psf final showcase event 29 th september 2015

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

WELCOME

DR EMMA VAUX CEO & EXECUTIVE CHAIR

PATIENT SAFETY FEDERATION

http://www.patientsafetyfederation.nhs.uk

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

Patient Safety

Tim BensonPatient Leader, RBH

What patients want

• To feel better and do more• Excellent service

– Safe and reliable– Right every time– Not worried

• To feel as much as possible in control

Quality Culture

• Institute of Medicine– To err is human (2000)– Crossing the quality chasm (2001)

• NHS Quality Framework– Outcomes– Experience and Safety

• Listen to the patient– Most important stakeholder– Self-efficacy– Patient perceptions

Safety is not...

• Counting errors– Complaints handling– Never events– Coroner's inquests

• Inspections– CQC– Litigation – Blame culture

Deming’s 14 points

1. Constant improvement2. New philosophy (TQM)3. Cease dependence on inspection4. Stop procuring on basis of price alone5. Design in quality6. Training on the job7. Leadership is to help people do better8. Drive out fear9. Team work not demarcation10. Eliminate targets11. Pride in work for staff12. Pride in work for managers13. Vigorous education and improvement14. It is everyone’s job

– W.Edwards Deming. Out of the Crisis. MIT Press 1982

Question

• Do we need a safety measure based on patients’ perceptions?

• If so what aspects are relevant?

Thanks

Tim Bensontim.benson@r-outcomes.com

@timbenson

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

12

Zero tolerance to never events: standardise, educate and harmonise.

Tom Crawford Project Lead

13

Never events• Are a particular type of serious incident

that meet all the following criteria • They are wholly preventable, where

guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers

Ref: NHS England Patient Safety Domain

14

BackgroundDate of incident Location of incident Category Description of the incident

09-Sep-13 Theatres Surgical error Retained Guide wire

23-Sep-13 Theatres Surgical error Retained humeral protector plate

28-Jan-14 Theatres Surgical errorWrong acetabular liner (size) inserted during total hip replacement.

31-Jan-14PCEU

OphthamologySurgical error Wrong size intraocular lens

21-Mar-14Theatres

AnaestheticsSurgical error Retained guide wire

25-May-14

Theatres Surgical error Wrong site surgery

25-Jun-14 Theatres Surgical error Wrong tooth extraction

15

1. Zero tolerance to never events2. To improve attitudes limiting

safety behaviour and practice3. Culture of reporting of adverse

events 4. Reduce waste (cost of

complications, cost to patients, cost to staff)

Aim/Purpose

16

Domain 1. Safety Culture

Aim:Improving safety

culture can improve staff

behaviour and patient safety

outcomes

Aim:A good safety

culture, requires

leadership and frontline staff taking

shared responsibility

Aim:Providing learning &

information that can

contribute to an

understanding of Human Error and

prevention .

Aim: Implementation

of good practice helps to ensure safe standards of patient care

are delivered

Aim:Reporting and

learning the lessons from incidents to

ensure it will not happen

again

Aim:Patient

engagement can deliver

more appropriate

care and improved outcomes

Domain 2 Leadership

Domain 3 Promote Reporting

Domain 4.Promote Learning

Domain 5Implementing Best practice

Domain 6. Patient & staff Involvement

Safe Strategy

17

Developments and Successes 1. Published Patient Safety Newsletter detailing recent serious

incidents and lessons learned, disseminated to all staff by email and hard copies in the staff rooms.

2. Baseline assessment of theatre safety culture using the University of Texas Safety Attitudes Questionnaire .

3. Developed standing safety agenda with performance reporting against key metrics .

4. Implement the WHO patient safety curriculum and incident report scenario pilot to improve junior doctor’s awareness .

5. Developed an audit tool to assess adequacy and method of completion of WHO Surgical Safety Checklist

6. Human factors training for theatre staff7. Implemented formal briefing/debriefing tool.8. Bespoke leadership training programme for Consultant Surgeons

18

19

2.5

7.5

12.5

17.5

22.5

27.5

32.5

Days between Never Event(s) Jun 2014_Sept 2015

159 days 293 days

Domain 2 Leadership

Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014/15 Q1 2015

Rate/100 proc

1.33101851851852

1.75032547374512

1.39888632350944

1.53021187549045

1.75755584756899

1.8 2.45749202975558

2.06130370766966

1.99870214146658

1.1

1.3

1.5

1.7

1.9

2.1

2.3

2.5

RBFT Theatre Datix Rate/100 Procedures April 2013_June 2015

Target 2.0

21

Challenges and Lessons learnt

1. Team work2. Observational audit3. Achievable targets4. Pace of behavioural change5. Operational pressures for optimum theatre utilisation6. Geographical spread of operating theatres7. Clinical engagement

