1. Overview of SPSP
Wendy Sayan, Acting Patient Safety Development Manager

2. 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

3. 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!

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

5. 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

6. 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

7. 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

11. Adverse Event Rate – Ninewells Hospital

12. Critical Care High Level Aims

14. Staph. Aureus Bacteraemias - NHS Tayside

15. Crash Call Rate Ninewells

16. Crash Call Rate PRI

17. Surgical Site Infections – NHS Tayside

18. NHS Tayside Patient Safety Five years on…..

19. 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
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
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

21. 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

22. 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 % 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

23. Sepsis Six Bundle

24. Sepsis Acute & Specialty Data – Ward 42, Ninewells

25. Sepsis Acute & Specialty Data – A&E, Ninewells

26. Sepsis Acute & Specialty Data – AMU, Ninewells

27. Implementation & Sustainability

28. 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

29. The Improvement Guide, API29 29

30. 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

31. 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

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

33. 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

34. 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.

35. 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

36. Local Display and Feedback of Data

37. Developing a Patient Safety Culture

38. 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

39. Bureaucratic: Standardise, don’t paralyse
Supporting frontline staff is critical

40. 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 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: 40

41. Patient Safety Dashboard – this is audit of everyone’s work

42. 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

43. 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.

44. 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

45. 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?

46. 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?

47. 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

49. Data & Measurement

50. 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.

51. 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

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

53. 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

54. Data Management Initial local reporting using Microsoft Excel
National use of IHI SPSP Extranet
Development of NHS Tayside Data Dashboards

55. 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 Data is entered on a monthly basis by ward staff. This info then feeds in to the clinical dashboard on a monthly basis.

56. Can be filtered down to ward level

57. Dashboard dials can be filtered down to show run charts

58. Overview

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

60. 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

63. 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

64. 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

65. 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.

66. Older Peoples Improvement Collaborative
FAILURE TO RESCUE
CRASH CALLS
&
SEWS
Diane Campbell
Programme Director
Older Peoples Improvement Collaborative

67. 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

68. Crash Call review tool
SBAR
tool

69. Crash call review tool page 2
Human
factors

70. 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

71. 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

72. SEWS journey so far…… (Nov 2011- present)

73. Modification to oxygen recording
Target saturations
Aid appropriate
management
Additional score of 1 if
Receiving supplemental
oxygen
Document Oxygen
Code
on SEWS

74. Modifications to Blood Pressure & Neurological Assessment
BP < 80mmHg
Now score a 3
Pain
&
Unresponsive
Score a 3

75. 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’

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

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

78. Pilot ward
Pilot Ward CQI Data
Testing

79. 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