Introduction to Safer Practice Dr Helen Glenister 3 October 2005 NPSA

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Introduction to Safer PracticeDr Helen
Glenister3 October 2005NPSA
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How we are organised
Professor Sir John Lilleyman Medical Director
COREC National Confidential Enquiries Medical
Advisory Panel
Peter Mansell - Director for Patient Experience
and Public Involvement Patient involvement across
NPSA
Joint Chief Executive
Jenny Grey Director of Communications Corporate
Communications Brand and corporate identity Media
Newsletters Parliamentary Enquiries Events Dissem
ination Awards and sponsorship
John Hennessey Director of Finance Finance
Facilities IT Risk Management Business Support
Professor Alistair Scotland - Director NCAS
Helen Glenister-Director of Safer Practice
Nursing/Deputy CE Safer Practice Patient Safety
Improvement Hospital Cleaning Food Nutrition
Design Nursing Midwifery Advisory Group
Richard Thomson- Director of Epidemiology and
Research Analysis and Statistics, Patient Safety
Observatory, Prioritisation, Development
Research
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Department Of Safer Practice
Head of Nutrition and Cleaning
Nutrition Lead
Cleaning Lead
PEAT Co-ordinator
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Focus of Safer Practice

• To identify solutions to reduce the risk of
  patient safety incidents

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Approach to Solution Development

• Address root causes
• Make designs of equipment, systems, processes,
  more intuitive
• Make wrong actions more difficult
• Make incorrect actions correct
• Make it easier to discover errorTelling people
  to be more careful doesnt work

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Developing Safer Practice Solutions

• Solutions to reduce the risk of patient safety
  incidents need to be developed in a systematic
  way especially if they are to be promoted widely.

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Developing Safer Practice Solutions NPSA approach

• Understanding the problem
• Identifying potential solutions
• Risk assessing solutions
• Piloting and learning
• Implementation
• Evaluation and closing the loop
• Project closure

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What Can Be Done to Remove Problems?

• Design out the problem (Design Solution)

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Which dial turns on the burner?
Natural Mappings
Stove A
Stove B
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What Can Be Done to Remove Problems?

• Design out the problem (Design Solution)
• Change the system (System Solution)
• - standardisation

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Crash Call Survey27 different
numbers used in Hospitals across England.
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What Can Be Done to Remove Problems?

• Design out the problem (Design Solution)
• Change the system (System Solution)
• Change the practice (Practice Solution)

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To Mark or Not To Mark That Is The Question

• or X ?
• Both or one side ?
• Wrong side marked ?
• Other Marks ?

• Visit www.npsa.nhs.uk/newsletter/newsline.asp to
  subscribe to updates on safety solutions

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What Can Be Done to Remove Problems?

• Design out the problem (Design Solution)
• Change the system (System Solution)
• Change the practice (Practice Solution)
• Train the staff (Educate and Training Solution)
• - Simulation
• - Teams
• - Rehearse

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What Can Be Done to Remove Problems ?

• Design out the problem (Design Solution)
• Change the system (System solution)
• Change practice (Practice Solution)
• Train the staff (Educate and Training Solution)
• - Simulation
• - Teams
• - Rehearse
• Involve the patient

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The cleanyourhands campaign
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Understanding the problem

• Is it a patient safety issue?
• Global and local
• UK 5000 deaths
• UK 1bn
• UK 300,000 patients per year
• Hand hygiene can probably reduce 9-50

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Understanding the problem does it require
national action?

• Pre-pilot survey (England and Wales) 2002
• 77 definite need for national campaign
• Q. What should the role of NPSA be?
• Facilitate patient involvement
• Heighten the media profile
• Produce a national resource
• Promote the use of alcohol rubs

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Elements of campaign

• Alcohol hand rubs at bedside
• Posters and other promotional products
• Its ok to Ask Involvement of Patient

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Implementation

• Push levers

• Pull levers

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Cleanyourhands

• Push
• Patient Safety Alert
• Frequent mentions in the media
• Patient Safety Managers
• Infection Control Nurses and Doctors
• Department of Health
• Apply to become implementer sites

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Cleanyourhands campaign

• Pull
• Healthcare Commission Patient Safety Standard
• DH Targets (MRSA (Nov 04))
• PEAT (Patient Experience Action Teams) Scores
• Performance Indicators
• Patient Confidence

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Solutions DevelopmentThe NPSA workplan

• Hospital
• Primary Care
• Mental Health
• Learning Disability