Welcome and the National Patient Safety Plan - Dr Mike Durkin (Chair), Director for Patient Safety, NHS England Presentation from the Patient Safety Collaborative launch event held in London on 14 October 2014 More information at http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety/patient-safety-collaboratives.aspx

1. National Patient Safety Plan
Dr Mike Durkin,
NHS England
Director of Patient Safety
14 October 2014

2. The Berwick legacy and journey so far
2
www.england.nhs.uk
“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.
“We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.”
- A promise to learn– a commitment to act, August 2013

3. Don Berwick’s Findings (2014/15)
www.england.nhs.uk

4. www.england.nhs.uk 4
• A unique opportunity only the NHS can bring
• Led with the innovation and expertise of the
AHSNs
• Largest collaborative patient safety programme
in the world
• We can be stronger by learning together
• A chance to build on existing success
This is our big opportunity

5. •To create the conditions where the AHSNs can excel, lead and provide a catalyst for local improvements
•To ensure continual patient safety learning sits at the heart of healthcare in England
•To create the largest and most comprehensive collaborative patient safety programme in the world
Our collective ambition
5
www.england.nhs.uk

6. Scale of the problem: reported incidents
•Each report an opportunity to learn: 68% no harm and 25% low harm
•But each report also represents actual or potential distress or harm to patients and concern from staff
NRLS Quarterly Data workbooks April 2012 – March 2013 England data: 1,353,430 incidents in total
Other
Patient abuse (by third party/staff)
Infection Control Incident
Medical device / equipment
Disruptive, aggressive behaviour
Self-harming behaviour
Consent, communication, confidentiality
Clinical assessment & diagnosis
Infrastructure
Documentation
Access, admission, transfer, discharge
Medication
Treatment, procedure
Implementation of care
Patient accident
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000

7. Scale of the problem: death & severe harm
19%
17%
14%
8%
6%
6%
6%
5%
9%
Suicide/severe self harm
Fall (hip #/sub-dural)
Pressure ulcer grade 4
Treatment error or delay
Obstetric-specific incident
Operation/procedure related
Clinical diagnostic error/delay
Missed deterioration
Medication incident
Healthcare associated infection
Pulmonary embolus
Test results not acted on
Transfer or discharge incident
Other/unclear
NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents
Over 8,000 reported fatal or severe harm incidents each year
www.england.nhs.uk

8. Scale of the problem: other sources
•Around 4,400 people commit suicide each year; 27% are known to mental health services; most are known to GPs
•4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year
•9,500 patients with grade 2/3/4 pressure ulcers on each monthly survey
•Around 3,000 hip fractures from falls in hospitals each year identified by the National Hip Fracture database
NCISH 2014 report - HSCIC NHS OF Aug 2014 - Safety Thermometer Sept 2014 – NHFD 2014 report
Suicides - England 2002-2012
www.england.nhs.uk

9. Topic area Patient Safety Topic
The
‘essentials’
Leadership Measurement
NHS
Outcomes
Framework
improvement
areas
Venous
Thrombo-embolism
Healthcare
Associated
Infections
Pressure
Ulcers
Maternity
Medication
Errors
Deterioration in
children
Other major
sources of
death and
severe harm
Falls
Handover
and
Discharge
Nutrition and
hydration
Acute
Kidney
Injury
Missed and
delayed
diagnosis
Deterioration
of patients
Medical
Device
Errors
Sepsis
Vulnerable
groups for
whom
improving
safety is a
priority
People with
Mental Health
needs
People with
Learning
Disabilities
Children Offenders
Acutely ill older
people
Transition
between
paediatric and
adult care
Collaborative priorities - proposals
www.england.nhs.uk 9

10. Building on successes and sharing learning across organisations
10
www.england.nhs.uk

11. A range of safety indicators included in Intelligent Monitoring to prioritise trusts for early inspection:
CQC Inspections Analysis
Note initial inspections were directed at trusts more likely to have safety concerns and so sample is skewed
Of the first 47 NHS trusts inspected by the Care Quality Commission under its new inspection regime:
•81% ‘requiring improvement’ or ‘inadequate’ for Safety
www.england.nhs.uk

