Scotland’s Approach to Safety and Quality Jason Leitch Clinical Director The Quality Unit, Scottish Government @jasonleitch

Moving towards social care integration 5 million people £12 billion 14 Health Boards 8 Support Boards Integrated delivery Moving towards social care integration 2

Public Finances Fall in Government expenditure

Health Budget

Scotland’s Demographics 1911 - 2011 1991 2011 1951 1931 1911 1971 Source: Scotland 2011 Census

Projected % Change in Scotland’s Population by age group 2006-2031 Scotland’s 65+ population projected to rise by 21% between 2006 – 2016 By 2031 it will have risen by 62% For the 85+ age group specifically, a 38% rise is projected for 2016 And, for 2031, the increase is 144% Source: GRO Scotland, 2007

Strategic Objectives

Aims: To deliver the highest quality healthcare services to the people of Scotland For NHSScotland to be recognised as world-leading in the quality of healthcare it provides

The Healthcare Quality Strategy for Scotland Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Health of the Population The IHI Triple Aim Triple Aim Health of the Population Best Value for Money Experience of Care 11

17 years to get 14% of evidence into practice Evidence based discovery Evidence based delivery 17 years to get 14% of evidence into practice

Implementing at scale…. can it be done? Will Ideas Execution

Primary Drivers Secondary Drivers Boards accept SPSP as a key strategic priority for effective governance Scottish Government sets SPSP as strategic priority Deliver the programme Build a sustainable infrastructure for improvement Align SPSP with national improvement programmes Agreed set of outcomes Review & address outcome delivery Quality & safety on every agenda Infrastructure supports Involve patients Demonstrable results Clear, shared measurement set Visible on all senior leader agendas A cohesive and united programme Improve Safety of Healthcare Services in Scotland (15% reduction in HSMR by end of 2012) BTS collaborative Acceptance of pragmatic science Royal Colleges support Clinical faculty expert at improvement methods and coaching Programme design and structure Inventory of national programmes Engage with national programmes Harmonize metrics

By what method? W. Edwards Deming

The Typical Approach… Conference Room Real World APPROVE DESIGN DESIGN Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business. e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable. IMPLEMENT

The Quality Improvement Approach Conference Room DESIGN APPROVE IF NECESSARY Real World Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business. e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable. START TO IMPLEMENT TEST & MODIFY TEST & MODIFY TEST & MODIFY

Our change theory A clear and stretch goal A method Predictive, iterative testing

Breakthrough Series Collaborative

The Model for Improvement ‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’ Dr Donald M. Berwick Former Administrator of the Centres for Medicare & Medicaid Services Professor of Paediatrics and Health Care Policy at the Harvard Medical School MFI is made up of 2 parts – the thinking part and the doing part The 3 questions – the thinking part prepares you for the test by asking the ‘so what’ question They need to be thought through, answered and written down by the improver to ensure that they, and therefore their colleagues, are clear on the benefits to them and their work. That message often gets lost in the many things we are expected and asked to do and is one of the reasons why so many interventions are not implemented reliably. If we are not clear on the benefits of something we are much less likely to do it. The Plan Do Study Act cycle is a simple tool that’s used to test out ideas that will improve your systems and processes while learning what works and doesn’t work. It’s a structured approach for making small incremental changes to systems that allow you to test on a small scale, learn from successes and failure and redesign as you go It builds learning and buy in incrementally as tests ramp up and allows clinicians knowledge about their own system is built in to the process

NHSScotland Surgical Safety Briefings Data from at least 9 out of 10 Boards with Data available on Extranet. Each month has an average sample size of 2949 procedures

NHSScotland Surgical Mortality 23% reduction from median

Hospital Standardised Mortality Ratios (Seasonally Adjusted) Scotland: Dec 2002 to Mar 2012 average annual reduction 4.2% (Apr 2010 to Mar 2012) 1.4% average annual reduction (Oct 2002 to Jan 2010) Smoothed SMR Smoothed the seasonal effect. Fit regression line: shows a marked acceleration over the most recent two year period. Why is this ? We cant say for certain – but one explanation is the cumulative additive effect of the many many small changes and improvements made across a nation. Made by you and the people you work with The so called aggregation of marginal gains The sum is greater than the whole- there is probably a synergistic effect beyond the simple addition or cumulation- achieving a critical mass. Fits with our thinking- focus on processes – and outcomes will follow – often after a delay or lag 24

How has the frontline done it? Get goals Get bold Get together Get a model (and stick with it) Get patients and families Get the facts Get to the field Get a clock Get the numbers Get the stories 26 26

The Early Years Collaborative - Ambition To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.

The Early Years Collaborative - Aims 1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015). 2. To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s 27-30 month child health review, by end-2016. 3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017.

Some Useful Links Scotland’s 2020 Vision: The Quality Strategy: www.scotland.gov.uk/Topics/Health/Policy/2020-Vision/Strategic-Narrative The Quality Strategy: www.scotland.gov.uk/Topics/Health/Policy/2020-Vision/Quality-Strategy The Quality Improvement Hub: www.qihub.scot.nhs.uk Institute for Healthcare Improvement: www.ihi.org.uk

@jasonleitch