1. National Patient Safety Programme Clydebank 9 th November 2007

2. Scottish Patient Safety Alliance Care in NHSScotland is safe by international standards We are leading the way in improving our position even further Our focus is on improving quality and patient experience

3. Patient Safety – A Global Issue

4. Adverse Events in Hospital 3.7% Harvard 1991 16.6% Australia 1995 10.8% London 2001 3 million bed days in UK £1 billion per annum in UK 50% PREVENTABLE

5. Process vs. Outcome Process Outcome No Adverse Outcome No M&M Case History ♂ 54♂, angina Gi Bleed Endoscopy Injection DU Transfused X 2 D/C

6. Process vs. Outcome Process No pulse No coagulation No ECG - AF No X match O negative blood Outcome No Adverse Outcome No M&M Case History ♂ 54♂, angina Gi Bleed Endoscopy Injection DU Transfused X 2 D/C

7. NCEPOD 2005  27% of hospitals have no early warning system  44% of hospitals have no outreach  66% of admissions to ICU were unstable for >12hrs (in hospital >24hrs)  25% were not reviewed by ITU consultant in first 12 hrs  In ICU frequent deficiencies in care: less than good in 47%  Deficiencies in care may have contributed to death in 11%

8. A Major Study of Reliability in American Health Care… McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) –439 indicators of clinical quality of care –30 acute and chronic conditions –Medical records for 6712 patients –Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%) Conclusion: The Defect Rate in technical quality of American health care is approximately 45%

9. Reliability in Healthcare Healthcare is a high hazard industry Approx 10% ( 900,000 ) patients admitted to hospital experience an incident. 72,000 of these incidents / adverse events contribute to the death of patients Many go unrecognised

11. The vision – Scotland leading the way in Patient Safety Scotland at the forefront - a whole healthcare system approach A strategic development priority for NHS Scotland An explicit and tested approach to improving patient safety Build on foundations laid through audit, clinical effectiveness and clinical governance Alignment with wider NHS QIS Patient Safety work

12. Key Aims Build on what's already been achieved Tried and tested interventions Improve safety and reliability of boards and a safety focused culture Capacity and capability for improvement methodology Spread and sustainability

13. How will we do this? National approach – Advisory board CMO National steering group National Team / Clinical Lead IHI National learning sessions / site visits Regional support Evidence based interventions Outputs from SPI 1 & 2

14. Scottish Patient Safety Alliance- Key Partners Scottish Government NHS Scotland QIS Royal Colleges and Professional bodies World leading experts on patient safety Patients NHS Education

15. Outcome Aims Reduce healthcare associated infections Reduce adverse surgical incidents Reduce adverse drug events Improve critical care outcomes Improve the organisational and leadership culture on safety

16. Associated benefits Reductions in length of stay Reduction in complaints Cost benefits Care is given in the right place at the right time and in the right way Increased improvement capability amongst staff

17. Key objectives Work AreaChange Package Element Critical Care Establish infrastructure –Daily goal sheets –Daily multi-disciplinary rounds Infection Prevention –Ventilator bundle –Central line bundle –General infection prevention practices –Glucose control (ITU then to HDU) General Ward Risk Identification and Response –Rapid response (Outreach) teams –Early warning system Infection Prevention –MRSA Reliable care for Congestive heart failure Communication and Teamwork –Safety briefings –Communication tools (e.g. SBAR) –Prevention pressure ulcers

18. Leadership Infrastructure to support safety Walkrounds Safety a strategic priority Medicines Management Reconciliation Anticoagulation, Insulin, Conduct an FMEA on a high risk medication process Perioperative DVT Prophylaxis Continuity of Beta blockers SSI bundle Team culture - briefings

19. Outcomes Critical Care –E.g: ventilator acquired pneumonia rate Ward –E.g.: Crash call rate Medicines management –E.g.: Adverse drug events Theatres –E.g.: Surgical site infection rate Leadership –E.g.:Safety walkarounds

20. Aims Make care safer by a measurable amount –Mortality: 15% reduction –Adverse Events: 30% reduction Build improvement capacity in NHS Scotland

21. Communications Letters to Chief Execs Pre work Networking event – Nov 20 th Learning session 1 – Jan 14 th, 15 th, 16 th Learning session 2 – May Learning session 3 – Nov Regular and ongoing throughout the programme

22. Programme / Learning sessions Pre work period Oct – Dec Jan 08 LS1 – 3 day event, work stream breakout sessions Collaborative approach – Learn from faculty / colleagues Coaching from faculty Gather new information on the subject matter and process improvement Share information and build work on improvement plans

23. NHS - opportunity for Improvement in Healthcare? For Single system Universal access Population approach Team working No other incentives Loyal and motivated workforce Against Negativity Sparse clinical leadership Professional silos Organisational silos Low level of improvement skills