s not a panic. What we need to do is make sure
that we’re planning. If we know we’re going to have a five-day cold snap, what are
we putting in place to proactively plan for this?” [6]
“It is very much a team approach there. We realise it is not an A&E problem. It is
not even just an organisational problem it goes right across the sub-economy”. [2]
Most trusts studied were making attempts at a team based problem solving approach but many
resorted to fire fighting around key targets. Team based approaches were associated with
higher performers.
Page 28 of 65
3.8 Spreading best practice and internal communications
Interviewees were asked how improvement priorities, improvement activity and achievements
were communicated. A particular focus was the way in which good practice in one area could
be disseminated and potentially therefore replicated elsewhere in the Trust. Table 3.8
summarises these responses.
Table 3.8 Spreading Best Practice
Trust Routesof dissemination in Trust In wider community
1Regular seminars; Monthly magazine; Link to
clinical excellence awards
2Through Clinical Directors
3Awards events; regular lectures; dissemination
through Executives
4Involve staff at all levels; Recognising excellence Local network
5Quarterly quality report; Reports to ops board
6Directorate structures but also via matrons
7In house magazine
8Internal network
9Annual awards; newsletters
10 No comments recorded
11 Newsletter
12 Through directorate structure; team brief via e-
mail
13 Through managerial structure
14 Monthly board report; safety related notices in
canteen; high performing wards have graphs on
display in public areas; quality improvement
events
Public displays in hospital;
public consultation forums
15 Newsletter; Suggestion scheme
16 Team briefing
17 Newsletters; posters
18 Team briefing; newsletter
19 Clinical network team Uses MA collaborative
events as means of
networking
A first look at the qualitative evidence demonstrates the following points can be made from
the opinions expressed:
Most units spread good practice by team briefings and newsletters;
There is some use of awards schemes;
Little mention of spreading by involvement of staff from all levels;
Very little mention of spreading across the wider community outside the Trust or via
networks outside of the Learning Networks, such as the South West London SHA
learning network mentioned by two Trusts.
Some respondents admitted there was a lack of communication, especially now that the
collaborative programmes were no longer happening:
Page 29 of 65
“I think what this trust is poor at is sharing its learning and its innovation externally
– and that is a tension for me at times”. [15]
First generation knowledge management involves the capture of knowledge within the
organisation. There was no site that gave the impression of a systematic approach to this
collection. Individuals mostly had to feed this information up the managerial chain.
Second generation knowledge management looks at how knowledge is created and
disseminated. The NHS appears to have a very simplistic approach to this with relation to
service improvement using traditional methods such as cascade systems and newsletter.
Successful organisations are more organic but many do not appear to recognise the concept
that learning and doing are more important factors in organisational success than
dissemination and imitation. Provoking curiosity to search for existing information is likely to
be a more effective means of spreading service improvement knowledge than simply
providing information on others’ success.
Trusts often struggled to find the people in the right positions to champion change. This
especially applied to clinical champions:
“We’ve got some brilliant champions and we’ve got some laggards like everybody I
think.” [5]
The lack of peer pressure and the lack of evidence of other places persisting is still a potential
cause of failure. There is still a point where people wait for a fad to be dropped:
“‘Oh… here she comes again with another… big idea ... ‘Don’t worry … her balloon
will pop and it’ll pass’, so that was an absolute flop for us.” [5]
3.9 The benefits of CSI working
Most sites were at the early stages of use of CSI tools and techniques. They were asked to
identify improvements that had been made within a time span (of completion) of 12 months.
They were asked for illustrative examples of key issues being tackled and how significant
they perceived the changes have been. Table 3.9 summarises the examples received.
Many sites mentioned work around achieving the A&E target, reducing length of stay and
keeping patients in the community. However many were described in such a way as to imply
they were being managed in a performance management style rather than as a service
improvement project. The examples above are where people have revealed use of service
improvement methodologies. The examples of good practice are limited and diverse in their
areas, implying that the techniques are not widespread in their uptake and may be related to
individuals rather than organisations commitment to them.
Page 30 of 65
Table 3.9 Benefits of CSI and where it has worked
Key 1 Minimal use of CSI in organisation
2 Some use of CSI in organisation
3 Localised use of CSI in organisation
4 Systematised use of CSI in organisation
Trust Examples Score
1Lung cancer A&E 2
2Ultrasound LOS in COPD 3
3Admission
avoidance 3
4cancer EAU project LOS 2
5Unscheduled
care Clinic pooling Loads of
others 3
6Emergency
care Pathology 3
7Pooling
ultrasound
demand
1
8Whole elective
care system Pooling
widespread 3
9No specific
examples just
say lots
2
10 LoS 1
11 Long LOS 1
12 Pooling
referrals Rehabilitation
beds 2
13 Endoscopy 2
14 LoS for COPD Reduced
diabetes
referrals
Reduced
waiting times
for inpatient
diagnostics
3/4
15 ENT A&E 2
16 Orthogeriatric A&E 2
17 radiology Endoscopy 2
18 New proactive
management of
target breaches
Improvement
in cancer
waiting times
2/3
19 Predictive LOS 1
Page 31 of 65
Some people were quite clear that the styles of working associated with continuous
improvement had distinct benefits:
“The way we have achieved change and achieved savings has always been through
service improvement.” [11]
One of the key benefits is the evidence that successful improvement systems provide about
their own worth:
“In Radiology and Endoscopy [improvements have been] very clear… you can see
how their waiting lists have come down…, it’s very clear. We’ve also got good length
of stay reductions we’ve … got graph evidence of that. [17]
It is clear that although most Acute trusts have undertaken some service improvement
projects, the techniques are not widely or systematically used.
Page 32 of 65
4. Primary Care Trust Results
The following section outlines the results of interviews with PCTs. Interviews followed a
similar structure to that of Acute Trusts, in order that conclusions could be drawn which
focussed on the current working relationships between the two types of organisations.
4.1 PCT Improvement Focus
PCT interviewees were asked to identify the main focus for improvement activity. Table 4.1
shows a summary of the themes recorded:
Table 4.1 The Improvement Focus of PCTs
Trust Examples of improvement priorities
21 Improvement activity driven by demands of NSFs
22 Substance misuse; financial savings
23 Finance, outpatients, developing community-based care in a rural area
24 Developing community care
25 Redirecting people out of secondary care; reduction in bed-blocking by elderly
patients
26 Devolution of services to the community; financial savings; ISIP (e.g. focus on
stroke pathways)
27 Increasing district nursing capabilities to support community-based care and
reducing length of stay; reduction in outpatient diagnostics waiting time
28 Previous service redesign superseded by current focus on financial recovery
29 Activity fired by Government targets but integrated into internally driven projects
There were two main drivers for improvement activity. First, Government policy to move
treatment away from hospitals into the community has influenced improvement as
exemplified in Bringing Healthcare to the PatientXII and the White paper on health and care
services in the communityXIII This was linked to work in achieving the standards in the
NSFs, which are linked to government policy
The vast majority of the improvement programmes have been linked to the NSF
activity [21]
Second, there was a clear perspective of local health needs, focusing on specific local issues.
