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Parallel Session 2.3.2 What's Your Problem? Lessons on How to Solve National and Local Challenges
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Parallel Session 2.3.2 What's Your Problem? Lessons on How to Solve National and Local Challenges


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  • The purpose of this presentation is to attempt summarise a two and a half year journey into 30 mins and share with you the lessons we’ve learnt about how to measure harm and the development of a safety culture within the paediatric community in Scotland. What this won’t be is an academic presentation on the theory and practice of achieving a safety culture – but try to explain some of the elements that we’ve found that have influenced the development of SPSPP and where the programme has evolved. James Reason believes that ‘safety cultures evolve gradually in response to local conditions, past events, the character of leadership and the mood of the workforce’.
  • SPSPP launched in June 2010 – the first of it’s kind
  • Story of where we reached – Paediatric Trigger Tool – wasn’t applicable to care delivered in hospitals in Scotland
  • Low rates of harm seenMedian = 0 therefore “no useable data?” by run chart rules So we can all relax and stop worrying about improvement!
  • Has there been any point in the the trigger tool?Identifying common triggers to direct improvementPoor documentation of adherence with PEWS – are we missing sick children? Are we allowing children to deteriorate unrecognised in our care?
  • Redefining the purpose of case note reviews – linking it to the Safe Ambition and supporting the identification of avoidable harm at a local level.
  • Develop a methodology to measure harm in paediatric wards across NHSScotland - to support local quality improvement & reduce avoidable harm
  • Feedback – quicker / more relevant / finding issues
  • Feedback – quicker / more relevant / finding issues
  • Transcript

    • 1. Safety Culture the journey inpaediatrics – so far......
    • 2. Scottish Patient Safety Paediatric Programme• Success of SPSP – adopted work streams.• SPSPP launched – June 2010• Inpatient paediatric care (all ages).• Aims: – paediatric evidence-base; – „best in class‟; – linked to measurable outcomes.• Dynamic quality improvement programme.• Relevant to paediatric hospital care delivered in Scotland.
    • 3. SPSPP Key Aim: 30% reduction in adverse events by June 2013 “Harm” – anything done you wouldn‟t like done to yourself
    • 4. Defining the problem
    • 5. Measuring Harm – Paediatric Trigger ToolAim: 30% reduction in Adverse Events (measured by PTT) by June 2013 140 120 per 1000 patient days 100 80 60 40 20 Median = 0 0
    • 6. What can we do with the data?
    • 7. Working with People 100% 80% 60% 40% 20% 0%Adapted from R Scoville, R Lloyd, IHI
    • 8. Subject Matter Experts Triggers not Liked the multi- applicable to disciplinary DGH care approach to reviews Culture shift –Adverse Events understanding „rare events‟ – of harm!how to improve Many triggers addressed by SPSPP
    • 9. What are we trying to accomplish?
    • 10. The aim.....
    • 11. Testing / Change Concepts • Methodology • Review to follow admission • Identify what causes harm / common system failures – Long-term conditions – Child Protection
    • 12. What change can we make that will result in improvement?SPSPP Avoidable Harm - Structured Case Note ReviewIs Avoidable Harm Indicator Present? y n Was there y n Was harm y n comments documentation state harm? grade preventable? missing E-IDid the child deteriorate? If yes... Failure to recognise? Highlight parental concerns not actioned. Failure to escalate? Escalation failure? Failure to adhere to standard practice or local/national guidance? Delay in administering treatment? If AVPU abnormal were full neuro obs documented? Was there an escalation of level of care, i.e. child admitted to HDU/PICU?
    • 13. How will we know a change is an improvement?
    • 14. Improvement Journey
    • 15. Cultural Shift –Adverse Events to Avoidable Harm Trigger Tool Measure Methodology „avoidable harm Harm within wards Support local quality improvement to reduce avoidable injury and harm