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” Emphasise this about every patient every time Every Patient Every Time!

DVD Although developed for NHS Tayside if we changed the name to any Board in Scotland the messages and changes would be the same

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

Change Package Element Work Area Change Package Element Critical Care 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 Key objectives

Scottish Patient Safety Programme SPSP Aims Primary Drivers 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 GENERAL WARD Reduced infections, crash calls, pressure ulcers, AE in CHF and AMI patients 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) 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 PERI-OPERATIVE Reduce peri-operative adverse events: infections, cardiovascular events CRITICAL CARE Reduced Mortality, Infections, & Other Adverse 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 MEDICINES MANAGEMENT Reduce adverse drug events: r/t high risk processes & medicines e.g. medicines at the interface and anticoagulation 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

Adverse Event Rate – Ninewells Hospital

Critical Care High Level Aims

Staph. Aureus Bacteraemias - NHS Tayside

Crash Call Rate Ninewells

Crash Call Rate PRI

Surgical Site Infections – NHS Tayside

NHS Tayside Patient Safety Five years on…..

Aim Implementation of Mental 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 Implementation of Mental Health Patient Safety Interventions Aim To improve the safety and reliability of care throughout NHS Tayside by Dec 2012 Outcomes:  Mortality (15% reduction across NHSS)  Adverse Events (30% reduction across NHSS) 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 Implementation of Women & Child Health Patient Safety Interventions 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 Patient Safety in Prison Services SPSP Primary Care 2013 launch Medication Safety 180 Day Rapid Improvement Collaborative – focus on Medicines Reconciliation admission & discharge in Medicine for the Elderly 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 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 Reliable Sepsis screening (EWS + SIRS) Ensure reliable communication across clinical teams of at risk patients Ensure timely rescue of deteriorating patient by competent teams 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 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 Reliable Care Delivery Education & Awareness Education on burden of illness & current performance Provide training to staff on clinical knowledge and improvement skills Introduce the driver diagram for the sepsis collaborative, focussing on reliable care delivery, i.e. sepsis bundle bundle within 1 hour Executive Sponsorship Clinical Leadership Multidisciplinary team working Develop measurement frameworks to guide improvement Culture of safety and Quality Improvement Patient & Family Centred Care 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 29 29

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 11 30 30

Move Quickly to Testing Changes Year Quarter Month Week Day Hour “What tests can we complete by next Tuesday?” “If you think we can test the change in a month, what can you test a day from now?” Assumptions about Time: 2 Orders of Magnitude LESS teams are most effective when they move quickly to testing changes (& maintain momentum) best to first test innovative changes on a small scale okay to test multiple changes at once test under a variety of conditions importance of linking tests of change don’t try to get buy-in or consensus for tests (but will be necessary for implementation) 31

Start Small ~ 1:3:5:All Select your pilot area to start to test: 1 patient 1 day 1 admission 1 clinician 32

Repeated Use of the PDSA Cycle Changes That Result in Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement A P S D DATA D S P A Implementation of Change A P S D A P S D Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test 33

DATA 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 DATA 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 Know when and how to make the change permanent Implement the change

Local Display and Feedback of Data

Developing a Patient Safety Culture

What is Quality in Healthcare? Traditional Approach New Approach Quality is what we do Clinical effectiveness and safety Patients (populations)/people Standards delivered by high quality education Large scale ‘roll-out’ of evidence Attitude 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 Scope Focus Requisites Scale Content adapted from a presentation from Professor Peter Davey, University of Dundee

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 Data for improvement should provide regular feedback to the data subjects about their performance compared with targets that they agree are important because they are based on processes that are known to directly influence health outcomes. Data for accountability or judgement should provide others (users of the service, purchasers, government) with information that helps them to identify outliers, make choices about which services to use or investigate poor performance. Data for research should generate new knowledge about the relationships between processes and outcome. For improvement: Tests can be observable, everyone needs to know what is going on. Consistent bias is acceptable. For example it is a good idea to start your improvement intervention with a unit or team who are unusually keen to try this or one in which you have a lot of influence. If it does not work there it is unlikely to work somewhere else. If it does work then you have other people who can help you spread to the next team. Samples only need to be big enough to tell you that you are (or are not) at the level of reliability that you want to achieve. If this is >95% then you only need 10-20 observations per time point. The hypothesis can be flexible in the sense that the change strategy you use can be adapted to different settings. However the change that you are trying to bring about should probably not be too flexible if it is evidence based. It is better to have repeated small samples than one big one. Improvement data are designed to feed back to the data subjects. The data should only be made public if the subjects agree. Think hard about disclosure. Worrying patients is not the aim of quality improvement but openness can build trust. Solberg et al Journal on Quality Improvement 1997, 23:135-147. 40

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.

