NES April 2009

Global Trigger Tool Reviews

3 Exemplar Hospitals (900 notes)

40 Bed rural Hospital (300 notes)

10 Hospital Research Project (240 notes)

7 Hospital System (3000 notes)

Multi-state Tertiary System (2000 notes)

Events/1000 Days

83 90 NA 119 86

Events/100 admissions

45 40 37 41 38

Admissions with adverse events

32% 30% 30% 29% 30%

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

Conclusion: The “Defect Rate” in the technical quality of American health care is

approximately 45%

Jean Boal

Outcome Aims

• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days

between• Central Line Bloodstream Infection: 0 or 300 days

between• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in

range• Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction

Primary Outcomes

• Develop and build a quality improvement and patient safety culture in our hospitals

• Build in long term sustainability and capability to drive this approach at all levels

Source:British Airways (NPSA adapted)

British Airways air safety reports, 1994-99Total reported events

Total events

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1994 1995 1996 1997 1998 1999

High/medium risk events

0

20

40

60

80

100

120

140

Number of reported events: high and medium risk

Theory of transformation

Our Theory (Part 1)

• Build a compelling case for change• Involve patients and carers• Work on processes and outcomes that engage

the hearts and minds• Work at the coal face and at the executive level• Data feedback, data feedback, data feedback• Set the tempo!

Our Theory (Part 2)

• Changes in process and outcomes are directly connected.

• The changes beginning tested, when fully implemented, will lead to large system aims.

-Align aims and measures with national programmes -Develop a portfolio and execution model-Build connection to safety in national work-Define within clinical governance framework

Improve Safety of Healthcare Services in Scotland

Boards Endorse Safety as Key

Strategic Priority

Deliver the programme

Build a Sustainable Infrastructure for

Improvement

Align SPSP with national improvement

programmes and measures

Primary Drivers

-

Secondary DriversScottish Patient Safety Alliance

(SPSA) Driver Diagram

-One Team-Develop experts in imp. methods and coaching-In-country measurement system, culture survey-Safety work migrates to appropriate agency-Training programmes developed in Scotland- Work with IST, QIS and HES to develop unified improvement approach

-Segment hospitals , customize approach-In-country support for Boards-Spread strategy community hosp., primary care-One Team -”Everyone in the tent”

Scottish Government Sets PSA as Strategic

Priority-National Board development strategy -Ownership of agreed upon set of outcomes and measures -Quality and safety comprises 25% of agenda--Development of infrastructure that supports improvement and measurement-Clear improvement aims in strategic plan

National leaders openly endorse SPSP aims, failure is not an option for execs- Time and space given for improvement (not a target)-Royal Colleges serve in official capacity-Safety is an element of all programmes

Integration

Judgement vs Improvement

Prototype and Spread

Successes from Action Period Two

No central line bloodstream infections since July

Shift

Successes from Action Period Two

Trend

Successes from Action Period Two

Trend

Shift

CRBSI (CRI 3) Monthly Incidence Sept 2005 - Aug 2008c chart

0

1

2

3

4

Sept Oct Nov Dec J an Feb Mar Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar Apr May J un J ul aug

2005 2006 2007 2008

coun

t per

mon

th

NES?

• What is NES already doing that relates to this agenda?

• How can NES help inform those working on this agenda?

• What can NES do in addition to present activities?

Who needs to know and what do they need to know?

• Patients, carers and the public• Executives• Non-executives including chairs• Middle managers• Clinicians

– Senior– Middle grade– Trainees

• Administrators• Health professional students – Cab. Sec promise

“NHS Scotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety.  The dedication of NHS leadership at all levels to this endeavor is apparent to me, and bodes

well for success.  In its scale and ambition, the Scottish Patient Safety Programme marks

Scotland as leader – second to no nation on earth – in its commitment to  reducing harm to

patients dramatically and continually.”

Don Berwick June 2008