Improving Patient Improving Patient SafetySafetyat theat theRD&ERD&ECouncil of GovernorsCouncil of GovernorsJanuary 2010, Item 9January 2010, Item 9

Respond, Deliver & Enable

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Florence . . .

“ It may seem a strange principle to enunciate that a sick patient in hospital will come to harm ”Harm can be defined as anything unwanted or unexpected

Why should we worry?

Estimated 900,000 incidents a year result in harm or near harm to NHS patients (2006)

25% of incidents and 39% of near misses go unreported

840 incidents where a patient will die

400 will die due to medical device incidents

27,000 extra bed days

Average cost of £7.4m per hospital

Adverse events cost £2b in hospital stays alone

£400m clinical negligence settlements

(Source: NPSA)

Where are we at?

All new cases of MRSA

identified more than 3 days after admission

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No of MRSA

Mean

Upper Control Limit

Low er Control Limit

Reduction in Clostridium difficile Infection . . .

Clostridium Difficile Infections

Clostridium Difficile Infections 72 Hours Post Admission

7.91

15.11

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Infections Mean

End of First Deep Cleaning Programme

Total bed days saved per annum = 1815@ £200 per bed day = £363,000

72 hours post admission

The campaign cause is: To make the safety of patients

everyone’s highest priority

The campaign aim is to achieve: No avoidable death,

and no avoidable harm

for the Campaign

The vision

Signed up to:

•Patient Safety First Campaign in September 2008

•South West Quality & patient Safety programme Oct 2009

Patient safety

Respond, Deliver & Enable

Previous Improvement andsafety initiatives:

Pursuing Perfection2003

Leading ImprovementIn Patient Safety

(LIPS)Programme

2007

What have we signed

up to

We’ve made a public statement to our staff and promoted the use of a number of evidence-based interventions so we can track improvement over time

Is patient safety our top priority?

Leadership for Safety

Reducing harm from Deterioration

Reducing harm in Perioperative Care

Surgical Site InfectionWHO Surgical Safety Checklist

Reducing harm in Critical Care Ventilator care bundle Central line bundle

Reducing harm to patients from Falls

RD&E’s own Intervention(not yet part of Campaign)

SW Quality & Patient Safety Improvement Programme

General Ward• Deterioration• HAIs• VTE• Safety briefings

Perioperative Care• Surgical site infections• Team briefing• WHO surgical check list• Pe-op VTE

Critical Care• Central line infections• VAP

Medicines Management• Warfarin• Insulin• Medicine reconciliation

LEADERSHIPLEADERSHIP

Leadership for Safety

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Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09

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Number of Executive Walkrounds

Develop explicit strategic priorities

Provide demonstrable leadership

Ensure executive accountability

Establish and monitor explicit system level measures

Monitor progress and drive execution of projects

Build improvement knowledge and capability

National & SW Campaign Expectations Six Actions to Improve Quality and Safety

The deteriorating patientSBAR Generic Communication tool

SSituationituation

BBackgroundackground

AAction requiredction required

RResponse neededesponse neededPiloted and now in use

Aide memoireAide memoireFunded by the League of Friends• Issued to all staff on induction• EWS plus phlebitis score• Plans to link to self assessment and ESR

one-day snapshot audit resultsone-day snapshot audit results

“… significant improvement in the 08/09 recording of EWS across all areas compared to 2007 ” (over 80% of patients had EWS scores)

Proposed new Observation Chart piloted and now

in production

Annual Mortality Review Standards of Care

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Planning failures Failure torecognise,

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ICU admission Missed ICUadmission

DNR order

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Nov-08%

Review of 50 sets of casenotes of patients who have died Comparison of October 2007 and November 2008

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per 1000 bed days

• Management of– VTE treatment– GI bleeding– AF

• Delay in antibiotic treatment• Missed deterioration

Reduction inAdverse Event Rate:

