TTT \ year ago, Mersey Regional Ambulance Service trust vas faring very badly — until an interim chief executive hanged the culture of decision making. By Alexis Nolan ‘We are not looking for blame but improvement’ ty the rime you rend this, Alan Murray willno previous year: 43 per cent for emergencies, 10 ongerbe interim chief executive of Mersey per cent for GP urgent admissions and 15.4 per Regional Ambulance Service trust; the trust will cent for sub-aeute transfers, save merged with three others to create North ‘And there isa standout patient outcome West Ambulance Service tust and he will have statistic when you look at the corresponding noved on. But like all good managers, he leaves 8 improvement in return of spontaneous circulation ralable legacy, despite being in position for only (ROSC) following cardiac arrest in the final months. ‘quater of 2005-06. 2005-06, Mersey Regional Ambulance ‘Againot a national average of 13 per cent ROSC. service lost te two stars and waslabelled the at the hospital door, Mersey Regional Ambulance poorest performing ambulance trust in England, Service's performance rase from 16 per cent to 26 n July 2008, its compliance with the key per cent? says Mr Murray. In human terms, standards to respond to 75 per cent ofife- against this ane measure, 69 additional patients hreatening calls within eight minutes and 95 per _ were given a chance of survival’ sent within 14 minutes (or 19 in rurel areas) was 70.5 per cent and 92.9 per cent respectively - and Fast work declining. “The changes are understandably weleomed by Only 51 per cent of GP urgent admissi trust chair Ken Hoskisson, who is surprised by often the sickest patients the service has to deal the speed of progress since a new strategy was with — were being admitted within the time pt in place for the trust last July specified by the GP, against 2.95 percent target, ‘We never thought that our turnaround “There was reliable evidence thet GPs had lost __strategy would achieve such impressive results so confidence in the service and were using the 999 quickly, he says, ‘The changes in the management ‘The need for speed: Alon Murray with paramedics Tan Brown (ef) and Gerard Davies, t Mersey BR system to ensure their patients received timely approach and culture have been extraordinary Regional Ambulance Service headquarters, attention} says Mr Murray. ‘and have transformed the standing of the trust trusts last year to.conduet a strategie review. By mic-Aprl this year, the trusts performance with our colleagues in the emergency care ‘At the heart ofthis report was the had been transformed. Compliance with the 75 community? recommenclation thatthe trust adopt a and 95 per cent standards for life-threatening, Cheshire and Merseyside strategic health comprehensive approach to performance emergencies had risen to 75-4 per eent and 978 authority director of performance Helen Bellairs measurement and management, drawing on best per cent respectively, Urgent performance had _says the SHA hasbeen similarly impressed by the _ practice and supported by ‘performance Figen to 92 per cent. Mr Murray is proud to point ‘scale and speed! of transformation. dashboard’ software out that these improvements were achieved “The new management approach has not only His July report clearly struck the right chord against abackground ofrising activity over the demonstrated its ability to address some deep-_and he was inwited to become interim chief ‘seated performance problems quickly and ‘executive, tasked with implementing his own Key points effectively? she says, It has also introduced state-_recommendatic @ itersey Regional Ambulance Service was Te wor ‘of the-art information-management techniques His immediate actions included restructwsing performing inthe country. thatare already proving theie valuein the delivery and simplifying the management arrangemen's @ A stiategicroview recommended obustapproachto of emergency care tothe local community? based on demand analysis and the use of performance messurement andmanagement. Mr Murray, management consultant and emergency ambulance unit hours. @ Anjimpressive turnaround was achievedby simplifying former ambulance trust chief execative, was Tn October, the trust hoard signed off an management systems, ethinkingresponses toemergency commissioned by Mersey Regional Ambulance _18-month strategy called Tlne fo Make a Diffeene patients andintroducing anew perfornanceframework, Service trust, the SHA and local primary care which set out goals for delivering clinically 24 Health Service journal 13 July 2006 bsjeoweffective responses to emergency and urgent patients and improving appropriateness for 999 aller who did not need an ambulance response ‘was Supported by a trustwide e-learning veclage which tet nt demonstrate the relationship between rapid tesponse and good patient outcome, We have given frontline managers in the organisation a role says Mr Murray. ‘Their tole 2 fairly centralised approach, refering upwards ‘or permission to act and sometimes acting then not getting support from above. We have looked to change that The development of a performance: management fmework's te fomaacon orne between honest trust's improvement. The trust worked with NHS i , Heth andSoce Ca Intron cemmews ee ad Negligence’ “no-blameculture”, hsicouk ‘InthepastIhavetried has traditionally een ill defined. Therehas been USING terminology like like But people get confused _ advice on best practice in performance management processes and with Light Solutions for information analysis and the dashboard software. ‘The trust went through a review pros censure performance improvement could be understood and rolled out at every operational level, that there was clear communication from the executive team and that the right key performance indicators would be used. ‘The rollout of the programme began in late ‘November with middle managers running through training sessions on the software and. hhow to interpret data and also on how to undertake effective performance review meetin Once this was achieved managers were given & “T would have ses months ago that 13 July 2006 Health Service Journal25€ would have preferred to start out by ielivering coaching skills to managers but now I say what We did was right? says Mr Murray. ‘The vim was to get the attention of managers and