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Patient safety strategies and measures at several levels

Berit AxelssonPeter Kammerlind

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Content

• Patient Safety

• Safe Health Care - every time, all the time

• Measurements – Macro– Micro

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High risk worksites

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What is Patient Safety?

According to the new Patient Safety Law:• The definition of an adverse event is

suffering, physical or mental harm or illness and death that was avoidable if adequative steps had been done for the patient. An adverse event that is permanent or that have caused an considerable amount of care or have caused death is defined as a seriousharm.

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A measure of Adverse events

• 2000 records was rewied2003 - 2004

• Only Hospital care• Specialtrained nurses and

doctors rewied the records

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How often happens adverse events?

USA 3,2–5,4%

Australia 10,6–16,6%

UK 11,7%

Denmark 9%

New Zealand 12,9%

Canada 7,5%

Japan 11%

Sweden 8,6%

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If we translate it to Jönköping County Council…..

(We have approximately 3,6% of the Swedish Population)

• We have almost 360 patients with a adverseevent

• Almost 100 patients diesJönköping

Höglandet

Värnamo

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Did someone react?

• The Newspapers wrote about it, one or two days, but it was never a Headline.

• The patients didn't …..hear about it.

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Somebody cared….

GovernmentSKLThe Swedish Association of LocalAuthorities and Regions (SALAR).

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Patientsäkerhetsutredningen

Patient Safety Law(2010:659)

From 2011-01-01

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The Caregivers responsibility• Implement systematic Patient Safety Works and work preventative.

• They have an obligation to analyse adverse events

• They must inform patients and relatives as soon as possible due to harm. They shall also inform what they have done to prevent the same thing to happen again.

• The Patient and the relatives should be a part of the Patient Safety work

Ny patientsäkerhetslag

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If something happens

• An report goes to The National Board of Health and Welfare (Socialstyrelsen) and they investigate the adverse event• If necessary The National Board of Health and Welfare criticizes the Clinic. • The National Board of Health and Welfare leave the report to HSAN (The Committee of responsibility in Health Care) with a request about disciplinary arrangement.• HSAN acquit or give judgement.

Ny patientsäkerhetslag

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Penalty• Warnings and reminders are gone.• Period of probation is to be used more often. A plan must be set by the Clinic together with the National Board of Health and Welfare.• HSANs decision can be appealed against.• … but not the decision made by the National Board of Health and Welfare

Ny patientsäkerhetslag

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The Swedish Association of LocalAuthorities and Regions (SALAR).

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Följsamhet Basala Hygienrutiner och Rätt kläddLandstinget, sjukhusen 2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010

janu

ari

febru

ari

mars

april maj jun

ijul

i

augu

sti

septe

mber

oktob

er

nove

mber

dece

mber

Tidsperiod

Procent

Basala hygienrutiner

Rätt klädd

Målvärde

Fundamental demands 2011 Indicator Pay for performance 2011

Patient Safety story

Local group for STRAMA

NPÖ (Give access to records)

National survey for patients (Primary Care Centres)

Use of Antibiotic

Survey Patient Safety culture

Pressure ulcer

Handhygien and clothes rules

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V a l u e f o r p a t i e n t i n c r e a s e s

AccessHow we receive

Coopera-tion/flow

Clinical improvement

work

Patient safety

Medication

Learning and innovation

Good finances

Reliability

Strategic Improvement Areas

PreventionSelfcare

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Klicka här för att ändra format på bakgrundsrubriken

• Klicka här för att ändra format påbakgrundstexten– Nivå två

• Nivå tre– Nivå fyra

» Nivå fem

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Vision Patient Safety

Create conditions to make it right from the beginning

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2009 2010 2011Patient Safety programme

