1. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

2. WELCOME DR EMMA VAUX CEO & EXECUTIVE CHAIR PATIENT SAFETY FEDERATION http://www.patientsafetyfederation.nhs.uk

3. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

4. Patient Safety Tim Benson Patient Leader, RBH

5. What patients want To feel better and do more Excellent service – Safe and reliable – Right every time – Not worried To feel as much as possible in control

6. Quality Culture Institute of Medicine – To err is human (2000) – Crossing the quality chasm (2001) NHS Quality Framework – Outcomes – Experience and Safety Listen to the patient – Most important stakeholder – Self-efficacy – Patient perceptions

7. Safety is not... Counting errors – Complaints handling – Never events – Coroner's inquests Inspections – CQC – Litigation – Blame culture

8. Deming’s 14 points 1.Constant improvement 2.New philosophy (TQM) 3.Cease dependence on inspection 4.Stop procuring on basis of price alone 5.Design in quality 6.Training on the job 7.Leadership is to help people do better 8.Drive out fear 9.Team work not demarcation 10.Eliminate targets 11.Pride in work for staff 12.Pride in work for managers 13.Vigorous education and improvement 14.It is everyone’s job – W.Edwards Deming. Out of the Crisis. MIT Press 1982

9. Question Do we need a safety measure based on patients’ perceptions? If so what aspects are relevant?

10. Thanks Tim Benson tim.benson@r-outcomes.com @timbenson

11. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

12. Zero tolerance to never events: standardise, educate and harmonise. Tom Crawford Project Lead 12

13. Never events Are a particular type of serious incident that meet all the following criteria They are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers 13 Ref: NHS England Patient Safety Domain

14. Background Date of incidentLocation of incidentCategoryDescription of the incident 09-Sep-13TheatresSurgical errorRetained Guide wire 23-Sep-13TheatresSurgical errorRetained humeral protector plate 28-Jan-14TheatresSurgical error Wrong acetabular liner (size) inserted during total hip replacement. 31-Jan-14 PCEU Ophthamology Surgical errorWrong size intraocular lens 21-Mar-14 Theatres Anaesthetics Surgical errorRetained guide wire 25-May-14TheatresSurgical errorWrong site surgery 25-Jun-14TheatresSurgical errorWrong tooth extraction 14

15. 1.Zero tolerance to never events 2.To improve attitudes limiting safety behaviour and practice 3.Culture of reporting of adverse events 4.Reduce waste (cost of complications, cost to patients, cost to staff) 15 Aim/Purpose

16. Domain 1. Safety Culture Aim: Improving safety culture can improve staff behaviour and patient safety outcomes Aim: A good safety culture, requires leadership and frontline staff taking shared responsibility Aim: Providing learning & information that can contribute to an understanding of Human Error and prevention. Aim: Implementatio n of good practice helps to ensure safe standards of patient care are delivered Aim: Reporting and learning the lessons from incidents to ensure it will not happen again Aim: Patient engagement can deliver more appropriate care and improved outcomes Domain 2 Leadership Domain 3 Promote Reporting Domain 4. Promote Learning Domain 5 Implementing Best practice Domain 6. Patient & staff Involvement Safe Strategy 16

17. Developments and Successes 1.Published Patient Safety Newsletter detailing recent serious incidents and lessons learned, disseminated to all staff by email and hard copies in the staff rooms. 2.Baseline assessment of theatre safety culture using the University of Texas Safety Attitudes Questionnaire. 3.Developed standing safety agenda with performance reporting against key metrics. 4.Implement the WHO patient safety curriculum and incident report scenario pilot to improve junior doctor’s awareness. 5.Developed an audit tool to assess adequacy and method of completion of WHO Surgical Safety Checklist 6.Human factors training for theatre staff 7.Implemented formal briefing/debriefing tool. 8.Bespoke leadership training programme for Consultant Surgeons 17

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20. Domain 2 Leadership Target 2.0

21. Challenges and Lessons learnt 21 1.Team work 2.Observational audit 3.Achievable targets 4.Pace of behavioural change 5.Operational pressures for optimum theatre utilisation 6.Geographical spread of operating theatres 7.Clinical engagement

22. 22

23. Contact Details: tom.crawford@royalberkshire.nhs.uk 23

24. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

25. Making medicines safer for patients (The Safe Medicines Pathway Toolkit) Patient Safety Federation Conference Sept 15 Jane Hough, Associate Director, NHS Specialist Pharmacy Service Triss Clark, PSF Programme Director & PSF Project Manager for SMP Safe Medicines Pathway

