Judges for the HSJ Award for acute healthcare organisation of the year said if you pulled together all the best practice around the country, you would have the perfect trust. So what would it look like, asks Daloni Carlisle

Judging the 2007 HSJ Awards was a tough task. Judging the acute healthcare organisation of the year category was particularly difficult. It was not just that it is hard for the judges to decide which trust really is the best, it was also that they saw so much fantastic work - and they wanted to share it.

"I visit lots of hospitals, quite apart from the HSJ judging," says Matthew Swindells, Department of Health information and programme integration director general. "Everywhere you go you find people doing great stuff and people doing stuff that's rubbish. The question is, who knows about this and what should we do to get the NHS better at sharing and adapting what's going on elsewhere?"

Admittedly there does not seem to be anything terribly revolutionary about this, except that the NHS is notoriously bad at it.

Mr Swindells says: "If Sainsbury's invented a better way of steering supermarket trolleys, by next week Tesco and Asda would have copied it. If you did that in the NHS, by next week other hospitals would be explaining why it was unsafe."

Chief executives and medical directors need to take the supermarkets' approach and learn from others, he says. "It needs to be part of your core business to go out and find out what works for your patients."

It is not that the good stuff has to be radical or unique - there are common characteristics to be found in all the best trusts. Many of these are based around styles of management that enable innovation and good practice to thrive or partnerships to flourish. Some are organisational features or a particular focus that, in the judges' view, cropped up again and again.

Many overlap and only a few are mutually exclusive.

And while the best of the best may have several of these characteristics, none was perfect.

So HSJ judges decided to set out not the usual case studies but to try to identify some of these characteristics. Do you find these at your trust? And could they be combined to create the perfect acute trust?

Very possibly, says Helen Bevan, director of service transformation for the NHS Institute for Innovation and Improvement and an awards judge.

"There is a difference between the good and the excellent," she says. The excellent organisation not only delivers financially and operationally but also has an eye on the future and links to its community. "It's this ability to deliver in the present and design a future that makes organisations really stand out," she says.

The strong chief executive

"This sort of leader is someone who feels very secure doing their job and getting on with it," says Paul Robinson, head of marketing intelligence for CHKS and another of the judges.

They are passionate, adds Ms Bevan. "They really show their values and live them every day."

But the chief executive who leads from the front does not have to be a macho monster. "We saw no old-style, macho chief executives [during the judging]," says Mr Swindells.

"Without exception they were at the supportive, facilitative, team-building end of the scale."

The trust led by the strong chief executive will have strong organisational development and strong personal development. It is a place where corporate responsibility is a high priority.

"You find that people are very proud to work for the organisation, from consultants right down to admin staff," says Mr Robinson.

You will also find strong engagement with clinicians and a real interest from clinicians to develop their own leadership roles, supported by the trust. "The talk is about developing leaders, not managers," adds Mr Robinson.

Where leadership is strong, people know what is expected of them and the aims of the organisation are explicit, it frees them to be passionate about what they do. They have the authority to speak for themselves rather than be micro-managed by an insecure leader.

Ms Bevan feels this sort of leadership develops over time. "The best trusts we saw were ones where the chief executive had been in post for some years," she says. "It takes five years to settle into the job and only then can you start to blossom."

Variations on this theme include:

  • The charismatic chief executive. Persuasive, visible and coherent about what the trust should be doing; tells a story that is understandable and relevant to staff, partners and the public.

  • The empowering chief executive. "This is the sort of leader who makes staff feel that if they have an idea they can try it in a culture where people are allowed to try out good ideas," says Mr Robinson.

  • The sheepdog chief executive. This is the person who leads from behind, almost so clinicians do not realise they are being led. No one can enforce heavy workloads on an unwilling staff; the sheepdog will get them to take heavy workloads on themselves.

At the heart of the community

In many places the local hospital is the biggest employer and has an impact on the entire economy. Some of the best trusts recognise this. The trust that operates in this way may, for example, have strong and sustained policies on greenhouse gases and environmental issues. It may have programmes to support long-term unemployed people into work and strong links with the local voluntary sector.

"The culture is very much about improving the lives of local people. Yes, we treat people when they are ill, but we also participate as a good member of the local community," says Mr Swindells.

Trusts that take this approach probably will not be high profile and will not have their representatives co-opted to national groups or speaking at conferences. Nor will they find themselves at the centre of a reconfiguration row; they will have the partnerships in place to support them through change in a constructive way.

The smooth running machine

A trust can have the best accident and emergency department in the country but a terrible elective care service. To be an excellent trust, the service needs to be consistent throughout and one way of achieving this is to do everything well; not by doing everything fantastically well or by creating a wow factor but by concentrating on the basics and getting them right, day in, day out.

It is what Mr Robinson calls "the smooth running machine". "This is a place where people look after each other and where there is a culture of good membership in the foundation trust," he says. "People like working there and there is a real family atmosphere. It is a place that is taking work from other local trusts because it has better waiting times and lower infection rates."

Ms Bevan agrees. "The excellent trust is one that is really on top of its current workload, delivering financially and operationally, is really good at the detail and at doing ordinary things in extraordinary ways."

Clinically, it is a place where there is a good rapport between GPs and hospital physicians who can work together to reduce emergency admissions.

