1. Scotland’s Approach to
Safety and Quality
Jason Leitch
Clinical Director
The Quality Unit, Scottish Government
@jasonleitch

2. Moving towards social care integration
5 million people
£12 billion
14 Health Boards
8 Support Boards
Integrated delivery
Moving towards social care integration 2

3. Public Finances Fall in Government expenditure

4. Health Budget

5. Scotland’s Demographics 1911 - 2011
1991
2011
1951
1931
1911
1971
Source: Scotland 2011 Census

6. Projected % Change in Scotland’s Population
by age group
Scotland’s 65+ population projected to rise by 21% between 2006 – 2016
By 2031 it will have risen by 62%
For the 85+ age group specifically, a 38% rise is projected for 2016
And, for 2031, the increase is 144%
Source: GRO Scotland, 2007

8. Strategic Objectives

9. Aims:
To deliver the highest quality healthcare services to the people of Scotland
For NHSScotland to be recognised as world-leading in the quality of healthcare it provides

10. The Healthcare Quality Strategy for Scotland
Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

11. Health of the Population
The IHI Triple Aim
Triple Aim
Health of the Population
Best Value
for Money
Experience of Care 11

12. 17 years to get 14% of evidence into practice
Evidence based discovery Evidence based delivery
17 years to get 14% of evidence into practice

13. Implementing at scale…. can it be done?
Will
Ideas
Execution

15. Primary Drivers Secondary Drivers
Boards accept SPSP as a key strategic priority for effective governance
Scottish Government
sets SPSP as strategic priority
Deliver the programme
Build a sustainable infrastructure for improvement
Align SPSP with national improvement programmes
Agreed set of outcomes
Review & address outcome delivery
Quality & safety on every agenda
Infrastructure supports
Involve patients
Demonstrable results
Clear, shared measurement set
Visible on all senior leader agendas
A cohesive and united programme
Improve Safety of Healthcare Services in Scotland
(15% reduction in HSMR by end of 2012)
BTS collaborative
Acceptance of pragmatic science
Royal Colleges support
Clinical faculty expert at improvement methods and coaching
Programme design and structure
Inventory of national programmes
Engage with national programmes
Harmonize metrics

16. By what method?
W. Edwards Deming

17. The Typical Approach… Conference Room Real World APPROVE DESIGN DESIGN
Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business.
e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable.
IMPLEMENT

18. The Quality Improvement Approach
Conference Room
DESIGN
APPROVE
IF NECESSARY
Real World
Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business.
e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable.
START TO IMPLEMENT
TEST & MODIFY
TEST & MODIFY
TEST & MODIFY

19. Our change theory A clear and stretch goal A method
Predictive, iterative testing

20. Breakthrough Series Collaborative

21. The Model for Improvement
‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’
Dr Donald M. Berwick
Former Administrator of the Centres for Medicare & Medicaid Services
Professor of Paediatrics and Health Care Policy
at the Harvard Medical School
MFI is made up of 2 parts – the thinking part and the doing part
The 3 questions – the thinking part prepares you for the test by asking the ‘so what’ question
They need to be thought through, answered and written down by the improver to ensure that they, and therefore their colleagues, are clear on the benefits to them and their work.
That message often gets lost in the many things we are expected and asked to do and is one of the reasons why so many interventions are not implemented reliably.
If we are not clear on the benefits of something we are much less likely to do it.
The Plan Do Study Act cycle is a simple tool that’s used to test out ideas that will improve your systems and processes while learning what works and doesn’t work.
It’s a structured approach for making small incremental changes to systems that allow you to test on a small scale, learn from successes and failure and redesign as you go
It builds learning and buy in incrementally as tests ramp up and allows clinicians knowledge about their own system is built in to the process

22. NHSScotland Surgical Safety Briefings
Data from at least 9 out of 10 Boards with Data available on Extranet. Each month has an average sample size of 2949 procedures

23. NHSScotland Surgical Mortality
23% reduction from median

24. Hospital Standardised Mortality Ratios
(Seasonally Adjusted) Scotland: Dec 2002 to Mar 2012
average annual reduction %
(Apr 2010 to Mar 2012)
1.4%
average annual reduction
(Oct 2002 to Jan 2010)
Smoothed SMR
Smoothed the seasonal effect.
Fit regression line: shows a marked acceleration over the most recent two year period.
Why is this ?
We cant say for certain
– but one explanation is the cumulative additive effect of the many many small changes and improvements made across a nation.
Made by you and the people you work with
The so called aggregation of marginal gains
The sum is greater than the whole- there is probably a synergistic effect beyond the simple addition or cumulation- achieving a critical mass.
Fits with our thinking- focus on processes – and outcomes will follow – often after a delay or lag 24

26. How has the frontline done it?
Get goals
Get bold
Get together
Get a model (and stick with it)
Get patients and families
Get the facts
Get to the field
Get a clock
Get the numbers
Get the stories 26 26

29. The Early Years Collaborative - Ambition
To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.

30. The Early Years Collaborative - Aims
1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015). 2. To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s month child health review, by end To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017.

32. Some Useful Links Scotland’s 2020 Vision: The Quality Strategy:
The Quality Strategy:
The Quality Improvement Hub:
Institute for Healthcare Improvement:

34. @jasonleitch