Sheffield Microsystem Coaching Academy
Network Event
3rd October 2013
Agenda
Topic
Time
Welcome – Steve Harrison
12.00
NHS England, Overview and Patient Safety Priorities Bruce Warner
12.05
Questions & Discussion
12.45
Informal Networking
13.00
Close
13.30
Microsystems Coaching Academy Aim
To improve the quality and value of care we provide
in the Sheffield Healthcare system
Through the development of team coaching
To build improvement capability at the front line with
knowledge, processes and tools including the
Dartmouth Microsystem Improvement Curriculum.
4
It’s about redesigning the system
“Every system is perfectly designed to
get the results it gets.”
Paul B. Batalden, MD
Co-Founder The Institute for Healthcare Improvement
Founding Director, Center for Leadership and Improvement,
The Dartmouth Institute for Health Policy and Clinical Practice
5
Improving Microsystems - Elements
Team Coaching
QI
Microsystem
18
Improvement
Science
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information?
www.sheffieldmca.org.uk
• Stories & case
Studies
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Invite)
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Coach
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team coached
NHS England
Overview and Patient Safety Priorities
Dr. Bruce Warner
Deputy Director of Patient Safety
NHS England
NHS England
Overview and Patient Safety
Priorities
Dr. Bruce Warner
Deputy Director of Patient Safety
NHS England
OLD! Flowchart For Problem Resolution
NO
YES
Is It Working?
Don’t Mess About
With It!
YES
Did You
Mess About
With It?
You Daft Prat
NO
Anyone Else
Know?
NO
Hide It under a desk
YES
You’re stuffed!
NO
YES
Will it
Blow Up
In Your
Hands?
NO
Can You Blame
Someone else?
Yes
SORTED!
Deny All Knowledge
International and National Recognition of
Patient Safety
1999
1
1
2000
2001
2001 National Patient Safety
Agency Established
• Collect and analyse information on adverse
events
• Assimilate other safety-related information
• Learn lessons and ensure that they are fed
back into practice
• Where risks are identified, produce solutions to
prevent harm
June 2012 - National Patient
Safety Agency Abolished
“We propose to abolish the
National Patient Safety
Agency”
The work of the Patient Safety
Division relating to reporting and
learning from serious patient
safety incidents should move to
the NHS Commissioning
Board…
… covering the whole function
from getting evidence to working
up evidence-based safe
services.”
“
2
Time to Move On
NPSA Patient Safety
Division
NRLS
to
ICHT
1
4
Patient Safety Function
to
NHSCB(A)
What is NHS England?
6,500 people in new roles in national, regional, and
local offices across England
Create the culture and conditions for health and care
services and staff to deliver the highest standard of
care and ensure that valuable public resources are
used effectively to get the best outcomes for
individuals, communities and society for now and for
future generations
Role of NHS England
NHS England has three distinct but interconnected roles:
CCGs were
allocated £65bn in
2012/13
£26bn in 2012/13
Supporting
and enabling
the local
commissioning
system (CCGs
and Area
Teams)
Working with
partners: CQC,
Monitor, NHS TDA,
NICE,
HSC IC, HEE
Directly
commissioning
primary care,
specialised,
armed forces
and justice
health services
System wide leader
for quality
improvement
CCGs, CSUs,
NHSIQ, NHS
Leadership
Academy, Local
Gov
The Mandate
Government sets annual objectives that NHS England are legally obliged to
pursue, but NHS England is independent in pursuing those objectives
NHS England is held accountable to the government against the
achievement of those objectives, and the level of continuous improvement
First Mandate for NHS England
• Sets out what the Government expects in
return for handing over £95bn of tax payers
money to NHS England
• The NHS Outcomes Framework sits at the
heart of this Mandate. NHS England is
expected to demonstrate progress across the
entire framework
NHS Outcomes Framework
We need to make this vision a reality, translating
it into how patients care looks and feels
NHS Outcomes Framework
Structure
Domain 1
Domain 2
Domain 3
Preventing
people from
dying
prematurely
Enhancing
quality of life
for people
with longterm
conditions
Helping
people to
recover from
episodes of ill
health or
following
injury
Domain 4
Ensuring people have a positive
experience of care
Domain 5
Treating and caring for people in a safe
environment and protecting them from avoidable
harm
Effectiveness
Experience
Safety
Domain teams priority action areas
1
DOMAINS
2
3
Preventing people from dying
prematurely
•
•
•
•
•
Maximising the contribution that the NHS can make to preventing disease
Finding the ‘missing millions’ and diagnosing earlier and more accurately
Treating people in an appropriate and timely way
Addressing unwarranted variation in mortality and survival rates