For example, PCTs within mainly rural communities tended to emphasise the availability of
local services and recognised the need to develop out-of-hospital care to a greater extent than
existing capabilities.
One simple example is we’ve now got ambulances taking people to our community
hospital if they’ve got certain conditions so that it doesn’t get taken straight to A&E,
so they actually go into some step up beds at the community hospital. [28]
Yes, we have done a lot of work around sexual health services locally. It was one of
our local priorities as well as a national one and also mental health services…We’ve
seen some real service improvements there. [23]
Page 33 of 65
So we’ve now sort of improved the system in a number of ways by putting new
initiatives in place but also reviewing the sort of processes …Why delays happen in
terms of…older people going into hospital and then ending up in a bed forever. We’ve
done quite a lot of work on that. [24]
It should be observed that as complex, in-hospital care services were not the main focus for
improvement activity, hospital Trusts were not being put under as much pressure by the PCT to
change these processes.
In many cases systems improvement activity was superseded by performance management,
due to the pressure to achieve government targets. Many participants expressed frustration
with the high numbers of measured targets and, like those from Acute Trusts, suggested that
these directed resources away from improving systems and patient care:
The performance strategy of the PCT is of course driven by the Healthcare
Commission… I think a lot of our time has to be geared around meeting national
performance targets and Healthcare Commission assessments. [21]
We’re very keen in this PCT to put process in place if it’s going to make a
difference…that’s why we challenge targets because [we ask ourselves] Is it going to
make a difference? Are we challenging the right things? Are we…actually improving
the quality of care? [25]
So you hit the target because you’ve got to hit it. The fact it makes not a jot of
difference to a patient is neither here nor there. [24]
The continuing conflict between policies is evident in these answers with people wanting to
achieve local services responsive to individuals as in ‘Keeping the NHS Local’XIV, choice
initiativesXV and user involvementXVI but realising the main pressure being related to
achieving financial and other targetsXVII.
Whilst others, in a similar response to those Acute Trusts undergoing FT diagnostics,
acknowledged the potential benefits of targets which focus and motivate improvement
activity:
Whilst having a focus on the sort of 2008 targets particularly sort of access related
ones and that throws into very sharp focus the requirement for service improvement
and new ways of working. [29]
The PCT focus was similarly on financial issues and government targets but there was also
an important agenda around keeping patients in the community and some local issues.
Page 34 of 65
4.2 Strategy and Improvement
Table 4.2 Links between strategy and improvement
Trust Comments on Strategy
21 Effort to connect strategy across whole local healthcare economy
22 Board manage improvement activity
23 No comments recorded
24 Clear links between acute strategy and improvement plans
25 Improvement well integrated into PCT strategy
26 Integrated strategy with emphasis on re-design
27 No comments recorded although PCT appears to be supporting improvement
activity
28 Links weakened by patchy understanding of organisational roles amongst staff
29 Improvement activity mainstreamed within PCT
The responses were inconsistent, with few comments recorded showing direct links between
strategy and improvement. Most PCT boards took an active interest in the improvement
activity going on in the organisation but evidence of an explicit engagement at the level of a
written strategy was sparse. This should not, however, be interpreted as evidence of an
absence of a link but rather suggests that the links between strategy and improvement were
largely informal. In two cases, there was clear evidence of some form of policy deployment:
There’s a clear picture of what we’re trying to do on the north side in particular,
through the sort of acute strategy and again, through the programme board we try
and performance manage that [24]
Q: In your performance strategy as an organisation, do improvement priorities play a
large role in that? A: Yes but obviously it’s about transformation and not about new
investment… The reality is that everywhere is stuck for money and actually we can do
a lot with looking at what needs to change but that’s both a provider and a
commissioner role. [25]
As in acute trusts, there appeared to be poor linkage between strategy and improvement work.
4.3 Joint Working
To compare with the Trusts perspectives of working with PCTs, the PCTs were asked their
opinion of the extent of joint working with the Trusts. Table 3.3 compares the comments
made by PCTs with those of their local Acute Trusts:
Page 35 of 65
Table 4.3 Trust and PCT levels of Joint Working
Key 1 Joint working on required areas only
2 Specific projects
3 Work together
4 Plan together
PCT Score PCT Comments Acute
Trust
Score
Acute Trust comment
21 3 Recent improvement in PCT/Trust
working relationship 1 Not joint working
22 2 Local PFI affecting flexibility in
Acute Trust/PCT relationship
23 2 3 Recent change to joint working
and planning in several areas
24 2/3 Hands-on change management of
challenged acute Trust 2 Mostly target but some
admission avoidance joint
working
25 2 Challenged Trust in state of flux.
Explicit efforts to increase
partnership working
1 Performance management
26 3/2 Enthusiasm for joint working.
Current collaboration is around
existing projects
n/a
27 2/3 Current work on building
relationships whilst helping Acute
Trust be more independent
2 Lots of joint projects
28 2/3 Close relationship with main
Acute provider, no comment made
about other partners
3 PCT financially stretched –
work closely to manage
finance
29 4 Good working relationship 1 Mainly national targets
This was an aspect where much change is taking place. It was recognised that current
relationships were relatively transactional, i.e. focussing on specific transactions in a simple
commissioner-provider purchasing relationship, although PCTs presented a rosier picture of
their relationships with Trusts than the Acute Trusts did of their PCTs. In some cases,
Foundation status of the Acute Trusts also adversely influenced this relationship. One Acute
Trust in particular commented that their local PCT prevented close working, due to its
different legal status:
There is a county transformation board with the CE’s from the different organisations
across the county on it… But we are excluded from the structure apart from emergency
care [because]…PCTs are saying as we are a foundation trust it is not appropriate to
include us because they would not include an independent sector treatment centre [2].
However, most PCTs reported a good, if somewhat inconsistent, working relationship with
their largest hospital trust and in many cases this had improved over recent years:
Page 36 of 65
Part of their [the leadership group]’s role in improvement was to provide an
environment which improvement could be generated and tested out and sustained when
successful so part of their role was to set up a really good relationship… The
relationships vary from being that sort of partnership to being very much more
acrimonious which is a shame. [28]
I think we trust each other. We sort of know each other’s business without crossing
over the line. [29]
In some cases the PCT closely monitored the activity of the acute trust:
We’ve got a performance framework that’s on the intranet that we can see on a daily
and weekly basis so we’ve got a really good idea of what’s actually happening in the
acute trust. [25]
Whereas in other cases the emphasis was on stepping back and allowing the acute Trust to be
more independent:
So for instance, a lot of the moving from inpatient elective to day care selective you
know, we… we were attending the meetings for a while but actually it was quite clear
that most of the issues were internal ones, so we’re quite happy to let the Trust… to
lead on that and just keep us posted really. [26]
[When] we have a degree of work to do where that is joint,…some of the challenges
are actually about recognising what a trust can do independently by itself. [26]
The relationship between PCT and Acute Trusts seems to be reported more optimistically by
the PCTs but still reflects a project based and target based approach to working rather than
working towards an overall pre-agreed strategy.