26. Content of the presentation Background Aim/Purpose Developments and Successes Challenges & Lessons Learnt Safe Medicines Pathway

27. Background to project starting No Needless Medication Error work-stream PSF held meetings with stakeholders Concern raised about large number of medication errors Safe Medicines Pathway conceived Safe Medicines Pathway

28. Aims 1.To simplify, standardise and make reliable some of the elements of the medicines pathway: such that the likelihood of errors occurring is reduced. 2.To share work through a Web-based tool kit. Safe Medicines Pathway

29. Purpose of the Project To understand the processes undertaken when information about patient’s medicines and the medicines themselves enter and leave the system. To test changes to the system in one organisation To work with other organisations in the PSF geography to test tools developed To share the experiences, learning and tools through a web-based tool-kit Safe Medicines Pathway

30. Who is respons ible for writing up the Drugs Clarity of Drugs Charts Timing of LTC Meds being written up Portering Collection and Distribution Use or Not of PODs Lockers Themes LTC Medicati on Omitted Medicatio n Omitted at Initial Visit Loss of Medic ation Delays in the writing of TTO’s Single Storage space for all Medicat ion on the Wards Safe Medicines Pathway Duplication of Medication Lack of Consistency in the use of technology i.e. iPADS New meds only given in certain departments Delay in Writing TTO’s Condition of Patient on admission Communication with GP’s/Community Pharmacists

31. Story Board No one had told her, she had started on new Medication Patient/family sometimes return to collect meds ? ? Some patients unaware of the medication they are taking Looked after his own meds at home. Did not need additional medication – had more supplies at home Patients eye drops not charted throughout stay. Lost somewhere along the pathway She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge Pt sent home without own meds; meds thrown out by Nursing Staff Safe Medicines Pathway

32. Developments and Successes Data collection tools Interventions across prescribers, nursing and pharmacy Patient involvement Working with an FY2 Improvement in medicines reconciliation DART campaign (prescribing) SMP Website Safe Medicines Pathway

33. Interventions Safe Medicines Pathway

36. Challenges and Lessons learnt Team/Timescales Releasing staff and running a project on top of “day job” Complexity of the pathways Engagement and clarity of purpose Impact of the introduction of EPR Safe Medicines Pathway

37. Purposeful Observation People do not always do what they say they do People do not always do what they think they do People do not always do what you think they do People cannot always tell you what they need Things are not always as they seem ……. (adapted from IDEO) Safe Medicines Pathway

38. Thank you! Contact Details PSF Project Manager for SMP – Triss Clark Triss.Clark@nhs.netTriss.Clark@nhs.net Tel 01865 221557 Project Lead - Jane Hough jane.hough4@nhs.net Safety/Improvement Expert – Dr Clare Crowley Clare.Crowley@ouh.nhs.ukClare.Crowley@ouh.nhs.uk Tel 01865 857879 Safe Medicines Pathway

39. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

40. Improving Safety & Quality of Antimicrobial Prescribing in Berkshire HFT Kiran Hewitt, Lead Clinical Pharmacist (Project Lead) Jenny Perry, Senior Pharmacist (Project Manager)

41. Background (1)  UK 5 year antimicrobial resistance strategy 2013-18  7 key areas for action, including optimising prescribing practice, improving IC, improving education and training  ESPAUR  PMs commission on ABR by the Wellcome Trust  EAAD 18 th November

42. Background (2) Between 2010 and 2013:  Antibiotic use  by 6%  general practice prescribing  by 4%  prescribing to hospital inpatients  by 12%  other community prescriptions (dentists, out of hours prescribers, nurses, NMPs)  by 32%

43. Audit Standards & Results Criteria Audit Criteria – Standards = 100% Findings 1 Relevant cultures will be taken before antimicrobial therapy is started 49% 2 Drug allergies (antimicrobials) will be noted on the chart 74% 3 Route of administration will be indicated on the chart 98% 4 Dose and frequency will be indicated on the chart 97% 5 The antimicrobial start date will be noted on the chart 85% 6 The duration will be noted on the drug chart 77% 7 Indication will be noted on the chart 47% 8Treatment will be in line with trust guidelines83%

44. Aims Leadership role (pharmacist) to drive stewardship across the Trust Better access to guidelines – to support remote working Training and better education of prescribers - main focus of action plan and internal self assessment Use of technology to enhance the deliver of these Networking and regional collaboration with subject experts – Membership of TVWAPN (sub group of Chief Pharmacists group) Guidelines review in collaboration with both local hospitals PSF bid April 2014

