Day 44: Learning from Berwick

I attended a round table discussion today about how we can best apply learning from Don Berwick’s review of patient safety.  We talked about the need to develop ‘shared purpose’ between commissioners, providers and other stakeholders to achieve the quality of outcomes we all should be aspiring to for patients.

We talked about leadership behaviours and how we, as commissioners, need to role model the behaviours we expect to see from all partners in the health system.

I left the session enthused to look to identify incentives and approaches to commissioning for quality across organisational boundaries, as this is where there is great potential benefit to be gained.  This isn't going to be easy, but when did I ever choose to do something because it was easy?!

Day 43: The Grand Tour

I spent today with matrons and other staff at our local hospital who introduced me to their respective departments.

I was impressed by the work that Yvonne is doing across the hospital for patients with dementia and to support staff to better serve these vulnerable patients.  The 'This Is Me' documentation will help staff better understand patients' needs.

The piloting of ‘The Perfect Day’ (nothing to do with Lou Reed, RIP) on some wards that Helen showed me was innovative and exciting.  This approach is adapted from Germany and sees staff roles focussed on particular tasks, such as bed-making, discharge planning and supporting meal-times, which frees nurses and healthcare assistants to be with patients for a much greater proportion of their working time.  This has great potential to release more time to care, to improve outcomes and productivity, for a better patient experience & job satisfaction for staff.

Many thanks to Sheran, Helen, Edmund, Mel, Liz, Yvonne, Katie, Helen, Chris and many others with whom I have spent time today.

(PS had a really enjoyable day and could have written 100 words many times over, but what I have written really is just a few of the highlights)

Day 42: The World’s Bigger Here!

A colleague said to me today “the world’s bigger out here in commissioning than in hospital”.  An interesting observation from working in the same organisation for many years then moving to another.

This resonated with me, as I did the same; worked for one organisation for many years and then moved into this role.  My new ‘world’ also feels bigger in some ways and smaller in others.  I wonder if this is less to do with size and scale and more about confidence and moving from the comfort of the familiar. 

I am enjoying diversity of meeting new people and experiencing different styles and ways of working, which can make the world feel bigger.  New experiences and being outside of what is ‘comfortable’ can help us learn and grow.

Tomorrow, I am spending the day with front-line staff and patients at our local hospital to expand my experience of this bigger world…

Day 41: Finances

The financial situation of the CCG is currently very serious for a number of reasons: one is that we are under-funded as a local healthy system based on the needs of our population and relative to other parts of the country; another reason is that our main hospital provider is ‘over-performing’ (that’s NHS jargon for seeing more patients and/or doing more than contracted to).

We are currently forecasting a year-end deficit (more NHS jargon for predicting that we will spend more money than we have this financial year).

The quality impact is that we risk now having to use resources we may have ear-marked to develop and improve patient pathways to meet our financial obligations.

There is a significant range of work currently ongoing within the CCG to both reduce the deficit to a minimum, eliminating it if possible, and also to mitigate the quality impact if we do find ourselves in this position.

Day 40: Spinning Plates

General reflections after 40 working days in the role (two months) are…

Everyone has been incredibly welcoming and open to work together; however, recent NHS changes, not just since April mean that there are a number of barriers to effective working.

There isn't a clear, common understanding about CCGs or NHS England Area Teams' roles between NHS/Local Authority commissioners, providers and other partners.

The relative newness of CCGs as organisations means we still have work to do to develop internal processes where previous PCT approaches don’t work.  Administration of our core business needs to improve to release time to focus on the more significant challenges.

Specifically within my team we need to improve our focus on the quality governance framework across the whole health community including for our smaller contracts with care & nursing homes, whilst maintaining sufficient focus on continued improvement through bigger contracts at the same time.

In summary, we can’t just keep plate spinning; they need cleaning, polishing and synchronising as well.

Thanks for reading.

Day 39: The Dog That Doesn’t Bark

“The dog that doesn't bark” was jargon used today (new one to me) to describe a 'measure' that suggests there may be no problem, but behind the measure there are problems!

This was at an Area Team Mortality Workshop today to locally share best practise and learn from Sir Bruce Keogh’s Mortality Reviews of 14 hospitals. Very helpful presentation about the different measures that are used to monitor mortality in hospitals, including the benefits and pitfalls of each.  If you want to know the difference between your SHMI, HSMR or RAMI, Advancing Quality Alliance have written a good paper.

