Mary Day Chief Executive MMUH Patient Safety Conference 2014 MATER BOARD ON BOARD Quality Improvement Project.

Mary DayChief ExecutiveMMUH

Patient SafetyConference 2014

MATER BOARD ON BOARD Quality Improvement Project

BACKGROUND

Driven by the MMUH Board of Directors

A collaboration between MMUH, HSE and the Scottish Patient Safety fellowship programme

Jan 2014 to November 2014 ; Phase1

October- November 2014; handover to Phase 2

• Established in city centre in 1861 by Religious Sisters of Mercy • University teaching hospital,

providing acute and specialist services• 610 beds, including day beds• Annually

- 16,000 patients admitted, including 9,500 emergency admissions

- 48,000 day cases- 58,000 emergency

department visits- >200,000 OPD visits

• National centre for: cardiac surgery, heart lung transplant, pulmonary hypertension, spinal injury, national isolation unit

MMUH OVERVIEW

Fiduciary responsibility for quality of care and financial control of the hospital

14 members

7 non-executive directors

Invited for membership by Sisters of Mercy

No maximum duration on board

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MMUH BOARD OF DIRECTORS

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get a comprehensive picture of the quality of clinical care

have an understanding of same, and

act to hold the hospital accountable on the quality of clinical care (QCC) delivered

By Nov 2014 the Board of Directors, individually and collectively:

PROJECT AIM

METHODOLOGY

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The project followed the Model for Improvement methodology

The baseline was established through:– Review of board minutes

and agenda in the 6 months prior to the project commencing

– Interviews with the board of directors (n=14)

Planning & Implementing 10 change packages – Picture (2)– Understanding (4)– Action (4)

Measuring the changes

Selecting quality indicators

Developing a dashboard

Targeted reading for board members

Shared learning with Sr Stephen Moss

ISBAR communication tool for discussion

IMPROVEMENT ACTIONS

Board workshop

25% of meeting time on quality

Restructuring of board minutes

Restructuring of board agenda

Quality walk rounds

IMPROVEMENT ACTIONS -2

BOARD QUALITY DASHBOARD

UNDERSTANDING: BUILDING KNOWLEDGE

Monthly Targeted reading On understanding quality of clinical care

Board Workshop Interactive learning session was held with the board on interpreting the quality dashboard

Shared LearningSir Stephen Moss,

former chairman of the Mid

Staffordshire Hospital

ISBAR ToolDevelopment of a summary

report for each indicator using the ISBAR tool at

Board meeting

ACT: HOLD TO ACCOUNT

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Spend time at board meeting on discussing quality

Non- Executive Quality Walk rounds to meet the clinical providers on the wards

Restructuring of board meeting agenda

Restructuring of board meeting minutes to reflect recommendations

RESULTS

150% increase in the time spent discussing quality of clinical care at board meetings

Dedicated time for the discussion of quality of clinical care at board meetings

Quality of clinical care indicators are analysis monthly by the board

An improvement in the quality of discussion and the number of recommendations made by the board in relation to quality of clinical

care.

SUSTAINABILITY

improve information

provided to the board on quality of

clinical care

improve communication

and transparency

from the board

strengthen the

governance of quality and safety

strengthen patient

engagement

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A further 21 recommendations have been endorsed by the board under 4 headings:

Project must be sponsored at board level

Regular interaction and feedback between board and project group

Interviews of board members at onset invaluable in setting the approach for the project.

Quality Information at board level to be reflected at executive level

Project must be sponsored at board level

LESSONS LEARNED

Use of outcomes measures at board level

Express information in terms of the quality domains in the National standards

Indicator selection needs to be reviewed at regular intervals to select most appropriate indicators that reflect the hospital strategy

Focus on patient experiences and clinical practice audits

Automation of Data for sustainability

LESSONS LEARNED - 2

Mr John Morgan

ChairMMUH Board

Ms Maureen Flynn

Director of Nursing Quality

and Safety Governance

Development, HSE, & External Project Co- lead

Dr Jennifer Martin

National Lead, Information &

Analysis, Quality & Patient Safety Division, HSE, & External Project

Co- lead

Prof Conor O’Keane,

Clinical Director of Quality & Patient safety, MMUH &

Joint Project Sponsor

Phase 1 Project group

Lead by Ruth Buckley, Quality

Manager, MMUH

ACKNOWLEDGEMENTS

CONTACT

• Mary Day• 8032328 / 8034756• [email protected]• www.mater.ie