22

23

Contact Details: tom.crawford@royalberkshire.nhs.uk

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

Making medicines safer for patients(The Safe Medicines Pathway

Toolkit)

Patient Safety Federation Conference Sept 15

Jane Hough, Associate Director, NHS Specialist Pharmacy Service

Triss Clark, PSF Programme Director & PSF Project Manager for SMP

Safe Medicines Pathway

Content of the presentation

• Background • Aim/Purpose• Developments and Successes• Challenges & Lessons Learnt

Safe Medicines Pathway

Background to project starting • No Needless Medication Error work-stream• PSF held meetings with stakeholders • Concern raised about large number of

medication errors • Safe Medicines Pathway conceived

Safe Medicines Pathway

Aims 1. To simplify, standardise and make reliable

some of the elements of the medicines pathway: such that the likelihood of errors occurring is reduced.

2. To share work through a Web-based tool kit.

Safe Medicines Pathway

Purpose of the Project• To understand the processes undertaken when

information about patient’s medicines and the medicines themselves enter and leave the system.

• To test changes to the system in one organisation

• To work with other organisations in the PSF geography to test tools developed

• To share the experiences, learning and tools through a web-based tool-kit

Safe Medicines Pathway

Who is responsible for writing up the Drugs

Clarity of Drugs

Charts

Timing of LTC Meds being written up

Portering Collection

and Distribution

Portering Collection

and Distribution

Use or Not of PODs

Lockers

Use or Not of PODs

Lockers

• Themes

LTC Medicati

on Omitted

Medication Omitted at Initial

Visit

Loss of Medication

Delays in the writing

of TTO’s

Single Storage space for all

Medication on

the Wards

Safe Medicines Pathway

Duplication of Medication

Duplication of Medication

Lack of Consistency in the use of technology i.e. iPADS

New meds only given in certain departments

Delay in Writing TTO’s Condition

of Patient on admission Communication

with GP’s/Community

Pharmacists

Communication with

GP’s/Community Pharmacists

Story Board

No one had told her, she had started on new Medication

No one had told her, she had started on new Medication

Patient/family sometimes return to collect meds

Patient/family sometimes return to collect meds

??

Some patients unaware of the medication they are taking

Some patients unaware of the medication they are taking

Looked after his own meds at home. Did not need additional medication – had more supplies at home

Looked after his own meds at home. Did not need additional medication – had more supplies at home

Patients eye drops not charted throughout stay. Lost somewhere along the pathway

Patients eye drops not charted throughout stay. Lost somewhere along the pathway

She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge

She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge

Pt sent home without own meds; meds thrown out by Nursing Staff

Pt sent home without own meds; meds thrown out by Nursing Staff

Safe Medicines Pathway

Developments and Successes • Data collection tools • Interventions across prescribers, nursing

and pharmacy• Patient involvement • Working with an FY2• Improvement in medicines reconciliation • DART campaign (prescribing)• SMP Website

Safe Medicines Pathway

Interventions

Summary Safe Medicines Pathway proposed projects

Patient history

taken, including

medication

Diagnosis made

and medicines

prescribed

Medicines

sourced

Medicines given Discharge Admission

Pharm

Nurse

Dr Nurse Dr

Dr Pharm Nurse Nurse Pharm

Nurse

Dr

Projects:

Prescribing of high and low risk medicines when a patient

is admitted to hospital and appropriate documentation.

Prescribing Accuracy Audit (legality and legibility).

Audit based on the EQUIP study looking at prescribing

accuracy and high risk medicine prescribing.

Allocation of function tool – medicines reconciliation

Review of pharmacist medicines reconciliation

Projects:

Observational audit on delayed and omitted doses.

Critical decision making tool

Projects:

Information forms part

of project 1. Other

aspects – discharge

group.

Aim: Improve safety of prescribing for patients and reduce risk of harm caused by medication errors relating to medicines reconciliation – Better communication between healthcare professionals and others involved in the transfer of patient care.

Aim: Reduction in number and severity of prescribing errors in particular in relation to high risk medicines (higher potential for serious patient harm).

Aim: Reduction of delays in medication being available on the ward for timely administration to the patient.

Aim: Improve patient safety through timely administration of the correct medicine, particularly in relation to medicines which are considered “time critical”

Aim: Reduce errors relating to patient discharge (including unintentional changes) from the inpatient care setting and prevention of patient harm in relation through accurate communication at discharge.

