Has patient safety moved since last year Has patient safety moved since last year? What the Safety Express data tells us Gill Harris Deputy Chief Executive, Director of Nursing & Performance, DIPC

Wrightington, Wigan & Leigh NHS Foundation Trust Royal Albert Edward Infirmary Wrightington Hosptal Leigh Infirmary Thomas Linacre Centre

Strong track record Infection Prevention & Control Reducing Harm from Pressure Ulcers Reducing Harm From Falls Quality & Safety Improvement

Context Safety Express

WWL Approach to Harm Free Care Harm Free Wards Leadership Collaborative Approach Small scale steps of change Measurement

The role of the ward leader Hearts and minds Collaborative Approach Leadership The role of the ward leader Hearts and minds Collaborative Approach Overcoming silo working Sharing & learning Small scale steps of change PDSA cycles Led by frontline teams Measurement NHS Safety Thermometer In – house data NW Transparency Pilot

NHS Safety Thermometer Measurement NHS Safety Thermometer Monthly point prevalence Falls Pressure Ulcers Catheter + UTI VTE In House Data Set Every discharge, death or transfer ST plus…other infections, weight loss Deep dives NW Transparency Harm from falls (moderate- severe) & pressure ulcers(grades 2-4) Root cause analysis – all cases Patient & staff experience

Harm Free Care: ST Data

NHS Safety Thermometer Monthly point prevalence Sample size increased over time Pilot 2 wards 50% pts n≅30 May 2011 6 wards 100% pts n≅150 Dec 2011 100%inpts n>400

Pilot 2 Wards Harm Free Cohort 6 Wards Trust wide

Internal data set Looks only at harms that occur on that ward Includes all falls regardless of harm Includes all hospital acquired infection Prompts deeper dives when weight loss identified

Internal data set

NW Transparency Project Data published for Jan, Feb & March 8 Trusts in pilot WWL data Jan Feb Mar Falls 3 2 Pressure Ulcers 1

Patient Survey (March)

Staff Survey (March)

Thoughts on Measurement Varying definitions Varying sample sizes Is pre 72 hour pressure ulcer hospital acquired? When is skin damage a pressure ulcer? When is a fall not a fall? Snapshot v every patient Large Trusts v small Trusts Measurement for performance or improvement?

So what does the safety express data tell us? Difficult to make inferences about trends from data due to sample changes over time. Early data based on smaller sample leading to bigger swings in % harm free Possibly >94% of our patients are harm free as measured by ST (based on last 3 consecutive months of monitoring all in patients) Our first cohort of harm free wards are achieving >96% harm free care as measured by our internal data set …we are now into our 3rd cohort

…and…. Prevalent harm seen on ST is pressure ulcer present on admission. We need to work more closely with community care providers We have reduced harm from falls but there are still frequent falls without physical harm Weight loss can be a useful prompt to case note review

Has patient safety moved since last year? ..hear what some of our ward leaders have to say