Overview of SPSP
Wendy Sayan, Acting Patient Safety Development Manager
Aims of the Session
Morning Session
• Overview of the current Patient Safety Programme
• New Patient Safety Programmes
• Implementation, Sustainability & Spread
• Developing a Patient Safety Culture
Afternoon Session
• Data and Measurement
• Failure to Rescue and SEWS
Scottish Patient Safety Programme
Vision
“To transform the safety of acute care in Scotland
thereby improving care and radically reducing
needless death and harm”
Every Patient Every Time!
DVD
Aims
• 15% reduction in mortality
• 30% reduction in adverse events
•
Reduce healthcare associated infections
•
Reduce adverse surgical incidents
•
Reduce adverse drug events
•
Improve critical care outcomes
•
Data for improvement
•
Develop and build a quality improvement and patient safety culture in our
hospitals
•
Build in long term sustainability and capability to drive this approach at all
levels
Work Area
Change Package Element
Critical Care
Key objectives
Establish infrastructure
•Daily goal sheets
•Daily multi-disciplinary rounds
Infection Prevention
•Ventilator bundle
•Central line bundle
•General infection prevention practices
•Glucose control (ITU then to HDU)
General Ward
Risk Identification and Response
•Rapid response (Outreach) teams
•Early warning system
Infection Prevention -MRSA
Reliable care for Congestive heart failure
Communication and Teamwork
•Safety briefings
•Communication tools (e.g. SBAR)
•Prevention pressure ulcers
Leadership
Infrastructure to support safety
Walkrounds
Safety a strategic priority
Medicines Management
Reconciliation
Anticoagulation , Insulin,
Conduct an FMEA on a high risk medication process
Perioperative
DVT Prophylaxis
Continuity of Beta blockers
SSI bundle
Team culture - briefings
Scottish Patient Safety Programme
SPSP Aims
•Mortality: 15% reduction
•Adverse events: 30%
reduction
•Ventilator associated
pneumonia: 0 or 300 days
between
*CL CR-BSI: 0 or 300 days
between
*Staph aureus bacteraemias:
30% reduction
*Crash Calls: 30% reduction
*Surgical site infections:
50% reduction (clean)
Primary Drivers
GENERAL WARD
Reduced infections,
crash calls,
pressure
ulcers, AE in CHF and AMI patients
PERI-OPERATIVE
Reduce peri-operative adverse
events: infections, cardiovascular
events
CRITICAL CARE
Reduced Mortality,
Infections, & Other
Adverse Events
MEDICINES MANAGEMENT
Reduce adverse drug events: r/t high
risk processes & medicines e.g.
medicines at the interface and
anticoagulation
Secondary Drivers
Provide reliable, timely, care using evidence-based
therapies
Create a collaborative team and safety culture
Ensure patient and family centred care
Develop infrastructure that promotes quality care
Provide appropriate, reliable and timely care to
patients using evidenced-based therapies to prevent
surgical site infections
Create a team culture attuned to detecting and
rectifying intraoperative errors
Provide appropriate, reliable and timely care to
patients using evidenced-based therapies to prevent
peri-operative cardiovascular events
Provide reliable, timely, care using evidence-based
therapies
Integrate patient and family into care
Develop infrastructure that promotes quality care
Create a collaborative team and safety culture
Provide reliable medicines management processes
Coordination of care
Patient and family involvement
LEADERSHIP
Provide the Leadership System to
Support the Improvement of Safety
and Quality Outcomes in your Board
Develop the infrastructure to support quality and safety
improvement
Provide oversight to programme
Promote the position of safety and quality in the
organisation
NHS Tayside Patient Safety
Five years on…..
Aim
To improve the
safety and
reliability of care
throughout NHS
Tayside by Dec
2012
Implementation of Mental
Health Patient Safety
Interventions
Implementation of Women &
Child Health Patient Safety
Interventions
Continued support to sustain Current levels of reliability in all Acute
Adult Work streams
Spread Plan development for all acute adult workstreams
Improve Patient Rescue – SEWS revision and implementation,
Crash call reviews, mortality reviews
Improve Sepsis and VTE – Sepsis/VTE Collaborative 2012 - 2014
Antimicrobial Management
PVC Insertion & Maintenance Bundle Development
Heart Failure
HDU workstream Development
Scottish Patient Safety Programme in Paediatrics - SPSPP
Paediatrics – appropriate, timely and reliable evidence-based critical care therapies.
