trust performance

Published: 07/11/2002, Volume II2, No. 5830 Page 24 25 26 27

Can a chief executive really turn round an underperforming trust? Jan Filochowski believes he is about to prove it for the second time. Jeremy Davies reports

Not many NHS managers can claim to have received a personal message of support from health secretary Alan Milburn on Radio 4's To d a y programme. But Jan Filochowski, chief executive at Medway trust, Kent - currently on secondment to the beleaguered Royal United Hospital Bath trust - is a notable exception.

'Unfortunately, I missed it, ' confesses Mr Filochowski. 'Apparently he was talking about failing hospitals and how a zero rating can provoke the extra determination needed to turn around a hospital in difficulties, and my name came up.'

Mr Filochowski has clearly been making a name for himself in high places, and there is little doubt that his high-profile secondment to RUH Bath - labelled by many as the 'worst trust in the country' - will be watched closely by government ministers, civil servants and the NHS management community alike.When he joined Medway trust in autumn 1999, Mr Filochowski's career had included chief executive posts at Southmead and Poole hospitals.He had also run the NHS orthopaedic collaborative and worked with Don Berwick, professor of health policy at Harvard, among others, during a fellowship to Harvard University.

The brief at Medway was a challenging one - waiting lists were, he says, practically out of control; there were huge problems in accident and emergency, leading to 12-hour trolley waits; and within three months of his arrival the trust had no executive directors, no chair and three non-executive vacancies.

Three months later, towards the end of the 19992000 financial year, he discovered there was 'a£4m hole in the budget', despite previous assurances that the trust's finances were sound.

'One of the departing directors said: 'Welcome and good luck', ' says Mr Filochowski. 'In management terms, it felt a bit like climbing on board the Mary Celeste.'

Mr Filochowski set about turning the trust's performance around, focusing initially on emergencies. 'I had some very good people working with me to manage the emergency side - we built a new patient pathway, got a new medical assessment unit in and by January 2000, 12-hour trolley waits were a thing of the past, ' he explains.

By March, the focus had switched to electives - though Mr Filochowski stresses that the key to turning organisations around is to 'go in, sort out the problem and, most importantly, stop it ever happening again - It is no good fighting a fire if you do not then remove the flammable materials that could start it all off again'. To prevent the problems recurring, he set up a cohort management scheme (see box above).

When Paula Friend - then Medway's general manager for surgical services, now on secondment to RUH Bath as director of service renewal - joined the team at the end of March 2000, Medway's inpatient waits were, says Mr Filochowski, the third worst in the country.

The system Ms Friend developed, working with clinical director for surgical services Gulzar Mufti and business planning manager David Dawson, became known as 'cohort management' and presaged what the NHS Modernisation Agency labels 'primary targeting lists' (see box above).

'The agency contacted us to tell us about primary targeting lists and were amazed to find that we'd already developed our own version of it and were using it to enormous effect, ' says Mr Filochowski.

Mr Dawson says the crucial factor in implementing the system - through which consultants have access to weekly graphs showing their progress in treating target patient cohorts - was establishing common ownership of waiting-list targets. 'Historically, There is been a perceived gulf between the patients' clinical interests and the 'bureaucratic' imperative to meet targets. The reality is that there should be huge common ground - on a basic level, the longer a routine patient sits on a waiting list, the more likely they are to later develop into an urgent case, ' he says.

Bridging the clinical-managerial divide is not easy, but it is crucial and utterly dependent on 'toplevel support', he says: 'You have to develop trust.

That means providing consultants with information That is meaningful to them, and taking the necessary action where it becomes apparent that the problem is lack of capacity.'

By Christmas 2000, the inpatient waiting list was under control and, partly due to a change of emphasis from target setters at the Department of Health, the focus then shifted to outpatients. At that time, the trust had 5,500 patients waiting over 13 weeks for initial appointments, and the target for March 2001 was 4,000.

Ms Friend designed a pioneering partial booking system, the idea being to identify and eliminate any administrative processes that had the potential to slow down the patient journey.