Reducing deaths in babies and young children
Enhancing the quality of life for
people with long term
conditions
•
•
•
•
Helping patients take charge of their care
Enabling good primary care
Ensuring continuity of care
Ensuring a parity of esteem for mental health
Helping people to recover from
episodes of ill health or
following recovery
•
•
•
•
Keeping people out of hospital when appropriate
Effective interfaces between primary, secondary and community care
High quality, efficient care for people in hospital
Co-ordinated care and support for people following discharge from hospital
4
Ensuring that people have a
positive experience of care
5
Treating and caring for people
in a safe environment and
protecting from avoidable harm
• Improving our understanding of the patient experience
• Reduce inequality in patient experience
• Enabling commissioners and providers to create a culture that puts good
patient experience and positive staff experience at the heart of services
• Establishing clear lines of accountability for patient experience in the NHS
•
•
•
•
•
Increase our understanding of the problem
Create the conditions for patient safety
Build capacity for safe care
Create a whole system response
Address our key patient safety concerns
Domain 5
Patient Safety
April 2013
Our vision: What we want to
achieve over the next decade
To ensure that anyone accessing
NHS-funded services is treated in an
environment where their safety is the
paramount concern and where the
whole system actively seeks to
reduce the risks, inherent in health
care, to a minimum.
““… [we all] need to
place the safety of
patients at the forefront
of the agenda in
healthcare. Safety
cannot be allowed to
play second fiddle to
other objectives that
may emerge from time
to time. It is the first
objective.”
Sir Ian Kennedy,
Chairman Healthcare Commission
Safety
Effectiveness
Patient
experience
Safety is not a
minimum threshold –
all services can and
should strive to
excellence in safety
A. Why waste our
time on safety?
PATHOLOGICAL
B. We do
something when
we have an
incident
REACTIVE
C. We have
systems in place
to manage all
identified risks
E. Risk
management is an
integral part of
everything that we
do
D. We are always
on the alert for
risks that might
emerge
BUREAUCRATIC PROACTIVE
The Manchester Patient Safety Assessment Framework
GENERATIVE
The interplay between patient safety
and clinical guidelines
It is about the way we safely deliver
care once the clinical decision on how
to treat has been made – the clinical
decision may be the right one but it is
not a given that we will deliver it without
error.
The scale of the challenges
53,000,000+ people
140,000+ different ways
the human body can go
wrong
6000+
medicines for
treating
diseases
4,300+ ways
of treating
diseases
BNF
ICD10 codes
and we wonder why people are harmed….?
The scale of the challenges
• Mid-Staffordshire – and the pockets of it that exist everywhere else
• 1 in 10 patients admitted experience an adverse event
• Half of adverse events are judged to be preventable
• 5% of deaths in English acute hospitals had at least a 50% chance of being
preventable
• Principal problems associated with preventable deaths
• poor clinical monitoring (31.3%),
• diagnostic errors (29.7%), and
• inadequate drug or fluid management (21.1%)
• Most preventable deaths (60%) occurred in elderly patients with multiple
comorbidities and less than 1 year of life left
• 72% of all patient safety incidents are from the acute sector, 13% from Mental
Health, 11% from Community, 2% from Learning Disability, 0.6% from
Community Pharmacy and 0.4% from General Practice.
National Reporting &
Learning System
NHS Trusts
International
NRLS
Practitioners
& Staff
Community
Pharmacy
multiples
Patients
Carers
Standardised reporting
Commissioners
Collaboration
Australia
USA
CQC
MHRA
NHS Complaints
NHS Litigation
Authority
Europe
Searching by keywords: example
NICE Quality Standard
for Bacterial meningitis
and meningococcal
septicaemia in children
Key word search for
‘mening*’ in free text of
incident reports identified
182 relevant incidents, all
clinically reviewed and
themes summarised to
inform the development of
the Quality Standard
We need a trigger
Review of Deaths and Severe Harms
Local audit data
PCT audit of vaccine storage in
GP practices shared with NPSA
Significant proportion of vaccines
stored outside recommended
temperature range
NRLS Searched
National guidance produced
3
NHS
| Presentation to [XXXX Company] | [Type Date]
4
Media Reports, Coroners Courts etc.
By 31 March 2012
7,070,261
reports had been
reported.
Approximately
3,700 incidents
are reported to the
NRLS per day.
94%
Around
of
incidents cause low
or no harm
Levels of Harm
•
The NHS leads the world in incident reporting, with the National Reporting and
Learning System receiving nearly 8 million incident reports since late 2003 to date.
