Transcript No Slide Title

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
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USA 3.7%
Australia 16.6%
England 10.8%
Denmark 9%
New Zealand 12.9%
Canada 7.5%
Japan 11%
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10
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% of acute admissions
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
Case History
54♂, angina
Gi Bleed
Endoscopy
Injection DU
Transfused X 2
D/C
Outcome
No
Adverse
Outcome
No M&M
Process vs. Outcome
Process
Case History
No pulse
54♂, angina
No coagulation
Gi Bleed
No ECG - AF
Endoscopy
No Xmatch
Injection DU
O negative
blood
Transfused X 2
D/C
Outcome
No
Adverse
Outcome
No M&M
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
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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
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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
Work Area
Critical Care
Change Package Element
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)
Key objectives
General Ward
Risk Identification and Response
–Rapid response (Outreach) teams
–Early warning system
Infection Prevention
–MRSA
Reliable care for Congestive heart failure
Communication and Teamwork
–Safety briefings
–Communication tools (e.g. SBAR)
–Prevention pressure ulcers
Leadership
Infrastructure to support safety
Walkrounds
Safety a strategic priority
Medicines
Management
Reconciliation
Anticoagulation , Insulin,
Conduct an FMEA on a high risk
medication process
Perioperative
DVT Prophylaxis
Continuity of Beta blockers
SSI bundle
Team 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
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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 / colleagues
Coaching 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
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Single system
Universal access
Population approach
Team working
No other incentives
Loyal and motivated
workforce
Against
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Negativity
Sparse clinical leadership
Professional silos
Organisational silos
Low level of improvement
skills