Improve medicines management processes and decrease harm from medicines
Improve paediatric perioperative outcomes
Improve paediatric general ward outcomes
Safety Beyond Acute – "Improving Maternity Services through teamwork solutions"
Maternity Care Quality Improvement Collaborative 2012 - 2015
Outcomes:
 Mortality (15%
reduction across
NHSS)
 Adverse Events
(30% reduction
across NHSS)
Implementation of Primary
Care Patient Safety
Interventions
SIPC 1 & 2
Improve management of immunosuppressive drugs
Improve care for LVSD heart failure
Improve Medicine Reconciliation processes
Medication Safety
180 Day Rapid Improvement Collaborative – focus on Medicines Reconciliation
admission & discharge in Medicine for the Elderly
Patient Safety in Prison Services
SPSP Primary Care 2013 launch
National Medicines Management Collaborative June 2012 launch
Develop Infrastructure to
Support Quality and Safety
Improvement, Promoting the
Position of Safety and
Quality within NHS Tayside
Building Capacity, using data at the frontline
Continue spreading Patient Safety and Quality Improvement to non-clinical areas:
Sterile Services Department
Mortality & Morbidity Reviews
Embedding Patient Safety and Quality Improvement in Medical Curricula
Further develop the NHST Framework for Spread and sustainability
Review of further development of existing Walkround Process
Sepsis Collaborative
Background
• National collaborative launched by the Scottish Patient
Safety Programme and Scottish Antimicrobial
Management Group in January 2012
• Four pilot areas within NHS Tayside
o
o
o
o
Ward 15, Ninewells Hospital
Ward 42, Ninewells Hospital
Accident & Emergency, Ninewells Hospital
Ward 4, Perth Royal Infirmary
• Aim to achieve 5% reduction in mortality by December
2012, rising to 10% by December 2014.
• Early spread to wards 5/6 and orthopaedics
How will we do this?
Reliable Recognition
&
Assessment
To improve the
recognition and
timely management
of Sepsis in acute
hospitals
Outcome:
Reduction in
mortality in pilot
population from
Sepsis
5% by December
2012 10% by
December 2014
Reliable Care
Delivery
Education
&
Awareness
Culture of safety
and Quality
Improvement
Patient & Family
Centred Care
Reliable Sepsis screening (EWS + SIRS)
Ensure reliable communication across clinical
teams of at risk patients
Ensure timely rescue of deteriorating patient
by competent teams
Ensure reliable delivery of Sepsis Six within 1
hour
Source Control
Ensure reliable escalation of septic patients to
higher level of care
Improve Antimicrobial stewardship - 3 day review
Education on burden of illness & current
performance
Provide training to staff on clinical knowledge
and improvement skills
Executive Sponsorship
Clinical Leadership
Multidisciplinary team working
Develop measurement frameworks to guide
improvement
Involve patients & families in treatment
process and care planning
Sepsis Six Bundle
Sepsis Acute & Specialty
Data – Ward 42, Ninewells
Sepsis Acute & Specialty
Data – A&E, Ninewells
Sepsis Acute & Specialty
Data – AMU, Ninewells
Implementation & Sustainability
Our Theory
•
•
•
•
•
•
•
•
Build a compelling case for change
Work on processes and outcomes that engage hearts & minds
Reduce waste and redundancy
Work at the coal face and at the executive level
Data feedback, data feedback, data feedback
Set the tempo!
Changes in process and outcomes are directly connected
The changes being tested, when fully implemented, will lead to
large system aims
The Improvement Guide, API
To Be Considered a
Real Test
• Test was planned, including a plan for
collecting data
• Plan was carried out and data was
collected
• Time was set aside to analyse data and
study the results
• Action was based on what was learned
Move Quickly
to Testing Changes
•
•
•
•
•
•
Year
Quarter
Month
Week
Day
Hour
“What tests can
we complete by
next Tuesday?”
Start
Small
~ 1:3:5:All
Select your pilot area to start to test:
• 1 patient
• 1 day
• 1 admission
• 1 clinician
Repeated Use of the
PDSA Cycle
Changes That
Result in
Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A P
S D
What change can we make that
will result in improvement?