4.4 The Structure of Service Improvement
PCTs were asked to explain how personnel involved in service improvement fitted into the
organisation. Table 4.4 summarises the responses.
Two models for service improvement structure emerged. First, some PCTs have established
small service improvement teams that operate independently of other functions or roles.
The way I want to structure it is that so we do have this sort of development redesign
team that actually purely do redevelopment design…and they spend some time
working in twos and threes, working on specific projects for a number of days …it’s
just sort of an internal contracting model. [24]
Second, service improvement was seen to be part of the commissioning role:
We do actually have a whole department called service redesign, which is the
commissioning function really – arm of the PCT. [23]
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This may be interpreted that service improvement is mainly about achieving change or cost
reduction to services as part of a negotiation process, rather than active intervention in system
redesign.
Table 4.4 Service Improvement Structure
Key 1 None
2 Service improvement activity performed by individuals
3 Dedicated Service Improvement team
4 Service improvement embedded in the organisation across all individuals
Trust Score Notes
21 3 Four people in SI team
22 2 Large commissioning team involved in SI
23 3Service improvement team (12) part of commissioning etc also work
closely with SHA
24 2 Internally commissioned to work in individual projects in small groups
25 2/3 Moving towards dedicated team internally commissioned to consult on
projects
26 2 Full time SI manager – others retain line roles
27 3 Dedicated team of 7 – plus others brought in for specific projects
28 2 Team dismantled by financial pressures
29 2/4 Emphasis on breadth of improvement by involving all staff
The use of CSI as a cost-saving measure by some PCTs (and Acute Trusts) was contingent on
having managers already well-versed in improvement activity.
One of the things we need to do with this service improvement is two things; we want
to improve services but we want to save a lot of money to put it brutally. [24]
This was in contrast to some of the more challenged trusts who had attempted to save money
by cutting back on improvement staff:
My whole job is quality improvement and again up till relatively recently there were
other people in the trust but again we have been through a redundancy process in the
last year which has lost some of those people [28]
It would appear that service improvement team structure is highly variable. Unfortunately it is
seen by some as an area where cuts can be made when there is financial pressure. This implies
that the organisations do not see a service improvement department that as an area that
improves productivity and therefore required if financial pressures are present.
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4.5 Use of CSI Tools
Interviewees were asked to report on the level of use of common process improvement tools
and comparable holistic management approaches, such as Lean Thinking. Only those tools
that recorded some level of awareness or use are reported in Table 4.5:
Table 4.5 Levels of use of CSI Tools
Key 1 No use recorded/little use
2 Awareness and partial use
3 Good levels of use
4 Extensive use, probably at top of national practice standards
Trust Process
Mapping PDSA Demand
Measures Other
21 2 cross-service
pathway 2 1
22 3 3 2 Lots of
SPC
23 1 1 2
24 3 2 1
25 3 2/3 1
26 3 2 1 SPC
27 3 2/3 1 SPC
28 3 3 1 Some SPC
29 3 2 1
Figure 4.5 Radar plot to demonstrate the average score of usage of selected CSI tools:
0.00
1.00
2.00
3.00
joint working
structure
process mappingpdsa
demand measures
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Most PCTs were familiar with process mapping methodologies and many reported good
levels of use:
With Primary Care the sort of process mapping stuff is the key for us, because one of
the problems is that processes don’t work [24]
We’ve been trying to make sure that when we do a particular service area, that we do
do the process mapping to understand exactly what’s going on at the moment against
where we want to be, because otherwise you can’t make the change. [24]
Some reference was made to the limitations of mapping which focussed on individual
programmes and was not carried out across the local healthcare economy:
Yes in the past there has been process mapping. It has been overtaken by the ISIP
now. So it is very much around looking at individual pathways or specialties where
taking the sort of traditional approach we have done a bit of taking stock and scoping
and then mapped the process. [29]
Process mapping is very much limited to the individual programmes what I think we
are lacking is that helicopter view of what is happening across the whole of health and
social care. [21]
Most PCTs reported that they used an improvement methodology, similar to PDSA, but in
many cases this method was not given this acronym:
I think probably we still do do the PDSA cycle I don’t think we call it that…I think there
is a bit of a tarnished image of the Mod now for whatever reason in the service and I
think people do use those methodologies…But maybe don’t give it the labels that they
once did. [27]
The main surprise was the level of reported use of SPC. It is likely that this was influenced
by courses previously run by the Modernisation Agency, but some local training was also
reported.
Yes, I mean we basically SPC chart all of our contract performance monitoring, so
we’ll SPC chart excess bed day, we’ll SPC chart referrals, we’ll SPC chart not just
collar outpatient activity. [26]
Commitment to the use of SPC was maintained even in the face of resistance from other
agencies:
Some of the difficulties that I have is that the social services for instance seriously
don’t understand it so when we do the SPC they go well ‘why can’t I just do the
average?’, so it sometimes takes a bit of time to get all the partners onboard as to the
benefits of using that sort of statistical analysis. [25]
I think with process mapping and SPC I think people think it’s really difficult and the
things that have been most powerful have been the very simple guides to it. [22]
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The most worrying aspect is the lack of reported use of capacity and demand theory although
this may be either because the work is strongly led by the Acute trusts without PCT
intervention or that the question was not always asked in interviews. If the lack of data does
in fact reflect a disengagement from capacity and demand work in primary care, then this
could have implications for the levels of activity commissioned by PCTs. Understanding of
the demand for services and the capacity of various organisations to achieve this should be at
the core of any commissioning process. Recorded exceptions to this include engagement with
GPs in demand management:
There have been some really good examples there about where people have used
improvement science to actually model on very, very simple things about levels of
demand and numbers of appointments and all of those kinds of things. [22]
Similarly, whilst there was widespread recognition of the benefits of Lean methodologies, no
PCT had yet implemented it widely:
Everybody’s talking about Lean Thinking. I’m not sure they know what they mean
[24]
My background is industry so I’d kind of come across the Lean Thinking stuff prior to
that, but I’d say I don’t think it’s particularly taken hold as a way of thinking or
methodology. [26]
We’ve considered Lean Thinking and we were approached by a company who wanted
to invest in our service [who]… described what a fantastic saving it can do and we
know it can because we do transformation all the time but actually what they wanted
to charge us was £160,000 to do it and that would be a waste of NHS money. [25]
Once again, there is a great deal of variability in the use of improvement tools but it appeared
that SPC in particular was increasing in its usage in PCTs.
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4.6 Communication
Two aspects of communication were assessed. First, interviewees were asked to report on
how best practice was communicated. Second, the extent of communication in the wider
community was studied. They were given the opportunity to describe the range of
communication methods.
