The Scottish Patient
Safety Programme
• Scotland at the forefront - a whole healthcare
system approach
• A strategic development priority for NHS
Scotland
• An ...
• 3.7% Harvard 1991
• 16.6% Australia 1995
• 10.8% London 2001
• 3 million bed days in UK
• £1 billion per annum in UK
• 5...
• McGlynn, et al: The quality of health care delivered to
adults in the United States. NEJM 2003; 348: 2635-
2645 (June 26...
17 years to apply 14% of
research knowledge to
patient care.
Balas EA, Boren SA. Managing clinical knowledge for
health ca...
• Launched 2007 by the CMO
• Aims to strategically improve safety for
Scotland’s hospital patients
• SPSP is the first pro...
• The Scottish Government
• NHS Scotland
• NHS QIS
• Royal Colleges and Professional bodies
• World leading experts on pat...
• Led by National Co-ordinator Jane Murkin, and the National
Co-ordinating Team, based within NHS Quality Improvement
Scot...
• Build a compelling case for change
• Work on processes and outcomes that engage hearts
& minds
• Reduce waste and redund...
Inventory national programmes and
measurements
Meet with programme leader to understand
programme intent, audience, histor...
• 15% reduction in mortality
• 30% reduction in adverse events
• Reduce healthcare associated infections
• Reduce adverse ...
• Leadership
• Critical care
• General ward
• Medicines management
• Peri-operative
Workstreams
Key objectives
Work Area Change Package Element
Critical Care Establish infrastructure
–Daily goal sheets
–Daily multi-dis...
SPSP Engine and Timeline
2 day
LS
Alignment
with national
work Support
Expert clinical faculty Site Visit
Networking event...
• Learning sessions
• National capacity and capability events
• Patient Safety Officer
• Fellowship programme
• Developing...
• Over 600 Leadership walkrounds have
now taken place throughout Scotland.
• 52 pilot wards throughout Scotland
have imple...
• Reductions in length of stay
• Reduction in complaints
• Cost benefits
• Care is given in the right place at the
right t...
“The Scottish Patient Safety Programme is without
doubt one of the most ambitious patient safety
initiatives in the world ...
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  • Site visits, technical assistance to build capability in measurement and improvement
    Virtual community – conference calls, email, listserv, monthly progress reports using web based system
  • Download our SPSP An Introduction PowerPoint

    1. 1. The Scottish Patient Safety Programme
    2. 2. • Scotland at the forefront - a whole healthcare system approach • A strategic development priority for NHS Scotland • An explicit and tested approach to improving patient safety • Build on foundations laid through audit, clinical effectiveness and clinical governance • Alignment with wider NHS QIS Patient Safety work The vision – Scotland leading the way in patient safety
    3. 3. • 3.7% Harvard 1991 • 16.6% Australia 1995 • 10.8% London 2001 • 3 million bed days in UK • £1 billion per annum in UK • 50% PREVENTABLE Adverse Events in Hospital
    4. 4. • McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635- 2645 (June 26, 2003) – 439 indicators of clinical quality of care – 30 acute and chronic conditions – Medical records for 6712 patients – Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%) • Conclusion: The Defect Rate in technical quality of American health care is approximately • 45% Reliability
    5. 5. 17 years to apply 14% of research knowledge to patient care. Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
    6. 6. • Launched 2007 by the CMO • Aims to strategically improve safety for Scotland’s hospital patients • SPSP is the first programme of work of SPSA • Brings key healthcare organisations together Scottish Patient Safety Alliance (SPSA)
    7. 7. • The Scottish Government • NHS Scotland • NHS QIS • Royal Colleges and Professional bodies • World leading experts on patient safety • Patients • NHS Education for Scotland • Health Protection Scotland Scottish Patient Safety Alliance Key Partners
    8. 8. • Led by National Co-ordinator Jane Murkin, and the National Co-ordinating Team, based within NHS Quality Improvement Scotland (NHS QIS) • Jason Leitch, National Clinical Lead for Safety & Improvement • Ros Gray, Wendy Sayan and Jane Ross, National Facilitators • Technical partner: the Institute for Healthcare Improvement (IHI) • Pat O’Connor, National Patient Safety Development Advisor • Scottish faculty • NHS boards Delivery
    9. 9. • 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 Our Theory
    10. 10. Inventory national programmes and measurements Meet with programme leader to understand programme intent, audience, history Harmonize our metrics Improve Safety of Hospital Healthcare Services in Scotland Scottish Government Sets Patient Safety as Strategic Priority Boards Accept Safety as Key Strategic Priority for Effective Governance Robust, evidence based proven clinical changes IHI/QIS Team Expert at Content, Coaching and Programme Management Align SPSP with national improvement programmes and measures Primary Drivers Demonstrable results to community Clear, shared measurement set Visible on all senior leader agenda PSA represents & demonstrates cohesive, united programme National Policy alignment Secondary Drivers Ownership of agreed upon set of outcomes Review of outcomes at each meeting Quality and safety comprises 25% of agenda Recovery plans for unmet outcomes Infrastructure supports improvement and measurement Involve patients in safety Scottish Patient Safety Programme Driver Diagram International expert clinical faculty Faculty expert at improvement methods and coaching Programme design and structure Acceptance of pragmatic science Royal College Supports PSA Programme
    11. 11. • 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 Aims
    12. 12. • Leadership • Critical care • General ward • Medicines management • Peri-operative Workstreams
    13. 13. Key objectives 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
    14. 14. SPSP Engine and Timeline 2 day LS Alignment with national work Support Expert clinical faculty Site Visit Networking events Phone conf Listserv Assessments Monthly Reports via web 2 day LS A P D S A D P S 2 day Kickoff D S P A 2 day LS Key Changes Improvement Measures Jun 08 Jun 09Jan 09Jan 08 Organisational Self Assessment Oct 07 Continued Support Jan 11
    15. 15. • Learning sessions • National capacity and capability events • Patient Safety Officer • Fellowship programme • Developing Scottish Faculty • Improvement Advisors Building a sustainable infrastructure for improvement
    16. 16. • Over 600 Leadership walkrounds have now taken place throughout Scotland. • 52 pilot wards throughout Scotland have implemented daily safety briefings as a routine part of their work. • Critical Care teams are able to demonstrate significant periods of time without central line infection in ITU. Progress so far
    17. 17. • Reductions in length of stay • Reduction in complaints • Cost benefits • Care is given in the right place at the right time and in the right way • Increased improvement capability amongst staff Benefits
    18. 18. “The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland’s health care leaders –NHS executives, QIS experts, clinical professionals, civil servants, and more – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care.” Don Berwick, IHI

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