Data is important, but, as the jargon suggests, much more important to work together locally across organisations within a local community and to look at mortality from a patient perspective, not being constrained by corporate boundaries. This needs to include the components of quality (as defined by Lord Darzi & expanded by Don Berwick):

• Safety (avoiding harm from the care that is intended to help).
• Effectiveness (aligning care with science and ensuring efficiency).
• Patient-experience (including patient-centeredness, timeliness and equity)

 We need to locally develop an approach to reviewing mortality at a patient, organisation, pathway, community and population level that is based on best evidence from England and internationally.  Also, and probably most importantly, we must engage with and involve patients and carers in the design and use of this process.  This will also help in communicating what we’re doing to the public to provide clear transparent messages that include appropriate reassurance.

(sorry, wrote 200 words today; could have written much more, such an important and interesting subject)

Day 38: CQUIN – pronounced [see-kwin]

No, this isn’t about Strictly Come Dancing! I attended two ‘Quarter 2’ CQUIN (Commissioning for Quality & Innovation) Review Panels today. CQUINs are schemes agreed with providers intended to secure improvements in quality of services and better outcomes for patients above the expected levels of quality agreed elsewhere in contracts.

The process for evidencing & reviewing actions, which I witnessed for the first time today as a commissioner, is very rigorous.  I was reassured by the robustness and fairness with which evidence was scrutinised by the panel and compared to what’s required before agreeing payment.

In addition to agreeing whether providers have achieved what was agreed, we identified areas for learning and improvement for the process for this and next year, which will make things even more outcome-focussed and further reduce any ambiguity.

Day 37: Public Board

My first public Board Meeting today; I did attend the last one, but that was before I officially started.  We met in a local community centre to be more accessible to the public instead of expecting them to come to the CCG offices.  There was a good number of the public there, including Healthwatch, but not all stayed to the end of a very long agenda.

Many important issues directly affecting patients covered, including agreement of a new policy for handling individual treatment requests, performance against national NHS Outcomes Framework targets, how complaints are managed and progress in meeting our local priorities.

Some good challenge & helpful contribution from Lay Board Members & public, but on reflection I can’t help feeling that we still have work to do to make the information we share & discuss in public more accessible; still too much jargon!

Day 36: Interviews – recruiting for values

Interviews today for Quality & Patient Safety Manager.  We have found a fantastic individual who performed well, demonstrating that calm and composed credibility can be just as influential, sometimes more so, than more extroverted styles of communication.

Very important to our decision-making was getting someone with the right values.  Competence in the role is important; however, QIPP, CQUIN and other acronym-based stuff can be learnt.  Displaying the values, enshrined in the NHS Constitution, are the foundation-stone I look for in anyone I would want to employ.

I believe we've found a great addition to the team and really look forward to when they start with us.

NHS Employers advocates a values-based approach to recruitment including support tools available online.

Day 35: Role Diversity

Another fantastic week; the diversity of my role is truly amazing! Here’s a few things I’ve done this week:

• Communications & Engagement Steering Group
• Reviewing procurement documentation
• Team One 2 Ones
• Equality & quality impact assessment process development
• Quality & Safety Manager shortlisting
• Community services visit
• Integration programme service area development
• Board Patient Safety & Quality Committee
• Safeguarding adults process review
• HSJ reporter interview for piece on Quality Governance
• Meeting Healthwatch
• Acute provider Contract Management Board
• Executive Committee
• Local Nursing & Quality Directors peer group meeting
• Developing action plan to improve QIPP programme progress

To top off a great week, I’ve just had a tweet from Dr Ranj!

Day 34 Difficult Conversations

Contract review meetings with main acute hospital provider today, including difficult conversations about areas where they’ve provided services to patients above contracted quantity.  We have limited resources to pay beyond the contracted levels.  Further discussion to be had with the Trust and at our Board meeting next week.

The Trust and CCG are continuing to work to help patients access the right services; particularly ‘unplanned’ care.  This is an area where patients have different options and A&E is not always the best place for them.  Our ‘Is A&E For Me?’ Campaign aims to help inform better decisions about self-care, seeking advice and using services like community pharmacy, GP out of hours, 111 and where appropriate, A&E.