Synergi – incident reportingsystem

Survey – Patient Safety culture

MeasurementADEAE - GTT

Safe Health Care – every time, all the time

Care Related Infection in the region

Care Prevention

Patient Safety and Medication for Children

Root Cause Analysis 7Root Cause Analysis 8

Riskanalysis FMEA 7Riskanalysis FMEA 8

Leading for Patient Safety, National, number 6

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Risk an

d Safe

ty whe

el

Risk an

d roo

t cau

sean

alysis

Lead

ership

for P

atien

t Safe

ty

Better

use of

medici

ne

HSMRMortalityAE - Glober Trigger ToolADE

ReadmissionInfections”Senior Alert”Costs per capita

Safer Health Care – every time, all the time

Areas

Measures

Meetingsand methodsOpe

n acc

ess

Nation

al Qua

lityreg

ister

Measu

remen

tsfor

manag

emen

ts

Lead

ership

progra

mmetIT - su

pport

The P

atien

tens c

ompla

ins

Driver Diagram Patient Safety

Aim: Safe Health Care All The Time

Primary drivers Secondary drivers

Reliability

Standardize work routines

Skill training

Use Checklist

Competenceand Skills

Adaptability

Awareness of the currentsituation

Decrease variation

LearningOrganisation

Incident reporting system

Patient involvement

Improvement work

Measurements

The process of patient

Microsystem

Patient Safety Culture

Motivation, action, follow up and feedbackLeadershipChallenge

Access

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Prevent Central Line infection

• A forum for people with great knowledge of central lines from different places in the county

( from microsystem level)The goal is to work safe and in the same way with central line in the whole county.

• Checklist• Education

– A movie for education– Skill center- Metodikum

• Information to the patient

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Reduce Surgical Complications

• Following WHO´s Surgical checklist• Checklist

– Before operation– Preparation at the operationroom– Time Out– Conclusion

• At all hospitals• Pay for performance

– > 80% = 100% – 70-80% = 50%

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Reduce MRB infections

• Risk assessment (Checklist)– Visit in another country– Infected wounds

• Screening – samples• Compliance to guidelines of Hand hygiene

and Clothes– Pay for performance

• >85% = 100% • 80-85% = 50% • < 80 % = 0%

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Measurement for management

• Broad - two or more Perspectives/ dimensions• Depth – links• Time - dynamic• Visualization – dashboard• Improvements – PDSA cycles

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Macro level

Meso level

Microsystem

Process measure Outcome measure

Measurement for management

Time?Visualization?

Depth

Broad

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Macro level

Meso level

Microsystem

Process measure Outcome measure

Compliance relevant bundles

Compliance bundle 1Compliance bundle 2…Compliance bundle 14

Health Care RelatedInfectionsOutcome measures Area 1Outcome measures Area 2…Outcome measures Area 14

Adverse EventsAdverse Drug EventsRaw MortalityHealth Care RelatedInfections

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Driver Diagram: Safe Health Care

Aim: Safe Health CareEvery time, all the time

Primary Drivers

Compliance bundle Prevent ADE and harm from High Alert Medications

Secondary Drivers

Avoid Health Care

Associated Infections

Compliance Hand Hygiene and Dress Code

Compliance bundle Prevent Pressure Ulcer and Falls

Compliance bundle 4, 5, 6, 10 and 13

Avoid Adverse Drug Events

Avoid Falls and Pressure Ulcer

Reliable Cardiac Care

Compliance bundle Evidence Based Care for AMI and CHF

Compliance bundle Get the Boards on Board

Compliance bundle Develop Rapid Response Team

Leadership

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Driver Diagram: Safe Health Care