45. Developments (1) Recruitment of Project Manager Sept-14 Purchase, training and development of Microguide smartphone app – Sept to Nov-14 Key Benefits:

46. Developments (2) Initial Promotion – EAAD launch Face to face intro for all ward staff – Presentation of audit findings, App demo, posters, Start Smart Then Focus reminder cards

47. Developments (3) Trust-wide Publicity: – Annual Quality Improvement Event – first prize winner (Nov-14) – IC Link Practitioners annual study day (Nov-14) – Trust Best Practice and Innovation Event (Feb-15)

49. Developments (4) E-learning package introduction Original plan – regional module to utilise local and regional expertise = best option Delayed launch – Options appraisal for alternatives – Bespoke Trust package developed – Feb-15

50. Essential training requirement agreed – for medical and nursing staff groups, pharmacy – Managed through L&D User group feedback prior to launch Added to medical trainee induction “Start Smart Then Focus” and App posters on wards GP and Out of Hours GP presentation – May-15 Successes (1)

51. Targetted training for GPs PDSA 3 e-learning module formally implemented PDSA 5 Targetting S1 on WBCH PDSA 4 Three training sessions for all ward staff on WBCH PDSA 1a) Training roll out on Rose ward PDSA 1b) Display StartSmart Poster PDSA 2

52. Nationally - NICE Guidelines NG15 – AMS: systems and processes for effective antimicrobial medicine use – August 2015 Baseline audit of compliance = 41% – Establish key areas of improvement formal approval of AMS programme AM team development AM Pharmacist Better communication across care settings Robust documentation of Rx decisions

53. Challenges Trust wide roll out – Oct-15 for all CHS wards, Dec-15 for MH Audit of other non-inpatient areas? Improvements over time – sustainability? Champion/lead needed E-learning for local GPs and sharing with others CCG engagement for primary care – Regional group membership already established (TV&WAPN) – – MUS conference Work with local acute trusts – Own agenda – Internal influence and Board approval – Expanding boundaries in the East Sharing our “package” with the TV&W group – Already the experts!

54. Lessons Learnt What would we have achieved without PSF support? A lot can be achieved with commitment Sufficient project management time is essential. QI experience important. Does it make a difference to patient care? – yes Future area for research Applicable to all – yes

55. Contact Details  Kiran.hewitt@berkshire.nhs.uk   Jenny.perry@berkshire.nhs.ukJenny.perry@berkshire.nhs.uk  0118 960 5075

58. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

59. Is avoidable mortality a good measure of the quality of healthcare? Dr Helen Hogan Clinical Senior Lecturer in Public Health London School of Hygiene and Tropical Medicine

60. Outline What drives interest in avoidable mortality Problems with use as a measure of hospital quality Approaches to measurement and what we have learned Local and national developments The future

63. Why it matters?

64. Limitations of avoidable deaths a measure of quality

65. Measuring avoidable death using population-level data HSMR/ SHMI/ RAMI Coded adverse events linked to death Known avoidable harms linked to death Patient Safety Indicators Prospective surveillance systems

66. Measuring avoidable deaths at patient level

67. What have we learnt so far Preventable Incidents Survival and Mortality studies (PRISM) 1 and 2 (co-applicants Nick Black, Frances Healy, Graham Neale, Richard Thomson, Charles Vincent, Ara Darzi) Association between avoidable deaths (RCRR) and excess deaths (hospital-wide mortality ratios)

68. PRISM 1 Study 2010/2011 Aims: – estimate proportion of avoidable hospital deaths – identify ‘problems in care’ and contributory factors – estimate years of life lost Method: – RCRR (1000 adult deaths across 10 acute Trusts in England) – Trained, retired doctors with standard form

69. Findings 75% good or excellent care 11.3% ‘problem in care’ contributing to death 5.2% deaths probably avoidable – range 3% - 8% (low variation between Trusts) – estimate 11,859 avoidable adult deaths/year in England NHS Life expectancy of avoidable death patients – 60% patients had life expectancy less than 12 months Inter-rater reliability Kappa 0.49

