1. Scottish Patient Safety Programme SAPG/SAM 8 th June 2010 Dr Emma Watson HAI Lead Scottish Patient Safety Alliance Scottish Government Healthcare Policy and Strategy Directorate

2. SPSP and the SAM using QI to manage infection What is SPSP Reliability How can we utilise QI to manage infection The Future

4. The Scottish Patient Safety Programme Clinician owned with a political imperative The right thing for the right patient at the right time – the only variation is the patient Not research but how to implement research System redesign not working harder but differently

6. Global Trigger Tool Reviews 3 Exemplar Hospitals (900 notes) 40 Bed rural Hospital (300 notes) 10 Hospital Research Project (240 notes) 7 Hospital System (3000 notes) Multi-state Tertiary System (2000 notes) Events/1000 Days 8390NA11986 Events/100 admissions 4540374138 Admissions with adverse events 32%30% 29%30%

7. Outcome Aims Mortality: 15% reduction Adverse Events: 30% reduction

8. The “Quality Journey” Compliance Comparison Culture ▪ To meet all required targets ▪ To be better than others, locally or nationally ▪ To be the best we can possibly be ▪ From outside – Imposed ▪ From outside – Top-down ▪ From inside – Internal, personal ▪ Episodic ▪ Ongoing How we define ‘good’ Source of motivation to deliver Duration

9. Reliability For healthcare processes where failure does not cause immediate catastrophic consequences: 5 front line staff can not easily articulate the process ~80-90% 5 front line staff can easily articulate the process and there is some variability.> 95% All staff understand a well designed system with low variation and cooperative relationships >99.9%

10. Health Care Processes Desired - variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom - variation Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Terry Borman, MD Mayo Health System

11. SPSP and SAM and Infection Recognise an acutely unwell patient Recognise that they have a infection Recognise which system the infection is in! Understand where they are on the sepsis spectrum Recognise the need for antibiotics Know which antibiotic Know which route etc etc etc ………

12. Where are we now? We create a policy We circulate it We audit it……….. Do we change behaviour?

14. System redesign on how

15. Process and Outcome

17. SPSP and SAM Working together Using SPSA methodology and SAM expert knowledge Implementation of the Quality Strategy

19. Wise words……. “Knowing is not enough we must do” Goethe “Try ? Do not try, DO” Yoda

20. With grateful thanks to SPSP and the SAPG for sharing data and resources