Aim: Safe Health CareEvery time, all the time

Outcome Measure:AE per 1000 patient days

Primary Drivers

Compliance bundle Prevent ADE and harm from High Alert Medications

Secondary Drivers

Avoid Health Care

Associated Infections

Compliance Hand Hygiene and Dress Code

Compliance bundle Prevent Pressure Ulcer and Falls

Compliance bundle 4, 5, 6, 10 and 13

Avoid Adverse Drug Events

Avoid Falls and Pressure Ulcer

Reliable Cardiac Care

Compliance bundle Evidence Based Care for AMI and CHF

Compliance bundle Get the Boards on Board

Compliance bundle Develop Rapid Response Team

ADE rate

% of patients that falls/ % of patients with Pressure Ulcer

% of patients with Health Care Associated Infections

Leadership

% of patients treatedaccording to bundle 13

% of staff following bundle for hand hygiene

% of patients being risk assessed

0

10

20

30

40

50

60

70

80

90

100

sep-08

okt-08

nov-08

dec-08

jan-09

feb-09

mar-09

apr-09

maj-09

jun-09

jul-09

aug-09

sep-09

okt-09

nov-09

dec-09

jan-10

feb-10

mar-10

apr-10

maj-10

jun-10

jul-10

aug-10

sep-10

okt-10

nov-10

dec-10%

Jönköpings sjukvårdsområde Höglandets sjukvårdsområde Värnamo sjukvårdsområde Folktandvård Målvärde

Outcome Process Measure

Driver Diagram January 2011 (uppdated 110208)Följsamhet till riktlinjer basala hygienrutinerPunktprevalensmätning Vårdrelaterade rutiner (PPM VRI) Följsamhet Område 3 Förebygg läkemedelsfel vid

vårdens övergångar. Mål:100 procent

Förebyggande bedömning på operationsenhetVårdprevention – Riskbedömning av fall, nutrition och trycksår

Patientskador per vårddagar (AE) - Landstinget i Jönköpings länGenomsnitt 18 patientskador per 1000 vårddagar

0

10

20

30

40

50

60

70

80

90

100

Oktober 2008 April 2009 Oktober 2009 April 2010 Oktober 2010

Proc

ent

Jönköpings Sjukvårdsområde Höglandets Sjukvårdsområde Värnamo Sjukvårdsområde Mål

0%

50%

100%

jan-09

feb-09

mar-09

apr-09

maj-09

jun-09

jul-09

aug-09

sep-09

okt-09

nov-09

dec-09

jan-10

feb-10

mar-10

apr-10

maj-10

jun-10

jul-10

aug-10

sep-10

okt-10

nov-10

dec-10A

ndel

(%)

Jönköpings sjukvårdsområde Höglandets sjukvårdsområde

Värnamo sjukvårdsområde Mål

Mål: Säker Vårdalla gånger

Övergripanderesultatmått:

Antal patientskadorper 1000 patientdygn

Primära drivkrafter

Följsamhet område 3 och 7

Sekundära drivkrafter

Undvik Vårdrelaterade infektioner

Följsamhet Basala Hygienrutiner och Rätt Klädd

Följsamhet område 9 och 14

Följsamhet område 4, 5, 6, 8, 10 och 13

Undvik LäkemedelsrelpatientskadorUndvik Fall och trycksår

Tillförlitlig Hjärtsjukvård Följsamhet område 2 och 11

Följsamhet omr 12

Följsamhet omr 1

Stödjande ledarskap

0

5

10

15

20

Maj 2008 November 2008 April 2009 November 2009 April 2010 November 2010

Proc

ent

Höglandets Sjukvårdsområde Jönköpings SjukvårdsområdeVärnamo Sjukvårdsområde Mål

0%

50%

100%

jan-

10

feb-

10

mar

-10

apr-1

0

maj

-10

jun-

10

jul-1

0

aug-

10

sep-

10

okt-1

0

nov-

10

dec-

10

%

Höglandets sjukvårdsområde på op enhet Jönköpings sjukvårdsområde på op enhetVärnamo sjukvårdsområde på op enhet Mål

Följsamhet riktlinjer ”KAD bara när det behövs”

0

10

20

30

40

50

60

70

80

90

100

janu

ari

febr

uari

mar

s

april

maj

juni juli

augu

sti

sept

embe

r

okto

ber

nove

mbe

r

dece

mbe

r

janu

ari

febr

uari

mar

s

april

maj

juni juli

augu

sti

sept

embe

r

okto

ber

nove

mbe

r

dece

mbe

r

n=6 n=4 n=8 n=7 n=12 n=8 n=6 n=8 n=15 n=14 n=11 n=15 n=18 n=16 n=19 n=25 n=26 n=20 n=16 n=18 n=24 n=28 n=28 n=20

