mike durkin collaborative launch event oct 2014

National Patient Safety Plan

Dr Mike Durkin,

NHS England

Director of Patient Safety

14 October 2014

The Berwick legacy and journey

so far

2 www.england.nhs.uk

“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.

“We have made specific

recommendations around this point,

including the need for improve training

and education, and for NHS England to

support a network of safety

improvement collaboratives to identify

and spread safety improvement

approaches across the NHS.”

- A promise to learn– a commitment to act, August 2013

Don Berwick’s Findings (2014/15)

www.england.nhs.uk


• A unique opportunity only the NHS can bring • Led with the innovation and expertise of the

AHSNs • Largest collaborative patient safety programme

in the world • We can be stronger by learning together • A chance to build on existing success

This is our big opportunity

• To create the conditions

where the AHSNs can excel,

lead and provide a catalyst

for local improvements

• To ensure continual patient

safety learning sits at the

heart of healthcare in

England

• To create the largest and

most comprehensive

collaborative patient safety

programme in the world

Our collective ambition


Scale of the problem: reported

incidents • Each report an opportunity to learn: 68% no harm and 25% low harm

• But each report also represents actual or potential distress or harm to patients and concern from staff

NRLS Quarterly Data workbooks April 2012 – March 2013 England data: 1,353,430 incidents in total

Other

Patient abuse (by third party/staff)

Infection Control Incident

Medical device / equipment

Disruptive, aggressive behaviour

Self-harming behaviour

Consent, communication, confidentiality

Clinical assessment & diagnosis

Infrastructure

Documentation

Access, admission, transfer, discharge

Medication

Treatment, procedure

Implementation of care

Patient accident

0 50,000 100,000 150,000 200,000 250,000 300,000 350,000

Scale of the problem: death & severe

harm

19%

17%

14% 8%

6%

6%

6%

5%

9% Suicide/severe self harm

Fall (hip #/sub-dural)

Pressure ulcer grade 4

Treatment error or delay

Obstetric-specific incident

Operation/procedure related

Clinical diagnostic error/delay

Missed deterioration

Medication incident

Healthcare associated infection

Pulmonary embolus

Test results not acted on

Transfer or discharge incident

Other/unclear

NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents

Over 8,000 reported fatal or severe harm incidents each year

www.england.nhs.uk

Scale of the problem: other sources

• Around 4,400 people commit suicide each year; 27% are known to mental health services; most are known to GPs

• 4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year

• 9,500 patients with grade 2/3/4 pressure ulcers on each monthly survey

• Around 3,000 hip fractures from falls in hospitals each year identified by the National Hip Fracture database

NCISH 2014 report - HSCIC NHS OF Aug 2014 - Safety Thermometer Sept 2014 – NHFD 2014 report

Suicides - England 2002-2012

www.england.nhs.uk

Topic area Patient Safety Topic

The

‘essentials’ Leadership Measurement

NHS

Outcomes

Framework

improvement

areas

Venous

Thrombo-

embolism

Healthcare Associated Infections

Pressure Ulcers

Maternity Medication

Errors

Deterioration in

children

Other major

sources of

death and

severe harm

Falls Handover

and Discharge

Nutrition and

hydration

Acute Kidney Injury

Missed and delayed

diagnosis

Deterioration of patients

Medical Device Errors

Sepsis

Vulnerable

groups for

whom

improving

safety is a

priority

People with

Mental Health

needs

People with

Learning

Disabilities

Children Offenders Acutely ill older

people

Transition

between

paediatric and

adult care

Collaborative priorities - proposals


Building on successes and sharing

learning across organisations


A range of safety indicators included in Intelligent Monitoring to prioritise trusts for early inspection:

CQC Inspections Analysis

Note initial inspections were directed at trusts more likely to have safety concerns and so sample is skewed

Of the first 47 NHS trusts inspected by the Care Quality Commission under its new inspection regime:

• 81% ‘requiring improvement’ or ‘inadequate’ for Safety

www.england.nhs.uk

Our 2014/15 strategic plan and vision

12

Gaining a better understanding of what goes

wrong in healthcare

Enhancing the capability and capacity of the NHS to deliver patient safety improvement