Implementation
of Change
A P
S D
Hunches
Theories
Ideas
Followup Tests
Very Small
Scale Test
Wide-Scale
Tests of
Change
PVC Bundle, Orthopaedic Ward - PDSA Cycle
Implement PVC Bundle all Wd 16 patients Ninewells Hospital
95% compliance with PVC
Bundle Process by Dec 2009
Adapt and test existing PVC Bundle process
carried out within ward 16 to align with
SPSP PVC Bundle
Implementation of PVC bundle process
and audit tool
Continue to test process and accompanying
audit documentation with all patients and
involving all staff to ensure all issues are
discovered and resolved
Further adaptation of process, test with 3-5 patients
and 3 nurses, parallel testing of locally developed audit
tool to suit revised process.
Test SPSP PVC Bundle within orthopaedic clinical setting with one patient
and one nurse. PVC maintenance was already carried out within this
Major Joint Replacement Orthopaedic Ward. Testing was required
around the implementation of the SPSP Bundle which differed slightly.
5 Key Principles of
Improvement:
• Knowing why you need to improve
• Feedback mechanisms to tell if your improvement is
happening
• Develop effective change that will result in improvement
• Test a change before implementing
• Know when and how to make the change permanent
Local Display and Feedback of Data
Developing a Patient Safety Culture
What is Quality in
Healthcare?
Traditional Approach
New Approach
Attitude
•
Quality is what we do
•
Scope
•
Clinical effectiveness
and safety
•
Focus
•
Patients
(populations)/people
•
Requisites
•
Standards delivered by •
high quality education
Scale
•
Large scale ‘roll-out’ of
•
evidence
Content adapted from a presentation from Professor Peter Davey, University of Dundee
Quality is what we strive
for
Effective, Safe, Patient
Centred, Timely,
Equitable, Efficient
Patients, populations,
and Systems
Continuous improvement
through learning
Small scale testing and
context-specific spread
Bureaucratic:
Standardise, don’t paralyse
Supporting frontline staff is critical
We are
increasingly
realising not only
how critical
measurement is to
the quality
improvement we
seek but also how
counterproductive
it can be to mix
measurement for
accountability or
research with
measurement for
improvement
Solberg et al Journal on Quality Improvement 1997, 23:135-147.
Patient Safety Dashboard – this is audit
of everyone’s work
Patient Safety Executive
Walkrounds
“I found it a very interesting experience
and valued the opportunity to spend time
with senior staff from the management
side of NHS Tayside, who had time to
listen to me and share their experience
and knowledge.”
Staff Comment on experience of Walkround
Patient Safety Executive
Walkrounds
Quality Improvement & Safety
• Both parties willing to discuss relevant issues, and being focussed on
continuous improvement regarding patient care & safety.
• Interaction with staff and patients and the completion of the quality loop.
• Visible reminder for staff of the importance of the safety agenda
• Openness of process and opportunity to see evidence of patient safety &
improvement work.
• Opportunity to look for compliance with safety processes
Communication
• Discussion with the Senior Charge Nurse after the walk around the ward is
particularly useful.
• Positive engagement with staff team and service leads
• Opportunity to talk with patients and staff
• Open discussions
• Giving staff the opportunity to showcase what they are doing well and receive
recognition for their hard work.
The Healthcare Quality Strategy
for NHSScotland
Institute of Medicine’s
6 Dimensions of Quality
Scottish Government, May 2010
• What does high quality healthcare look like
for you, your team and your service- and
what gets in the way of achieving this, all the
time?
• What is the first simple thing you have the
power to change, immediately, or in the very
short term, which would improve the reliability
of the quality of the service deliver today?
• What other practical ideas do you have that
would improve the experience and outcomes
of care for patients, carers and for us all?
• What prevents you from putting this idea into
practice?
• What else would it take to make this happen?
What are your learning objectives?
1.
2.
3.
4.
5.
6.
7.
What are human factors and why are they important?
Understanding systems & complexity in health care
Being an effective team player
Understanding and learning from errors
Understanding and managing clinical risk
Use of quality improvement methods
Engaging with patients and carers
Data & Measurement
Measurement for
Improvement
• Improvement is not about measurement however,
effective measurement and data collection plays
an important role.
• Improvement is about making changes to
processes and systems, with measurement
playing a key role in the process.
The Improvement Guide, API
Why are you measuring?
Improvement?
The answer to this question will guide your entire
quality measurement journey!
Overall Project Measures vs.
