Royal Liverpool Hospital

Source: Exec Digital UK

Date :10/29/2007 6:44:43 AM

The Royal Liverpool and Broadgreen University Hospitals NHS Trust has decided that its policies must be decided by what happens on the wards, not the other way around.

Many senior administrators in the health service come from a nursing background, though quite a few of these don’t noise it abroad. They are still wary of the perception that nursing is the handmaiden of the health service. But that perception belongs, as they say, in the history books.

Written by John O’Hanlon & Produced by Paul Radbourne

Nursing, as every one of us who has ever been in hospital knows, is right at the sharp end of the NHS. We should therefore be very glad when the people who run the hospitals come from a nursing background. They have their priorities right.

Talib Yaseen OBE, Acting Chief Executive of RLBUHT, had been directing nursing services for 14 years before moving from his job as director of nursing & quality, and director of infection, prevention and control, to take on his present role in May 2006. He has no doubt whatever of the need to focus the management on the all important ‘point of care’. “Get nursing right and you have 90 percent of the business right,” he says.

A magnet for good nurses

That’s a big claim for a big business, one that employs 5,500 people and has an annual budget of £300 million. To run a commercial company of that size would be the dream of many aspiring executives. Yet such companies are only now beginning to get their heads round the idea that their customers’ experience is vital. Vital? Literally so in the health service.

“Low mortality, and good outcomes, are directly related to good nursing practice,” says Yaseen. “Hospitals where this is understood are magnets for good nurses,” he added when I pointed out to him that the public’s view of the nursing profession is coloured by stories of low pay, low motivation and low standards of training.

The Trust doesn’t use any agency nurses at all, he reveals. There’s an adequate local ‘bank’ of nurses. Good nursing practice isn’t really about money, he says. It is just as much a product of understanding that patient care is where the hospital adds value and the people who deliver it understand that they are valued. “I have tried to make sure that nursing is integrated with corporate performance,” he says.

The Royal Liverpool and Broadgreen University Hospitals NHS Trust was formed in April 1995 by the merger of the Royal Liverpool University Hospital and Broadgreen Hospital NHS Trust. It is one of the largest and busiest hospital trusts in the North of England with almost a million patients being seen every year.

It employs approximately 300 consultants, many of whom have honorary senior lecturer contracts with the University of Liverpool. It operates three main hospitals, the Royal Liverpool Hospital, Broadgreen, which has been largely rebuilt in the last 15 years, and the Liverpool University Dental Hospital. Altogether the trust has more than 1,000 beds.

As its title implies, it is among the top 20 teaching trusts in the country with well established links to both the University of Liverpool and John Moores University. Each year the trust provides a large number of placements for student doctors, dentists, nurses and allied health professions who benefit from the expertise and experience of some of the most skilled clinicians in the country. Currently in excess of 200 undergraduate medical students are receiving training within the Royal Liverpool University Hospital and Liverpool University Dental Hospital.

As a business, the Trust is highly diverse. It has a very complex supply chain, all the HR and PR issues associated with any large organization, and of course it has to balance its budget. As has been shown recently at the Medway NHS Trust, there’s a danger of putting targets, and especially financial goals, ahead of patient care. As soon as that happens, the key indicators like poor care, mortality and in-hospital infection start to rise and the whole reason for having a hospital is compromised.

A tool for quality and performance

That is why the Royal shines a very bright light on its wards. “We developed our Nursing Quality Performance Assessment tool to allow us to benchmark the performance of every ward. Measuring the quality of nursing care delivered by individuals and teams is not easy. This performance assessment framework based on the Essence of Care standards and other key nursing indicators, is designed to support nurses in practice to understand how they deliver care, identify what works well and where further improvement is needed.”

Wards are assessed as Green, Amber or Red. That hardly needs explaining, though he stresses that a Green does not mean perfect. There is always room for improvement, and Green just means that the ward meets the expected standards in three key areas:

• Leadership in the ward

• Environment and

• The way care is organised

The tool was launched in the spring of 2006. “We went through a process of development in which we ran workshops, devised processes, and consulted the Patients’ Forum and other bodies. Then from September that year we assessed every one of the 50 wards in the Royal Liverpool and Broadgreen hospitals.”

