1. High Reliability Healthcare 16 October 2009

2. Patient Safety Events - a Global Problem: 10% of hospital patients suffer an adverse event each year (UK, New Zealand, Canada and Europe) 16.6% of hospital patients suffer an adverse event (Australian study) 1.4 million hospital patients worldwide acquire Healthcare Associated Infections (HAI) 100,000 cases of HAI lead to 5,000 deaths a year (UK) 1 out of every 135 hospital patients acquires HAI (USA) 98,000 hospital deaths every year through medical error (USA)

3. High Reliability Healthcare Systems

4. Safe, high quality care Provider Market Evidence Based Practice Governance Regulatory Framework Political Legislative Commissioning for Quality Insurers Service Users, Public Key Levers and Drivers

5. Key Ingredients Person-centred care Open and transparent learning culture Strong leadership, governance, accountability, management and team working Clinicians in executive management Fit for purpose workforce Effective information management and measurement Informed decision-making Robust quality assurance – internal and external

6. Systems and processes are only as good as the people who work within them

7. COMMUNICATIONS LEADERSHIP MULTI-DISCIPLINARY TEAM WORKING BEHAVIOURS CULTURE RELATIONSHIPS

9. Open and Transparent Culture… …as soon as we knew we d made the mistake we met with the family and told them …telling relatives – well you see, we don t do that here it s not in our culture …I thought I d made myself clear, I don t speak to patients, I have people who do that for me

10. A culture and ethos of professionalism, courage, openness, informed decision- making, effectiveness, efficiency, learning, innovation and knowledge. High Reliability Culture

11. Leadership

12. Us, doing the right thing

13. If we are ever in doubt about what to do, it is a good rule to ask ourselves what we shall wish on the morrow that we had done. John Lubbock