1. Safer Clinical Systems About Safer Clinical Systems June 2011

2. A systems approach to building safe and reliable patient care through: proactively searching for and managing risk, ensuring feedback to create continuous learning, engagement and sustainable solutions Safer Clinical Systems 2

3. Harm continues 3 Continuing harm of 1 in 10 in US and UK Despite many initiatives Failure to spread Failure to sustain Evidence on impact of systems factors Evaluation of Safer Patients Initiative February 2011 Patient Safety First Campaign report March 2011

4. Our research shows poor reliability 4 Failures in reliability pose real risk to patient safety 15% of outpatient appointments affected by missing clinical information Important clinical systems and processes are unreliable Four clinical systems measured had failure rate of 13%-19% Wide variations in reliability between organisations Unreliability is the result of common factors Lack of feedback mechanisms and poor communication. It is possible to create highly reliable systems. The Health Foundation May 2010

5. What is a safe clinical system? 5 Our working definition of a safe clinical system is: A clinical system that delivers value to the patient, is demonstrably free from unacceptable levels of risk and has the resilience to withstand normal and unexpected variations and fluctuations

6. Building Safer Clinical Systems Understanding the system Identifying and managing the risk Systems thinking Designing for safety Ensuring valid standards and improving reliability Creating resilience 6

7. 7 You will be taken through a systematic approach which will involve: A tailored learning and development programme Expert help On-site support facilitated by a named person Peer-review Opportunity to review your progress at key intervals Central learning events Key Features of the Programme

8. Learning and Development Learning and development will be provided by the Support Team through: Induction event Collaboration and training conferences Shared learning events On-site training needs analysis through site facilitators On-site and/or remote response through technical experts Communities of practice and learning sets 8

9. Phase 2 Interventions Many adverse events occur in patient pathways where handovers or prescribing are an issue. They can often be traced back to system design and contextual factors. In Phase 2 we will be working within patient pathways, focusing on these supporting processes and systems : Safe, reliable prescribing in patient pathways (e.g. prescribing by staff throughout the pathway, together with upstream processes such as information transfer and downstream administration) Safe, reliable clinical handovers in patient pathways (e.g. transfer of clinical information, tasks, responsibility and authority) 9

10. 123456789101112131415161718192021222324 Pathway definition and context System diagnosis Option appraisal and planning Option appraisal and planning System Improvement Cycles SCS Programme Steps Collaborative and training events Induction Launch event and Training and Human Factors event 1 Training and Human Factors event 2 Shared learning event Shared learning event Shared learning event Next steps learning event Award holder site support Award holder Communities of Practice support Expert review (gates) – Site plans & progress by TST Non-technical skills training event Oct Expert review (gates) – Programme by external experts Timeline of the Programme 2011 20122013 Dec Nov Jan Mar Feb May Apr Jul Jun Sept Aug Nov Oct Jan Dec Mar Feb May Apr Jul Jun Aug Sept Step 1 Step 2Step 3Step 4

11. A systems approach to building safe and reliable patient care through: proactively searching for and managing risk, ensuring feedback to create continuous learning, engagement and sustainable solutions Safer Clinical Systems 11