The Safer Patients Initiative

1
The Health Foundation

• The Safer Patients Initiative
• Pat OConnor
• NHS Tayside

2
Why the Health Foundation chose to work on
improving patient safety
To Improve health, and the quality of healthcare
for the people of the UK

• There is an identified need for patient safety to
  improve
• There is a strong evidence base for what works
• A focus on patient safety involves clinicians,
  managers, and patients

3
Selection

• Met the rigorous criteria
• Had an existing focus and drive to improve
  patient safety
• Willing to become exemplars
• The best in a strong field
• NHS Tayside Down Lisburn
• Conwy Denbeighshire Luton and Dustable

4
Working to deliver the Initiative
The Institute for Healthcare Improvement
The Health Foundation
The four safer patients initiative sites
Working together to improve patient safety in the
UK
Evaluation team (Led by Professor Richard
Lilford)
Measuring our achievements, reporting on success
Leadership development consultants
Supporting the teams to implement, sustain and
spread improvements in patient safety
5
Teams and Leaders Roles

• Set Aims
• Build Will
• Assure Resources
• Remove Obstacles
• Review and Reflect
• Assure Spread

Senior Leaders
Teams

• Make Improvements
• Test and Learn
• Report Lessons
• Make Requests

• Human Resources
• Technical Expertise
• Information Technology
• Budget and Capital
• System for Spread

Infrastructure
6
The Key Elements of Breakthrough Improvement

• Will to do what it takes to change to a new
  system
• Ideas on which to base the design of the new
  system
• Execution of the ideas

7
Leadership

• Patient Safety as a Strategic Imperative
• Clear Goals and Measurement Strategy
• Reduce variability, waste and harm
• Build capacity and skill to prevent harm
• Focus the organisation on Quality Improvement

8
Cultural Elements

• Robust Governance and Risk management
  arrangements
• A preoccupancy with failure
• A culture of openness
• Abandoning blame as a major mode of action
• Trust in the workforce
• Involvement of patients and families

9
Local teams

• Leadership
• Medicines management
• Peri-operative care
• Intensive care
• General ward

10
Key Actions

• Safety at the top of the agenda
• Use of multiple tests using PDSA cycles
• Multiple projects for each team
• Rapid response team
• Anti- coagulation
• Medication systems
• Use of bundles ICU, Central line
• Infection Prevention
• Infusion devices
• Falls prevention
• Perioperative care
• Leadership walkrounds

11
IHI Model for Improvement

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in
  improvement?
• Always consider How good by when in your aim?

12
Why are we measuring?
Judgment?
Improvement?
Research?
The answer to this question will guide your
entire quality measurement journey!
13
The Three Faces of Performance Measurement
The Three Faces of Performance Measurement
Improvement, Accountability and ResearchLief
Solberg, Gordon Mosser and Sharon McDonald
Journal on Quality Improvement vol. 23, no. 3,
(March 1997), 135-147.
14
A Framework for an Improvement Measure

• Establish a system-level measure
• Set an aim for the measure
• Develop a theory of a strategy for how to achieve
  the aim and an appropriate time frame for testing
• Test your theory implement the strategy, follow
  the measure monthly
• Revise the strategy as needed

Plan
Act
Study
Do
15
The Problem
Aggregated data presented in tabular formats or
with summary statistics, will not help you
measure the impact of process improvement/redesign
efforts. Aggregated data can only lead to
judgment, not to improvement. IHI 2005
16
Understanding Variation

• If you dont understand the variation that lives
  in your data, you will be tempted to ...
• Deny the data (It doesnt fit my view of
  reality!)
• See trends where there are no trends
• Try to explain natural variation as special
  events
• Blame and give credit to people for things over
  which they have no control
• Distort the process that produced the data
• Kill the messenger!
• IHI 2005 ?

17
Rapid Cycle Change with PDSA

• What does this mean?
• Plan, Do, Study, Act
• Rapid cycle starts with e.g. One doctor, one
  nurse, one patient
• Moving to 1..3..5..All
• These changes happen in hours and days not weeks
  and months

18
Repeated Use of the PDSA Cycle
Model for Improvement
Changes That Result in Improvement
How will we KNOW that a
change is an improvement?
What are we trying to
accomplish?
A
P
What change can we make that
S
D
will result in improvement?
DATA
D
S
Implementation of Change
P
A
A
P
S
Wide-Scale Tests of Change
D
A
P
S
D
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
19
The Quality Measurement Journey
AIM Concept Indicator Operational
Definitions Data Collection Plan Data
Collection Analysis
ACTION
20
The Results

• 71 reduction in adverse events(case note review)
• 91 reduction in medication errors rates on
  admission
• 66 reduction of line infections in renal and ICU
  (no tunnel line and central line infections for
  5 months)
• SSI bundle 95 compliance
• 50 reduction in VAP
• Hand Hygiene 96 compliance

21
Compliance with Peri Operative SSI Bundle

22
Adverse events per 1000 patient days
23
Compliance with Theatre Safety Briefings
24
Percent of Un reconciled Medicines
25
Trust Handwashing Compliance
26
CLC Bloodstream Infection Rate
27
Monthly Crash Call Rate per 1000 Discharges
28
Fall rate
29
NEED MORE INFO.

• Further details
• Contact Pat OConnor
• Safer Patients Initiative
• NHS Tayside
• 01382 424169

pat.oconnor_at_.nhs.net