1. Patient Safety Guidance Implementation: The challenge for organisations - Burning Platform or Information Overload? conference Making health care safer: learning from social and organisational research conference St Andrews University Scotland 27 th June 2011 Pauline Cumming Risk Manager, NHS Fife

2. First do no harm …

3. Burning Platform…

4. Information overload

5. Information overload? (Alvin Toffler, Future shock…1970) NPSA SIGN NICE NHS Institute for Innovation and Improvement MHRA HSE HTA MRC PATIENT SAFETY 1 ST WHO IHI The Health Foundation

6. NPSA output - a flavour Patient Safety Alerts: advice on patient safety issues that are important and have a specific timeline for implementation Patient Safety Alerts: advice on patient safety issues that are important and have a specific timeline for implementation Safer Practice Notices: guidance on patient safety issues that contribute to improving patient safety Safer Practice Notices: guidance on patient safety issues that contribute to improving patient safety Rapid Response Reports: advice on patient safety issues that need immediate local attention Rapid Response Reports: advice on patient safety issues that need immediate local attention Patient safety alerts on issues: That are a serious threat to patient safety, usually based on data showing repeated harm or loss of life That can be addressed through practical, evidence based actions

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8. ‘ An Evaluation of NHS Quality Improvement Scotland’s Dissemination Process of NPSA Alerts’ (NHS QIS, July 2010) Main challenges for NHS Boards : Knowing which alerts to prioritise and implement locally Knowing which alerts to prioritise and implement locally The current status of NPSA guidance in Scotland The current status of NPSA guidance in Scotland The expectations of NHS QIS and SGHD on how NHS Boards should respond to NPSA information The expectations of NHS QIS and SGHD on how NHS Boards should respond to NPSA information How guidance from England can be applied to Scotland How guidance from England can be applied to Scotland

9. Healthcare Quality Strategy 2010 Quality Ambitions Mutually beneficial partnerships between patients, families and those delivering services No avoidable harm or injury from healthcare and care within a clean & safe environment Most appropriate treatments, interventions, support & services and no wasteful or harmful variation

10. Patient as partner… “We need to move, over time, to a more inclusive relationship with the Scottish people; a relationship where patients and the public are affirmed as partners rather than recipients of care. We need to move towards an NHS that is truly publicly owned…where ownership and accountability is shared with the Scottish people and the staff of the NHS…where we think of the people of Scotland not just as consumers– with only rights – but as owners – with both rights and responsibilities ” ( “We need to move, over time, to a more inclusive relationship with the Scottish people; a relationship where patients and the public are affirmed as partners rather than recipients of care. We need to move towards an NHS that is truly publicly owned…where ownership and accountability is shared with the Scottish people and the staff of the NHS…where we think of the people of Scotland not just as consumers– with only rights – but as owners – with both rights and responsibilities ” (A Participation Standard for the NHS in Scotland, August 2010, Scottish Health Council )

11. Keys to implementation Quality of the evidence - who produced it Quality of the evidence - who produced it Relevance to practice Relevance to practice Effectiveness of dissemination Effectiveness of dissemination Strong leadership Strong leadership Timing & importance - Opportunity costs Timing & importance - Opportunity costs Facilitation – Champions- someone to help keeps up impetus & boosts chances of success Facilitation – Champions- someone to help keeps up impetus & boosts chances of success Reliable measurement Reliable measurement Accountability Accountability Ownership: Is it about making it personal? Ownership: Is it about making it personal? Culture Culture

12. Patient Safety…. “Patient safety should no more be seen as a programme for the NHS than breathing should be seen as a programme for human beings… ” (Don Berwick, Institute for Healthcare Improvement Chair, Patient Safety Congress, 2008)

13. What is safety culture? The shared beliefs and values of staff working in an organisation that determine the commitment to and quality of an organisation’s health and safety management Alternatively….the way we do things around here (Dr Harry Burns, CMO, May 2007, NHS Fife)

14. Levels of maturity with respect to a ‘safety culture’ Pathological W hy waste our time on safety? Reactive We do something when we have an incident Calculative We have systems in place to manage all like risks Proactive We are always on the alert for risks that might emerge Generative Risk management is an integral part of everything that we do

15. Levels of organisational culture (Westrum) Pathological Information is hidden Messengers are “shot” Messengers are “shot” Responsibilities are shirked Responsibilities are shirked Bridging is discouraged Bridging is discouraged Failure covered up Failure covered up New ideas are actively crushed New ideas are actively crushed Bureaucratic Information may be ignored Messengers are tolerated Responsibility is compartmentalised Bridging is allowed but neglected Organisation is just and merciful New ideas create problems Generative Information is actively sought Messengers are trained Responsibilities are shared Bridging is rewarded Failure causes inquiry New ideas are welcomed

16. Paradigm shift - the grass is greener

17. Consider…. What do you think are the factors which enable uptake, implementation and sustainability of patient safety guidance? What do you think are the factors which enable uptake, implementation and sustainability of patient safety guidance? What do you think are the factors which hinder uptake, implementation and sustainability of patient safety guidance? What do you think are the factors which hinder uptake, implementation and sustainability of patient safety guidance? Is there is a moral imperative to act on such alerts? Is there is a moral imperative to act on such alerts? Does non-mandatory status confuse, weaken the message and undermine the need to act? Does non-mandatory status confuse, weaken the message and undermine the need to act? How do you think HIS and the Quality Improvement Hub might help patient safety knowledge management locally and nationally? How do you think HIS and the Quality Improvement Hub might help patient safety knowledge management locally and nationally?