Table 4.6 Stakeholder Involvement and Spreading Best Practice
Trust Communication with GPs and Secondary
Providers In wider community
21 GP forum, newsletter Conferences
22 Demand/patient management work with GPs Public consultation forums
23 No comments recorded No comments recorded
24 100% PBC – setting up clinical executive committee No comments recorded
25 GPs on executive committee Quarterly public
stakeholder meetings
26 Professional Executive Committee including
representative GPs are closely involved in decision-
making. Quarterly stakeholder discussion forum on
mental health
27 No comments recorded Website, patient forum
28 GP engagement on specific programmes No comments recorded
29 Certain enthusiastic GPs engaged in inevitably
limited way; local Oscar ceremony Patient forums etc
There did not appear to be a pattern of formal collection and communication of best practice
ideas. Instead, there appears to be a more passive information network that focuses on routine
planning activities and general communication. The communication with stakeholders
appears to be equally passive, despite an obvious commitment to involving both GPs and
patients in improvement activity:
It’s one of our five service principles about involving staff…, it is about involving staff
at all sorts of levels in all sorts of ways and suggestion boxes are just one of those
ways that we involve staff in improving services. [23]
We’ve contacted all GPs and explained the process and asked them to flag up areas
where they’d got a specialty interest, so we’re incorporating them into those
processes. [26]
We’ve done a lot of work with service users around their views on how services were
and how they are now. [23]
It appears from these case studies that knowledge transfer techniques are still very simplistic
in PCTs. There is no evidence of using more sophisticated techniques that are employed in
many sectors now. Similarly there was little mention of the key role of staff involvement in
projects to facilitate knowledge transfer.
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4.7 Benefits of CSI
Interviewees were asked to provide examples of successful CSI-style improvement,
preferably where the work had been completed within the last 12 months. Table 4.7 identifies
the list of answers.
Table 4.7 Benefits of CSI and where it has worked
Trust Example 1 Example 2
21 Emergency Department
performance Physiotherapy services
22 Improving management
of long-term conditions
23 Sexual health Long-term conditions
24 Physiotherapy triage
system - diverting back-
pain out of Acute care
Elderly bed-blocking
25 Length of stay Orthopaedic triage
26 Reduction in admission
rates through support
for district nursing
27 External consultancy on
cardiac care
28 Developing cross-
agency work on
perinatal mortality
Ultrasound queues
29 Re-admission rates in
general medicine
The results show that there is a mix of examples from PCT/Trust joint working and those
focused purely on PCT/Community service provision. The themes are partly influenced by
the performance target agenda, such as work to help with A&E demand. There are also
examples of attempts to reduce the costs of hospital-based care through LoS reduction and
admission prevention. The interviewees did not so much stress the cost aspects of these
improvements, but instead stressed the impact on local availability of services and diverting
patients out of acute care:
We’ve got the award winning orthopaedic triage service where we’ve shifted seventy
per cent of activity into primary care… And that is a really… good evidence of good
demand management. [24]
We’ve now got ambulances taking people to our community hospital if they’ve got
certain conditions so that it doesn’t get taken straight to A&E, so they actually go into
some step up beds at the community hospital [24]
There is evidence that we have made a substantial improvement to care in relation to
patients in particular who have had emergency admissions [24]
Financial issues were an important area for many PCTs. Recent media attention has focussed
on redundancies in the NHS and this was raised by many organisations. However some did
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highlight that service transformation can improve efficiency and so prevent work force
reductions whilst improving quality:
Over the last 18 months we’ve done a massive financial recovery plan and
transformation of services in that we haven’t had to do any massive workforce
reductions. [25]
It is clear that most PCTs have undertaken service improvement projects but that the
techniques are not widely used and the philosophy is not embedded in the organisations.
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5. Conclusions
The following key themes have been drawn from this work:
1. Financial pressures and target achievement are still the main drivers of strategy in
most NHS Trusts. This means that improvement strategies tend to focus more on cost-
saving than quality improvement. The ability of CSI methods to deliver lower costs
through the improvement of quality was not appreciated by some interviewees and
reported to be unappreciated by some mangers in their organisations. There is a lack
of link between global strategy and improvement, which is exemplified by the
withdrawal of service improvement at times of financial constraint;[sections 3.1, 4.1,
3.2, 4.2, 3.4]
2. Foundation Trusts exhibited the greatest freedom to develop their own strategies that
can focus on longer-term sustainability (although the number of Foundation Trusts in
the sample is very small). The more ambitious non-Foundation Trusts tend to develop
strategy that works towards the needs of Foundation achievement or target
achievement. [multiple sections]
3. Most trusts studied and PCTs expressed goodwill and a willingness to work together
to develop an effective healthcare supply network. A few Trusts had developed a
strategic partnership with their local PCTs and were working closely and effectively.
In the majority of cases, the relationship between Trusts and PCTs is currently being
enhanced from a purely transactional relationship towards one of strategic partnership.
PCTs are not always actively involved in Trust-based improvement, other than
changes that occur during the usual commissioning process. There is an opportunity
to further join up the improvement work being carried out in Trusts and PCTs;
[sections 3.3, 4.3]
4. Trust Service improvement infrastructure varies widely and the approach very much
depends upon the individual organisations. The top-performing Trusts ( by star rating)
are at a stage where continuous process improvement mechanisms are embedded in
the organisation, such that CSI tools and techniques are considered part of routine
working practice rather than used only for individual projects. In these cases there is
no need to rely upon separate service improvement departments for incremental
change. We see this as the ideal state that all Trusts should strive to achieve.
Elsewhere service improvement is driven mainly by project-based teams. Some of
these teams are small, but many report directly to board level. These departments
have a useful role to maintain an improvement capability, up to the point where there
is sufficient critical mass of support for people to continue this work on their own
initiative. Consequently, average Trusts without Service Improvement departments
should reconsider how service improvement can be supported and sustained; [sections
3.4, 4.4]
5. Service improvement currently mainly focuses on areas where targets are applied or
on functional bottleneck processes such as Radiology. CSI can add value to the
approach by moving the agenda on from departmental optimisation towards the ideal
state of whole system change; [section 3.5]
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6. Top-performing sites exhibit good practice in their use of CSI tools and techniques.
There are also many other sites that demonstrate good practice, either with specific
methodologies or in some work streams. The use of CSI tools can be summarized as:
All sites have used process mapping and have obtained value out of it
PDSA methodologies were seen to be valuable, but current practice is limited
to top-performing sites. The term PDSA is not used frequently and there are
probably other names that can be used instead (e.g. the “four quadrant
approach”)
Some Trusts have championed the use of SPC and have demonstrated its value
to communicate the behaviour of processes and to assess the impact of process
change in complex systems
There is good awareness of the term “Lean Thinking” and a recognition that it
involves considerable effort to implement the approach successfully
The “Theory of Constraints” is one approach consistent with CSI principles
that was seen to be successful at a research site. It should not be overlooked as
a valuable improvement methodology. It appears to be especially attractive
from the perspective of ease of implementation as it seems to fit more closely
with current management styles
Capacity and demand theory was clearly the most successful CSI practice
within the study. Many Trusts had made significant improvements to waiting
time reductions and capacity yield using the methodology.