Institute of Medicine’s The Healthcare Quality Strategy for NHSScotland Approach to quality is based upon the Institute of Medicine’s six dimensions of quality. These six dimensions will focus the way we measure healthcare quality to ensure we deliver the right care safely, at the right time, and in a way that is built around the particular needs of the individual # The ambitions are based upon the Institute of Medicines six dimensions of quality It is a commitment to integrate and embed quality in all that we do. It will build on the approach to service planning and delivery that we already have. SPSP is referred to throughout They want a caring and compassionate health service, to see real partnership between patients, clinicians and wider public sector, cared for in a clean and safe care environment, with improved access and continuity right though their journey and of course they want to have confidence they are receiving the best care. In simple terms patients want Clean wards Staff to wash their hands Treated quickly in an emergency Drs to know enough about their procedures and getting clear explanations that they can understand And of course they want to be treated with dignity and respect The Quality Strategy puts people at the heart of everything the health service does. It establishes our commitment to ensuring that the way in which people receive healthcare is as important as how quickly they receive it. Through the implementation of the strategy, people will be encouraged to be partners in their own care and can expect to experience improvements reflecting the things they have told us that they want and need from their health services: Caring and compassionate staff and services; Clear communication and explanation about conditions and treatment; Effective collaboration between clinicians, patients and others; A clean and safe care environment; Continuity of care; and Clinical excellence. This means: Putting people at the heart of NHSScotland. Those working in the health service will listen to peoples' views, gather information about their perceptions and personal experience of care and use that information to further improve care. Building on the values of the people working in and with NHSScotland and their commitment to providing the best possible care and advice compassionately and reliably, by making the right thing easier to do for every person, every time. Making measurable improvement in the aspects of quality of care that patients, their families and carers and those providing healthcare services see as really important. Institute of Medicine’s 6 Dimensions of Quality Scottish Government, May 2010 44

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? 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 47

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 The Model for Improvement, (Langley et. al. 2009) consists of three fundamental questions to drive improvement and the Plan-Do-Study-Act (PDSA) Cycle. The focus of this data session is around measurement for improvement, which is key answering the second question: “How will we know that a change is an improvement?”, however all parts of the Model for Improvement are inextricably linked. The Improvement Guide, API 51

Judgment? Research? Improvement? Why are you measuring? Judgment? Research? Improvement? The answer to this question will guide your entire quality measurement journey!

Overall Project Measures vs. PDSA Cycle Measures Achieving Aim Data for Project Measures: - Overall results related to the project aim (outcome, process, and balancing measures) for the life of the project Adapting Changes During PDSA Cycles 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

Example of new NHS Tayside generic data entry tool Example of new NHS Tayside generic data entry tool. This was implemented to all wards in February 2011. Data is entered on a monthly basis by ward staff. This info then feeds in to the clinical dashboard on a monthly basis.

Can be filtered down to ward level

Dashboard dials can be filtered down to show run charts

Overview

Presenting your data This tells a story, without annotations it shows good dot/bad dot.

What happened here? 1 astronomical point – what happened there? 2 shifts above the median May need to consider re-setting the median as rules were applied when less than 20 data points 1 trend decreasing 2 shifts below the median ? Re-set to a new median following shift in data below (21 data points) Annotations to describe the tests of change Look at how this is annotated

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.

Older Peoples Improvement Collaborative 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 When healthcare workers believe that they didn’t respond early to a change in clinical deterioration – this will help drive a change in practice. Emotionally,,, job satisfaction….. Help drive improvement Review cases where the care has been sup optimal

Crash Call review tool SBAR tool

Crash call review tool page 2 Human factors

DNA/CPR Prioritisation of Care Examples of Clinical Excellence Team working Communication SUMMARY OF CRASH CALL FINDINGS NINEWELLS & PRI Overnight Observations Delayed Escalation Underscoring Lack of Documentation Vital signs are done as a batch process Delegated to the most junior person in the team Prolonged periods With No Observations Observations performed in isolation No increased Frequency when SEWS >2

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 2011- present)

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’

Escalations/Exclusion Clear monitoring plan Escalations/Exclusion ‘Red Flag’ Monitoring Guide Frequency Of Obs Improving Nursing Documentation

NICE guidelines – generate graded responses of escalated care so that patients receive care from staff with appropriate levels of training, experience and skill

Pilot ward Pilot Ward CQI Data Testing

SEWS is fundamental to patient safety & should guide safe monitoring for EVERY PATIENT EVERY TIME! Sews are a fundamental aspect of patient care and will significantly add to our patient experience and outcome if used appropriately