Richard Smith: Turning round failing hospitals
The Care Quality Commission has placed 27 health institutions, most of them hospitals, into “special measures,” and so far 11 have emerged. Few jobs can be tougher or lonelier than taking over the leadership of a failing hospital. Regulators may put you under tremendous pressure for quick results, while staff may hope to “see you off.” The Cambridge Health Network heard last week from a chief executive and a chair of the board who are both in the process of turning round failing hospitals.
An Essex hospital
Clare Panniker, a nurse, became chief executive of Basildon and Thurrock University Hospitals NHS Foundation Trust in September 2012 and knew that the hospital was in a bad way. It was constantly attacked in the local media, many staff felt ashamed when asked where they worked, and many patients came to the hospital critical, aggressive, and with low expectations. There had been 11 deaths from legionella. Death rates were among the highest in the country. In a CQC inspection walls had been found to be spattered with blood. Patients with learning difficulties were badly managed resulting in families blaming the hospital for their death.
The hospital was a first wave foundation trust, which may have led to complacency. Attempts had been made to fix problems, but they had been fixed individually without attention to the underlying causes The Care Quality Commission and Monitor, the regulators, had been worried about the hospital for several years.
Panniker began with a diagnostic exercise, trying to recognise all the problems not just those recognised by the regulators and the media. She encouraged openness and emphasised engagement with the staff, particularly key people who were willing to contribute to change. The hospital had failed before to acknowledge the extent of its problems, but she was open with staff and regulators about the scale of the problems.
But she also quickly began to take action, hiring new staff, including some 200 new nurses. The number of beds was increased, and the trust looked outside for help. Great emphasis was placed on safety and quality improvement, which was good for engaging staff. The hospital developed “its own brand of quality improvement.” Panniker came under pressure from some to get quick results She had to emphasise that this wasn’t possible and that turning round an institution as complex as a hospital can not be achieved through command and control.
Despite beginning to show signs of improvement the hospital was placed into special measures in the summer of 2013, which “felt like a backward step.” Part of special measures is partnering with a successful hospital, and the hospital partnered with the Royal Free, which works as a district general hospital as well as a specialist hospital. There was mutual learning, and improvements continued so that the hospital came out of special measures in March 2014. Indeed, it is now rated as “good,” one of only three hospitals to move from special measures to good.
The hospital, like many others in the country, is still under great pressure, not least with up to 400 attendances a day in its accident and emergency department—which is disproportionate for a population of 300 to 400 000. Primary care in Essex is variable, and some of the problems of the hospital stem from the whole health system in Essex being fragmented and weak. Attempts are being made to improve the system, and the three hospital trusts are looking to form a “group model.” Panniker has had experience of hospitals talking positively about working together but failing to do so because one of them might lose badly, particularly financially. Essex is trying to find a mechanism to avoid this happening.
Two hospitals in North East London
Barking, Havering, and Redbridge NHS University Hospitals NHS Trust, as well as having one of the longest names in the NHS, was a “troubled case” when Maureen Dalziel became the chair of the board. The trust has two hospitals and is positioned in North East London, which has weak primary care with many single handed and elderly GPs.
Dalziel did her due diligence before accepting the position and negotiated with the regulators that things could not be fixed in a few months. The chair of another hospital trust in the audience spoke plaintively about being set up as “the fall guy” in a failing hospital, and Dalziel followed a string of chairs. There was agreement at the meeting, including from regulators, that it’s essential for leaders of organisations to know the full extent of problems and to be open with regulators and staff about the problems.
People, partnerships, and processes are the three essentials of turnaround, said Dalziel. You must have the right people at the top, and those people must have had experience of turning round a failing hospital. It requires courage to become the chief executive of a failing hospital, and it takes time to find such a person and the rest of the management team. The trust had to use some interim managers from management consultants.
You can’t do it on your own, emphasised Dalziel, and the trust is working in partnership with regulators, oversight bodies, and local organisations. It’s working as well with the Virginia Mason Institute from Seattle to improve its operations, particularly diagnostics and the first 24 hours that patients spend in the hospital.
Improving processes is the third priority identified by Dalziel, and she marvelled at how poor some of the processes were in the hospital. The guidance on managing waiting lists was 88 pages long. Some problems were as basic as allowing all the consultant staff in some departments to take their holidays at once. Information technology in the hospitals was poor with no wifi and printers that didn’t work. The hospital has an improvement plan and has had the support of an independent directors of improvement,
The trust was placed into special measures in December 2013, which was a “real blow,” but Dalziel accepted at the meeting that it was probably a good thing. There will be a reinspection later in the year, and the trust hopes to emerge from special measures. There have been improvements: the staff survey has started to see green shoots of improvement, staff are in the top 20 most motivated in the country; the hospital is on track financially; and clinical services have improved—with the maternity unit moving from one of the worst to one of the best. The trust still, however, has substantial problems with over a thousand people waiting a lengthy time on their waiting list and very high rates of attendance at accident and emergency departments. These are not problems the hospital can fix on its own and it requires strong primary care and partnership working with partners locally to manage demand, that ensures patients get the right treatment in the right place.
As in Essex, the trust suffers from problems in the whole health system, and an attempt is being made to create an accountable care organisation from three local authorities, two NHS trusts, and three clinical commissioning groups.
Both trusts work in areas where the whole health system is struggling, and focusing on turning around the hospital is not enough. Indeed, the problems in the hospitals may be symptom of the wider problems, but different organisations seem to have great difficulty working together. I wonder whether part of the problem is that each institution—whether it’s a hospital, general practice, or mental health trust—starts, usually implicitly, with the conviction that “whatever happens we must survive.” There are many organisations—and I’ve been on the board of some of them—where the mission of the organisation might best be advanced not by it continuing but rather by its resources being passed to an organisation better able to advance the mission. For example, the mission of “improving health and health care in Essex and North East London,” is probably not best achieved by all the current organisations continuing.
Asked at the end of the meeting about the essentials of turning hospitals round, the two speakers mentioned openness about the problems, achieving the right staffing levels, focusing on quality and safety of care, and getting the leadership and governance right. Many hospitals may find these lessons useful in the next decade.
The Cambridge Health Network brings together people from the NHS, social care, academia, the private sector, and charities to discuss health and social care issues. Its meetings use Chatham House Rules for the discussion after the speakers have spoken, meaning that quotes cannot be attributed.
Richard Smith was the editor of The BMJ until 2004.
The original article was published in The BMJ and can be accessed here.