Mr Swindells identifies the same characteristic. "One of the types of organisation I come across is the hospital that understands what it is for. One that recognises and aspires to be a fantastic district general hospital.

"It does not want to be a teaching hospital but wants to be the best hospital for its local people."

This hinges on maintaining a consistent and high level of performance, which is achieved through clinical engagement as well as good community engagement.

"It's a story about focusing on the nitty-gritty, knowing what your population needs and delivering it," he says.

Data dexterity

One of the factors that separated the finalists from the rest was the use of data. "There was a real difference between the extent to which frontline clinical teams were using data to drive improvement," says Ms Bevan.

Say, for example, a clinical team is looking at their care of patients with a fractured neck of femur. "Unless you have the data on how long it is taking from admission to operation, or mortality rates, or complication rates or readmission rates, you have no idea how good your care is," she says.

"It is not just a case of having access to it but using it to create knowledge and make decisions from it."

Ms Bevan argues it is up to leaders to make data useful to clinicians and embed its daily use.

"It is a huge responsibility and it is up to senior leaders, executive directors and boards to lead from the front and to be making data-led decisions."

The competitive culture

This characteristic is not so much winner takes all as competition being a driver towards excellence.

Starting at the top, trusts with this culture will see themselves working in a marketplace where their job is to attract patients by providing a high-quality service. That requires an understanding that efficiency will follow quality.

"Trusts that can do that and focus on quality will find that they do not have to tell people it's about money all the time," says Mr Robinson.

With the focus on quality, clinical teams are enabled to work on patient pathways and improve them. "What you see is clinical teams - and not just doctors - redesigning pathways," he adds. Because staff are enabled to deliver what really works for patients, efficiencies follow and more patients are attracted to a service, he says.

When the competitive drive is to provide the highest-quality services, the result is more patients. Such a culture permeates the trust.

Clinicians understand the data and use it - partly because the management team has made it meaningful for them - and performance management has a sharp focus.

"We saw a really wide variation in the level of sophistication of performance management during the judging," says Helen Bevan. "Some places were really on top of it and had great systems for understanding variations whether it was in quality, safety or financially."

In the best places, performance management drives the competitive culture, department by department, team by team and clinician by clinician.

"Understanding why, say, one clinician does five operations a session and another does three when the national benchmark is six can really drive improvement," she says.

Where it works well it is clinically led by medical and clinical directors who had the management skills to use the consultant contract to full effect. "They used it to work with colleagues to understand where the opportunities were to do things better, more productively and to make changes in clinical roles.

"Performance management was clinically led and aligned to the objectives of the organisation," adds Ms Bevan.

Management that does not get in the way

"In one of the very best trusts we visited I asked clinicians what the managers there did," says Mr Swindells. "They said, 'management does not get in the way'."

Achieving this requires a very engaging and supportive management style, he adds.

"When it works it is because management sees problems in quite a sophisticated way and quite early and presents them in such a way that clinical teams can take ownership of them."

Which is not to say that clinicians were allowed to get on with their work unmanaged; far from it.

"I think what goes unseen in organisations where clinicians feel like this is the very hard work behind the scenes, clearing away the problems that would otherwise stymie them," he says.

"If the A&E is to transform, you have to assume that someone is in the background rushing around fixing things like radiology and imaging. Someone has to be in the background clearing away the blockages."

A one-track mind

Another sign of excellence is the entire hospital grasping one issue that fundamentally affects everything and running with it.

Take safety. Mr Swindells explains: "If you have a place where the patient safety agenda is well embedded you achieve a situation where everybody, management and clinicians, are all asking: what do we do that puts patients at risk and how do we stop it?"

That translates into initiatives as simple as the surgeons talking to their entire team before theatre starts so nurses can identify any missing equipment before the patient is unconscious in front of them.

"It creates a culture of putting the patient first and reducing unforced error," says Mr Swindells.

The trust that achieves this can take on a wider role too - becoming the champion nationally for a particular focus or driving it up the political agenda through campaigning.

How to achieve this, though?

"You need to identify what is important to patients and clinicians and to the NHS as a whole, even though it is not sexy or glamorous, and then embed it. This is where leadership comes in. You need to be very visible, very persuasive and very confident while also being very supportive," says Mr Swindells.

Location, location, location

The state of the estate, while important, is not a fundamental, the judges agreed. The HSJ judges saw outstanding trusts that had wonderful new buildings but a challenging local population with high levels of social deprivation; great estates in an area of high social affluence; old-fashioned and ugly buildings in an area with a very mixed population including high levels of social inequality and average buildings serving average populations.

"Of course the estate makes a difference," says Ms Bevan. "It's better for patients to have a nicer quality of facilities. But if you have great clinical care and good team work, focusing on the important things and knowing your business well, that's more important."

"It's nice to have a good building that is designed with a modern healthcare system's needs in mind and that is a pleasure to work in," agrees Mr Robinson. "But I do think what some people are doing in the most difficult of places with the most challenging of populations is incredible."

The HSJ acute healthcare organisation of the year 2007 was South Tees Hospitals trust. The finalists were Calderdale and Huddersfield foundation trust, Heatherwood and Wexham Park Hospitals foundation trust, Harrogate and District foundation trust and Luton and Dunstable Hospital foundation trust.

Do you agree with the judges' picture of the ideal acute trust? Let us know at hsj.feedback@emap.com