Månad 2009-2010 (n=antal mätande enheter)

Proc

entu

ell a

ndel

Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde

Månad

AD

E pe

r do

s

okt

aug

jun

apr

febdec

okt

aug

jun

apr

febdec

okt

aug

jun

apr

febdec

okt

aug

jun

apr

febdec

o ktaug

jun

apr

febdec

oktaug

jun

apr

febdec

oktaug

jun

apr

febdec

oktaug

jun

0,006

0,005

0,004

0,003

0,002

0,001

0,000

_U=0,003358

UCL=0,005876

LCL=0,000840

2003 2004 2005 2006 2007 2008 2009 20101

11

11

Tests performed with unequal sample sizes

Läkemedelsrelaterade patientskador (ADE), genomsnitt 3,4 ADE per 1000 doser

AE

ADE

Health Care AssociatedInfections

Preventative Care

Hand Hygiene

WHO Checklist

Indwelling urethral catheter (IUC)

Medication errors

Macro

0

5

10

15

20

25

30

35

40

2008 Tertial 1 Tertial 2 Tertial 3 2009 Tertial 1 Tertial 2 Tertial 3 2010 Tertial 1 Tertial 2

Patie

ntsk

ador

per

tuse

n vå

rdda

gar

Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde Landstinget

17

0

5

10

15

20

Maj 2008 November 2008 April 2009 November 2009 April 2010 November 2010

Proc

ent

Höglandets Sjukvårdsområde Jönköpings SjukvårdsområdeVärnamo Sjukvårdsområde Mål

Följsamhet till riktlinjer, basala hygienrutinerMål 100

0%

25%

50%

75%

100%

jan-10

feb-10

mar-10

apr-10

maj-10

jun-10

jul-10 aug-10

sep-10

okt-10

nov-10

dec-10

%

*Följsamhet till riktlinjer, basala hygienrutiner

Vårdprevention, riskbedömning av fall, nutrition och trycksårMål 80 %

0%

25%

50%

75%

100%

jan-10

feb-10

mar-10

apr-10

maj-10

jun-10

jul-10 aug-10

sep-10

okt-10

nov-10

dec-10

%

* Vårdprevention, riskbedömning av fall, nutrition och trycksår

Outcome Process Measure

An idea of a microsystem dashboard

Mål: Säker Vårdalla gånger

Övergripanderesultatmått:

Antal patientskadorper 1000 patientdygn

Primära drivkrafter

Följsamhet område 3 och 7

Sekundära drivkrafter

Undvik Vårdrelaterade infektioner

Följsamhet Basala Hygienrutiner och Rätt Klädd

Följsamhet område 9 och 14

Följsamhet område 4, 5, 6, 8, 10 och 13

Undvik LäkemedelsrelpatientskadorUndvik Fall och trycksår

Tillförlitlig Hjärtsjukvård Följsamhet område 2 och 11

Följsamhet omr 12

Följsamhet omr 1

Stödjande ledarskap

Health Care AssociatedInfections

Preventative Care

Hand Hygiene and Dress Code

Indwelling urethral catheter (IUC)

Medication errors

Micro

Central Line Associated infections

M å l : 1 0 0 %

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

O k t o b e r 2 0 0 8 J a n u a r i 2 0 0 9 A p r i l 2 0 0 9 O k t o b e r 2 0 0 9 A p r i l 2 0 1 0 O k t o b e r 2 0

Proc

ent

0102030405060708090

100

april jun

iau

g okt dec feb april jun

ise

ptnov jan mars

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1:a mätning 2:a mätning 3:e mätning 4:e mätning

Förebyggande bedömningar i samband med operation100 %

0%

25%

50%

75%

100%

*Förebyggande bedömningar i samband med operation- på avd (före op)

apr-10 aug-10 dec-10

WHO Checklist

0%

5%

10%

15%

20%

25%

CVK KRI CVK Kontamination

Ant

al

Central Lines Associated infections