Day 33: Local Healthwatch

Met with local Healthwatch Chair and Project Manager and learnt loads about their role in bringing together local voices to influence improvement in services today and shape services of tomorrow.

We identified a lot of common ground including where we can share information about services and people’s experiences.  It was good to hear about their priorities and how closely they fit with ours.

I was also interested to hear about the recently published first Healthwatch England Annual Report and the eight rights it describes.  One of the next steps is the conversation that they are having with the public about the responsibilities that go with these rights.

You can join the conversation on their website or on Twitter using the hashtag #ThinkRights.  You can also find my list of Local Healthwatch organisations on Twitter here.

Day 32: Community Services

I finally got to see our local community services today. It was great to see the staff who serve our patients in their own homes. I heard particularly positive things about the way that the Board members, particularly non-executives engage with front-line services on a regular basis.

As we progress to recommissioning community services, it was good to hear the positive attitude front-line staff have towards this impending future change.  During this period the current services need to be maintained and developed with a continued focus on quality and continuous improvement.

I look forward to spending more time with our community services and their staff in the future.

Day 31: Communications & Engagement

My first meeting of our Communications & Engagement Steering Group today.  We discussed our engagement with patients & communities about our commissioning intentions, acknowledging it isn’t the most exciting subject, but we have improved on last year and there is more we will do.

Further discussion on who and how we engage public in upcoming procurement for our mental health & community services.

We reviewed progress in our social marketing campaign 'Is A&E for Me'.  Much success in local engagement activities, but need to see this in changed behaviours - more info here.

We also discussed developing a social media strategy and agreed we need to focus on embedding social media in other strategies, projects & plans and to do a few things well rather than try to do too much.

Finally, we’re recruiting for a new Lay Board Member to lead on engagement & empowerment.  Advert is here, do take a look and share with anyone you think would be suitable.

Day 30: Stop Accepting The UNACCEPTABLE

Spent today at the Chief Nursing Officer Black & Minority Ethnic Advisory Group Annual Conference.  I was concerned, but sadly not surprised, that the majority attending were from BME groups (bear with me, I’ll explain this later).

Theme for the day was “Cultures of Compassion”.  Underlying this was a clear message that the current situation remains UNACCEPTABLE. Just some of the evidence I heard today:

• Number of BME senior leaders in the NHS remains tiny compared to society & overall staffing – UNACCEPTABLE

• Proportion of nurses & midwives referred to NMC for fitness to practise far exceeds representation in the profession with the vast majority found with no case to answer – UNNACCEPTABLE

• Only 10 of first 400 participants in the NHS Leadership Academy’s development programmes from BME groups - UNNACCEPTABLE

• Student nurses from BME groups have disproportionately high drop-out rates – UNNACCEPTABLE

 I could go on, but you get the picture!

Whilst those in at the conference were enthused to ‘be the change they want to see’; the only real way to make the step change needed is for positive action from those who weren’t there. Those who aren’t from BME groups must affect change, as they are, in the main, the decision-makers affecting recruitment, development opportunities and support and mentoring for staff, both in training & in practice.

We must eliminate the current situation being ACCEPTABLE and we have a long way still to go.  Sign-up to the NHS Employers Personal Fair & Diverse NHS Campaign today! PS there’s a free App too.

Day 29: Today's Diary

Two weeks after floating the idea that we become a paperless organisation we held our first paper-free Executive Committee. We also agreed the process for prioritising our commissioning intentions for 2014/14; there's so much we want to achieve, but we can't do it all and need to prioritise what has most benefit for patients.

First one 2 one meetings with key team members in safeguarding: Designated Doctor and Named GP.

Finalised papers for our first Patient Safety & Quality Committee meeting next week (thanks team!).

Tonight I'm at E-Health Insider Awards; privileged to be joining the WeNurses team, who're nominated for best use of social media in healthcare; fingers crossed!

Day 28: Bring Your Bear To Work Day (Guest Blog)

Hi there, I’m Pooh Pooh Bo Bo Baby Bear (don’t ask!) and I am guest writing David’s blog today on Bring Your Bear To Work Day.

This pales into insignificance with World Mental Health Day tomorrow 10 October:  One in four of us will experience a mental illness during our lives.

