NES April 2009
description
Transcript of NES April 2009
NES April 2009
Global Trigger Tool Reviews
3 Exemplar Hospitals (900 notes)
40 Bed rural Hospital (300 notes)
10 Hospital Research Project (240 notes)
7 Hospital System (3000 notes)
Multi-state Tertiary System (2000 notes)
Events/1000 Days
83 90 NA 119 86
Events/100 admissions
45 40 37 41 38
Admissions with adverse events
32% 30% 30% 29% 30%
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)
Conclusion: The “Defect Rate” in the technical quality of American health care is
approximately 45%
Jean Boal
Outcome Aims
• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days
between• Central Line Bloodstream Infection: 0 or 300 days
between• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
range• Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction
Primary Outcomes
• 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
Source:British Airways (NPSA adapted)
British Airways air safety reports, 1994-99Total reported events
Total events
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1994 1995 1996 1997 1998 1999
High/medium risk events
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Number of reported events: high and medium risk
Theory of transformation
Our Theory (Part 1)
• Build a compelling case for change• Involve patients and carers• Work on processes and outcomes that engage
the hearts and minds• Work at the coal face and at the executive level• Data feedback, data feedback, data feedback• Set the tempo!
Our Theory (Part 2)
• Changes in process and outcomes are directly connected.
• The changes beginning tested, when fully implemented, will lead to large system aims.
-Align aims and measures with national programmes -Develop a portfolio and execution model-Build connection to safety in national work-Define within clinical governance framework
Improve Safety of Healthcare Services in Scotland
Boards Endorse Safety as Key
Strategic Priority
Deliver the programme
Build a Sustainable Infrastructure for
Improvement
Align SPSP with national improvement
programmes and measures
Primary Drivers
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Secondary DriversScottish Patient Safety Alliance
(SPSA) Driver Diagram
-One Team-Develop experts in imp. methods and coaching-In-country measurement system, culture survey-Safety work migrates to appropriate agency-Training programmes developed in Scotland- Work with IST, QIS and HES to develop unified improvement approach
-Segment hospitals , customize approach-In-country support for Boards-Spread strategy community hosp., primary care-One Team -”Everyone in the tent”
Scottish Government Sets PSA as Strategic
Priority-National Board development strategy -Ownership of agreed upon set of outcomes and measures -Quality and safety comprises 25% of agenda--Development of infrastructure that supports improvement and measurement-Clear improvement aims in strategic plan
National leaders openly endorse SPSP aims, failure is not an option for execs- Time and space given for improvement (not a target)-Royal Colleges serve in official capacity-Safety is an element of all programmes
Integration
Judgement vs Improvement
Prototype and Spread
Successes from Action Period Two
No central line bloodstream infections since July
Shift
Successes from Action Period Two
Trend
Successes from Action Period Two
Trend
Shift
CRBSI (CRI 3) Monthly Incidence Sept 2005 - Aug 2008c chart
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Sept Oct Nov Dec J an Feb Mar Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar Apr May J un J ul aug
2005 2006 2007 2008
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NES?
• What is NES already doing that relates to this agenda?
• How can NES help inform those working on this agenda?
• What can NES do in addition to present activities?
Who needs to know and what do they need to know?
• Patients, carers and the public• Executives• Non-executives including chairs• Middle managers• Clinicians
– Senior– Middle grade– Trainees
• Administrators• Health professional students – Cab. Sec promise
“NHS Scotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety. The dedication of NHS leadership at all levels to this endeavor is apparent to me, and bodes
well for success. In its scale and ambition, the Scottish Patient Safety Programme marks
Scotland as leader – second to no nation on earth – in its commitment to reducing harm to
patients dramatically and continually.”
Don Berwick June 2008