The relentless quest for perfection

North Tees and Hartlepool NHS Foundation Trust is almost unique in England for being a trust of both community and acute services. It also has a major change agenda to deal with in the shape of a new ways of working, playing a major part in the creation of integrated care centres to move services out of hospital and closer to people’s homes complemented by a new hospital with single rooms. The aim is to make the new health care system the envy of the country if not the world. Its mantra is that quality, performance and financial stability go hand in hand.
    
Director of nursing and patient safety Sue Smith, who joined the trust in August 2008, explained: “Like many trusts North Tees and Hartlepool had put finance, by necessity, at the top of the agenda. While we know we’re heading into choppy waters financially there is a shared understanding that quality (including patient safety, patient outcomes and patient experience) is as important as finance and operational performance.
    
“Actually when you think about it, getting it right first time for the patient does mean better performance and the best use of financial resources so, apart from being the right thing to do for patients, it makes sense. That commitment to quality pervades the organisation; people know that quality is everyone’s job and it has paved the way for some incredible ideas and work which is making a real difference to patients and the staff who look after them.”

Ward reviews
By November 2008 Sue had set up a programme of quality review panels. Each month Sue and her senior nursing team get back into their uniforms, split into small teams and visit every ward in the hospital. They use a scoring tool that could best be described as firm but fair.
    
Sue said: “The first thing we look for is almost a gut reaction; do we feel calm, secure and safe when we enter the ward or do we feel ‘get me out of here’. I’m happy to report it’s never the latter.
    
“We score wards on a number of indicators including nursing documentation, nursing care and dress code and one missing observation means a failure in that whole section. We also ask around 10 per cent of the patients on every ward about their experience and ask them to tell us one thing that would have made their experience better.
    
“I think at first there was some resistance and suspicion but now the race to be top has become competitive. We’ve had tears of sorrow when an indicator is missed and tears of joy with the sheer pride of being top.
    
“We’ve adapted the programme and extended it to the community visits and we’re picking up areas which we know we can improve on both for patients and staff.
    
“One of the most important things the quality review panels have achieved is raising the profile of nursing. We’ve had guests with us on our panels including our own chairman; he’s an ex police chief constable and he was staggered at the military precision with which we plan the visits. We’ve also welcomed representatives of the Royal College of Nursing, other nursing directors and – I think very importantly – student nurses who see first hand why we place such importance on getting things right for patients.
    
“What it does mean is I’m out and about a lot and I can see for myself that everyone is on the ball. In the early days I might have had to challenge a clinician who wasn’t following our no tie, bare below the elbows dress code but I must say that hardly ever happens now. I sense that people now get it; they know that everything they do makes a difference.”

Leading improvements
North Tees and Hartlepool NHS Foundation Trust was one of the first trusts to sign up for both the Patient Safety Campaign and the Leading Improvements in Patient Safety programme (LIPS) programme. It captured the imagination of many clinicians because they could see the potential to learn quickly, put things right straightaway and, most importantly, prevent errors and harm to patients.
    
Sue said: “We were lucky enough to be one of the early implementer trusts in the country to take this methodology on board. Clinicians and managers in service areas review sets of notes and look at areas where we could have caused harm using a tool called the global trigger tool. It’s excellent for spotting where things have the potential to start going wrong and we’re already saving lives as a result of using it.
    
“You know you’re getting somewhere when you can win over orthopaedic surgeons. The LIPS programme has done that; it’s turned people who might have previously shown a bit of cynicism to this type of approach into patient safety champions.”

Being open
“One of the reasons I wanted to come to this organisation was its reputation for good clinical governance, including its being open policy. I believe we are a leader in this area and our patients can rest assured we will be open with them, regardless of the circumstances. For example when we had an equipment error in pathology which caused a number of false positive Clostridium Difficile results we informed every patient this had happened,” Sue said.
    
“Culturally this is not the easiest thing to achieve but we work hard to set a the tone of incident and near miss reporting as well as being open rather than a name, shame and blame culture which might have made people less forthcoming in the past when things went wrong.”

Tackling the spread of infection
“We are relentless in tackling C. diff and MRSA and we are very open with our commissioners when we have something to report,” Sue explained.
    
“We’ve toughened up our hand hygiene assessment with the introduction of the new, more complex Lewisham assessment tool. Actually this caused a temporary dip in our compliance rates but it was worth it to raise the bar.
    
“It says something about our staff that while we’ve had outbreaks of Norovirus, we’ve contained it well and had no spread of C. diff. This tells me our nursing, medical, allied health professional and support staff put the safety of the patient first and it makes me extremely proud. We’ve appointed an antimicrobial pharmacist who targets high risk areas and audits our antibiotic prescribing policy.
    
“We’re now reporting our performance on other infections such as MSSA to the board because we’re not content to look only at the infections we’re monitored on. I’m particularly proud of our critical care team who have been using the Matching Michigan tool to reduce infections from central line catheters for critically ill patients. With total engagement right across medical and nursing staff in critical care we’re seeing major improvements.”

Mortality rates
Discovering you’re an outlier in mortality rates (the numbers of patients who die in your hospitals measured against the numbers of patients who would be expected to die) is a sobering thought for directors of nursing and patient safety and medical directors alike. Sue said: “The temptation is to blame the coding and not to lift every stone to make sure there’s nothing lurking underneath.
    
“Working closely with the medical director I’ve looked at this area in detail. Because if the range of patient safety measures we’ve got in place; quality review panels, a wide range of measures to help us tackle the spread of infection, LIPs reviews of patients’ notes, effective clinical governance and an open reporting culture we’ve seen our mortality rates improve dramatically.
    
“Quite rightly the bar is being constantly raised. As every organisation improves we have to keep raising our game but that absolutely the right thing to do for patients and we’re up for the challenge.”

Team effort
It’s all a team effort and never more so in keeping the clinical areas clean and safe. Director of operations Kevin Oxley and his team work closely with Sue and her team on all aspects of the clinical environment.
    
Kevin said: “Our design team has patient safety at the top of its agenda when refurbishing areas. They understand the importance of safety and cleanliness and design these features in, working and consulting with clinical staff.
    
“Keeping it clean is as important as designing it clean. We’ve been fortunate in bringing in some innovative practice to help us stay at the top of our game. We’ve bought five hydrogen peroxide vapour machines, used in wards where we’ve been able to decant patients. We can leave beds and cupboards in place because the machines create a fog which permeates everything it touches. It’s proving very effective. The machines are run by a specialist team of ward hygienists. Their role is also to reach the parts that others don’t reach by giving all of our equipment and furniture a thorough inspection and clean.”
    
Sue concluded: “You never reach the end with patient safety but we’re striving for perfection because good enough isn’t good enough for us. We’re always looking at what we do and how we could do it better. That’s the joy of the whole thing.”