[sections 3.6, 4.6]
7. The practice of CSI methodologies was seen to be at different levels across the NHS
Trusts. When cross tabulated to the performance of the Trust by star rating the
following themes were apparent:
A small number of top-performing Trusts have the capability to deliver government
targets within financial constraints through the use of CSI methods. Many of these
will have also gained independence through Foundation status, allowing further
strategic development. These Trusts have an embedded improvement culture that
allows staff-driven process change to create sustainable changes to the performance
capability of the healthcare system. The Trusts provide objective evidence of the
value of CSI practices, sharing a number of common characteristics:
Strong leadership that is able to implement difficult and sensitive change
Senior managers that possess a high level of awareness of the process and
systems issues that they face
A workforce that is receptive to new ideas or lacks “change fatigue”
Strategies that are policy deployed, to reconcile conflicting priorities and
tensions between short and long-term improvement pressures
A critical mass of people trained in the use of improvement tools and
techniques
A management style that is able to harness staff-driven process improvement
Trusts that have historically had a very poor performance record have consistently
appointed new management teams with intention to put them on a fast improvement
trajectory. It will be important to follow-up on the progress these Trusts, to discover
the valuable lessons concerning the implementation of process improvement in
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potentially difficult situations. The survey gained the impression that the calibre of
senior managers in these Trusts was extremely high when judged from their
knowledge of CSI methods and practices in the interviews.
CSI practice is not as widespread in Trusts exhibiting average performance or below.
There is even some suggestion of a reversal in CSI practice, as these organisations
become distracted by financial pressures and target breaches. These sites need to be
convinced that CSI improvement is a practicable way of implementing sustainable
performance improvement in a timely manner. They may find that sites currently
below them will soon overtake them through better use of CSI methods; [all sections]
Figure 5.1 shows an interpretation of the “improvement vector” of Trusts within the
study.
8. CSI requires a management style that allows the engagement of front-line staff in
improvement activity, as a basic principle of the acknowledge concepts behind
philosophies such as lean thinking. Under the present performance management
regime, Trust management style often reverts to “command and control” crisis
management when pressure is applied, threatening the sustainability of change;
[section 3.7]
9. Many Trusts are eager to keep up-to-date with “Best Practice” from within the
healthcare community. The London Learning Network is reported to be a valuable
source of learning that complements the work of the NHS Institute to disseminate
knowledge. Most organisations use very traditional methods of knowledge
dissemination and do not utilise methods to promote engagement and transfer rather
than simple knowledge dissemination. At a national level, the coordination of such
learning would be a valuable service to provide for Trusts, especially those outside of
existing networks;[sections 3.8, 4.6]
Figure 5.1 Improvement Vectors across Trusts
Troubled
Trusts Top
Trusts
Stable
Trusts
???
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10. Across all Trusts, there was very clear evidence of the good practice that had been
embedded by previous Modernisation Agency collaborative programmes such as the
Emergency Services Collaborative and the Improvement Partnership for Hospitals. It
was frequently reported that the techniques had been learnt in these projects and they
then seem to have been applied elsewhere. These programmes were useful for the
ways they structured process-based improvement in practical work streams and for the
extent of training in CSI tools. In our opinion, there was a clear, positive legacy of
these programmes in above-average Trusts. Furthermore, some of these Trusts would
have benefited from an additional 12 months or so of collaborative working to fully
embed this good practice. In many cases, it is not yet too late to help sustain these
gains, if the right external support is provided.[sections 3.9, 4.6, 3.9, 4.7]
6. Limitations of this Study
This study is a snapshot using limited qualitative case studies and therefore has the recognized
limitations of these techniques including;
Only one individual from each organisation
Small sample size
Use of illustrative examples
Subgroup analysis may depend on very small numbers
Measures have been taken to minimize these limitations, such as stratification of Trusts before
their selection. We therefore believe that the results are broadly generalisable across Acute
Trusts and Primary Care Trusts in England. Knowledge of local factors will always be
required to adopt the conclusions of this report in a specific locality. However the authors
believe that the underlying principles and findings should be applicable.
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7. Recommendations
These recommendations combine the results of this study with the pre-existing knowledge
and expertise of the authors in the area of clinical systems improvement and recent literature
in the areaXVIII.
CSI techniques are still only used for specific projects and in varying degrees, there was an
implication that there were still only relatively few staff trained in CSI techniques in the
organisations studied. Other than for the top-performing Trusts where improvement is already
embedded into staff roles, we recommend that Trusts should establish service improvement
departments with a core of individuals trained in CSI who can promote the techniques and
help support service improvement initiatives. We believe that in the longer term, service
improvement needs embedding in the training of all clinical and managerial staff so that it
becomes part of all NHS staffs role to improve the service. Once it becomes embedded then
there will be a realisation that in crisis the techniques are needed more not less. Capacity and
Demand work is core to present changes in the NHS and the existing good work can be
consolidated across the whole system through the integration of Primary and secondary care
demand data.
Service improvement does not only rely on techniques and adopting approaches from other
sectors, it is a whole philosophy. The culture, management style, team working, leadership
and user involvement are all components of successful improvement culture. These need to be
addressed in parallel to the adoption of new techniques in the NHS. Organisations need to
develop their strategies and link these with their service improvement plans. Communicating
good practice and change is undertaken in very traditional ways. We believe that the
development of better knowledge transfer systems, e.g. improvement networks and
knowledge transfer partnerships, is an important next step. The NHS needs to look at how it
can transfer knowledge more efficiently and effectively via such networks and what support it
should provide for them.
The evidence shows that Trusts can become distracted from CSI. Quality needs to be brought
to the fore as the key driver that will not only improve outcomes but also improve the value
for money of the service hence enabling targets to be achieved and financial balance to be
secured. It is clear that most staff, especially important stakeholders such as senior clinicians,
will embrace change that promotes quality as opposed to change that focuses purely on
process efficiency. We believe that the role of CSI to improve quality for patients and to
generate a better working environment for staff can be increased.
It is also important that policy makers are aware of the impact that clinical systems
improvement could have on the NHS. It is important for them to realize that in the short term
that over zealous performance management to focused targets may work against the adoption
of CSI techniques and culture that could have longer terms greater befits in cost, quality and
timeliness of healthcare.
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Future CSI Training and Development needs
i) The top-performing Trusts should be engaged in a structured programme to codify
and then disseminate their best practice. We suggest the idea of “Beacon” sites,
similar to the successful programme in Local Government as one approach. We
support establishing local improvement networks to enable improvement leaders
to share skills, ideas and best practice in order to combat Trust isolation. Isolation
and introspection amongst Trusts has significantly contributed to poor
performance amongst those Trusts undergoing turnaround. The London Learning
Network was cited by those Trusts involved as a successful example of a
supportive partnership that has already facilitated the sharing of best practice in the
South East. Similar models could be developed across the country.
ii) CSI methods can be further adapted to fit the healthcare environment, especially to
use terms and language that engages clinicians more readily. Our experience
suggests that many of the difficulties facing those trying to implement CSI-based
changes within healthcare have been attributed to a lack of a common language
between CSI adapted from manufacturing and that used in a healthcare setting.
