The document outlines the NHS's Patient Safety Collaborative Programme from 2014-2019, aimed at improving patient care and safety by fostering continuous learning and improvement across the healthcare system. It emphasizes the importance of active participation from NHS staff, patients, and caregivers in enhancing care quality and addresses the over-prescription of psychotropic medications for individuals with learning disabilities through the Winterbourne Medicines Programme. The document also details the collaborative's operational model, objectives, and partnerships established to ensure effective medication management and safety practices.

1. Improving quality, safety
and lives -The Patient
Safety Collaborative
Programme 2014-2019
NHS Improving Quality
Chief Nursing
Officer for England’s
Summit 2014
Barbara Zutshi
26 November 2014Network

2. Responding to Francis and
Berwick
“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.”
Berwick Report, August 2013

3. For NHS staff and clinicians
• Participate actively in the improvement of systems of
care.
• Acquire the skills to do so.
• Speak up when things go wrong.
• Involve patients as active partners and co-producers
in their own care.

4. For patients and carers
• As far as you are able, become active partners in
your healthcare and always expect to be treated as
such by those providing your healthcare.
• Speak up about what you see – right and wrong.
You have extraordinarily valuable information on the
basis of which to make the NHS better.

5. Responding to Francis and
Berwick
“Following Don Berwick’s recommendation, NHS
England will establish a new Patient Safety
Collaborative Programme across England to
spread best practice, build skills and capabilities in
patient safety and improvement science, and to
focus on actions that can make the biggest
difference to patients in every part of the country.
They will be supported to systematically tackle the
leading causes of harm to patients. The
programme will start in April 2014.”
The government’s response to Francis
and Berwick, November 2013

6. Patient safety collaboratives
• AHSN footprint
• 2-5m population
• Locally owned and run
• Majority of funding devolved
to support local improvement
programme activity
• National support for;
• change packages/
interventions;
• knowledge sharing;
• consistent measurement;
• networks/communities.

7. A different kind of collaborative
• Locally driven and led
• Designed in partnership
• Provide support, co-ordination & rapid spread and
adoption
• Developing capacity & capability for QI & Safety
• Variation on traditional breakthrough model
• Far reaching, all levels, whole system

9. A Theoretical Framework

10. NHS IQ Role
• A small national supporting / coordinating function
• Developing joint approaches with partners to:
o Measurement - expert group, baseline metric
development and national aggregation
o Leadership and Culture
o Capability building
o Programme evaluation and ROI
o Partner with patients and carers
• Provide QI and change expertise nationally
• Develop programme support materials
• Do what adds value nationally - help align work, connect
and join up the dots

11. Collaboratives progress to date (1)
• 15 patient safety collaboratives established in each AHSN
across England and confirmed in July 2014
• Event held on 14th Oct 2014 to formally launch patient safety
collaboratives, supported by SoS and National Medical
Director
• Patient Safety Collaborative Programme Board established–
Chaired by Norman Williams with membership from DH,
NHS England, NHS IQ, AHSNs, NHS Leadership Academy,
‘Sign up to Safety’ campaign
• Leadership and Measurement groups being established and
developing strategies with AHSNs
• Funding devolved to AHSNs as contract uplift – recruiting
posts etc

12. Collaboratives progress to date (2)
• Local engagement with member organisations and
establishment of patient safety priorities ongoing
• AHSN’s connecting with organisations that have ‘signed up to
safety’ to ensure alignment
• Developed first stage improvement work plans for 2014/15
that have been shared across all collaboratives.
• Developing patient and carer engagement plans as a
foundation of the work
• Developing a central system that enables shared learning
and practical implementation of good practice

13. The operational model
National Patient Safety Collaborative Programme - Operational Model
Pressure Ulcers VTE
Medication
Errors HCAI Maternity Falls
AHSN
1 x x x
2 x x x
3 x x x
4 x x
5 x x
6 x x x
7 x x
8 x x
9 x x
10 x x x
11 x x x
12 x
13 x x x
14 x x
15 x x
Leadership and Measurement
NHS IQ
Accelerated
Learning Groups
Evidence
Toolkits
Social media
Campaigns
Spread

14. Cluster groups
• Primary focus: leadership and measurement
• First 5 - Medicines, Acute Kidney Injury(AKI), mental
health, pressure ulcers, deterioration & sepsis
• Groups focus on topic specific improvement
• Bringing expertise together with practical application
• Examine the evidence and guidance
• Peer support and problem solving
• Accelerate and share learning across the NHS

