MATER BOARD ON BOARD
Quality Improvement Project
Mary Day
Chief Executive
MMUH
Patient Safety
Conference 2014
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
OctoberNovember
2014; handover
to Phase 2
MMUH OVERVIEW
• 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 BOARD OF DIRECTORS
1
Fiduciary
responsibility
for quality of
care and
financial
control of the
hospital
2
14 members
7 nonexecutive
directors
3
Invited for
membership
by Sisters of
Mercy
4
No maximum
duration on
board
By Nov 2014 the Board of Directors,
individually and collectively:
get a comprehensive picture of the
1
quality of clinical care
PROJECT AIM
have an understanding of same,
2 and
act to hold the hospital accountable
3 on the quality of clinical care (QCC)
delivered
METHODOLOGY
The project followed the Model for Improvement methodology
1
2
Measuring the changes
4
3
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)
IMPROVEMENT ACTIONS
Selecting quality indicators
Developing a dashboard
Targeted reading for board members
Shared learning with Sr Stephen Moss
ISBAR communication tool for discussion
IMPROVEMENT ACTIONS -2
Board workshop
25% of meeting time on quality
Restructuring of board minutes
Restructuring of board agenda
Quality walk rounds
BOARD QUALITY DASHBOARD
UNDERSTANDING:
BUILDING KNOWLEDGE
Board Workshop
Interactive learning session
was held with the board on
interpreting the quality
dashboard
Monthly
Targeted reading
On understanding
quality of clinical
care
ISBAR Tool
Development of a summary
report for each indicator
using the ISBAR tool at
Board meeting
Shared Learning
Sir Stephen Moss,
former chairman
of the Mid
Staffordshire
Hospital
ACT: HOLD TO ACCOUNT
Spend time at board meeting on discussing quality
1
2
Restructuring of board
meeting minutes to
reflect
recommendations
4
3
Restructuring of board meeting agenda
Non- Executive Quality Walk
rounds to meet the clinical
providers on the wards
RESULTS
Dedicated time
for the discussion
of quality of
clinical care at
board meetings
Quality of
clinical care
indicators are
analysis monthly
by the board
150% increase in
the time spent
discussing quality
of clinical care at
board meetings
An improvement in the quality of discussion and the number of
recommendations made by the board in relation to quality of clinical
care.
SUSTAINABILITY
A further 21 recommendations have been endorsed
by the board under 4 headings:
1
3
2
improve
information
provided to the
board on
quality of
clinical care
improve
communication
and
transparency
from the
board
4
strengthen
the
governance
of quality
and safety
strengthen
patient
engagement
LESSONS LEARNED
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 - 2
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
ACKNOWLEDGEMENTS
Mr John
Morgan
Ms Maureen
Flynn
Dr Jennifer
Martin
Prof Conor
O’Keane,
Phase 1
Project group
Chair
MMUH Board
Director of
Nursing Quality
and Safety
Governance
Development,
HSE, & External
Project Co- lead
National Lead,
Information &
Analysis, Quality
& Patient Safety
Division, HSE, &
External Project
Co- lead
Clinical Director of
Quality & Patient
safety, MMUH &
Joint Project
Sponsor
Lead by Ruth
Buckley, Quality
Manager, MMUH
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Mary Day
8032328 / 8034756
mday@mater.ie
www.mater.ie