The Mental Health Foundation’s theme is older adults and the positive aspects of mental health in later life.  Mental health problems are not an inevitable aspect of ageing.

Rethink will launch a guide to staying well with bipolar disorder.

Mind is asking you to tweet them your pictures to help in the fight for support and respect using #WMHD.

See Time To Change and join 45,000 people who’ve pledged to help end mental health stigma.

However you’re affected, we all need to know more for prevention, support & recovery.

Thanks for having me,

Pooh

Day 27: Learning When Things Go Well (Appreciative Inquiry)

Safeguarding Masterclass today in Leeds, led by NHS England’s @HilaryGarratt.

Learned loads about different ways safeguarding’s being managed across England and particularly liked the way Appreciative Inquiry’s being used in the North East.

Appreciative inquiry turns the problem solving approach on its head.  It focuses on achievements rather than problems.  It is great to see that time is specifically being set aside to learn from what works and spread good practise rather than just concentrating on where things have gone wrong in the past.

I will be sharing this with colleagues locally to see if we can do something similar.

(exactly 100 words again; I must be getting better at this!)

Day 26: A shameless plug

For today’s blog, I’ll take advantage of you with a job advert (sorry).  Do you want to come and join my team working in quality in commissioning in the role of Quality & Safety Manager?  If you’re interested in being part of an evolving team focussed on improving services and outcomes for patients, then this role may be just for you.

Band 8A, based in Luton, this is ideal for a ward sister/matron, district nurse, specialist nurse, therapist or any other senior clinician with relevant experience.  Get your application in quickly; it closes Friday 11 October.

Thanks for letting me take advantage of your attention; tomorrow I’ll post on a different subject, I promise!

Day 25: The Courage to Follow – #WeNurses

It was amazing how many people, particularly student nurses engaged in last night’s leadership #WeNurses Twitter Chat (If you don’t know what a Twitter Chat is or have never joined on before, visit the WeNurses Twitterversity to lean more). Student nurses are future leaders and need support in growing as leaders, not just ‘trained’ in management.

Leadership isn't about who shouts loudest, has the fanciest job title or biggest office.  Leadership is being clear and courageous to stick to what you believe in and enthuse others in your vision.

I was reminded today (thanks @BethSwanson6) by a YouTube clip I first saw three years ago that it isn’t all about leaders.  Early followers who resolve to stand out and act on what they believe in are as, if not more, courageous.

A leader will be defined by his or her followership; be inspired, have the guts to be the first person to stand up and follow a cause who you believe in.

Day 24: Listening – National Poetry Day

Today was my first all-staff meeting at the CCG,

An opportunity for me to meet people who didn't already know me.

I ran a brief workshop to listen to what they thought,

About what we can do better for patients from ideas they had brought.

We discussed barriers to being effective day-to-day,

And how we might overcome them in a positive way.

There were ideas aplenty for a better patient-focus,

But no magic solutions or hocus pocus.

Listening to our staff was time well spent,

Now to make changes that are well-meant.

I will feedback what I heard our staff had to say,

And how this will change what we do for our patients every day.

Day 23: “Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen” Winston Churchill

I spent time today thinking about courage (one of the 6 Cs in the NHS’s aim to improve compassionate care).

I had an induction meeting with our local Director of Adult Social Services and reflected afterwards how some of the integration we need to do will take courage

I thought about the courage displayed today by members of my team in dealing with difficult situations and challenging the established way of doing things.

I am also hoping for courage tomorrow from CCG staff when we undertake a listening exercise at our monthly staff meeting aiming to identify barriers to change and how we overcome them.

Day 22: Asking 'Carefrontational' Questions

Today was the first meeting of the Hertfordshire & South Midlands Area Safeguarding Forum.  This brought together medical and nurse safeguarding leaders from NHS commissioners and providers to determine how the forum will support our collective future work on safeguarding and to agree priorities.  At the end of the session we had an inspiring presentation from an independent Chair of a local safeguarding board. In this presentation I was taken by the concept of developing capacity in front-line staff to ask ‘carefrontational’ questions.  This involves all 6C’s: Care, Compassion, Competence, Communication, Courage & Commitment, to ensure we are able to support effective safeguarding of children and vulnerable adults.