Did you know that every year in England there are…

Judgement!!Improvement!!

Research!!

• View data over time

• View different data sources side by side

• Look for similarities and understand the reasons for differences; don’t be afraid of uncertainty

– Plot as you go; set up a spreadsheet to help you– The more the better; try to measure as often as possible– Print and scribble; annotate your charts to add context

and additional qualitative information– Display your charts for all to see– Assess trends, not absolute numbers– Use run chart or SPC methods to help detect a change– Embrace your analytical resource……

Julie Jones, Patient Safety Lead, Birmingham Community Health Care NHS Trust www.ihi.org for advanced measurement for

improvement

1. When it comes to data collection: Reduce, Reuse, Recycle

2. Discuss as a team, and agree, your approach to recording and using data

3. Make data collection and analysis part of your daily routine

4. Triangulate different data sources to give a broader picture (consider a dashboard)

5. Plot your dots as you go- don’t leave it all to the ‘end’

• Carefully consider data collection mechanisms• Acknowledgement of different way of working • Data awareness sessions can help ‘demystify’

data for staff• Feed data back to front line staff as soon as

possible, with commentary• Utilise different incentive mechanisms

• Measures harm at the bedside in a systematic way

• Ask the right questions about key outcomes

•Integrates measurement of harm in to your daily work

•Supports patient care and patient experience

•Allows you to understand how things can be improved

•Measures across the health economy in any care setting

•HarmFreeCare

A call to action for frontline healthcare professionals – staff at Salford Royal NHS Foundation Trust are using the NHS Safety Thermometer once per month to rapidly review the proportion of patients free from harm: matron Dylan Edwards with patient Kathryn Shuttleworth, and staff nurse Helen Gresty

Question 1: Did the patient experience the harm?

Pressure Ulcer

Fall(with harm)

Urine Infection (catheters)

VTE

Patient 1 no yes yes yes

Patient 2 no no yes yes

Patient 3 yes yes yes yes

Patient 4 yes yes yes yes

Patient 5 yes yes no yes

3/5 4/5 4/5 5/5

Question 2: Was the patient protected from harm?

Question 3: PROTECTED FROM ALL 4 HARMS ?

Pressure Ulcer

Fall(withharm)

Urine Infection (catheters)

VTE Harm Free Care

Patient 1 no yes yes yes No

Patient 2 no no yes yes No

Patient 3 yes yes yes yes Yes

Patient 4 yes yes yes yes Yes

Patient 5 yes yes no yes No

2/5

76%

81%

86%

91%

96%

Mean UCL LCL

Harm free care

HarmFreeCarefrom pressure ulcers, falls, catheters & urine infection

& new VTE

What’s different about the way we measure ‘Harm Free Care’?

NHS Safety ThermometerHarm Free Measure

What does this mean?

• Two points outside the control limits

•Some organisations reaching 95% on pilot wards

The East Lancashire Story

John Goodenough - Deputy Director of Nursing Peter Weller - Associate Director Patient Safety & Governance

Where did we want to be …..?

1. Reduction in harm & the levels of harm

2. Full Health Economy Clinical Engagement

3. Measurement –

Measurement to understand

Measurement to engage

Measurement to improve

Measurement because “it was the right thing to do”

!

How did we get there …..?

1. Executive lead

2. Model - Clinically led / Managerially supported

3. Safety & Quality driving principles

4. Understanding Safety Express

5. Compliance with standards & targets were a

“given”

6. Full Health Economy engagement

7. “Driving the Drivers”

Measurement for Improvement

1. Reusing existing measuring systems

VTE

NHS Safety Thermometer

2. Engaging staff – creating a rising tide of change

3. Using Measurement

4. Commissioning

“A picture is worth a thousand words”

Have you developed an innovative approach to measuring harm?

Do you still have any burning measurement questions?