Is healthcare getting safer? Professor Charles Vincent - Patient safety lead, Oxford AHSN 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. Is healthcare getting safer?
Charles Vincent
Department of Psychology &
Oxford Academic Health Science Network

2. Evangelists & snails
‘Run don’t walk’
‘The correct question is whether there is a rationale for withholding critical care resources from critically ill patients outside the intensive care unit. The answer is obvious. No’
Walk, don’t run
‘In view of the limitations of the evidence and the heterogeneity of study results it seems premature to declare Rapid Response Teams as the standard of care’.
Davidoff, 2011

4. Table 4.3 Adverse events in acute hospitals in ten countries

5. Cutting error and
harm by 50%
within 5 years

6. UK National Reporting & Learning System
Hospital Episode Statistics: 11.8M
hospital admissions in England
2004/5

7. But incident
reporting only
detects 5% of
harmful events

9. Safety interventions The challenge of scaling up

10. Cumulative incidence radiologically confirmed thrombosis
Kreckler et al, 2010

11. Intensive care
Operating theatre
Major successes in focal clinical areas

12. Safer Patients Initiative
To reduce adverse events by 50% in 24 hospitals
11
 SPI programme elements 4
Improvement = shifting the level of the
process in the desirable direction (A) or
reducing variation (B)
A
A B
A B
Point of initial intervention B
Improvement = shifting the level of the
process in the desirable direction (A) or
reducing variation (B)
A
A B
A B
Point of initial intervention B
Annotated Run
Charts
80 metrics
(34 standard)
Process analysis
10
 SPI programme elements 3
Incremental
spread
Iterative
development of
local innovations
9
 SPI programme elements 2
8
 SPII programme ellementts 1
Breakthrough Series
Model
Programme model
Change elements Process measurement
QI methodology
Safer Patients Initiative
Participating hospital site
Collaborative learning
Expert support

13. SPI programme elements: Change package

14. Commentaries on patient safety in the United States five years after the publication of to key reports on patient safety in 2000 were characterised by some despair at an apparent lack of progress. Our data suggest that a more encouraging story on patient safety in the NHS can now be told
Benning et al, 2011

15. The Achievements of SPI
Inspirational and important legacy
Objectives over ambitious
Organisations in different states of readiness
First major UK safety initiative that took evaluation seriously
Simply getting basic clinical data and measures was a major challenge

16. Assessing safety interventions at population level

17. We do not know whether we are making progress or not

18. Temporal trends in rates of patient harm: |United States
Landrigan et al, NEJM 2011

19. Making Care Safer. Preventable hospital-acquired conditions would decrease by 40% compared to 2010.
This would mean 1.8 million fewer injuries to patients.
Improving Care Transitions. Preventable complications during a transition be decreased so that hospital readmissions would be reduced by 20% compared to 2010.
This would mean 1.6 million patients recovering without suffering a preventable complication requiring re- hospitalization.

21. Did Hospital Engagement Networks Actually Improve Care?
‘Weak study design and methods, combined with a lack of transparency and rigour in evaluation …’
‘These numbers appear impressive but given the publicly available data and the approach CMS used it’s nearly impossible to tell whether the PPP actually led to better care’
(Pronovost & Jha, NEJM 2014)

22. Aspiration and realism. The pace of change?

24. Measurement & Evaluation
Our major challenge will be to demonstrate change (rather than activity)
This has bedevilled all safety programmes in NHS
Measurement is therefore number 1 priority because:
–It focuses minds and priorities
–It has been the major headache for all safety programmes
–The time taken to get measures in place has been consistently underestimated
–It is essential for the programme teams to function effectively
–It is fundamental to evaluation