15. Principles:
• Build on existing pockets of excellence
• Co-produce - avoid duplication and share notable
practice and resources
• Establish ‘how’ to implement current evidence
• Test and refine new ways of working – where
evidence may be lacking
• Influence levers and drivers in the system to support
safer care
• Staff and patients – tools, skills and support
• Take & share learning, build networks e.g. SPSP
• Align with other initiatives – making safety
everyone’s business e.g. SU2S

16. 16

17. NHS England’s national patient safety plan

18. THANK YOU
Barbara.zutshi@nhsiq.nhs.uk
#saferNHS
Improving health outcomes across England
by providing improvement and change expertise.

19. Winterbourne
Medicines Programme
Carol Marley - Improvement Manager
@NHSIQ #winterbourne_meds
@ZoeLord1 @CarolMarley3
Improving health outcomes across England by providing improvement and change expertise

20. A national response to Winterbourne View Hospital
“7.31 We have heard deep concerns about over-use of
antipsychotic and antidepressant medicines.
Health professionals caring for people with learning
disabilities should assess and keep under review the
medicines requirements for each individual patient to
determine the best course of action for that patient, taking
into account the views of the person if possible and their
family and/or carer. Services should have systems and
policies in place to ensure that this is done safely and in a
timely manner and should carry out regular audits of
medication prescribing and management, involving
pharmacists, doctors and nurses.”

21. Case For Change
• It has been estimated that over 1 million people in England
(2% of the population) have a learning disability.
• The numbers known to learning disability services are much
smaller: an estimated 236,235 people.
• Between 20% and 66% of people with learning disabilities are
given psychotropic medication.
• Psychotropic medication is used to treat mental health
disorders; however the majority of people with a learning
disability who demonstrate challenging behaviour do not
have a mental health diagnosis.

22. Case For Change…
• It is often used as a form of chemical constraint for
behaviour management rather than to treat mental health
problems. Its effectiveness in addressing challenging
behaviour is questionable and there are strong arguments
for stopping (Winterbourne View – A serious Case Review)
• Studies note that the concurrent prescription of more than
one antipsychotic was associated with reduced survival.

23. Winterbourne
Medicines Programme

24. Programme Board and Reference Group
• Chaired by Dr Keith Ridge
• Family / Carers
• Department of Health
• NHS England
• NHS Improving Quality
• Royal Colleges across professions
• Care Quality Commission
• Independent sector
• Charities

25. Aim of the Winterbourne Medicines
Programme
Safe, appropriate and optimised use of medication
for people with learning disabilities whose behaviour
can challenge

27. Programme Objectives:
1. Ensure the service user is central to the work.
2. To review and develop a deep understanding of issues
around current medication processes.
3. To identify and share notable practice.
4. To identify a method of measuring change and
improvement.
5. Test new ways of working to improve process where
appropriate.
6. To improve awareness of the issues around medication.

28. Working in partnership with:
• Northumberland Tyne and Wear NHS Foundation Trust
• Cheshire and Wirral Partnership NHS Foundation Trust
• South West London and St Georges Mental Health Trust
• Sussex Partnership NHS Foundation Trust
• Hertfordshire Partnership Foundation Trust
• Devon Partnership NHS Trust

30. Community of Practice…
• 6C’s Website - www.6cs.england.nhs.uk
• Blogs
• Research Papers
• Documents & Publications
• News Articles
• Links and websites
• Forums
• Hot topics via webex!
• Quality Improvement Training

32. Ministerial Support
“I am very pleased to support the NHS Improving Quality
launch of the Winterbourne View Medicines Programme.
We know that inappropriate medication is a significant
problem across the country.
This programme through its project sites and
community of practice will help drive
improvement in safe and appropriate medication.
I look forward to seeing progress in this area.”
Norman Lamb MP, Minister of State for Care and Support

33. Message from Dominic Slowie,
National Clinical Director for Learning Disability, NHS England
“Far too many people have their behavioural problems
managed with anti-psychotics. The Learning Disability
Census highlighted that there are huge numbers of
people on anti-psychotic medication who haven’t got a
psychiatric diagnosis.
I see this as an infringement, or abuse of people’s human
rights. I am really looking forward to the findings of the
pilot in order to improve the care, and experiences of
care for people with learning disabilities.”

34. Winterbourne
Medicines Programme