1. NES April 2009

3. 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%

4. McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%

6. Jean Boal

7. Outcome Aims Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range Bloodstream Infection: 30% reduction Crash Calls: 30% reduction

8. Primary Outcomes Develop and build a quality improvement and patient safety culture in our hospitals Build in long term sustainability and capability to drive this approach at all levels

9. Source:British Airways (NPSA adapted) British Airways air safety reports, 1994-99 Total reported events Total events 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 199419951996199719981999 High/medium risk events 0 20 40 60 80 100 120 140 Number of reported events: high and medium risk

10. Theory of transformation

11. Our Theory (Part 1) Build a compelling case for change Involve patients and carers Work on processes and outcomes that engage the hearts and minds Work at the coal face and at the executive level Data feedback, data feedback, data feedback Set the tempo!

12. Our Theory (Part 2) Changes in process and outcomes are directly connected. The changes beginning tested, when fully implemented, will lead to large system aims.

13. -Align aims and measures with national programmes -Develop a portfolio and execution model -Build connection to safety in national work -Define within clinical governance framework Improve Safety of Healthcare Services in Scotland Boards Endorse Safety as Key Strategic Priority Deliver the programme Build a Sustainable Infrastructure for Improvement Align SPSP with national improvement programmes and measures Primary Drivers - Secondary Drivers Scottish Patient Safety Alliance (SPSA) Driver Diagram -One Team -Develop experts in imp. methods and coaching -In-country measurement system, culture survey -Safety work migrates to appropriate agency -Training programmes developed in Scotland - Work with IST, QIS and HES to develop unified improvement approach -Segment hospitals, customize approach -In-country support for Boards -Spread strategy community hosp., primary care -One Team -”Everyone in the tent” Scottish Government Sets PSA as Strategic Priority -National Board development strategy -Ownership of agreed upon set of outcomes and measures -Quality and safety comprises 25% of agenda --Development of infrastructure that supports improvement and measurement -Clear improvement aims in strategic plan National leaders openly endorse SPSP aims, failure is not an option for execs - Time and space given for improvement (not a target) -Royal Colleges serve in official capacity -Safety is an element of all programmes

14. Integration

15. Judgement vs Improvement

16. Prototype and Spread

17. Successes from Action Period Two No central line bloodstream infections since July Shift

18. Successes from Action Period Two Trend

19. Successes from Action Period Two Trend Shift

23. NES? What is NES already doing that relates to this agenda? How can NES help inform those working on this agenda? What can NES do in addition to present activities?

24. Who needs to know and what do they need to know? Patients, carers and the public Executives Non-executives including chairs Middle managers Clinicians –Senior –Middle grade –Trainees Administrators Health professional students – Cab. Sec promise

25. “NHS Scotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety. The dedication of NHS leadership at all levels to this endeavor is apparent to me, and bodes well for success. In its scale and ambition, the Scottish Patient Safety Programme marks Scotland as leader – second to no nation on earth – in its commitment to reducing harm to patients dramatically and continually.” Don Berwick June 2008