National Patient Safety Programme

Clydebank 9th November 2007

Scottish Patient Safety Alliance

• Care in NHSScotland is safe by international standards

• We are leading the way in improving our position even further

• Our focus is on improving quality and patient experience

Patient Safety – A Global Issue

0

2

4

6

8

10

12

14

16

18

% of acute admissions

USA 3.7%

Australia 16.6%

England 10.8%

Denmark 9%

New Zealand 12.9%

Canada 7.5%

Japan 11%

Adverse Events in Hospital

• 3.7% Harvard 1991• 16.6% Australia 1995• 10.8% London 2001

• 3 million bed days in UK• £1 billion per annum in UK

• 50% PREVENTABLE

Process vs. Outcome

Process

Outcome

NoAdverseOutcome

No M&M

Case History

54♂♂, angina

Gi Bleed

Endoscopy

Injection DU

Transfused X 2

D/C

Process vs. Outcome

Process

No pulse

No coagulation

No ECG - AF

No Xmatch

O negative blood

Outcome

NoAdverseOutcome

No M&M

Case History

54♂♂, angina

Gi Bleed

Endoscopy

Injection DU

Transfused X 2

D/C

NCEPOD 2005

27% of hospitals have no early warning system

44% of hospitals have no outreach 66% of admissions to ICU were unstable

for >12hrs (in hospital >24hrs) 25% were not reviewed by ITU consultant

in first 12 hrs In ICU frequent deficiencies in care: less

than good in 47% Deficiencies in care may have

contributed to death in 11%

A Major Study of Reliability in American Health Care…

• McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)– 439 indicators of clinical quality of care– 30 acute and chronic conditions– Medical records for 6712 patients– Participants had received 54.9% of

scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%)

• Conclusion: The Defect Rate in technical quality of American health care is approximately

•45%

Reliability in Healthcare

• Healthcare is a high hazard industry

• Approx 10% ( 900,000 ) patients admitted to hospital experience an incident.

• 72,000 of these incidents / adverse events contribute to the death of patients

• Many go unrecognised

The vision – Scotland leading the way in Patient Safety

• Scotland at the forefront - a whole healthcare system approach

• A strategic development priority for NHS Scotland

• An explicit and tested approach to improving patient safety

• Build on foundations laid through audit, clinical effectiveness and clinical governance

• Alignment with wider NHS QIS Patient Safety work

Key Aims

• Build on what's already been achieved

• Tried and tested interventions• Improve safety and reliability of

boards and a safety focused culture

• Capacity and capability for improvement methodology

• Spread and sustainability

How will we do this?

• National approach – Advisory board CMO

• National steering group• National Team / Clinical Lead• IHI • National learning sessions / site

visits• Regional support• Evidence based interventions• Outputs from SPI 1 & 2

Scottish Patient Safety Alliance- Key Partners

• Scottish Government• NHS Scotland• QIS• Royal Colleges and Professional bodies• World leading experts on patient

safety• Patients• NHS Education

Outcome Aims

• Reduce healthcare associated infections

• Reduce adverse surgical incidents

• Reduce adverse drug events• Improve critical care outcomes• Improve the organisational and

leadership culture on safety

Associated benefits

• Reductions in length of stay• Reduction in complaints• Cost benefits• Care is given in the right place at

the right time and in the right way

• Increased improvement capability amongst staff

Key objectives

Work Area Change Package ElementCritical Care Establish infrastructure

–Daily goal sheets–Daily multi-disciplinary rounds

Infection Prevention–Ventilator bundle–Central line bundle–General infection prevention practices–Glucose control (ITU then to HDU)

General Ward Risk Identification and Response–Rapid response (Outreach) teams–Early warning system

Infection Prevention–MRSA

Reliable care for Congestive heart failureCommunication and Teamwork

–Safety briefings–Communication tools (e.g. SBAR)–Prevention pressure ulcers

Leadership Infrastructure to support safetyWalkroundsSafety a strategic priority

Medicines Management

ReconciliationAnticoagulation , Insulin,Conduct an FMEA on a high risk medication process

Perioperative DVT ProphylaxisContinuity of Beta blockersSSI bundleTeam culture - briefings

Outcomes• Critical Care

– E.g: ventilator acquired pneumonia rate• Ward

– E.g.: Crash call rate• Medicines management

– E.g.: Adverse drug events• Theatres

– E.g.: Surgical site infection rate• Leadership

– E.g.:Safety walkarounds

Aims

• Make care safer by a measurable amount– Mortality: 15% reduction– Adverse Events: 30% reduction

• Build improvement capacity in NHS Scotland

Communications

• Letters to Chief Execs• Pre work• Networking event – Nov 20th

• Learning session 1 – Jan 14th, 15th, 16th

• Learning session 2 – May • Learning session 3 – Nov • Regular and ongoing throughout the

programme

Programme / Learning sessions

• Pre work period Oct – Dec• Jan 08 LS1 – 3 day event, work

stream breakout sessions • Collaborative approach –Learn from faculty / colleaguesCoaching from faculty Gather new information on the

subject matter and process improvement

Share information and build work on improvement plans

NHS - opportunity for Improvement in Healthcare?

For

• Single system• Universal access• Population approach• Team working• No other incentives• Loyal and motivated

workforce

Against

• Negativity• Sparse clinical

leadership• Professional silos• Organisational silos• Low level of

improvement skills