Safety, Collaboration and
Spread Across Boundaries
Andrew Longmate
National Clinical Lead for Patient Safety
Ann Holmes
De...
♯nhsscot13
Safety is a
dynamic non
event
Our Constancy of Purpose
Person
Centred
Safe
Effective
Safe Ambition
There will be no avoidable
injury or harm to people from
healthcare they receive, and
an appropriate, clean ...
To transform the
safety of acute care
thereby improving
care and radically
reducing needless
death and harm.
Triple Aim QualityAmbitions 12 PriorityAreas for Improvement
PersonCentered PersonCentered Care
Safe Safe Care
PrimaryCare...
Extended ambition
By December 2015
•20% reduction in hospital
mortality
•95% of patients will be free
from avoidable harm ...
11.8% - 9037 less than expected deaths
NHSScotland HSMR
(up to December 2012) 0.93
0.97
Further increase safety in acute
hospitals
Reduce avoidable harm and
death
Reduce Hospital Associated
Mortality
Reduce HSM...
HAI Taskforce
By Dec 2015 95% of
people experiencing
acute care will be free
from these avoidable
harms
Scottish Patient s...
SCOTTISH PATIENT SAFETY INDICATOR
[SPSI]
• Reducing key preventable harms
• Centred on the person
• Building on and integr...
Ayrshire and Arran Pressure
Ulcer Data
Our change theory
•A clear and stretch goal
•A method
•Predictive, iterative testing
•Reliable implementation
•Doing the c...
R.A.H. – GG&C
Psychological safety: create an environment
where no one is hesitant to voice a concern and
caregivers know that they will...
Every unit in a care system, clinical or
otherwise should start the day or
procedure with a briefing or huddle.
“What are ...
Just the usual things from me…if
everyone could pay attention
during the pauses, that would be
geatly appreciated…
…and if...
Scottish Amalgamated Hospital
Postoperative Surgical Mortality
Make your own saying
Just the usual things from me…if
everyone could pay attention
during the pauses, that would be
geatly appreciated…
…and if...
HOSPITAL HUDDLE AT YORKHILL- effects on delayed ICU discharges
What motivates people ?
Autonomy
Mastery
Purpose
Some Scientific Premises
1. Most people are trying hard most of the time to do
a job they can be proud of.
2. All improvem...
Some Rules of the Road
1.The needs of the patient come
first.
2.Trust each other.
3.The key task is to learn.
4.Blame won’...
One thing
• That you have seen today or seen at the posters ?
• That you can contribute to the spread of ?
• How are you g...
Create the Conditions (J Bloor)
•Purpose
•Leadership
•Time (commitment, priority,
resilience)
•Connections to people
•Conn...
Leadership
•Topic is a key strategic initiative
•Goals and Incentives aligned
•Executive sponsor assigned
•Day-to-day mana...
What will it take ?
•Integration, integration, integration
•Winning the hearts and minds of the
staff
•Spread
•Focusing on...
Three curves
Time
Performance
Performance
Improvement
Co-production
& assets
“Systems awareness and
systems design are important
for health professionals, but
are not enough. They are
enabling mechan...
@AndyLongmate
Andrew.Longmate@scotland.gsi.gov.uk
Ann.Holmes@scotland.gsi.gov.uk
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries
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Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries

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  • Our national context. Our national aim – driven by the Scottish Patient Safety Programme and led by the Scottish Government
  • So this is our aim – OUR aim – mine and yours – a bold aim – one which, as you will hear today and tomorrow, we are not quite sure what is all means – but we can be sure that ....
  • Data from at least 9 out of 10 Boards with Data available on Extranet. Each month has an average sample size of 2949 procedures
  • We share Derek ’ s vision for the 3 rd curve – however we are here – right here – in the improvement zone and we must concentrate our will and our work and our effort in this zone – to hold the gains and to drive forward .... Is important is the AUC (area under the curve) of all three curves combined We are not jumping from one curve to the next But we are utilising the collective impact of all three curves We will never be out of or off the improvement curve This work is so important that it will never be finished.
  • Special Interest Session 1: Safety, Collaboration and Spread Across Boundaries