Tackling key patient safety priorities

Statutory Responsibilities Mandate Objectives NHS Outcomes Framework

Keogh Review Ambitions Francis Response Berwick Report

• Improving completeness of reporting to the National Reporting and Learning System (NRLS)

• Developing a new national patient safety incident reporting system

• Developing patient safety thermometers

• Creating the first ever direct national measures of patient safety using retrospective case note review

• Developing patient safety data pages on NHS Choices Website

• Establishing the Patient Safety Collaborative programme

• Deliver programme to identify and recognise Patient Safety Fellows

• Further developing the investigations capability across the NHS

• Developing an improvement programme, including change packages, to tackle key clinical patient safety areas and vulnerable groups

• Establishing Medication Safety and Medical Device Safety Officer Network across England

Pressure Ulcers

Medication & Devices Error

Failure to Monitor children

Neonatal admissions

Anti-Microbial Resistance Imp

Mental health

Learning disabilities

Deaths and restraint whilst in custody

Acute Kidney Injury

Nutrition and Hydration

Primary Care (Increase GP reporting)

Discharge

Falls

Older People

Offender Health

Never Events

Handover

Deterioration

Sepsis

VTE

HCAI

• Specific work programmes to address:

www.england.nhs.uk

Patient Safety

’Fellows’

Patient Safety Collaboratives

A system devoted to continual

learning and improvement

NRLS

NaPSAS

Data

Transparency

Retrospective case note

review

Vulnerable groups

Vulnerable points of

care

Key types of harm

and reduce harm by 50%

SAFE team

NH

S E

ng

lan

d’s

In

teg

rate

d P

ati

en

t

Safe

ty S

tra

teg

y f

or

the N

HS

www.england.nhs.uk

VTE Risk Assessment


Numbers of patients receiving a VTE assessment: June 2010 - 45% July 2014 - 96%

What was done; • NICE Standard • CQUIN – 90% then 95% • Standard Contract

Sepsis


Estimated that that 35,000 people die from sepsis in England each year.

The reliable delivery of basic elements of sepsis care could save an estimated 11,000 lives a year and £150 million annually

NHS England sepsis programme aims to: • reduce avoidable harm and death • develop a care pathway approach • increase clinicians’ awareness of sepsis as a

medical emergency • increase patient and parent participation to

support the case for change • share best practice through the spread of

initiatives/ improvement work • make greater use of commissioning levers and

incentives

Acute Kidney Injury (AKI)


Up to 100,000 deaths in secondary care are associated with AKI ¼ to ⅓ have the potential to be prevented The AKI national programme: • Primary Care package • Secondary Care package • Measurement • Commissioning • Healthcare System Change • Public Campaign

Adios Bacteremias:

39 ICUs across 4 countries

in Latin America

17

18

Outcome measure: 56% reduction

over 12 months

Rate of CLABSI in participating Latin American ICUs

n=39

www.england.nhs.uk

The Sign up to Safety pledges • Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the

goals and plans developed locally

• Continually learn. Make organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe services are

• Honesty. Be transparent with people about progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong

• Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use

• Support. Help people to understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress

www.signuptosafety.nhs.uk

Vision • For the whole NHS to become the

safest healthcare system in the

world

Objective • 3-year shared objective to save

6,000 lives and reduce harm by

50%

Aims 1. To ensure patients get harm free care

every time, everywhere

2. To support the whole NHS to openly

and honestly tackle safety concerns

3. For local NHS organisations and

bodies to make clear commitments to

improve

Sign up to Safety campaign - LISTEN, LEARN, ACT (launched June 2014)

19

http://www.signuptosafety.nhs.uk/

NHS Patient Safety 5000

Fellowship Programme • Collaboration with the Health Foundation

• The 2013 Berwick Report recommendation:

‘organise a national system of NHS Improvement Fellowships, to recognise

the talent of staff with improvement capability and enable this to be

available to other organisations’

• The Health Foundation and NHS England are looking to develop an ambitious

initiative that will connect and support people with expertise in safety and wider

quality improvement working in health care across the UK.

• The initiative will recruit people from across the UK with advanced improvement

expertise.

• We plan to work with organisations at the forefront of safety and wider quality

improvement to develop and run this initiative.