We believe that work to start the translation and modification of such tools should
be started as soon as possible.
iii) CSI training courses now need UK-based, modern case examples. Particular care
should be taken to provide examples of out-of-hospital care as this key agenda
item for many PCTs is not currently covered by CSI training materials. Courses
should acknowledge and include the particular and different needs of PCTs as
opposed to Acute Trusts.
iv) We have experienced significant demand for in-house training on CSI techniques.
This allows the development of a local critical mass of trained people and can also
focus learning on local improvement priorities and strategy. Tailor-made local
courses will demonstrate to staff the potential effect of CSI techniques on their
own Trust’s particular priorities and pressures. As a practical step, there is scope
to convert the existing 5-day full CSI programme into a modular course, offering
1-day focused training on specific themes. This approach would retain the level of
content and the integration of material across topic areas, but it could be
redesigned to allow individuals the flexibility to match training to their own
personal needs and availability constraints. Consequently, we would hope that
more senior managers and clinicians would participate in CSI training.
v) For senior managers, there appears to be a need to focus CSI training around
leadership of staff-driven change, the value of process improvement and strategy
and policy deployment to achieve an integrated approach to sustainable system
improvement. Most effective deployment of CSI appears to occur when change
processes are driven from the bottom up. Managers need expert training on
empowering staff at all levels to develop and manage their own process redesign.
vi) Managers need better access to simple, relatively prescriptive methodologies in
some of these areas. We recommend that organisations establish infrastructure to
ensure staff have access to the appropriate expertise to undertake service
improvement projects using CSI techniques. Trust managers and clinicians may
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also find additional training and knowledge support in the following areas to be
helpful, in order to act as a knowledge resource of advanced operations
management techniques:
Demand measurement and Medium/Long-term capacity management
Lean Thinking and the Theory of Constraints
Advanced Process Redesign Methodologies
New Facilities Capacity & Supply Network
Flow and System Dynamics
These advanced techniques will develop on existing skills-bases in order to bring
about further advantages and rigorous system redesign.
vii) In order to increase their external credibility, CSI methods require increased
exposure in academic and other journals. This would help both clinicians and
managers assess the value of the approach and gain necessary additional support.
Clinical Systems Improvement is being slowly adopted by the NHS with examples of
consequent improvement in cost, quality and timeliness of care. There is a need to develop
both local and national strategies to improve understanding of these techniques. At local level
service more training and access to experts is required. At national level appreciation of CSI
but also appreciation of the potential contradictory effects of some policy needs to be
increased.
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Funding
This project was commissioned by the NHS Institute for Innovation and Improvement
The views expressed in this report of those of the authors and do not necessarily reflect those
of their employers or of the commissioning body.
The authors can be contacted at
University of Warwick
Coventry
CV4 7AL
United Kingdom
The report and other related work is available via www.warwick.ac.uk/go/csi
Page 52 of 65
8. Appendices
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8.1 Appendix A: Acute Trust interview question guide
1 The commissioner-provider relationship
What aspects of performance improvement do you discuss with your PCT
commissioner?
a) Cost issues (financial pressures)
In which ways is the PCT measuring perceived cost performance?
How far are you above or below tariff?
Are there specific reasons why cost performance is regarded to be good/poor?
For example: Unit costs
Tariff rates above/below
Management costs
Pharmacy costs
Other overhead rates
Annual cost down targets
Financial stability/Financial reserves
Other
b) Quality
General waste issues
Medical errors
Mortality rates
Thrombolysis
Patient focus issues
Customer Service quality e.g. patient empathy/satisfaction
Admin errors – examples?
Other errors e.g. pharmacy
c) Waiting list targets (speed)
Out-patient delays
In-patient delays
Radiology delays
Pathology delays
Failure to achieve waiting targets
Capacity availability
Temporary closures
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d) Flexibility issues
Seasonal demand factors
Responsiveness
Range of services
Types of service offered/not offered
Staff sickness
e) Dependability issues
f) Appointment cancellations
In-patient cancellations
Cancelled operations
2 CSI
Developing the ability to generate sustained improvement
a) Assessing the prevalence of small-scale team-based improvement activity that uses
evidence to identify the degrees of success of the change
Do you use PDSA? (Plan, Do, Study, Act)
Do you use other problem-solving tools
Do you use simple improvement measures (e.g. quality control, charting, statistical
process control)
Do members of staff work in teams on the improvement? What examples do you have
of group CI activity?
omulti-disciplinary working
osuggestion boxes
oquality circles
oquality improvement teams.
How do teams set goals?
How do teams manage their improvement process?
b) Role of leadership
Who provides CI leadership?
In your experience, how far do managers intervene in response to CI suggestions by
the service improvement teams?
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Do leaders formally recognise improvement work?
oWhat rewards are you getting? – (e.g. pride in your work, public
acknowledgements of successful ideas (rather than pay-related benefits)).
Do leaders lead by example (not dictatorship on bottom-up projects)
What happens when targets are not hit? (blame culture).
3 Understanding the structure of the improvement system
Do you have a service improvement department? How is it structured?
Understanding the service improvement structure in the Trust
a) Inputs
What are the inputs to process improvement?
You are the service improvement manager:
Who you report to?
Who you manage etc?
What is the organisational structure?
oWhere are the people involved?
oIs there a service improvement lead?
oIs there a service improvement department?
oIs the Chief Executive committed to service improvement?
oHave staff members been on process improvement courses?
oDo staff members have specified time to devote to service improvement?
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4 Continuous Improvement
a) Is there a link between the strategy of the organisation and the type of process
improvement?
Are improvement priorities clearly labelled in the performance strategy?
Are strategic objectives used to drive & prioritise improvements?
How far are formal strategies communicated to teams?
oWhat are teams being told about the sorts of changes they are being
expected to produce?
Are changes assessed against improvement priorities?
How do groups measure their progress?
Intrinsic vs extrinsic?
5 Spreading the Word
a) Continuous improvement across teams
Are teams cross-functional?
Do people share a view of the process?
Do you use internal/external customers’ terminology?
Do you have an idea of who your customer is?
Do you engage patients in the CI process as co-producers?
Do you use external consultants?
oIn what capacity?:
One-off improvement processes?
For developing internal capabilities for service improvement?
Have you had a recovery team in? (only ask if they appear to be a poor performing
trust)? Did they help or hinder?
Are there CI representatives at all levels of organisation?
Do you involve people from all levels: porters?
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b) Process Redesign/BPR
What proportion of major pathways have been mapped in depth?
Where are the process maps kept?
oWhere all staff can see it
oIn a process room
oBy the program manager
oElsewhere (does not exist)
c) Improvement methodologies
What kinds of methodologies are being used to improve?
oSPC
oLean Thinking e.g. value stream mapping
Do you know your throughput efficiency?
oTheory of Constraints/OPT
6 Capacity and Demand
What effort has been made to understand the demand?
