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VTE Showcase Maintaining the Momentum Mike Durkin Director of Patient Safety 16 September 2013 Portcullis House, London.

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Presentation on theme: "VTE Showcase Maintaining the Momentum Mike Durkin Director of Patient Safety 16 September 2013 Portcullis House, London."— Presentation transcript:

1 VTE Showcase Maintaining the Momentum Mike Durkin Director of Patient Safety 16 September 2013 Portcullis House, London

2 c58,000,000+ people The scale of the challenges 140,000+ different ways the human body can go wrong ICD10 codes 4,300+ ways of treating diseases 6000+ medicines for treating diseases BNF and we wonder why things go wrong….

3 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 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.

4 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 The scale of the challenges

5 WHO Checklist adapted for NHS 4

6 3 NHS Prioritisation 2004 2005 2006 2007 2008 2009 2010 2011 Adaptive strategy and consistent pressure prioritises VTE prevention across the UK The Journey so far

7 7 VTE: Delivering Improvement National VTE Prevention Programme - collaboration of clinical experts, NHS leaders and dedicated health professionals with the aim of ensuring that VTE prevention strategies are fully integrated in to NHS systems and processes for the future NICE CG92: Venous thromboembolism VTE Prevention Quality Standard (QS3) NICE CG144: Venous thromboembolic diseases Technology appraisals of oral anticoagulants for use in VTE Pathways for VTE National VTE Risk Assessment Tool Mandatory collection of VTE risk assessment data National CQUIN goal 2010 - only 41% of patients were being risk assessed Q1 2013/14 – 95.4% of admitted patients received a VTE risk assessment on admission Significant reduction in VTE – associated mortality (unpublished draft data )

8 Improved Risk Assessment Compliance

9 Proportion of adult patients risk assessed for VTE on admission to hospital: Q1 2013/14

10 VTE Risk Assessment by Region Q1 2013/14 NHS Region % Patients risk assessed for VTE on admission North96.30% Midlands & East97.10% London96.30% South96.70%

11 VTE (HES) Data sourced from Hospital Episode Statistics (HES) for the period April 2007 – October 2012. The data is presented by rate (U prime chart) of patients with VTE per 10,000 Finished Consultant Episodes in inpatients in England. The numerator is calculated from a count of episodes of VTE recorded in any diagnostic position (diagnostic codes I80.1, I80.2, I80.3, I80.9, I82.9, I26.0, I26.9) by month. The denominator is the number of finished clinical episodes by month. The mean rate for the latest re-based period is 111.6 VTE’s per 10,000 FCE’s, an 8% increase from the first period centre line. There appears to be a seasonality effect in January (although it appears to a lesser extent in 2012). There is some evidence of this trend in the literature – partly explained by changes in coagulation factor levels – see;; During the reported period there has been an increase (before and after, first (Aug-Oct) and last three data points) of 248,420 FCE’s.;

12 Postoperative pulmonary embolism or deep vein thrombosis, 2009 (or nearest year) OECD Health Data 2012. EU comparisons

13 NHS Safety Thermometer % of patients with new VTE

14 The proportion of patients being treated for a new VTE: NHS Safety Thermometer


16 How much variation is there nationally?


18 How much variation is there in your Trust?

19 NHS Outcomes Framework to measure success and enhance accountability Overarching Indicators- selected to measure the breadth of each domain i.e. the ‘comprehensive service’ Improvement Indicators- selected following analysis of multiple factors e.g. burden of disease, variation in quality, understanding what outcomes are most important to different groups e.g. children, working age adults, older people

20 Our fixed priorities that contribute to our vision Domain 5 of the NHS Outcomes Framework

21 National Patient Safety Dashboard Helping NHS England track progress towards achievement of improvement in Outcome Framework Domain 5 measures

22 NHS Outcomes Framework, indicator 5a: Patient Safety incident reporting 7. NHS Outcomes Framework: domain 5 CURRENT TRENDS Mar-Aug 2013 against Mar-Aug 2012 baseline DESIRED DIRECTION: UP UNTIL UNDER-REPORTING ELIMINATED Increase in reporting required by Outcomes Framework – reflecting increased willingness to recognise and address safety problems Current trends in 5a – all care settings +6% Increases in reporting sought Current trends in 5a – acute hospitals +7% High baseline in acute settings but further increases in reporting sought Current trends in 5a – mental health services +7% High baseline in MH settings but further increases in reporting sought Current trends in 5a - general practice +3% Increases sought particularly from GP settings where baseline is very poor Current trends in ‘NO HARM’ patient safety incidents +6% Increased willingness to report ‘near misses’ seen as a particularly positive sign of improving reporting culture Past trends from 2007-2012

23 7. Domain 5 - Safety NHS Outcomes Framework, indicator 5.2i MRSA bloodstream infections CURRENT TRENDS Feb-July2013 against Feb-July 2012 baseline DESIRED DIRECTION: DOWN TO AMBITION OF ZERO Our planning guidance for 2013/14 sets a zero tolerance approach to MRSA bloodstream infections. Current trends in MRSA bloodstream infections (all) 0% No change over current six months against seasonal equivalent (457/456) disappointing given marked downward trends in prior years Proportion of MRSA bloodstream infections acute provider/CCG since Apr 13 46% acute 54% CCG Note method of assignment changed from timing of infection to findings on Post Infection Review investigation in April 2013; no historic data available