Mortality Notes

Examples of some

planning failures

Reviewing:• 2x2 mortality table• Process of care• Adverse events

Interventions

Medicines Reconciliation

New clerking pro-forma

Small Tests of Change underway

Spreading tests in early 2010

Roll-out of pro-forma during Q2 2010

Audit standards of practice Q3 2010

• After fatalities, Lead Nurse led a ‘rebellion’ to achieve a change in staff attitudes and behaviours

• Used tools from ‘improvement science’ and patient safety

– Plan; Do; Study; Act (PDSA) small test of change

– Checklist for staff

– Intentional Rounding check patients hourly

– Pace

Falls and Intentional Rounding

SPC - Wards A & B weekly number of patient falls

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Patient Falls Median UCL

IR of all high risk patients commenced

Initial success

Weekly meetings commenced with Lead Nurse

Cohorting patients commenced

One very confused patient

The value of annoted run charts

Weekly Number of Patient FallsWards A and B - SPC

Reducing number of inpatient Falls

Number of falls

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Special Cause Flag

Total number of inpatient falls in 10 medical wards

April 2008 to July 2009

Patient Safety Structure

Board of Directors

Information to be cascaded to Directorate Governance Groups (DGGs) via members who sit on each committee listed above

Governance Committee

New group established July 2008

New group established

October 2008

AdverseEventsForum

FallsProject

Patient Safety Steering Group

ResuscitationCommittee

InfectionControl

Committee

MedicinesManagementCommittee

These groups are existing sub-committees of the Governance Committee, but have reporting responsibilities on the national PSF & SWQPSFP interventions

to the PSSG

New group established March 2009

VTECommittee

New group established March 2009

Learning Lessons Group

Quality Dashboard for the Board

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 TOTALPatients 6 24 42 52 49 38 211Wards 1 4 7 9 10 8 39

Quality Dashboard

The HSMR for the 'Diagnoses - HSMR' Groups as published on NHS Choices website was re-based on the 5th October. This had the efffect of moving the May-08 and Jun-09 figure from 89.3 to 94.2, the HSMR for the current 12 month period Jun-08 to Jul-09 is 93.2 and as such the RD&E is deemed to be 'as expected'. It should be noted that this figure is liable to change as the data is refreshed.

A stable baseline has now been ascertained and improvements or deterioration should be measured against the value of 70.6 Adverse Events per 1000 Bed Days. The current adverse event rate is being maintained at a level consistant with the 70.6 events per 1000 bed day baseline.

There were 6867 patient incidents between Oct 08 and Oct 09. This was an increase of 15% from the same period last year. 10 were catastrophic, 34 major, 128 moderate, 2787 minor and 3908 no harm. For employee incidents there were 2455 between Oct 08 and Oct 09. This was an increase of 6% from the same period last year. 1 major, 81 moderate, 1540 minor and 833 no harm.

Hospital Standardised Mortality Rate Adverse Events All Incidents Reported

29 of 30 Inpatient wards have conducted an NQAT. The Paediatrics tool is finished & due to be piloted on Bramble and NNU in Dec 09 - Jan 10. The Theatres tool has also been completed & is to be piloted in Dec 09.

Patient ExperienceC.difficile Infections ( CDI) MRSA Bloodstream Infections

6 Patients = 1 Nursing Quality Assessment on 1 ward.Previous good performance has been maintained.Higher numbers of CDI have been recorded, in the main due to a period of increased incidence on one ward. Ribotyping is being undertaken to determine if this reflects an outbreak. In the interim however, all control measures required for an outbreak have been implemented. For December ( up to 18th), only 2 cases have been identified trustwide and it is anticipated that by the end of this month we will be back on trajectory for this quarter.

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First month of GTT monitoring

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Answ

ered

'Yes

defi

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ly'

Have you felt safe throughout your stay?

Have you felt cared for throughout your stay?

Would you recommend this hospital to your friends and family

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HSMR Lower Control Limit Upper Control Limit National Average

Any questions?