PDSA Cycle Measures
Achieving
Aim
Adapting
Changes
During
PDSA
Cycles
Data for Project Measures:
- Overall results related to the project aim (outcome,
process, and balancing measures) for the life of the
project
Data for PDSA Measures:
- Quantitative data on the impact of a particular
change
- Qualitative data to help refine the change
- Collect only during cycles
Data Management
• Initial local reporting using Microsoft Excel
• National use of IHI SPSP Extranet
• Development of NHS Tayside Data Dashboards
Can be filtered down to ward level
Presenting your data
VAP Rate - ICU, Ninewells Hospital
70.00
What happened
here?
Implementation of daily goals
50.00
40.00
Chlorhexidine oral gel introduced over
previous 12 months
30.00
20.00
median (13.89)
10.00
0.00
Au
g -0
5
Oc
t-0
5
De
c -0
5
Fe
b-0
6
Ap
r-0
6
Ju
n-0
Au 6
g -0
6
Oc
t-0
6
De
c -0
6
Fe
b-0
7
Ap
r-0
7
Ju
n-0
7
Au
g -0
7
Oc
t-0
7
De
c -0
7
Fe
b-0
8
Ap
r-0
8
Ju
n-0
8
Au
g -0
8
Oc
t-0
8
De
c -0
8
Ja
n-0
9
Ma
r-0
9
Ma
y -0
9
Ju
l-0
9
Se
p -0
9
No
v -0
9
Ja
n-1
0
Ma
r-1
0
Ma
y -1
0
Ju
l-1
0
Se
p -1
0
No
v -1
0
Ja
n-1
1
VAP Rate per 1000 patient days
60.00
ICU now admitting all neuro patients
following closure of neuro ICU
Month
If you don’t understand the variation
that lives in your data, you will be
tempted to ...
• Deny the data (It doesn’t fit my view of
reality!)
• See trends where there are no trends
• Try to explain natural variation as special
events
• Blame and give credit to people for things
over which they have no control
Data Reporting Structure
• Data recorded locally using IT Dashboard
System
• Reports created by each Directorate and Patient
Safety Team for local and national reporting
purposes
• SPSP reporting to Clinical Quality Forum,
Executive Management Team and within local
Clinical Governance Groups
Measurement Principles
•
•
•
•
•
Develop aims before measuring
Design measures around aims
‘How Good, By When’
Establish a reliable baseline
Track progress over time
• The key purpose of measurement for
improvement is for learning.
• Teams need measures to give them feedback
that the changes they are making are having
the desired effect and are resulting in
improvement.
FAILURE TO RESCUE
CRASH CALLS
&
SEWS
Diane Campbell
Programme Director
Older Peoples Improvement Collaborative
Purpose of crash calls
reviews
• Gather reliable & real time information
•
Analysis to identify human factors & issues with SEWS
Examine potential opportunities for earlier interventions
and learning
•
•
Reflection – individual & team
Crash Call review tool
SBAR
tool
Crash call review tool page 2
Human
factors
Prioritisation of
Care
DNA/CPR
Team working
Overnight
Observations
Communication
SUMMARY OF
CRASH CALL FINDINGS
NINEWELLS & PRI
Underscoring
Observations
performed in
isolation
Examples of
Clinical
Excellence
Delayed
Escalation
Lack of
Documentation
No increased
Frequency when
SEWS >2
Prolonged periods
With No
Observations
SEWS Development
Drivers for Change:
• Based on review findings there was recognised
need to review the existing chart
• Local SEWS data
• National developments (NEWS)/NICE Clinical
Guideline 50
SEWS
journey
so far……
(Nov 2011present)
Modification to oxygen recording
Target saturations
Aid appropriate
management
Additional score of 1 if
Receiving supplemental
oxygen
Document Oxygen
Code
on SEWS
Modifications to Blood
Pressure
& Neurological
Assessment
BP < 80mmHg
Now score a 3
Pain
&
Unresponsive
Score a 3
Integrating Sepsis
Triggers
SEWS ≥4: THINK SEPSIS
If 2 or more of the following:
• Temperature >38 or <36
•Altered mental state
•Respiratory Rate >20 breaths per min
•Known/suspected neutropenia
•White cell <4 or >12
AND clinical suspicion or confirmed
Infection
Commence ‘Sepsis 6 Bundle within 1 hour’
Clear monitoring plan
Escalations/Exclusion
‘Red Flag’
Improving Nursing Documentation
Monitoring
Guide
Frequency
Of
Obs
Pilot Ward
CQI Data
Pilot ward
Testing
SEWS is fundamental to patient safety
&
should guide safe monitoring for
EVERY PATIENT EVERY TIME!