• Developing a detailed proposal in November to launch in early 2015.


National Patient Safety Alerting

System (NaPSAS)


• A new system launched in January 2014 for

alerting the NHS to emerging patient safety

risks

• Allows for timely dissemination of relevant

safety information to providers, as well as

acting as an educational and

implementation resource

• Builds on the best elements of the former

National Patient Safety Agency (NPSA)

system

• A three-stage alerting system based on

other high risk industries such as aviation

• Continue to issue alerts via the Central

Alerting System (CAS)

• Since June 2014, NHS

Choices provides a hospital

level display of patient safety

data accessed via searching

by location or viewing all

England and using a drop

down menu to select the

safety indicators to view

• Patients and the public can

see how hospitals are

performing on key safety

indicators in one place in an

easy and accessible way

• A direct link is included to

each organisations’ staffing

data presented to their Board

on a monthly basis

22

Patient Safety Data on NHS Choices

www.england.nhs.uk

• PRISM I study: Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study

• 1000 adults who died in 2009 in 10 acute hospitals in England

• Trained medical reviewers identified problems in care contributing to death and judged if deaths were preventable, taking into account patients’ overall condition at that time

• Reviewers judged 5.2% (approx. 12,000) of deaths as having a 50% or greater chance of being preventable

• Principal problems were poor clinical monitoring, diagnostic errors, and inadequate drug or fluid management

• Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities

Background PRISM I

www.england.nhs.uk

• This research will build on the PRISM I study

• The study will involve a further 24 Trusts (2400 deaths) with a range of HSMR and SHMI scores in order to facilitate more rigorous analysis of the association between these measures and the proportion of avoidable deaths in each hospital.

• Findings will help guide as to the best method of using hospital deaths as an indicator of safety and for tracking national trends over time.

• This will pave the way for the introduction of a new national indicator for measuring avoidable deaths arising from problems in care, including providing us with a national baseline.

Background PRISM II

www.england.nhs.uk

Modelled on A&E ECIST – delivered through NHS IMAS via NHS England

The Team Senior clinicians, managers, patients and academic evaluators who have a track record in delivering safety improvement

The Task The remit and scope of the task will be determined following identification of failings in hospital safety systems. Acting on intelligence from CQC, Trust Development Authority, Monitor and Commissioners

The Process With the agreement of the Trust or TDA. Data mining, Diagnostics and Site Visit Implementation of Safety Improvement Plan Monitoring and Mentorship by “Buddy” Trust

Resources National Leadership and Coordination NHS England Support capability from Patient Safety Collaboratives, High Performing Trusts, task specific turnaround teams sponsored by Royal Colleges and Specialist Associations and International Leaders Funding trust, TDA and Commissioners

Governance CCG & Area Team, NHS England

Intensive Support—Safety Action

Force England (SAFE teams)

www.england.nhs.uk

PDSA Health – Attendance Promotion

Classroom Virginia Bravo

Plan & Do Goal: To increase attendance of preschool children from ~75% of school days to 90% of school days

Name

Month

Days missed over

the last 2 weeks

Number of days that the

child with the best

record of assistance

has missed over the last

2 weeks Reminder of

‘chronic

absenteeism’

OBESITY PREVENTION

Plan & Do Goal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms

Sugar sweetened beverages

Water consumption

UCL

LCL 0%

10%

20%

30%

40%

50%

60%

4/2

/12

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% de Ninos q Trajeron Jugo -- Centro Parvularia Percent

UCL

LCL

0

0.5

1

1.5

2

2.5

4/2

/12

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0/1

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2

N Vasos de Agua Tomados por Ninos Presentes Rate

PDSA Health – Obesity prevention Classroom Centro Parvulario

Plan & Do Goal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms

Sugar sweetened beverages

Water consumption

Professor Avedis Donabedian

www.england.nhs.uk

“Systems awareness and

systems design are important

for health professionals, but

they are not enough. They are enabling mechanisms only. It is the

ethical dimensions of individuals that

are essential to a system’s success.

Ultimately, the secret of quality is

love.”

mike durkin collaborative launch event oct 2014

Healthcare

Transcript of mike durkin collaborative launch event oct 2014