1. 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

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

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

4. Context
Safety Express

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

6. 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

7. 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

8. Harm Free Care: ST Data

9. 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

10. Pilot 2 Wards
Harm Free Cohort 6 Wards
Trust wide

11. 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

12. Internal data set

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

14. Patient Survey (March)

15. Staff Survey (March)

16. 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?

17. 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

18. …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

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