70. Problems in care identified in cases of preventable death Stage of patient journey Types of problem identified PreadmissionPoor monitoring of warfarin Delays in admission for hospital procedure Contraindicated drug prescribed in outpatients Early in admission Failure to diagnose Delayed diagnosis Wrong diagnosis Failure to identify the severity of underlying conditions and risks posed by the chosen therapeutic approach Failure to optimise preoperative state Care during a procedure Procedure conducted in inappropriate environment Technical error Post procedureInadequate monitoring (fluid balance, infection) Poor assessment Ward careInadequate monitoring of overall condition, fluid balance, laboratory tests, side effects of medications (especially warfarin), pressure areas and infection Unsafe mobilisation leading to serious falls Hospital acquired infection Prescription of contraindicated drug Delay in undertaking required procedure

71. PRISM 2 Study Based on recommendations emerging from the Keogh review Relationship between ‘excess mortality rates’ and actual ‘avoidable deaths’ Findings to support introduction of a new national outcome framework “hospital deaths attributable to problems in care” and systematic approach to local mortality review

72. PRISM 2 Study 2014/2015 Extend PRISM 1 to further 24 Trusts Similar method to permit analyses of combined data from both studies (n=3,400 records) Random sample of Trusts across 4 strata of HSMR Trained reviewers (70% current consultants, 30% retired) Linear regression to determine the percentage increase in avoidable death proportion for a 10 point increase in HSMR/SHMI

73. Findings 78% good or excellent care 9.4% ‘problem in care’ contributing to death 3.0% deaths probably avoidable – range 0% - 9% (low variation between Trusts persists) Inter-rater reliability Kappa 0.35

74. Combined Findings 3.6% probably avoidable no statistical significant association between hospital SMRs and the proportion of avoidable deaths

75. The future Local Mortality Review – Standardised self-assessment will ensure robust process National approach to training and materials Electronic database/ NRLS All deaths screened, high risk cases selected for in-depth Multidisciplinary process National Tracking of Outcome Indicator Random sample of NHS deaths National panel of trained reviewers (multi-disciplinary) Multiple reviewers per record Timetable: Invitation to tender via HQIP – http://hqip.org.uk/tenders/rcrr%20tender%202015/

76. The future Direct comparison of Trusts based on avoidable X deaths Develop notional avoidable death proportions ?? Use a coherent set of indicators known to be associated with quality e.g. hospital acquired infections and measure as robustly as possible Develop indicators that reflect integrated care/ quality of care across health systems

77. Thank you helen.hogan@lshtm.ac.uk

78. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

79. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk

80. Passing the Baton 29/09/15 Geoff Cooper – Patient Safety Collaborative Manager Wessex Patient Safety Collaborative

81. Patient Safety Federation

82. Wessex and Oxford PSCs Wessex and Oxford Patient Safety Collaboratives are part of a network of 15 Collaboratives established in 2014 by NHSE to tackle the leading causes of avoidable harm to patients. The collaboratives aim to empower local patients and healthcare staff to work together to identify safety priorities and develop solutions. These solutions will then be implemented and tested within local healthcare organisations before being shared nationally with the other collaboratives.

83. Patient Safety Federation

85. Collaboratives and Clusters Patient Safety FederationWessex PSCNational Cluster Sepsis   (NW Coast) Global Comparators (Sepsis)  Safe Medicines Pathway* (Meds Opt)  (Wessex) Anti-microbial prescribing* (Meds Opt  (Wessex)

86. Local Priorities / Breakthrough Series

87. Wessex PSC Work Streams / Programme Model

88. Passing the Baton (Wessex) Patient Safety Federation Wessex Patient Safety Collaborative Safe Medicines Pathway Pharmacy and Transfer of care around medicines projects - Wessex AHSN Medicines Optimisation Programme Anti-microbial prescribing Work programme being led by the Thames Valley and Wessex Antimicrobial Pharmacists Network Sepsis Dr Matt Inada-Kim (WPSC Faculty) working for PSF and WPSC This programme will remain within organisations with Wessex PSC facilitation via the current BTS Collaborative which includes teams from: Dorset County Hospital NHS Foundation Trust Dorset Healthcare University NHS Foundation Trust Hampshire Hospitals NHS FT NHS Dorset Clinical Commissioning Group NHS West Hampshire Clinical Commissioning Group Poole Hospital NHS Foundation Trust Portsmouth Hospitals NHS Trust The Royal Bournemouth & Christchurch Hospital NHS FT Salisbury NHS Foundation Trust Southern Health NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust Wessex Paediatric Critical Care Network University Hospital Southampton NHS Foundation Trust

89. PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 http://www.patientsafetyfederation.nhs.uk