24 7. Domain 5 - Safety NHS Outcomes Framework, indicator 5.2ii Clostridium difficile CURRENT TRENDS Feb-July2013 against Feb-July 2012 baseline DESIRED DIRECTION: DOWN TO AMBITION OF 12,282 for 2013/14 The objective for 2013/14 is 12,282 - 16% reduction on 2012/13 total of 14,687 Current trends in all c. difficile -9% All ages and all care settings; a proportion of community-acquired cases will be healthcare-associated due to antibiotic use. Current six months 6734 against 2012 seasonal equivalent 7371 cases Current trends in post- admission c. difficile in patients aged ≥65 years -13% Healthcare associated c difficile in the sub-group of older patients particularly vulnerable to death or severe harm from c. difficile. Current six months 2185 against 2012 seasonal equivalent 2498 cases

25 Infection control Total number of MRSA bloodstream infections in England StandardThis monthLast monthLast year 0 (zero tolerance from April 2013) 61 7969 Total number of C. Difficile infections in England This monthLast monthLast year 1,067 1,1371,220

26 Mid-Staffordshire NHS Foundation Trust

27 Don Berwick’s National Advisory Group on the Safety of patients in England Independent of Government, NHS management, or any other influence Advised by senior advisers from across the NHS and elsewhere (Julie Bailey, Robert Francis, Ara Darzi, Liam Donaldson, Jeremy Taylor, Peter Walsh, HSE, CQC and others) Small number of recommendations delivered to; the Prime Minister; the Secretary of State for Health; the NHS England Executive; other clinical and executive leaders in the NHS; and the public at large The most important patient safety report in over a decade Will set the agenda for patient safety in the NHS for the next 10 years or more

28 Don Berwick Work Streams Implementation Aims for Improvement 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

29 Problems 1. Patient safety problems exist throughout the NHS: Like every other health care system in the world, the NHS experiences repeated defects in patient safety. 2. NHS staff are not to blame: A very few may be exceptions, but most staff wish to do a good job, to reduce suffering, and to be proud of their work. 3. Incorrect priorities do damage: In some organisations, goals of (a) hitting targets and (b) reducing costs have taken centre stage. 4. Warning signals abounded and were not heeded: Loud, and urgent signals were muffled and explained away. 5. Responsibility is diffused, and therefore not clearly owned: With so many in charge, no one is. 6. Improvement requires a system of support:. The most important single change in the NHS in response to this report would be for it to become a system devoted to continual learning and improvement of patient care, top to bottom and end to end. 7. Fear is toxic to both safety and improvement: Fear impedes improvement in complex human systems.

30 Solutions 1. Recognise with clarity and courage the need for wide systemic change: 2. Abandon blame as a tool. Trust the goodwill and good intentions of the staff, and help them achieve what they already want to achieve: 3. Reassert the primacy of working with patients and carers to set and achieve health care goals. 4. Use quantitative goals with caution. Such goals, (i.e., “targets”) do have an important role en route to progress, but should never displace the primary goal of better care. 5. Recognise that transparency is essential, and expect and insist on it at all levels and with regard to all types of information (other than personal data). 7. Ensure that responsibility for functions related to safety and improvement are vested clearly and simply 6. Give the people of the NHS – top to bottom – career-long help to learn, master, and apply modern methods for quality control, quality improvement, and quality planning 8. Make sure pride and joy in work, not fear, infuse the NHS.

31 Findings Our 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.

32 “You never get to safety through anger and blame. You get there through learning, curiosity and commitment” Don Berwick

33 Features of a safe NHS Create a learning safety culture; staff feel safe to report and act safety incidents; part of every role Develop high reliability systems and processes to support the identification and management of risks to patient safety Patient involvement and feedback recognised as an essential learning opportunity; our best warning system Responsive Boards proactively manage safety of their organisations

34 Features of a safe NHS ‘Displays’ of compliance are over; finance and safety are considered of equal importance What matters is measured (hard metrics, soft intelligence), tracked and used. Staff engaged, supported and empowered to deliver safe care; just and knowledgeable leadership. Clear standards are set for minimum safety levels, failures to meet the sanctions are understood, and used appropriately; peer review

35 Professor Avedis Donabedian “Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love”

36 Behaviours We prioritise patients in every decision we take. We listen and learn. We are evidence-based. We are open and transparent. We are inclusive. We strive for improvement 29

37 37 Improvement through learning Evaluation of outcomes is a priority work stream for the programme Continue to improve our understanding of VTE metrics nationally, regionally and locally Root Cause Analysis is an effective learning tool to drive improvement RCA included in the current National VTE CQUIN – submission of quarterly report to commissioners High quality VTE prevention should underpin commissioning of care Important to include VTE prevention in commissioning contracts with providers NICE Quality Standard provides as set of measures for performance management as regards best practice More information can be found on the National VTE Prevention Programme website:

38 Through the Eyes of our Patients Thank You

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