'The more decision makers you have in a process, the more potential there is for delay - whether that be GPs relying on their receptionists to send letters through on time, or relying on patients to remember when their appointment is and stick to it, when it was made several months previously, ' she explains.

Under the system, patients are split into those who need an appointment within two weeks - these are phoned and a time agreed there and then; those to be seen within six weeks, who receive a letter giving them a four-week window in which to arrange a slot; and others, who receive an initial letter followed at the six-week mark by an invitation to call in and arrange a slot. By June 2001, the trust had met its outpatient target.

In the meantime, Mr Filochowski and his new finance team took three months to diagnose what was causing the trust's£4m debt - in a nutshell, a loss of financial control relating to a major building development.

1It took three months to put the finances back on track - in October 2000 the trust was overspending at a rate of£400,000 a month, but by January the overspend was eliminated.

So by the summer of 2001, the trust was hitting its inpatient and outpatient targets - 'probably the only one in the country to do so', suggests Mr Filochowski, its financial black hole had been filled, and Ms Friend and Mr Dawson were embarking on an NHS Modernisation Agency lecture tour to promote their cohort management approach.

But in August came news of the 2001 star ratings.

Despite all its achievements, Medway, because of its previous year's performance, received no stars.

'We knew we were doing a great job, but it came as a terrible blow, ' says Mr Filochowski. 'The local press and MP were behind us, fortunately, and I had staff stopping me in the corridors to say I had their support - one group of staff even made me a card with lots of stars on. But it was a real low point for us all.'

Through the winter of 2001-02, the trust's performance was 'the best in the country', says Mr Filochowski - who was at this point on six months' probation as the chief of a no-star trust. 'A target of maximum four-hour trolley waits came in that January - we'd been achieving on that for the last four months.'

In January 2002 he received word, via a Sunday Times article, that Mr Milburn would not be axing him from his post. In March, the trust achieved financial balance, met its inpatient targets and over-achieved against its outpatient target of 3,200 13-week waiters by 80 per cent, coming in with just 500 patients over the limit.

Less than three years after Mr Filochowski took the helm, Medway was a three-star trust in all but name - though in fact, it narrowly missed its breast-cancer target and was awarded two stars in the 2002 round.

In July, Mr Filochowski accepted the DoH's offer of a six-month secondment to RUH Bath - one of eight trusts that had just been awarded no stars.

The scale of his task is considerable. The Commission for Health Improvement's November 2001 report on the trust identified problems in the organisation's finances, clinical governance and waiting-list agendas.

While recognising that former chief executive Barbara Harris - at that point on secondment as head of the NHS Leadership Centre - had spearheaded 'a long period of leadership based on dynamism, creativity and innovation', it found 'a serious lack of attention to process', contributing to 'a slowness by the trust to address major issues in the hospital and local health economy'.

In management terms, it found 'a serious disconnection between the executive team and the rest of the organisation and 'an inner circle with a limited focus on the needs of the wider staff group'.

There had been, CHI said, 'insufficient executive team energy directed at assuring basic good care for patients through focusing on quality and clinical governance'.

Ms Harris was suspended from the trust on full pay in late 2001, pending an investigation into manipulation of waiting lists - prompted by an earlier probe by the National Audit Office - and the trust's finances.

She resigned from her post at the NHS Leadership Centre in December 2001. Finance director Martin Dove was suspended and chair Gerald Chown resigned. The trust eventually sacked Ms Harris in August 2002.

In terms of government targets, at the end of 2001-02, RUH Bath accounted for 280 out of the 281 patients across England who had been waiting more than 15 months for inpatient treatment. It also had 337 patients waiting more than 26 weeks for an initial outpatient appointment - nearly 30 per cent of the total for England.

Research on 143 trusts has suggested that 'changing the chief executive of an organisation is unlikely to have any significant impact within a 12-month period'.

1David Dawes, development manager at the NHS Leadership Centre, and author of the study, concluded that 'holding new chief executives to account for their organisational performance within the first 12 months is unlikely to be effective'.