Do you use activity statistics to assess demand?
Have you researched/understand GP referral patterns well?
Have you done capacity and demand work in terms of queue management?
oWaiting list initiatives? (mostly?)
oPooling demand in new patient clinics/other waiting lists?
oReducing queues in radiology through carve out?
oPooling non-urgent queues e.g. mixed sessions in radiology?
oPooling discharges?
oPooling ward space?
oLoad smoothing elective lists?
Any activity to reduce variation?
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7 Improving the CI system
What CI information is reported to the board? How is it presented?
a) Making changes to the CI system
Recent changes to improvement strategies
Is the improvement system monitored and improved?
Do you have a cyclical planning process for improvement activity?
Do you make a periodic review of CI system?
Is CI sufficiently resourced?
Where does CI fit within the organisation structure?
What changes are assessed for impact upon CI?
b) Walking the talk
Does the leadership style reflect commitment to values?
Is the leadership style command and control?
[If interviewing senior leaders: If you identify a problem, how do you go about
organising the improvement team? Do you set one up? Ask people to volunteer?]
What happens if you have a performance target breach?
oResponse to crises?
oBlame or improvement?
oIs there a shared belief in incremental improvement?
8 Building the learning organisation
Do you capture experiences of successful improvement and translate that into action
elsewhere?
Do people seek out learning opportunities?
Is learning is shared across departments?
Is learning is captured?
Do leaders act on learning?
Page 59 of 65
How is learning communicated?
Is learning part of OD activity
Is CSI mainstream?
9 Outcomes/Outputs
What have been the performance improvement changes in the last 12 months in terms of
cost/time/quality?
Cost
oDo you have measures of reduced unit cost?
Time
oDo you have measures of queue reduction?
oDo you have measures of waiting list reduction?
Quality
oDo you have measures of a change in mortality?
oDo you have measures of an increase in technical quality (e.g. re-admission
rate?)
oDo you have an accuracy rate for pharmacy prescriptions?
Page 60 of 65
8.2 Appendix B: PCT interview question guide
1 The PCT as Provider
What are your current internal service improvement priorities as a provider of
healthcare?
a) Cost issues
Moving in-hospital work into primary care?
Costs of community work?
Demand levels
b) Quality issues
Internal waste
Patient focus
Customer service
Error rates
c) Access/Speed issues
48 hour GP access
Out of hours access
Access to community services
Other
d) Target achievement
e) Other
2 Understanding the structure of the improvement system
a) Who has executive responsibility for service improvement within the PCT?
b) How does service improvement sit within the PCT organisation structure?
c) Is there a service improvement department?
How many people
Are they seconded roles?
What is their background?
To whom do they report?
Have they received formal CI training? If so from whom?
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3 PCT Strategy
Is there a link between the strategy of the organisation and improvement?
Are improvement priorities clearly labelled in the performance strategy?
Are strategic objectives used to drive & prioritise improvements?
Are changes assessed against improvement priorities?
How do groups measure their progress?
4 The PCT as Commissioner
What are the main service improvement challenges for your largest provider hospital
trust?
a) Cost issues (financial pressures)
Are there specific reasons why cost performance is regarded to be good/poor?
For example: Unit costs
Tariff rates
Management costs
Pharmacy costs
Other overhead rates
Annual cost down targets
Financial stability
Other
b) Quality
General waste issues
Medical errors
Mortality rates
Patient focus issues
Customer Service quality e.g. patient empathy
Admin errors
Other errors e.g. pharmacy
c) Waiting list targets (speed)
Out-patient delays
In-patient delays
Radiology delays
Pathology delays
Failure to achieve waiting targets
Capacity availability
Temporary closures
Page 62 of 65
d) Flexibility issues
Seasonal demand factors
Responsiveness
Range of services
Types of service offered/not offered
e) Dependability issues
Appointment cancellations
In-patient cancellations
Probe questions
Are you satisfied with the progress that your provider is making in achieving these
improvements?
To what extent are you actively involved in influencing process change at the Trust?
What are you doing to facilitate that improvement?
5 CSI
Have you used service improvement tools and techniques promoted by the former
Modernisation Agency?
Do you use PDSA? (Plan, Do, Study, Act)
Do you use process mapping?
oWhat proportion of the process flows have been mapped
oWho does this?
oAre the maps visible
oAre they shared across organisations
Do you use other problem-solving tools
Do you use simple improvement measures (e.g. quality control, charting, statistical
process control)
Do members of staff work in teams on the improvement? What examples do you have
of group CI activity?
omulti-disciplinary working
osuggestion boxes
oquality circles
oquality improvement teams.
Page 63 of 65
c) Role of management & GPs
Do managers or GPs participate in CI suggestions?
Does management lead by example (not dictatorship on bottom-up projects)
What happens when targets are not hit? (blame culture).
6 Spreading the Word
a) Do you have CI teams?
Are teams cross-functional?
Do people share a view of the process?
Do you use internal/external customers’ terminology?
Do you have an idea of who your customer is?
Do you use external consultants?
oIn what capacity?:
One-off improvement processes?
For developing internal capabilities for service improvement?
7 Capacity and Demand
What effort has been made to understand the demand?
Do you use activity statistics to assess demand?
Do you use first appointment after GP referral to assess demand?
Have you done capacity and demand work in terms of queue management?
Do your GPs use “Advanced Access” effectively? (What is their performance?)
Page 64 of 65
8 Management Style
Does the management style reflect commitment to values?
Is the management style command and control?
[If interviewing senior management: If you identify a problem, how do you go about
organising the improvement team? Do you set one up? Ask people to volunteer?]
What happens if you have a performance target breach?
oResponse to crises?
oBlame or improvement?
oIs there a shared belief in incremental improvement?
9 Building the learning organisation
Do you capture experiences of successful improvement and translate that into action
elsewhere?
10 Outcomes/Outputs
What have been the performance improvement changes in the last 12 months in terms of
cost/time/quality?
Page 65 of 65
References
IChief Executives Report to the NHS, May 2006. Department of Health, London.
http://www.dh.gov.uk/assetRoot/04/11/03/83/04110383.pdf
II Chief Executives Report to the NHS, December 2005. Department of Health, London
http://www.dh.gov.uk/assetRoot/04/12/43/02/04124302.pdf
III http://www.nao.org.uk/publications/nao_reports/05-06/0506456.pdf
IV A Safer Place for Patients: Learning to improve patient safety National Audit Office, London. 2005.