The tool works very much like a lean programme in manufacturing or business process excellence as applied in a commercial setting. Ten core nursing standards are covered, and in each of these the overall standard is specified. To take an example, the standard for ‘Self Care’ stipulates that ‘Patients have control over their own health care and promote independence’

Below that, under each of the three areas of environment, care and leadership are eight specific goals, for example: ‘Has the patient been offered a choice of a bath, shower or wash (if choice is appropriate)’; ‘Toilets, bathrooms are wheelchair accessible and there is sufficient room for safe transfers’. The ten standards are each scored red, amber or green, and these scores used to decide the ward’s overall rating.

An action plan is then agreed, and the ward is reviewed within a year if it has achieved a green, six months if amber and within three months if it has shown up as red. “This is how we show the Board how we are doing, where we are delivering value and where we are falling below standard. But it’s at the point of care that a hospital delivers value, and when we designed the tool we had to make sure it made sense at ward level. If we had designed it to keep the Board happy the chances are it would have made no sense at this crucial point of care.”

The Nursing Quality Performance Assessment tool has become the focal point for the entire management strategy at the Royal and Broadgreen, and it is already becoming a benchmark for trusts throughout the country. Infection control is worrying the public, which is becoming increasingly convinced that any visit to hospital will be give them MRSA or C. Diff. The tool makes sure that each ward is maintaining standards and also allows management to see how the Trust’s hospitals are performing. Yaseen points out that, aware of issues in and around mental health needs, the management were able to identify inconsistencies in training and practice. These were addressed, and are now tracked as part of NQPA.

Investment in IT and infrastructure

Like any good business the Trust has invested in the latest IT. Some of it is national, such as the filmless imaging Picture Archiving and Communications System, more commonly known as PACS, which enables images such as x-rays and scans to be stored electronically accessed and compared with previous images at the touch of a button.

The Royal Liverpool implemented PACS in 2006, well ahead of most of the rest of the NHS in which it should be universal by the end of this year. In total there are now 117 PACS locations live across England. Over 371 million images have been stored, and PACS has been used for over 16 million patient studies.

The hospitals spend more than £3 million a year on infrastructure projects such as these and PACS for one will speed up patient throughput, and has also delivered a reduction in admin and support staff. But sometimes smaller, less expensive, patient focused initiatives have as much effect such as the Royal Liverpool’s plan to get wireless laptops onto the wards so that data can be recorded, again, at the point of care.

Lean practice has also been applied in the hospitals’ supply chain, very much as it would be in a manufacturing operation, with the objective of reducing inventory and the amount of capital tied up in stores. “Our supplies manager and our head of pharmacy have each been able to achieve terrific results through better procurement practices and making sustainable changes in the way we do things,” says Talib Yaseen.

And in line with the ethic of sustainable change the Trust has even brought in consultants from Nissan to look at operating theatre practices. A three year cost saving plan cut 4 percent, or £13 million off operational costs last year, and to the beginning of October 2007, a further £12 million, the entire year’s target, had already been saved.

It is a story of continuous improvement, driven by the desire to deliver what would be described in another context as a good customer experience. However the present Royal Liverpool Hospital is getting long in the tooth. It’s a 1960s design, completed in 1976, and everyone is looking forward to its replacement, a £400 million building on an adjacent site that is due to be completed in 2014.

It will have 25 percent fewer beds, because by then more patients will be treated in the new NHS treatment centres that will be up and running by 2011, and the patients who do need to come into the Royal Liverpool will have a shorter average stay.

The overall aim is to ensure that the new Royal Liverpool Hospital becomes a leading and specialist centre for A&E and cancer treatment while its sister hospital, Broadgreen, focuses on planned surgery. One thing that won’t change will be the Trust’s commitment to what happens on its wards – the point of care.