    1. 1. Safety, Collaboration and Spread Across Boundaries Andrew Longmate National Clinical Lead for Patient Safety Ann Holmes Deputy Chief Nursing Officer and Chief Midwife
    2. 2. ♯nhsscot13
    3. 3. Safety is a dynamic non event
    4. 4. Our Constancy of Purpose Person Centred Safe Effective
    5. 5. Safe Ambition There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times
    6. 6. To transform the safety of acute care thereby improving care and radically reducing needless death and harm.
    7. 7. Triple Aim QualityAmbitions 12 PriorityAreas for Improvement PersonCentered PersonCentered Care Safe Safe Care PrimaryCare Unscheduled and EmergencyCare Integrated Care Care for Multiple and Chronic Illnesses EarlyYears HealthInequalities Prevention Workforce Innovation Efficiencyand Productivity Effective ROUTE MAP TO THE 2020 HEALTH AND SOCIAL CARE VISION FOR SCOTLAND Healthofthe Population Value and Sustainability QualityofCare
    8. 8. Extended ambition By December 2015 •20% reduction in hospital mortality •95% of patients will be free from avoidable harm in our hospitals
    9. 9. 11.8% - 9037 less than expected deaths NHSScotland HSMR (up to December 2012) 0.93 0.97
    10. 10. Further increase safety in acute hospitals Reduce avoidable harm and death Reduce Hospital Associated Mortality Reduce HSMR by 20% 95% of people experiencing acute care free from harms in SPSI Reliable rescue MRSA C Diff VAP CRBSI SSI Prevent Hospital Associated Venous Thrombosis and Embolism Medicines Safety Insulin: out of range glucose Anticoagulants Team Working and Communication CHF Stroke Improve Management of Chronic Conditions Safety Briefings SBARWHO Checklist Sepsis MSSA Prevent HAI Palliative and end of life care at home or in a homely setting Anticipatory planning Supported discharge and decision making Primary-secondary care collaboration Prevent harms Pressure Ulcers Falls Evidence based care bundles Heart Failure, Stroke, MI, PVC, Community Acquired Pneumonia Population Health Hospital Safety Brief No missed doses E ColiCAUTI Best use of IT solutions Medicines Reconciliation High Risk Medicines Improve Flow and Demand-Capacity imbalance for unscheduled care
    11. 11. HAI Taskforce By Dec 2015 95% of people experiencing acute care will be free from these avoidable harms Scottish Patient safety Indicator SPSI
    12. 12. SCOTTISH PATIENT SAFETY INDICATOR [SPSI] • Reducing key preventable harms • Centred on the person • Building on and integrating the SPSP, LBC, HAI work • Ward based (multidisciplinary) team work • Spread improvement science, expand capability and capacity • Catalyst for true improvement work to prevent some of our more important harms, focus on some harms not yet addressed • A specific aim for SPSP
    13. 13. Ayrshire and Arran Pressure Ulcer Data
    14. 14. Our change theory •A clear and stretch goal •A method •Predictive, iterative testing •Reliable implementation •Doing the common things uncommonly well
    15. 15. R.A.H. – GG&C
    16. 16. Psychological safety: create an environment where no one is hesitant to voice a concern and caregivers know that they will be treated with respect when they do. Organisational fairness; caregivers know they are accountable for being capable, conscientious and not engaging in unsafe behaviour, but are not held accountable for systems failures. A learning system where engaged leaders hear patients’ and front line care givers’ concerns regarding defects that interfere with the delivery of safe care and promote improvements to increase safety and reduce waste.
    17. 17. Every unit in a care system, clinical or otherwise should start the day or procedure with a briefing or huddle. “What are we doing today ? Here’s what we are thinking…..Who’s here to help us ? Do we have what we need ? And what barriers or constraints are in our way ?
    18. 18. Just the usual things from me…if everyone could pay attention during the pauses, that would be geatly appreciated… …and if anyone sees anybody doing anything daft; particularly if its me; then please speak up and let them know
    19. 19. Scottish Amalgamated Hospital Postoperative Surgical Mortality
    20. 20. Make your own saying
    21. 21. Just the usual things from me…if everyone could pay attention during the pauses, that would be geatly appreciated… …and if anyone sees anybody doing anything daft; particularly if its me; then please speak up and let them know
    22. 22. HOSPITAL HUDDLE AT YORKHILL- effects on delayed ICU discharges
    23. 23. What motivates people ?
    24. 24. Autonomy Mastery Purpose
    25. 25. Some Scientific Premises 1. Most people are trying hard most of the time to do a job they can be proud of. 2. All improvement is change (though not all change is improvement). 3. Fear is an enemy of improvement. 4. All measurement systems to assess performance will eventually come under the control of the measured. 5. It is very hard to improve unless you know how you are doing. 33
    26. 26. Some Rules of the Road 1.The needs of the patient come first. 2.Trust each other. 3.The key task is to learn. 4.Blame won’t help. 34
    27. 27. One thing • That you have seen today or seen at the posters ? • That you can contribute to the spread of ? • How are you going to do it ?
    28. 28. Create the Conditions (J Bloor) •Purpose •Leadership •Time (commitment, priority, resilience) •Connections to people •Connections to information
    29. 29. Leadership •Topic is a key strategic initiative •Goals and Incentives aligned •Executive sponsor assigned •Day-to-day managers identified •Spread aim statement developed Better Ideas •Develop the case •Describe the ideas Set up •Adopter audiences •Successful sites •Structured enhancements •Key partners •Initial spread plan Knowledge management Measurement and feedback A Framework for Spread 2nd Edition the Improvement Guide Langley, Moen, Nolan, Nolan, Norman, Provost Social System Communication of awareness and technical knowledge •Key messengers •Peer-to-peer interaction •Technical support •Transition issues WILL, IDEAS, EXECUTION, INFRASTRUCTURE...
    30. 30. What will it take ? •Integration, integration, integration •Winning the hearts and minds of the staff •Spread •Focusing on improvement not targets •Leadership •Measurement that has meaning •Integration into daily work •Creating infrastructure – people, IT •Creating capability and capacity
    31. 31. Three curves Time Performance Performance Improvement Co-production & assets
    32. 32. “Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love.” Avedis Donabedian
    33. 33. @AndyLongmate Andrew.Longmate@scotland.gsi.gov.uk Ann.Holmes@scotland.gsi.gov.uk

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