Better quality care can be delivered at a lower cost

An overwhelming majority of senior health managers who attended the HMI Annual Conference believed it was possible to deliver better quality safer care at a lower cost, they told David Fillingham, Chief Executive of Advancing Quality Alliance (AQuA).

David Fillingham
David Fillingham, Chief Executive of Advancing Quality Alliance (AQuA)

However, there was real apprehension among those present as to the impact on safety and quality of the savings plans about which they knew in their own organisation.  They were fairly evenly split as to whether these plans would impact negatively on safety and quality, have no effect or result in improvements in these areas.

This emerged when Fillingham, who was speaking on “Success in Leading Change, Can we get better quality healthcare at a lower cost?” carried out an impromptu survey of those present.

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Illustrating how quality services could be improved and resources saved, he told the story of Harry, who was 72 years old, suffered from Parkinson’s and chest problems and was admitted to hospital in the UK on a bank holiday weekend.  There was a delay in getting a senior review, his Parkinson’s medication was lost, there was confusion regarding an x-ray test, he got a central line infection and there was a poorly co-ordinated discharge process.  The result was that Harry remained in hospital for 21 days and the hospital subsequently became involved in a complaints process. The avoidable cost to the NHS was estimated at 12,000 pounds and the cost to Harry and his family was incalculable.

There was real apprehension among those present as to the impact on safety and quality of the savings plans about which they knew in their own organisation

He said that there was strong evidence of a considerable volume of adverse events and poor quality in the system and significant potential for savings.  There was much less evidence on actual links between savings and costs and very few robust research studies showing the impact of quality improvement interventions on costs.

There was evidence for cost increases linked to poor quality.  This included overuse and underuse, hospital acquired infections, drug errors, complications in surgery, “failure to rescue” (not intervening soon enough) and misdiagnosis or maltreatment, through poor communication or co-ordination.

In the UK it was estimated that hospital acquired infections were costing 1 billion pounds a year, 25 per cent of radiological procedures were unnecessary, one patient fall causing a fractured neck of femur cost the system 11,452 pounds, pressure ulcers in 4 – 10 per cent of in patient admissions cost 1 million pounds per 600 beds per year and the cost of adverse drug events was 6.6 billion pounds.

Improvements had (rightly) focussed on safety and quality more than costs.  Payment by results incentivised activity not quality and providers who reduced length of stay through quality improvement earned more through extra activity than capacity reduction.  It would be interesting to see the effects of the movement towards commissioning.

Turning to the major changes in quality and costs achieved while he was CEO of the Royal Bolton Hospital, he said the aim was to create a system for improvement.  This was based on “lean” principles, creatively adapted for the NHS, with safety, quality and productivity at the heart of the business plan.  They had sought to engage all staff in a long term cultural transformation.

Some of the results were a reduction of 49 per cent in mortality and 33 per cent LOS for fractured hips, a reduction of 23 per cent in mortality and 24 per cent in LOS for stroke and a reduction of 20 per cent in mortality and 30 per cent in LOS for respiratory conditions.

An ophthalmology one stop shop resulted in patient visits being reduced by half, in pathology, test turnarounds were between three and ten times faster and there was a 40 per cent saving in floor space. There were six figure cost savings in laundry finance, estates and others,  Thirty three per cent of staff were involved in week long improvement events and 80 per cent in the Bolton Improving Care System  (BICs) Academy,  In 2010/2011, BICs contributed to 1.5 million pound cost savings and a 23 per cent fall in overall hospital mortality.

Some of the results were a reduction of 49 per cent in mortality and 33 per cent LOS for fractured hips, a reduction of 23 per cent in mortality and 24 per cent in LOS for stroke and a reduction of 20 per cent in mortality and 30 per cent in LOS for respiratory conditions

Since April 2009, due to their improvement work the respiratory team had reduced in patient mortality by 20 per cent, increased discharges by 25 per cent, reduced readmissions from 9.5 per cent to 8.5 per cent, reduced length of stay by more than one day and reduced complaints.

BICs underpinned quality gains and financial savings.  There was strong Board level and clinical engagement.  The biggest wastes and avoidable harms lay in preventable ill health and avoidable hospitalisation .He said the next step was using “lean” across the whole health and social care system.

Fillingham said that AQuA had been established as membership organisation through the active leadership of CEOs in north west England.  It was part of the NHS and 54 Primary Care Trusts and provider organisations were involved.  Results were already being delivered with improved outcomes and productivity for five conditions, improvements in falls, and pressure ulcers and a reduction of standard mortality rates in nine Trusts with the highest rates.

AQuA priorities for 2011/12 were harm free care, improved care for patients with long term conditions, shared decision making and the continual elimination of waste.

He concluded by saying that the job of leaders was to deliver better care at a lower cost.  To do this they needed to build a vision of a better service (quality and cost equalling value), engage all staff, patients and stakeholders in the improvement effort, personally master improvement know how (a hands on approach), build a system for continuing improvement and overcome opposition and setbacks.