12. Our 2014/15 strategic plan and vision
12
Gaining a better understanding of what goes wrong in healthcare
Enhancing the capability and capacity of the NHS to deliver patient safety improvement
Tackling key patient safety priorities
Statutory Responsibilities Mandate Objectives NHS Outcomes Framework
Keogh Review Ambitions Francis Response Berwick Report
•Improving completeness of reporting to the National Reporting and Learning System (NRLS)
•Developing a new national patient safety incident reporting system
•Developing patient safety thermometers
•Creating the first ever direct national measures of patient safety using retrospective case note review
•Developing patient safety data pages on NHS Choices Website
•Establishing the Patient Safety Collaborative programme
•Deliver programme to identify and recognise Patient Safety Fellows
•Further developing the investigations capability across the NHS
•Developing an improvement programme, including change packages, to tackle key clinical patient safety areas and vulnerable groups
•Establishing Medication Safety and Medical Device Safety Officer Network across England
Pressure Ulcers
Medication & Devices Error
Failure to Monitor children
Neonatal admissions
Anti-Microbial Resistance Imp
Mental health
Learning disabilities
Deaths and restraint whilst in custody
Acute Kidney Injury
Nutrition and Hydration
Primary Care (Increase GP reporting)
Discharge
Falls
Older People
Offender Health
Never Events
Handover
Deterioration
Sepsis
VTE
HCAI
•Specific work programmes to address:
www.england.nhs.uk

13. Patient
Safety
’Fellows’
Patient Safety
Collaboratives
A system
devoted to
continual
learning and
improvement
NRLS
NaPSAS
Data
Transparency
Retrospective
case note
review
Vulnerable
groups
Vulnerable
points of
care
Key types
of harm
and reduce harm by 50%
SAFE
team
NHS England’s Integrated Patient
Safety Strategy for the NHS
www.england.nhs.uk

14. VTE Risk Assessment
www.england.nhs.uk 14
Numbers of patients receiving a
VTE assessment:
June 2010 - 45%
July 2014 - 96%
What was done;
• NICE Standard
• CQUIN – 90% then 95%
• Standard Contract

15. Sepsis
www.england.nhs.uk 15
Estimated that that 35,000 people die from sepsis
in England each year.
The reliable delivery of basic elements of sepsis
care could save an estimated 11,000 lives a year
and £150 million annually
NHS England sepsis programme aims to:
• reduce avoidable harm and death
• develop a care pathway approach
• increase clinicians’ awareness of sepsis as a
medical emergency
• increase patient and parent participation to
support the case for change
• share best practice through the spread of
initiatives/ improvement work
• make greater use of commissioning levers and
incentives

16. Acute Kidney Injury (AKI)
www.england.nhs.uk 16
Up to 100,000 deaths in secondary care are
associated with AKI
¼ to ⅓ have the potential to be prevented
The AKI national programme:
• Primary Care package
• Secondary Care package
• Measurement
• Commissioning
• Healthcare System Change
• Public Campaign

17. Adios Bacteremias: 39 ICUs across 4 countries in Latin America
17

18. 18
Outcome measure: 56% reduction over 12 months
Rate of CLABSI in participating Latin American ICUs
n=39
www.england.nhs.uk

19. The Sign up to Safety pledges
•Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally
•Continually learn. Make organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe services are
•Honesty. Be transparent with people about progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong
•Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use
•Support. Help people to understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress
www.signuptosafety.nhs.uk
Vision
•For the whole NHS to become the safest healthcare system in the world Objective
•3-year shared objective to save 6,000 lives and reduce harm by 50%
Aims
1.To ensure patients get harm free care every time, everywhere
2.To support the whole NHS to openly and honestly tackle safety concerns
3.For local NHS organisations and bodies to make clear commitments to improve
Sign up to Safety campaign - LISTEN, LEARN, ACT (launched June 2014)
19

20. NHS Patient Safety 5000
Fellowship Programme
• Collaboration with the Health Foundation
• The 2013 Berwick Report recommendation:
‘organise a national system of NHS Improvement Fellowships, to recognise
the talent of staff with improvement capability and enable this to be
available to other organisations’
• The Health Foundation and NHS England are looking to develop an ambitious
initiative that will connect and support people with expertise in safety and wider
quality improvement working in health care across the UK.
• The initiative will recruit people from across the UK with advanced improvement
expertise.
• We plan to work with organisations at the forefront of safety and wider quality
improvement to develop and run this initiative.
• Developing a detailed proposal in November to launch in early 2015.
www.england.nhs.uk 20