then follow up with coaching skills. These coaching events not only helped support the earning cycle for individual managers out also helped their respective teams gain an insight into where critical problems were oecurring? ‘The next step was to link the sector manager work to frontline and executive managers, The blame game Mr Murray says the aim is o take up as little management time as possible. For example, sector managers’ meetings with frontline managers lst 60 minutes, focusing on three sues planned in advance, ‘They are decision- oriented not information but ection, says Mr Murray To help focus managers’ minds on personal action and help rid the organisation of what Mr Murray calls ‘a culture of upward referral’ the trust has introduced tw acronyms to drive home the message, The first is IDA: issue; decision; action. Picking up on planned meetings focusing on «small numberof issues, the perative is then to make a decision, act on it and then evaluate the impact Itmay sound simple, but Nix Murray says it is not necessarily easy to change entrenched mindsets, ‘In the past Ihave tried using terminology ike ‘no-blame culture’ Ihave rejected that ultimately because it confuses people. They get confused because ofthe difference between honest mistakes and negligence. “What we have called ithere is an improvernent culture. We are not looking for blame but improvement. You won't be punished for making an honest mistake, but the othe sie of the coin, is that you have to be prepared to discuss mistakes so that you and others leam, It's almost abadge of honour: a person who never made a mistake never did anything? ‘The second acronym is ABO: authority; beneficial; compliant, The theory is thet to judge whether someone can make a decision they need co judge whether i is in their authority to do $0, whether the decision would be beneficial and whether itis compliant with external legislation and internal policies. ‘Again, the practice should be simple. ‘Iits yes, yes and yes, just do it says Mr Murray. They would be expected to press ahead and take that action and, in exchange, be supported tothe hilt by their senior managers: ‘One example relates toa middle maneger review in Cheshire ~ with the decision and action raken a sector level between a sector manager and their operational service managers. The problem was underuse of the Northwich rapid response vehicle ~a solo paramedic in acar ~ because of an inappropriate pager profile for advanced paging of cals. "The identified solution was a reprofiled pager to capture incidents within a radius of Winsford rather than Northwich, The action was the pager reprofiled through the emergency medical dispatch centre manager, and the effect was @ greater capture of 999 calls and the rapid response vehi responding to 20 per ent more incidents, ‘Mc Murray says the response to the introduction of the performance-management system was surprisingly rapid, Within weeks a 26 Health Service Journal 13 July 2006 the Difference campaign/torecognise nd celebrate high-quality management Inthe face of rationalisation. To find out more, access Key publications and make your own contribution, vist wwets.co.uk/managersmakethe diforence “had come into the organisation. ‘People ‘began to believe they were going tobe allowed to rmske decisions. People become creative. They started 1 enjoy work again and use their imagination’ Another important issue has been funding ~ or rather the lack oft. Mr Murray says that all the work dane over the lst year has been ‘within the existing funding envelope. Not only that, but the ‘changes have ereated approximately £1.2m of acide! value in-year by getting more from the same. Shift cover has improved from 85 per eent ‘7 per cent within the existing set-up by using new production methods. Over fll wear this would equate to a capacity growth of 36 whole time equivalent sta or 16m. ‘Vehicle-elated lost unit hours have been eut by 90 per cent, equating to 1.62 whole-time ‘equivalent sta over a full yer, or £50,000. ‘Reducing call eyele times initially by 90 seconds equates over a all year to six whole-time equivalent staff, or £180,000. Adult education “Another way the performance framework has had ‘an impacts to clarify how managers and staff should relate to each other. With managers and sta‘Texpected to use their initiative and take responsibility, they have had tobe treated with respect. “We putit into very simple terms. If people are treated as adults and with respect in their own hhomes and out ofhouus socal activities then they have aright to expect the same thing at work says Mr Murray. "We have said to all managers they mus talk vo their staff on an adult-to-adult basis. If they do ‘hey wll evoke one of two responses: ether people will step up and take responsibility seriously or they won't “ifthere'’s no respect coming back, they have {got to persist in adult-o-adult discourse with staff and ifstaff persist in not taking responsibility they have the responsibility to deal ‘with that, bot only ifthey fllow that basic rule? Another crucial element in thisis that stl believe managers are focused on clinical ‘outcomes that ean be improved through the performance framework and not on key performance indicators for their own sake. “People don't join the ambulance service to achieve statistical standards, but they do need to understand the importance ofthese to outcomes. Getting to the patient in time to make « difference is about improving cinical outcomes. ‘Tn talking to staf on stations and out at hospital its very necessary to have leadership talking the same language as we do: patients and outcomes rather than spreadsheets and statistics? ‘As for Mr Murray, he becomes another statistic: one fewer chief executive in the reonganisation of ambulance trusts, PCTS and ‘SHAs, But he’ fr from biter He believes Mersey Regional Ambulance Service trust in better shape and thar this wll help to get it off toa Detter star. Mr Murray has been working with John Burnside, chief executive ofthe new trast © ‘liga the work achieved in Merseyside with a strategic direction for the new organisation. Mr areay wil tum to his consultaney business ‘nd Ieok for his next challenge. @ gg Registered users of HSPs website can access more information on this article at GF J) w.goodmanagement-s}.cou) eta” performance sjcow