END OF LI FE CAR E
improvement’ ideas in place. A nurse in the Emergency Assessment Unit (EAU) of the hospital led changes to the point where everyone recognised that the unit provided excellent care at the end of life. The staff in EAU worked in adverse circumstances – very little natural light, significant noise and a high throughput of patients – yet managed to individualise care and to support people and their families. The number of complaints dropped and then stopped. The unit received many letters of thanks. In describing her project, on consecutive years at the symposium, the nurse inspired many to look beyond limitations and aim high. The Executive team visibly demonstrated their interest in the work in many ways including attending the symposium and listening to staff and thanking them for their work.
The system in HLS Lowe and Plimmer propose that outcomes that matter are produced by whole systems rather than individuals. Healthy systems need to be fostered and developed in order to improve outcomes.
As the hospital project matured cross organisational issues that needed to be addressed were identified, for example the care of people with learning disabilities and meeting their particular needs. Departments worked together to reflect on outcomes that were unsatisfactory, examine practice and to identify steps to improve care. The project leads and the executive team identified what we knew and defined where we needed to gather intelligence. The team built a dataset that looked at the outcomes for individuals and also looked at organisational level outcomes. An example being the project team collected data to understand the pattern of where people died across the hospital, linking that pattern with knowledge of improvement projects to understand whether outcomes were good across all areas and where there was a need to focus and help to improve care. The executive team acted as stewards of the system – using appreciative enquiry to enable the project leads to build a governance structure. They asked questions about what next and whether ‘we – the hospital’ could be assured of the quality of care we provide at the end of life. The funders, Sobell Foundation, also acted as stewards. The project leads reported on how their financial contribution to the system change enabled good outcomes.
The impact of HLS
The culture of the hospital changed as a consequence of the project. The organisation recognised that care of the dying and those important to the dying person is part of the core business of the hospital. The hospital
MARCH 2021
recognised that care of the dying is an important marker of the quality of care delivered to all whom we serve. Staff working in the organisation were
supported in their learning, were enabled to make change and were inspired and motivated by each other and their achievements. The reputation of the project team and the department of palliative care grew and this enabled further opportunity to collaborate and influence the issues we care about namely the quality of care in hospital provided to those who are dying. The charitable donation given with trust by the Sobell foundation enabled change. The money supported the cost of additional staff both to see more dying people but also to fund a multitude of small projects given with few conditions and minimal reporting requirements. The project was able to demonstrate that the involvement of the palliative care team in patient care saves the hospital money. Most importantly we addressed our purpose – the outcomes that staff consider important improved. Complaints fell, thanks increased, our community now feel our hospital provides good and safe care at the end of life and our scores on the national audit of care of the dying improved several points.
Limitations Working in an HLS way to improve care of the dying was enabled by a charitable donation. It is much harder in a cash strapped NHS to break free of the current system of financial reporting processes. The executive team were key in supporting the project. Their wise stewardship and their comfort with calculated risks enabled the project success. Leadership in the NHS is key in unlocking staff potential to improve the outcomes for the people the NHS is there to serve. The goals and skills of NHS leaders will vary over time and across organisations.
This improvement project did not follow a prescribed quality improvement methodology but was more organic. The authors view this as a considerable strength but makes reporting in NHS structures more complicated and harder to teach. HLS is a paradigm in development and evolution. It is essential that the HLS movement develops a methodology that enables the evaluation of complexity.6
This would seem to be a
necessary condition to inspire confidence in the public sector to use this methodology to enable systemic change.
Conclusion Lowe and Plimmer’s work provides a framework for understanding and describing the evolution of the project to improve the care and quality of people who are dying in our hospital. They offer a construct that holds the potential for a paradigm shift in the
delivery of healthcare. Trust by the funders, Sobell Foundation, and by the executive team in the hospital was an essential ingredient of success. Staff have an easily identifiable key shared purpose in healthcare. Permission to inquire, learn and change departmental structures and processes enabled staff delivering care to improve outcomes with immediate effect. The project supported the hospital system to deliver better care with cost savings.
CSJ
References 1 Davidson Knight A, Lowe T, Brossard M, Wilson J. A whole new world: Funding and commissioning in complexity.
http://wordpress.collaboratei.com/ wp-content/uploads/A-Whole-New-World-Funding- Commissioning-in-Complexity.pdf Accessed 06.12.2020
2. Lowe T, Plimmer D. Exploring the new world: Practical insights for funding, commissioning and managing in complexity.
https://collaboratecic.com/exploring-the- new-world-practical-insights-for-funding- commissioning-and-managing-in-complexity- 20a0c53b89aa Accessed 06.12.2020
3
Popnat.hospiceuk.org. Accessed 29.11.2020 4 Etkind, S.N., Bone, A.E., Gomes, B. et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med 15, 102 (2017)
5 CQC Report 2014.
https://api.cqc.org.uk/ public/v1/reports/91243c0f-0885-40cb-86c0- 2572f95e788a?20160427145507.
6 Lowe T, French M, Hawkins M, Hesselgreaves H, Wilson R. New development: Responding to complexity in public services – the human learning systems approach. Public Money & Management; 2020: DOI: 10.1080/09540962.2020.1832738
About the authors
Corresponding author, Dr. Mary Miller, is a consultant in palliative medicine, Sir Michael Sobell House Hospice, Oxford University Hospitals NHS Foundation Trust, and an honorary senior clinical lecturer, Oxford University. She has worked as a consultant in Oxford for 22 years, leading the department of palliative care at Sobell House Hospice for 9 years. Dr. Miller led the quality improvement project in Oxford University Hospitals for 4 years, working alongside many people to successfully improve care of the dying. Email:
Mary.miller@
ouh.nhs.uk Dr. Hannah Hesselgreaves is an associate professor in Human Resource Development, Newcastle University Business School, Northumbria University. Ms Sharon Yates RN is the programme manager for end of life care, Oxford University Hospitals NHS Foundation Trust.
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