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VStatement from Kings Fund, London 10th may 2006
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VI McGlynn (2003), The quality of healthcare delivered to adults in the United States NEJM; 348
VII Releasing Resources for the Frontline: Independent Review of Public Sector Efficiency statement
from HM Treasury 12 July 2004 http://www.hm-
treasury.gov.uk/spending_review/spend_sr04/associated_documents/spending_sr04_efficiency.cfm
VIII Osprey - The Training Programme for Clinical System Engineers. Report 2004 – 2006 Programme
http://www.steyn.org.uk/OSPREY.pdf
IX Clinical Systems Improvement Programme http://www.wbs.ac.uk/executive/csi.cfm
XAudit Commission. By accident or design. Improving A services in England and Wales. London:
HMSO, 1996
XI M A Mohammed Using statistical process control to improve the quality of health care. Qual Saf
Health Care 2004; 13: 243-245
XII Taking Healthcare to the Patient Transforming NHS Ambulance Services. Department of Health,
London 2006 http://www.dh.gov.uk/assetRoot/04/11/42/70/04114270.pdf
XIII White Paper on health and care services in the community. Department of Health, London 2006
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PaperHealthCareCommunity/fs/en
XIV Keeping the NHS Local Department of Health, London 2003
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Summary/fs/en?CONTENT_ID=4086065&chk=qBZKnS
XV Patient choice Department of Health, London 2006
http://www.dh.gov.uk/PolicyAndGuidance/PatientChoice/fs/en
XVIEncouraging user involvement in commissioning a resource for commissioners Department of
Health, London 1996
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/Publica
tionsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4003231&chk=OaYAoV
XVII The annual health check in 2006/2007 Healthcare Commission 2006
http://www.healthcarecommission.org.uk/serviceproviderinformation/annualhealthcheck/theannualhea
lthcheckin2006/2007.cfm
XVIII Recent Literature on NHS improvement and innovation, University of Warwick 2006.
http://www2.warwick.ac.uk/fac/med/healthcom/emergencycare/research/sdo/csi2/papers/
- CitationsCitations7
- ReferencesReferences3
- This Italian experience corroborates the literature and experience of change management, continuous collaborative quality improvement actions [24,26,27,28]. It also suggests that the strategy outlined above constitutes an important trigger to improve patient safety as long as the following conditions are met: @BULLET Safe practices are implemented as a tool within a multi-level, large-scale, pluriannual programme.
[Show abstract] [Hide abstract] ABSTRACT: Background: The objective of this paper is to discuss how national collaborative programs based on the dissemination of good practices could effectively improve patient safety and be sustainable. The paper also aims at identifying some cross-system characteristics that would allow for a “safe practice programme” to run successfully. Methods: The quality and safety of the healthcare services provided by the Italian healthcare system to its citizens are very heterogeneous. Therefore, a public agency – by government mandate – instituted a national programme to improve patient safety. The model applied relies on a cyclic scheme for collecting, classifying and promoting the active dissemination of evidence-based safe practices throughout the network of healthcare providers. Results: The Italian programme has been reviewed by the OECD as a key action to improve patient safety as the results are very encouraging in terms of both effectiveness and sustainability. Conclusion: In this paper we use the experience of the Italian Observatory on Good Practices for Patient Safety to corroborate and enrich the literature about improvement programs based on good practices. If specific conditions of responsiveness and accountability are met at all levels, these programs can be successful and sustainable. Furthermore, such programs could be easily adapted to other health care systems.- Considering the long-term effects of quality improvement programmes raises the question of what overall property of the system is affected at the organisation-wide level. A recent review of the UK health system has shown that organisations vary considerably in their capacity for clinical systems improvement (Walley et al., 2006). From a care systems perspective, the outcome of primary interest from systems-level improvement programmes must be the capability for continuous improvement within the organisational health care system.
[Show abstract] [Hide abstract] ABSTRACT: Large-scale national and multi-institutional patient safety improvement programmes are being developed in the health care systems of several countries to address problems in the reliability of care delivered to patients. Drawing upon popular collaborative improvement models, these campaigns are ambitious in their aims to improve patient safety in macro-level systems such as whole health care organisations. This article considers the methodological issues involved in conducting research and evaluation of these programmes. Several specific research challenges are outlined, which result from the complexity of longitudinal, multi-level intervention programmes and the variable, highly sociotechnical care systems, with which they interact. Organisational-level improvement programmes are often underspecified due to local variations in context and organisational readiness for improvement work. The result is variable implementation patterns and local adaptations. Programme effects span levels and other boundaries within a system, vary dynamically or are cumulative over time and are problematic to understand in terms of cause and effect, where concurrent external influences exist and the impact upon study endpoints may be mediated by a range of organisational and social factors.- en to ensure and improve quality and safety, including regulatory activities or increasing the number of personnel or qualification level. TheBoaden et al (2008)review included interventions using the following methods and approaches: Plan-DoStudy-Act cycle, statistical process control, Six Sigma, Lean, theory of constraints and mass customisation.Walley et al (2006)defined clinical service improvement as: generic improvement methods, such as Lean thinking, Six Sigma, theory of constraints, reliability and safety engineering, as well as context-specific improvement knowledge, such as reducing hospital mortality, improving emergency flows in hospitals, and increasing productivity on wards and elsewhe
[Show abstract] [Hide abstract] ABSTRACT: Higher quality is mainly driven by professional reasons, which does not necessarily lower costs- [Show abstract] [Hide abstract] ABSTRACT: Purpose – Data have a critical role in supporting service improvement and this is particularly the case for service improvement to reduce waiting times. The purpose of this paper is to identify some of the barriers managers face in accessing and using data effectively for 18 weeks and then describes how a service improvement tool developed by the NHS Institute can help to overcome these. Design/methodology/approach – A review of the core function of data to support service improvement processes and the development of a national tool to support the transformation of access with the National Health Service in England. Findings – The review of the core function of data identified a range of barriers: access to data for service improvement; the appropriate use of data to analyse the dynamics of variation and therefore for decision making; and the capacity and capability to use data. The size and immediacy of the 18‐week challenge means that a national solution needs to focus on being practical and overcoming some of these barriers. Originality/value – A perspective of the reality of using data for service improvement and using it to transform access to health services.
- [Show abstract] [Hide abstract] ABSTRACT: The study had two specific objectives: (1) To analyse change in a survey measure of organisational patient safety climate and capability (SCC) resulting from participation in the UK Safer Patients Initiative and (2) To investigate the role of a range of programme and contextual factors in predicting change in SCC scores. Single group longitudinal design with repeated measurement at 12-month follow-up. Multiple service areas within NHS hospital sites across England, Wales, Scotland and Northern Ireland. Stratified sample of 284 respondents representing programme teams at 19 hospital sites. A complex intervention comprising a multi-component quality improvement collaborative focused upon patient safety and designed to impact upon hospital leadership, communication, organisation and safety climate. A survey including a 31-item SCC scale was administered at two time-points. Modest but significant positive movement in SCC score was observed between the study time-points. Individual programme responsibility, availability of early adopters, multi-professional collaboration and extent of process measurement were significant predictors of change in SCC. Hospital type and size, along with a range of programme preconditions, were not found to be significant. A range of social, cultural and organisational factors may be sensitive to this type of intervention but the measurable effect is small. Supporting critical local programme implementation factors may be an effective strategy in achieving development in organisational patient SCC, regardless of contextual factors and organisational preconditions.
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