•
Over 100,000 incidents are reported monthly.
•
HES data suggests there are over 100,000 cases of VTE per year
•
NHS Safety Thermometer data suggests 6-7% of patients have a pressure ulcer
•
There were 326 never events reported to SHAs in 2011/2
NRLS limitations:
very little reporting from general practice
Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11
All care settings: death and
severe harm themes 2011/12
1%
2%
3%
1%
1%
1%
Pressure ulcer grade 4 or above
Fall
Suicide/severe self harm
19%
4%
Treatment error or delay (excluding medication
Other or unable to theme
5%
Obstetric-specific incident
5%
Operation/ procedure
Clinical diagnostic error including delay of diagnosis
6%
17%
6%
Deterioration not recognised or not acted on
Healthcare associated infection
Medication incident
Test results not seen or not acted on (any type of test)
Transfer or discharge incident
8%
12%
9%
Pulmonary embolus - hospital acquired
Resuscitation (excluding medication)
Airway obstruction/ Aspiration pneumonia
Fixed priorities
Domain 5 of the
NHS Outcomes
Framework
Domain 5: embedded in all domain 1 – 5 work
Increase our
understanding
of the problem
Creating the
Conditions for
Safety
Building
Capacity for
Safety
A whole
system
response to
safety
Tackling key
safety
concerns
Domains 1 – 4 are expected to build these safety themes into
every programme/ project governance arrangement
Aim 1 – To increase our understanding of
the safety problem
Increase our
understanding
of the problem
New methodology for
measuring the safety of
NHS services (indicator
5c) based on case note
review of deaths in
hospital
Further NHS Safety
Thermometers (medicines,
mental health,
maternity)
Design and deliver the
new single incident
reporting and
management system to
replace/upgrade the NRLS
and simplify reporting
Aim 2: To create the conditions for safer care
Contract – SIs and
HCAI
Creating the
Conditions for
Safety
CQUIN and Quality
Premium – Pressure
ulcer improvement
Policy development
– Serious incident
management,
deaths in custody
Aim 3: To build capacity to deliver safer care
Safety Expert
Groups
Building
Capacity
for Safety
Patient Safety Skills
Strategy
Enhanced safety
leadership
Aim 4: To create an whole system response to
safety
Patient safety
collaboratives
A whole
system
response to
safety
Patient safety
Improvement
Fellows
Networks,
champions and
campaigns
Aim 5: To tackle key safety concerns
Outcomes
framework priorities
Tackling
key safety
concerns
Other key harms
Vulnerable groups
AIM 5: To address key areas of safety concern
Programme Objectives
Deliverables
Outcomes
Framework Safety
Concerns
•
•
•
•
•
•
Pressure Ulcers
VTE
Medication and devices
HCAI
CYP deterioration
Neonatal admissions
Key known harms
•
•
•
•
•
•
Falls (Older people in 1st 48hrs of acute illness)
Handover
Transitions
Nutrition and hydration
Deterioration
AKI
Vulnerable group
safety concerns
•
•
•
•
Primary Care strategy
Mental Health
Learning Disabilities Framework
Offender Health framework
Making the aims a reality
Four key delivery streams will be used:
1. Central patient safety development team
• Development of major initiatives such as reporting systems, safety
alerts, commissioning levers, etc
2. Patient Safety Collaboratives
• Regional effort across boundaries to improve safety concerns
3. National community of interest networks
• Led by the central patient safety team to link people together working
on key safety concerns across the country to accelerate sharing and
learning, and support Patient Safety Collaboratives across England
4. Domain 1 – 4 Effectiveness and experience
programmes
• Linking into other developing NHS England programmes of work
Berwick Report
Aims for Improvement
Implementation
Building Capacity through training, education, technical capability
Structural recommendations; Oversight, accountability and influence
Patient and Public Involvement
Measurement, transparency, tracking and learning
Legal penalties/criminal liability and their impact on safety
Implications for leaders at all levels
Staff and the work environment
Findings
Berwick - most important recommendations for the way forward envision the NHS
as a learning organisation, fully committed to the following:
 Placing the quality of patient care, especially patient safety,
above all other aims:
 Engaging, empowering, and hearing patients and carers
throughout the entire system and at all times:
 Fostering whole-heartedly the growth and development of all
staff, including their ability and support to improve the
processes in which they work:
 Embracing transparency unequivocally and everywhere, in
the service of accountability, trust, and the growth of
knowledge.
Thank you for listening
bruce.warner@nhs.net
www.sheffieldmca.org.uk