21. National Patient Safety Alerting
System (NaPSAS)
www.england.nhs.uk 21
• A new system launched in January 2014 for
alerting the NHS to emerging patient safety
risks
• Allows for timely dissemination of relevant
safety information to providers, as well as
acting as an educational and
implementation resource
• Builds on the best elements of the former
National Patient Safety Agency (NPSA)
system
• A three-stage alerting system based on
other high risk industries such as aviation
• Continue to issue alerts via the Central
Alerting System (CAS)

22. •Since June 2014, NHS Choices provides a hospital level display of patient safety data accessed via searching by location or viewing all England and using a drop down menu to select the safety indicators to view
•Patients and the public can see how hospitals are performing on key safety indicators in one place in an easy and accessible way
•A direct link is included to each organisations’ staffing data presented to their Board on a monthly basis
22
Patient Safety Data on NHS Choices
www.england.nhs.uk

23. • PRISM I study: Preventable deaths due to problems in care in English acute
hospitals: a retrospective case record review study
• 1000 adults who died in 2009 in 10 acute hospitals in England
• Trained medical reviewers identified problems in care contributing to death
and judged if deaths were preventable, taking into account patients’ overall
condition at that time
• Reviewers judged 5.2% (approx. 12,000) of deaths as having a 50% or greater
chance of being preventable
• Principal problems were poor clinical monitoring, diagnostic errors, and
inadequate drug or fluid management
• Most preventable deaths (60%) occurred in elderly, frail patients with
multiple comorbidities
Background PRISM I
www.england.nhs.uk

24. • This research will build on the PRISM I study
• The study will involve a further 24 Trusts (2400 deaths) with a range of HSMR
and SHMI scores in order to facilitate more rigorous analysis of the association
between these measures and the proportion of avoidable deaths in each
hospital.
• Findings will help guide as to the best method of using hospital deaths as an
indicator of safety and for tracking national trends over time.
• This will pave the way for the introduction of a new national indicator for
measuring avoidable deaths arising from problems in care, including providing
us with a national baseline.
Background PRISM II
www.england.nhs.uk

25. Modelled on A&E ECIST – delivered through NHS IMAS via NHS England
The Team Senior clinicians, managers, patients and academic evaluators who have a track
record in delivering safety improvement
The Task The remit and scope of the task will be determined following identification of
failings in hospital safety systems. Acting on intelligence from CQC, Trust
Development Authority, Monitor and Commissioners
The Process With the agreement of the Trust or TDA.
Data mining, Diagnostics and Site Visit
Implementation of Safety Improvement Plan
Monitoring and Mentorship by “Buddy” Trust
Resources National Leadership and Coordination NHS England
Support capability from Patient Safety Collaboratives, High Performing Trusts,
task specific turnaround teams sponsored by Royal Colleges and Specialist
Associations and International Leaders
Funding trust, TDA and Commissioners
Governance CCG & Area Team, NHS England
Intensive Support—Safety Action
Force England (SAFE teams)
www.england.nhs.uk

27. PDSA Health – Attendance Promotion Classroom Virginia Bravo Plan & Do Goal: To increase attendance of preschool children from ~75% of school days to 90% of school days

28. Name
Month
Days missed over the last 2 weeks
Number of days that the child with the best record of assistance has missed over the last 2 weeks
Reminder of ‘chronic absenteeism’

29. OBESITY PREVENTION Plan & Do Goal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms
Sugar sweetened beverages
Water consumption

30. UCL
LCL
0%
10%
20%
30%
40%
50%
60%
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% de Ninos q Trajeron Jugo -- Centro Parvularia
Percent
UCL
LCL
0
0.5
1
1.5
2
2.5
4/2/12
4/3/12
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N Vasos de Agua Tomados por Ninos Presentes
Rate
PDSA Health – Obesity prevention Classroom Centro Parvulario Plan & Do Goal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms
Sugar sweetened beverages
Water consumption

31. Professor Avedis Donabedian
www.england.nhs.uk
“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.”