1. Patient Safety Federation Achievements & Plans for the future Dr Jonathan Fielden Executive PSF Medical Director Royal Berkshire Foundation Trust www.patientsafetyfederation.nhs.uk

2. Summary PSF aim and achievements New future New Projects New ideas? What do we need from you? Questions?

3. Our Aim To improve Patient Safety in all health care organisations in the South Central area and to lead the way nationally and internationally in reducing harm to patients www.patientsafetyfederation.nhs.uk

4. How Safe is healthcare? HARM 82/319 (26%) of patients in 2009 at the Royal Berks had an adverse event that resulted in harm (Global trigger tool) DEATH 10% (15/150) patient deaths reviewed at the Royal Berks were thought to be “avoidable” (3% 5/150 probably) (Wain and Vaux 2010)

5. 8 workstreams No needless deaths No needless medication errors No needless ignorance – human factors No needless skin breakdown No needless malnutrition No needless infection No needless falls No needless harm in mental health www.patientsafetyfederation.nhs.uk

6. Unprecedented pressures Quarter more over 85s by 2015 Diseases of modern lifestyles Rising consumer expectations The cost of new drugs is increasing Note: Excludes unrealised losses on financial interventions. Source: HM Treasury. – CIPFA-SOLACE; ‘After the downturn’

7. Changing to a value culture What Is Value in Health Care? Michael E. Porter, Ph.D. n engl j med 363;26 nejm.org december 23, 2010

8. Value? Porter, M: NEJM 363 26 23rd Dec 2010

9. Quality improvements

10. Presentations

11. Patient Safety Federation Proposed future plans Jonathan Fielden Executive PSF Medical Director/CMO Royal Berkshire Foundation Trust www.patientsafetyfederation.nhs.uk

12. Investment Total invested = £1.3million in 2009 Balance at 31/1/12 = £545,000 Forecasted until March 2013 Spent £755,000 on: - Project Management= £330,174 -MRT=£60,000 (individual Trust funding) -Skin breakdown=£68,000 (intentional rounding training) -Falls=£58,000 (falls safe project) -Medicines=£167,777 (POD bags, injectable meds, e-learning) -Sepsis=£23,000 -Other workstreams: £18,049 -Website & Conferences= £30,000

14. www.patientsafetyfederation.nhs.uk Average rate per exposure of catastrophes and associated deaths in various industries and human activities. Amalberti R et al. Ann Intern Med 2005;142:756-764 ©2005 by American College of Physicians

15. www.patientsafetyfederation.nhs.uk Average rate per exposure of catastrophes and associated deaths in various industries and human activities. Amalberti R et al. Ann Intern Med 2005;142:756-764 ©2005 by American College of Physicians

16. Intentions going forward….. Consolidate workstreams Pack of PSF “products” for you to embed and to become business as usual More QIPP aligned – efficiency & productivity Meet with all Trusts to discuss ROI & future needs Future investment 25K per year for 3 years - equivalent to a band 4 with on-costs

17. Projects 2012 Consolidate work streams – business as usual Sepsis improvement project - Hampshire Hospitals - adoption and spread Improvements from medicines metrics Human Factors faculty - Oxford, Wessex Deanery, SCAS & Reading Your ideas……..

18. Future project ideas from Trusts SI reviews - how do you know your Trust is not another Mid Staffs? Maternity - vast number of SIs, collective learning? 7 day/24hr working - what are the patient safety issues? Peer review – aiding adoption and implementation of best practice “safe environment”

19. Next Steps Meetings with Trusts (over next 3 months) Future investment 25K per year for 3 years - equivalent to a band 4/5 with on-costs – Access to network, peers, support, value adding to your project ideas, project management support…..

20. We would welcome your feedback: Sarah.Mussett@royalberkshire.nhs.uk Jonathan.Fielden@royalberkshire.nhs.uk