Project 1:

Medicines

Reconciliation

Project 2:

Prescribing

accuracy

Project 3:

Medicines

provision to the

ward

Project 4:

Timely

administering of

medicines

Project 5:

Improving

communication to

GP at Discharge

Safe Medicines Pathway

Challenges and Lessons learnt • Team/Timescales • Releasing staff and running a project on

top of “day job”• Complexity of the pathways • Engagement and clarity of purpose • Impact of the introduction of EPR

Safe Medicines Pathway

Purposeful Observation

• People do not always do what they say they do

• People do not always do what they think they do

• People do not always do what you think they do

• People cannot always tell you what they need

• Things are not always as they seem …….

(adapted from IDEO)

Safe Medicines Pathway

Thank you!Contact Details

PSF Project Manager for SMP – Triss ClarkTriss.Clark@nhs.net Tel 01865 221557

Project Lead - Jane Houghjane.hough4@nhs.net

Safety/Improvement Expert – Dr Clare Crowley Clare.Crowley@ouh.nhs.uk Tel 01865 857879

Safe Medicines Pathway

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

Improving Safety & Quality of Antimicrobial Prescribing in

Berkshire HFT

Kiran Hewitt, Lead Clinical Pharmacist (Project Lead)

Jenny Perry, Senior Pharmacist (Project Manager)

Background (1)

UK 5 year antimicrobial resistance strategy 2013-187 key areas for action, including

optimising prescribing practice, improving IC, improving education and training

ESPAUR PMs commission on ABR by the

Wellcome Trust EAAD 18th November

Background (2)Between 2010 and 2013:

Antibiotic use by 6%general practice prescribing by

4%prescribing to hospital inpatients

by 12%other community prescriptions

(dentists, out of hours prescribers, nurses, NMPs) by 32%

Audit Standards & Results Criteria Audit Criteria – Standards = 100% Findings

1 Relevant cultures will be taken before antimicrobial therapy is started 49%

2 Drug allergies (antimicrobials) will be noted on the chart 74%

3 Route of administration will be indicated on the chart 98%

4 Dose and frequency will be indicated on the chart 97%

5 The antimicrobial start date will be noted on the chart 85%

6 The duration will be noted on the drug chart 77%

7 Indication will be noted on the chart 47%

8 Treatment will be in line with trust guidelines 83%

Aims • Leadership role (pharmacist) to drive stewardship across the

Trust• Better access to guidelines – to support remote working • Training and better education of prescribers - main focus of

action plan and internal self assessment • Use of technology to enhance the deliver of these• Networking and regional collaboration with subject experts

– Membership of TVWAPN (sub group of Chief Pharmacists group)• Guidelines review in collaboration with both local hospitals

• PSF bid April 2014

Developments (1)• Recruitment of Project

Manager Sept-14• Purchase, training and

development of Microguide smartphone app– Sept to Nov-14

• Key Benefits:

Developments (2)• Initial Promotion

– EAAD launch • Face to face intro for all ward staff

– Presentation of audit findings, App demo, posters, Start Smart Then Focus reminder cards

Developments (3)• Trust-wide Publicity:

– Annual Quality Improvement Event – first prize winner (Nov-14)

– IC Link Practitioners annual study day (Nov-14)– Trust Best Practice and Innovation Event (Feb-15)

S1 S2 S3 S4 S5 S6 S7 S80

20

40

60

80

100

120

Nov-13

Feb-15

Developments (4)• E-learning package introduction • Original plan – regional module to utilise

local and regional expertise = best option• Delayed launch

– Options appraisal for alternatives– Bespoke Trust package developed – Feb-15

• Essential training requirement agreed– for medical and nursing staff groups, pharmacy– Managed through L&D

• User group feedback prior to launch• Added to medical trainee induction • “Start Smart Then Focus” and App posters on

wards• GP and Out of Hours GP presentation – May-15

Successes (1)

Targetted training for GPs PDSA 3

e-learning module formally implemented PDSA 5

Targetting S1 on WBCH PDSA 4

Three training sessions for all ward staff on WBCH PDSA 1a)

Training roll out on Rose ward PDSA 1b)

Display StartSmart Poster PDSA 2

Nationally - • NICE Guidelines NG15 – AMS: systems and

processes for effective antimicrobial medicine use– August 2015

• Baseline audit of compliance = 41%– Establish key areas of improvement

• formal approval of AMS programme• AM team development• AM Pharmacist • Better communication across care settings• Robust documentation of Rx decisions

Challenges • Trust wide roll out – Oct-15 for all CHS wards, Dec-15 for MH • Audit of other non-inpatient areas?• Improvements over time – sustainability? Champion/lead needed• E-learning for local GPs and sharing with others• CCG engagement for primary care

– Regional group membership already established (TV&WAPN)– – MUS conference

• Work with local acute trusts – Own agenda– Internal influence and Board approval – Expanding boundaries in the East

• Sharing our “package” with the TV&W group – Already the experts!