But Mr Filochowski is clear that he has already made serious in-roads into some of the biggest problems at the trust.

'When I arrived, there were 18-month waiters and A&E was in a terrible state, with 12-hour trolley waits and ambulances circling around outside unable to drop people off.Outpatient waits were horrendous, too, ' says Mr Filochowski. 'We are back in the box now, and in three months' time we should be out the other side.'

Within four months of his arrival, Mr Filochowski has appointed a new board, including three directors drafted in on secondment: Paula Friend as director of service renewal, Corinne Hall from Hillingdon Hospital trust as nursing director, and Stephen Cass from Worthing and Southlands Hospitals trust as finance director.There was a new medical director, John Waldron, from within the trust.

So far, the trust has eliminated 12-hour trolley waits - this was achieved by mid-July - and is now working on four-hour waits.There are no more 18-month inpatient waiters, and by the end of August the trust had only one 15-month waiter.

Six-month outpatients were expected to be a thing of the past by the end of October.

Mr Filochowski will not give further details about the managerial and financial crisis he inherited at the trust. But he is confident he can turn it around, given the time and space to develop and embed his management philosophy there.As for what starrating RUH Bath can expect next summer, watch this space... l Cohort management: beating waiting-list targets the Medway way The central concept of what Jan Filochowski and colleagues called 'cohort management', and the NHS Modernisation Agency terms 'primary targeting lists', is that it is possible to identify all the patients covered by a time-based target at any point.

For example, the only patients who could wait in excess of 15 months for treatment as at the end of March 2003 are patients for whom a decision to admit was made before 1 January 2002.

No-one for whom a decision to admit was made after that date could possibly wait for more than 15 months by the end of March 2003.

Therefore all patients on the trust's inpatient waiting list on 1 January 2002 become a cohort of patients who could, if not managed properly, exceed the 15-month target.

Within this cohort, there will be some patients who are clinically urgent and others whose conditions are routine.By comparing the number of patients in the cohort at specialty and consultant level with the number on the waiting list at specialty and consultant level on 31 December 2001, the trust is able to make an initial assessment of its progress in delivering the 15month target.

Most clinically urgent patients should have been admitted and treated within a few months of going on the waiting list.Those who have not can be identified and progressed accordingly, using any remaining treatment capacity.

By engaging the necessary clinical and administrative input, the trust tracks any remaining cohort members to ensure they are treated as quickly as possible - while adhering to the principle that patients should be treated in order of clinical priority.

Progress for each cohort is monitored at trust, specialty, consultant and patient level, focusing on patients for whom treatment was planned, compared with actual patients treated.The chief executive holds weekly meetings with specialty managers to discuss numbers of patients admitted from the cohort against the planned profiles, and where delivery varies from the plan, discussions about how to clear any bottlenecks can be held.

If the monitoring reveals that for some reason a specialty or a particular consultant will not be able to treat all their patients, the trust makes contingency arrangements such as pooling of patients within a specialty, creation of extra in-house capacity, or agreements with other NHS or private providers.

Jan for all seasons: the Filochowski philosophy A handful of key themes underlie Jan Filochowski's management approach: 'lean thinking', ensuring a continuous flow of work, analysing root causes of problems and good communication.

'I am not a fan of people who go in, arms flailing, making decisions, 'he says.'You need to find the root cause of the problem - now that can take years to achieve in fact, but you can develop a sense of it within the first couple of weeks.

Once You have got a handle on it, you have to act quickly or you become a part of the problem.

'It is important to focus on the crisis issues, and keep a close eye on what you're doing.You need to keep asking, 'what did we do right there and can I generalise from that?'and then embed it in your system, so that eventually you can tie all the good stuff You have worked out together into a sustainable system.'

At both Medway trust and Royal United Hospital Bath trust, Mr Filochowski has made communication with staff and the media a major priority.

'Failing is 1 per cent about people and 99 per about systems, but often in a failing organisation staff have lost hope, and they need to feel they can be part of a solution, 'he says.

REFERENCE

1 Dawes D. Stars of Wonder. HSJ 2002; 112(5822):26-7.