PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
WELCOME
DR EMMA VAUX
CEO & EXECUTIVE CHAIR
PATIENT SAFETY FEDERATION
http://www.patientsafetyfederation.nhs.uk
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
Patient Safety
Tim Benson
Patient Leader, RBH
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
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
Safety is not...
• Counting errors
– Complaints handling
– Never events
– Coroner's inquests
• Inspections
– CQC
– Litigation
– Blame culture
Deming’s 14 points
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Constant improvement
New philosophy (TQM)
Cease dependence on inspection
Stop procuring on basis of price alone
Design in quality
Training on the job
Leadership is to help people do better
Drive out fear
Team work not demarcation
Eliminate targets
Pride in work for staff
Pride in work for managers
Vigorous education and improvement
It is everyone’s job
–
W.Edwards Deming. Out of the Crisis. MIT Press 1982
Question
• Do we need a safety measure based on
patients’ perceptions?
• If so what aspects are relevant?
Thanks
Tim Benson
tim.benson@r-outcomes.com
@timbenson
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
Zero tolerance to never events:
standardise, educate and
harmonise.
Tom Crawford Project Lead
12
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
Ref: NHS England Patient Safety Domain
13
Background
Date of incident
Location of incident
Category
Description of the incident
09-Sep-13
Theatres
Surgical error
Retained Guide wire
23-Sep-13
Theatres
Surgical error
Retained humeral protector plate
28-Jan-14
Theatres
Surgical error
Wrong acetabular liner (size) inserted
during total hip replacement.
31-Jan-14
PCEU
Ophthamology
Surgical error
Wrong size intraocular lens
21-Mar-14
Theatres
Anaesthetics
Surgical error
Retained guide wire
25-May-14
Theatres
Surgical error
Wrong site surgery
25-Jun-14
Theatres
Surgical error
Wrong tooth extraction
14
Aim/Purpose
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
Safe Strategy
Domain 1.
Safety Culture
Domain 2
Leadership
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
Domain 3
Promote
Reporting
Aim:
Reporting and
learning the
lessons from
incidents to
ensure it will
not happen
again
Domain 4.
Promote
Learning
Aim:
Providing
learning &
information
that can
contribute to
an
understanding
of Human
Error and
prevention .
Domain 5
Implementing
Best practice
Aim:
Implementation
of good
practice helps
to ensure safe
standards of
patient care
are delivered
Domain 6.
Patient & staff
Involvement
Aim:
Patient
engagement
can deliver
more
appropriate
care and
improved
outcomes
16
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
18
Days between Never Event(s) Jun 2014_Sept 2015
35
30
25
159 days
293 days
20
15
10
5
0
Jun-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
days
0
6
31
31
30
31
30
0
22
31
28
31
30
29
30
31
31
29
19
Domain 2 Leadership
RBFT Theatre Datix Rate/100 Procedures April 2013_June 2015
2.4
Target 2.0
2.2
2.0
1.8
1.6
1.4
1.2
1.0
Rate/100
proc
Q1 2013
Q2 2013
Q3 2013
Q4 2013
Q1 2014
Q2 2014
Q3 2014
Q4
2014/15
Q1 2015
1.3
1.8
1.4
1.5
1.8
1.8
2.5
2.1
2.0
Challenges and Lessons learnt
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
21
22
Contact Details:
tom.crawford@royalberkshire.nhs.uk
23
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
Safe Medicines
Pathway
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
Content of the presentation
•
•
•
•
Background
Aim/Purpose
Developments and Successes
Challenges & Lessons Learnt
Safe Medicines
Pathway
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
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
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
• Themes
Delay in
Writing
TTO’s
New meds
only given in
certain
departments
Condition
of Patient
on
admission
Lack of
Consistency in the
use of technology
i.e. iPADS
Use or
Not of
PODs
Lockers
Who is
respons
ible for
writing
up the
Drugs
Portering
Collection
and
Distribution
Communication
with
GP’s/Community
Clarity of Pharmacists
Drugs
Charts
Timing of LTC Meds
being written up
Duplication of
Medication
Single
Storage
space
for all
Medicat
ion on
the
Wards
Loss of
Medic
ation
Delays in
the writing
of TTO’s
Medicatio
n Omitted
at Initial
Visit
LTC
Medicati
on
Omitted
Safe Medicines
Pathway
Story Board
No one had told
her, she had
started on new
Medication
Patients eye drops
not charted
throughout stay. Lost
somewhere along the
pathway
?
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
Patient/family
sometimes
return to
collect meds
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
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
Interventions
Safe Medicines
Pathway
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
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
Thank you!
Contact Details
PSF Project Manager for SMP – Triss Clark
Triss.Clark@nhs.net Tel 01865 221557
Project Lead - Jane Hough
jane.hough4@nhs.net
Safety/Improvement Expert – Dr Clare Crowley
Clare.Crowley@ouh.nhs.uk Tel 01865 857879
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
Improving Safety & Quality of
Antimicrobial Prescribing in
Berkshire HFT
Kiran Hewitt, Lead Clinical Pharmacist
(Project Lead)
Jenny Perry, Senior Pharmacist
(Project Manager)
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 18th November
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%
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%
8
Treatment will be in line with trust guidelines
83%
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
Developments (1)
• Recruitment of Project
Manager Sept-14
• Purchase, training and
development of
Microguide smartphone
app
– Sept to Nov-14
• Key Benefits:
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
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)
120
100
80
Nov-13
60
Feb-15
40
20
0
S1
S2
S3
S4
S5
S6
S7
S8
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
Successes (1)
• 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
Targetted
training for
GPs PDSA 3
Three training
sessions for all
ward staff on
WBCH
PDSA 1a)
Targetting S1
on WBCH
PDSA 4
Display
StartSmart
Poster
PDSA 2
e-learning module
formally
implemented PDSA
5
Training
roll out on
Rose ward
PDSA 1b)
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
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!
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
Contact Details
 Kiran.hewitt@berkshire.nhs.uk
 Jenny.perry@berkshire.nhs.uk
 0118 960 5075
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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
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
Why it matters?
Limitations of avoidable deaths a
measure of quality
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
Measuring avoidable deaths at patient level
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)
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
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
Problems in care identified in cases of preventable death
Stage of patient Types of problem identified
journey
Preadmission
Poor 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 procedure
Inadequate monitoring (fluid balance, infection)
Poor assessment
Ward care
Inadequate 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
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
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
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
Combined Findings
• 3.6% probably avoidable
• no statistical significant association between
hospital SMRs and the proportion of avoidable
deaths
• Local Mortality Review
The future
– 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/
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
Thank you
helen.hogan@lshtm.ac.uk
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
Passing the Baton
29/09/15
Geoff Cooper – Patient Safety Collaborative Manager
Wessex Patient Safety Collaborative
Patient Safety Federation
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.
Patient Safety Federation
Patient Safety Federation
Collaboratives and Clusters
Patient Safety Federation
Wessex PSC
National Cluster
Sepsis

 (NW Coast)
Global Comparators (Sepsis)


Safe Medicines Pathway
* (Meds Opt)
 (Wessex)
Anti-microbial prescribing
* (Meds Opt
 (Wessex)
Local Priorities /
Breakthrough Series
Wessex PSC Work Streams /
Programme Model
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
PSF FINAL
SHOWCASE EVENT
TH
29 SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk