PATIENTS FOR PATIENT SAFETY in England and Wales Anna Allford, Project Manager, AvMA

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PATIENTS FOR PATIENT SAFETYin England and
Wales Anna Allford, Project Manager, AvMA


International Congress Turkey 19-21 March 2009
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Patients for Patient Safety

• WHO World Alliance for Patients for Patient
  Safety initiative
• In England Wales, a unique partnership between

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Action against Medical Accidents

• Action against Medical Accidents (AvMA) is the
  independent charity which promotes better patient
  safety and justice for people who have been
  affected by a medical accident. A 'medical
  accident' is where avoidable harm has been caused
  as a result of treatment or failure to treat
  appropriately. AvMA believes that whatever the
  cause of a medical accident, the people affected
  deserve explanations, support, and where
  appropriate, compensation. Furthermore, we all
  deserve to know that the necessary steps will be
  taken to prevent similar accidents being
  repeated.
• We provide free and confidential advice and
  support to people affected by medical accidents,
  via our helpline and casework service and can
  refer to our panel of specialist clinical
  negligence solicitors or other sources of support
  where appropriate.

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NHS National Patient Safety Agency (NPSA)

• NPSA is part of the NHS, established in 2001 with
  the mandate to identify patient safety issues and
  find appropriate solutions. NPSA is also
  responsible for the National Clinical Assessment
  Service National Research Ethics Service and
  National Confidential Inquiry into Suicide and
  Homicide (NCISH) Confidential Enquiry into
  Maternal and Child Health (CEMACH) and the
  National Confidential Enquiry into Patient
  Outcome and Death (NCEPOD).

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NHS Patient Safety Journey

• An organisation with a memory (DH 2000)
• Building a safer NHS for patients (DH 2001)
• Safety First A report for patients, clinicians
  and healthcare managers (DH 2006)

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Safety FirstDepartment of Health, 2006

• Recommendation 13
• The active involvement of patients and their
  families should be promoted by establishing a
  national network of patient champions who will
  work in partnership with NHS organisations and
  other key players to improve patient safety the
  network should have strong links with WHO World
  Alliance for Patient Safetys Patients for
  Patient Safety initiative

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Rationale

• Consumers in healthcare are at the heart of
  patient safety. When things go wrong they and
  their families suffer from the harm caused. Such
  harm is made worse by the defensive and secretive
  way that many healthcare organisations respond in
  the aftermath of an event

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Rationale 2

• Around the world, healthcare organisations that
  are most successful in improving safety are those
  that encourage cooperation with patients and
  their families. Patients and their families have
  a unique perspective on their experience of
  healthcare and may provide information and
  insights that healthcare workers may not
  otherwise have known

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Partnership

• Partnership must be a key theme patients, health
  professionals, policy makers and healthcare
  leaders should be working together to prevent
  avoidable harm in healthcare. A particular focus
  is to challenge the current culture of denial

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Patient Safety Champions

• May 2008 2 day Induction Workshop for 22
  Patient Safety Champions
• Additionally, 10 Patient Safety Action Team
  (PSAT) members from Strategic Health Authorities
  (SHAs) in England and 1 member of the Patient
  Safety Team in Wales joined the Workshop on day
  two.

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Champions and NHS Partners
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Induction Workshop Report

• The report of the Workshop is available on the
  AvMA website together with the six month report
  www.avma.org.uk/champions
• A further follow-up event took place 28/29th
  November 2008 to share experiences and
  disseminate information and learning.

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Role of Champions

• The role of the champions is to champion the
  cause of patient safety and the role that
  patients can play in patient safety work. They
  provide a patient perspective in the planning of
  patient safety work in their region and get
  involved in specific projects where they can make
  a useful contribution.

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Role of Champions continued

• In addition to being involved in regional and
  national events and planning, champions have
  worked with the NHS to organise particular
  patient user groups given talks / contributed to
  training and resources such as videos / DVDs and
  taken part in reviews of Serious Untoward
  Incident procedures and of how the NHS implements
  guidance on Being Open when things go wrong.

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Role of Champions continued

• Many Champions are also engaged in work to
  improve patient safety locally with individual
  NHS Trusts and Primary Care Trusts (PCTs) in
  England (Local Health Boards in Wales).
• Crucially, rather than duplicate or replace
  existing ways in which the NHS engages with
  patients on patient safety, the champions are
  there to act as a focal point and a resource and
  facilitator for wider patient and public
  involvement in patient safety in particular.

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Partnership working

• Patient Safety Champions will be supported to
  provide the patients perspective in improving
  patient safety at all levels locally, regionally
  and nationally, throughout England and Wales.
  Their role is to add value to both existing and
  planned work.
• The current focus is on the policy Being Open -
  communicating patient safety incidents with
  patients and their carers (NPSA, 2005)

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Being Open

• The NPSA has advised NHS organisations to put in
  place local policies to improve communication
  with patients who are unintentionally harmed by
  their treatment. 
• The NPSA's safer practice notice advises
  healthcare staff to apologise to patients, their
  families or carers if a mistake or error is made
  that leads to moderate or severe harm or death,
  explain clearly what went wrong and what will be
  done to stop the problem happening again. 
• Further information can be found on the website
  of the NPSA
• http//npsa.nhs.uk/nrls/alerts-and-directives/not
  ices/disclosure/

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Partnership Working (continued)

• Other national initiatives are being discussed
  including

• The Patient Safety Campaign in England

The 1000 Lives Campaign in Wales
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Partnership Working (continued)
The NHS Partners involved in this project are
being encouraged to invite the Champions to help
them include the patient perspective in their
work streams for improving patient safety.
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Wider Network

• The project is developing and supporting a
  community of interest in England and Wales. This
  social movement aims to ensure that the patients
  perspective and voice is included in the NHS
  improvements in patient safety.
• Approximately 270 individuals and representatives
  of organisations have registered on our database.
• The network has been invited to various Workshops
  and events and been invited to comment on
  national Consultations

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Wider Network (continued)

• The PfPS Project newsletter and email bulletins
  are circulated to this group and the AvMA
  website/forums provide a way to share information
  and views
• We also want to provide the opportunity for
  people to become more involved in the project by
  becoming associate Patients for Patient Safety
  Champions, working with and supporting the
  activities of the existing champions.

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Project Accountability
Strategy Advisory Group
Accountability Group
Project Team
Patient Champions
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Members

• Accountability Group members -Martin Fletcher,
  Sarndrah Horsfall, Dr Kevin Cleary, from the
  NPSA, and Peter Walsh and Anna Allford from AvMA
• Project Team Peter Walsh, Anna Allford and Dr
  Kevin Cleary

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Project Manager

• To facilitate and support Champions
• To understand the skill set and provide a
  developmental programme for Champions
• To support their relationship with stakeholders
  e.g. SHA PSATs and others
• To promote the role of the Champions and wider
  network by developing links and seeking
  opportunities for them to represent the patients
  voice in improving patient safety.

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Summary

• This project has developed in-country Patients
  For Patient Safety Champions in England and Wales
• We are helping to establish and grow a community
  of interest with people who want to help the NHS
  improve patient safety and learn from the
  mistakes or accidents
• Champions are already working in partnership with
  NHS healthcare professionals and policy makers
  and we want to share and disseminate the good
  practice that exists.

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For further information

• Anna Allford
• www.avma.org.uk
• safety_at_avma.org.uk
• Tel [phone]