In the words of Monty Python (well sort of): ‘what has pathway ever done for me?’ This is what I hear when I walk around the hospital chatting to nurses and other staff about our journey on the pathway to excellence. There is an air of suspicion still that this will mean extra work for people already maxed out delivering care and their day to day jobs. I’ve been on this journey since almost the very beginning and there is actually something really rather special about it all, how it galvanises everyone together in a common purpose.
I work in Northampton General Hospital, a district general in the middle of the country. It is an acute trust with approximately 760 beds and 1100 registered nurses. We were, like many hospitals a few years ago, struggling with ever rising demand and a stretched, tired nursing workforce. I would be lying if I said we were not still struggling in some ways like many hospitals out there. However would I describe our nursing workforce as a tired one now? No, I would not, and that is in part thanks to pathway to excellence.
Pathway to Excellence is an international accreditation system that acknowledges hospitals who put their nursing workforce at the forefront. This system understands that in order to deliver excellence in patient care you must first have a workforce that is enabled to deliver that. The American Nurses Credentialing Centre (ANCC) is the body who govern the process and have 6 standards that embody their values:
1. Shared decision making
6. Professional development
4 years ago (2014) I started as a band 7 sister in Northampton’s Emergency Department (ED). The trust had recently been rated as requires improvement by the Care Quality Committee (CQC) and I think it would be fair to say that morale was low. It was a marriage of convenience; I recently had a baby and was doing a 2 hour commute to work and back in London. After much deliberation I knew I had to move to a local hospital to balance my life. My new commute to Northampton General took 10 minutes. It was the hardest decision I have ever made, I loved my job in London and didn’t want to leave but equally knew I had to. It was probably the best decision I could have made because I landed here in a time of huge change. The culture in the hospital was in the grips of a shift that put patient safety above all else. There was a great drive for grass roots quality improvement. I’m not sure we even knew it at the time but we were laying the foundations for our pathway application.
In 2015 Carolyn Fox was appointed as our director of nursing and midwifery. She brought with her a vision to put nurses and midwives at the forefront, the driving force of excellence. A bold ambition but we are the largest, most stable workforce in the NHS. I can remember hearing about pathway to excellence, nobody knew much at this stage but a group of senior nurses were heading out to America to the pathway conference to find out if this was something that felt like a good fit for our hospital. Our conference was coming up and ED had been asked to have a stand to demonstrate our work in the department. We googled pathway to excellence and mapped our work in the department to the 6 standards. It was instantly recognisable as something really special.
These are the standards, and some of the work we have done that demonstrates we meet them:
1 Shared decision making
This is perhaps my favourite of the standards (although it’s tricky, like trying to choose a favourite child). Initially I thought we had this down in the ED. We have weekly meetings with the consultants and senior nurses, and make our decision together. This is hugely important, and one of the reasons our department was rated as outstanding for well led by the CQC in our re-inspection. However it was the creation of the shared decision councils that have really made the biggest impact during our pathway journey. The concept is very simple: have a small council, give them some basic training, protected time and corporate connections with support to make changes. Then let them fly, and watch the magic.
It is multi-professional and not hierarchical. Council chairs are appointed on the basis of their qualities not their grade; we have housekeepers and support workers as chairs. As a trust we have seen some really little changes as simple as getting apple juice on the paediatric wards, putting hooks on the wall in ED to use instead of drip stands. There have also been some bigger changes like creating a new therapies room on our stroke ward. These councils are innovative, and passionate about making a difference to their workplaces for both patients and staff. It is quite inspirational to hear about their work. One of the councils has worked out if they switch wristbands to match the type used in the ED it will save them thousands of pounds every year. We are talking about rolling that out trust wide, I can imagine the director of finance rubbing their hands together in glee as they do the maths. Want to know more about that? Get in touch.
