Mary Day Chief Executive MMUH Patient Safety Conference 2014 MATER BOARD ON BOARD Quality...
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Transcript of Mary Day Chief Executive MMUH Patient Safety Conference 2014 MATER BOARD ON BOARD Quality...
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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2
3
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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3
2
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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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3
2
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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