This standard probably sounds very familiar and not that daunting. It starts at the top and for probably the first time in my career I actually know who my director of nursing is and see her on a fairly regular basis. She is not a mystery character on the wall of executive photographs, or someone who I only see in times of strife or trouble. I once heard a director of nursing of another trust say there was a joke in her hospital that she would go the opening of an envelope. She was truly visible to all staff, she made sure of it. I actually liked that, I want to believe that the person in charge of us all is actually genuinely interested in getting out and about and meeting us all.
We have seen a big roll out of leadership training across the trust. We have started our 5th cohort of the Royal College of Nursing (RCN) clinical leadership programme October 2018. It has been hugely successful and the feedback has been overwhelmingly positive. The Matrons have also completed their leadership development programme recently. As I sat and listened to their presentations at the celebration event there was a common theme, experienced people who were a little sceptical when they were first put on the course having previously completed leadership courses. However the pride and sense of achievement they conveyed about their journey was wonderful to watch. I couldn’t help but wonder, all the little projects they had completed, would they have happened without it?
Things are starting to feel a bit different, leadership is really important to us now. People talk differently, challenge the status quo more and recognise the achievements of others. We push and challenge ourselves more, write abstracts, present at conferences and publish articles.
I know, this one sounds a little dry. But it’s what we are all here for isn’t it? Delivering world class safe care, in an ever demanding environment. This is about ensuring we all know what good, harm free care looks like.
Lots of our hospital processes already filled the criteria for this standard, however it was often lost in the upper echelons. Unless you were part of it you didn’t know about it. In ED we have worked hard to share learning from incidents in a number of ways, simulation, mortality review meetings (open to all staff), safety huddles, staff meetings and matron updates. One of my passions is learning from excellence, great practice is shared in all these ways too.
Within the trust we now have a number of collaborative groups which meet to drive harm free care: pressure ulcer prevention, falls and infection control are excellent examples. Their work has been nationally recognised at the HSJ patient safety awards and presented on the international stage.
When submitting evidence to the ANCC we had to demonstrate our resilience to natural disasters and our ability to maintain patient safety no matter what. We are a little short on hurricanes and earthquakes (it is after all an international accreditation system), we have however had very heavy snowfall recently which significantly affected the infrastructure of our rural community. Our trust arranged 4x4s, temporary accommodation and my personal favourite onsite emergency childcare to support people affected by the school closures.
With the new director of nursing came assessment and accreditation, a process where your ward/department are internally assessed against similar standards to CQC inspections and given a rating. It has inspired a bit of competition in the hospital, and certainly in ED we want to succeed, because we realise this is part of something special. This is part of what is making our hospital great, and a better place for staff and patients.
All of the leadership programmes include a quality improvement project for candidates, it captures their passion gives them the space and support to really drive quality in their areas. This is so important, too often we get bogged down in the day to day stuff and end up just getting by. We are now given the space and permission to change that, its part of the pathway magic.
Feedback is essential to great care, we have probably one of the best systems for sharing patient feedback that I have seen. It’s an interactive portal where ward charge nurses can comment if they have made a change because of the feedback received. Positive comments are regularly shared with staff via social media and personal cards from the chief executive. Where there is learning and changes to be made these are implemented. In ED we had feedback from our friends and family test that ED was confusing and communication was poor. Our shared decision making council designed improved signage throughout the department, to better explain the patient journey and promote better communication between staff and patients.
Healthcare professionals are renowned for neglecting themselves when caring for others. Resilience and self care are hugely topical right now. Medical Twitter is awash with chatter on the subject, some are a little sceptical that it is a sticking plaster for other issues, but it makes sense doesn’t it? It’s certainly not a substitute for dealing with bigger things but we cannot look after others if we do not look after ourselves. We have worked hard to promote wellbeing in the trust, social gatherings in wards and departments – so simple but so important. Health and fitness with reduced gym membership and support groups. My favourite on this one is the new wellbeing room in ED, a simple space with a massage chair so people have somewhere for 5 minutes of peace. Anyone who has shed a tear in a sluice will understand the true value of this little beauty.
This standard highlights that meaningful recognition for what people have achieved is integral to a happy workforce. One of the really special things here is the introduction of the Daisy awards. This is a charity set up by a family who lost a loved one, who were in awe of the care he received from the nurses. Nurses are nominated by patients or relatives for care they have given. Having witnessed a daisy presentation where the patient spoke about one of my colleagues and the difference she made to her. It was not only moving to hear, but made me so proud of not only my colleague but also my profession. We are the front line, we can make a remarkable difference.
There are lots of ward level recognition awards too, they are all branded slightly differently but the essence is they are for the people, from the people. The trust is working hard to recognise all staff for their achievements, we have the longstanding best possible care awards and the more recent winter hero awards.
6 Professional development
Oh actually this is my favourite standard! As an educator I know the importance of education, this is the backbone to it all. It goes back to people coming to work to be mediocre, no one does that. They get caught in a trap of getting by. Education maps it all out for them, we have career pathways, specialist programmes and different financially supported routes into registered nurse training. As a trust we have a professional development team ensuring our new nurses and international nurses are supported during their time with us. We have surgical skills, assessment skills, an extensive simulation programme available to all. There are so many things available to staff, however our pilot staff survey revealed to us that most nurses didn’t know about it all. Again there was this gap between what we thought people knew and what they actually know. Thanks to pathway we now have a glossy prospectus and updated intranet pages making this information accessible to all.
Study time is built into the rota establishment which means we are able to support individuals to attend the study they wish to. This is so important, and I believe it is one of the reasons our ED has a 1% registered nursing vacancy rate – the national average is for band 5 nurses 16% (NHS Providers 2017). As a trust our average vacancy rate is about 11%, evidence that what we are doing is making a difference.
Supervision and coaching are high on the professional development agenda, this is happening at every level within the trust. The RCN leadership programme and matron development programmes are really embedding this practice which is so valuable to individuals and the wider organisation. Reflective practice is something the nursing profession has been working really hard at getting right for some time now. I was recently involved in a group coaching session that was truly excellent.
This is merely a snap shot of all the work we are currently doing and have done, they call it a journey on your pathway to excellence and it is truly that. I think we had the foundations of excellence waiting in the background, sitting in silos on their own waiting to be discovered by everyone. What pathway does is weave it all together and make you build on it, improve it and most of all communicate it all. After all what is the point if people don’t get to benefit. How could we truly achieve excellence without everyone benefiting from it? All this effort after all is ultimately about providing world class patient care.
So is it really special? Yes, I believe it is. This journey hasn’t been easy, it has taken a whole hospital to get behind it all and our pathway lead Tara Pauley to pull it all together. There have been deadlines and changes on a corporate scale and we have worked hard to get to where we are now. All of our evidence has been submitted and at the time of writing we are hurtling towards a staff survey. Accreditation is a two stage process: first submit your evidence that proves you are living the standards in your hospital, then all of your registered nurses are surveyed to make sure they know about all the things you say are happening. There needs to be a high response rate and the responses need to be overwhelmingly positive across the board. Am I nervous? A little, but I believe it in all that we have achieved and think that it will speak for itself.
Well then, what has pathway ever done for me? It has given me a voice, made me feel like I matter and can influence and change for the better of staff and patients. It has inspired me, pushed me out of my comfort zone. It has made me more aware of the different initiates in the hospital that relate to all the standards. Most of all it has made me feel part of something, something special that I know is for good of all.
UPDATE November 2018
We did it! We have become the first hospital in the UK to receive the Pathway designated status. We have been internationally recognised as somewhere that supports and develops nurses. In my view this journey never ends, we can always improve and strive to do more and better. I’m proud of what we have achieved and excited to do more.
RCN competencies: GNP3, GNP4, GNP5 & CD7.