Lessons Learnt• What would we have achieved without PSF support?• A lot can be achieved with commitment• Sufficient project management time is essential.• QI experience important.• Does it make a difference to patient care?

– yes • Future area for research• Applicable to all – yes

Contact Details

Kiran.hewitt@berkshire.nhs.uk Jenny.perry@berkshire.nhs.uk

0118 960 5075

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

Is avoidable mortality a good measure of the quality of

healthcare?

Dr Helen Hogan Clinical Senior Lecturer in Public HealthLondon School of Hygiene and Tropical

Medicine

Outline

• What drives interest in avoidable mortality

• Problems with use as a measure of hospital quality

• Approaches to measurement and what we have learned

• Local and national developments

• The future

Why it matters?

Limitations of avoidable deaths a measure of quality

Measuring avoidable death using population-level data

• HSMR/ SHMI/ RAMI• Coded adverse events linked to death• Known avoidable harms linked to death• Patient Safety Indicators• Prospective surveillance systems

Measuring avoidable deaths at patient level

What have we learnt so far

• Preventable Incidents Survival and Mortality studies (PRISM) 1 and 2

(co-applicants Nick Black, Frances Healy, Graham Neale, Richard Thomson, Charles Vincent, Ara Darzi)

• Association between avoidable deaths (RCRR) and excess deaths (hospital-wide mortality ratios)

PRISM 1 Study

• 2010/2011• Aims:

– estimate proportion of avoidable hospital deaths– identify ‘problems in care’ and contributory factors – estimate years of life lost

• Method:– RCRR (1000 adult deaths across 10 acute Trusts in

England)– Trained, retired doctors with standard form

Findings• 75% good or excellent care• 11.3% ‘problem in care’ contributing to

death• 5.2% deaths probably avoidable

– range 3% - 8% (low variation between Trusts)– estimate 11,859 avoidable adult deaths/year in

England NHS

• Life expectancy of avoidable death patients– 60% patients had life expectancy less than 12 months

• Inter-rater reliability Kappa 0.49

Problems in care identified in cases of preventable deathStage of patient journey

Types of problem identified

Preadmission Poor monitoring of warfarinDelays in admission for hospital procedureContraindicated drug prescribed in outpatients

Early in admission

Failure to diagnoseDelayed diagnosisWrong diagnosisFailure to identify the severity of underlying conditions and risks posed by the chosen therapeutic approach Failure to optimise preoperative state

Care during a procedure

Procedure conducted in inappropriate environmentTechnical error

Post procedure Inadequate monitoring (fluid balance, infection)Poor assessment

Ward care Inadequate monitoring of overall condition, fluid balance, laboratory tests, side effects of medications (especially warfarin), pressure areas and infectionUnsafe mobilisation leading to serious fallsHospital acquired infectionPrescription of contraindicated drugDelay in undertaking required procedure

PRISM 2 Study• Based on recommendations emerging from the

Keogh review

• Relationship between ‘excess mortality rates’ and actual ‘avoidable deaths’

• Findings to support introduction of a new national outcome framework “hospital deaths attributable to problems in care” and systematic approach to local mortality review

PRISM 2 Study• 2014/2015• Extend PRISM 1 to further 24 Trusts• Similar method to permit analyses of combined

data from both studies (n=3,400 records)• Random sample of Trusts across 4 strata of HSMR• Trained reviewers (70% current consultants, 30%

retired)• Linear regression to determine the percentage

increase in avoidable death proportion for a 10 point increase in HSMR/SHMI

Findings• 78% good or excellent care• 9.4% ‘problem in care’ contributing to

death• 3.0% deaths probably avoidable

– range 0% - 9% (low variation between Trusts persists)

• Inter-rater reliability Kappa 0.35

Combined Findings

• 3.6% probably avoidable• no statistical significant association between

hospital SMRs and the proportion of avoidable deaths

The future

• Local Mortality Review– Standardised self-assessment will ensure robust process

• National approach to training and materials• Electronic database/ NRLS• All deaths screened, high risk cases selected for in-depth• Multidisciplinary process

• National Tracking of Outcome Indicator• Random sample of NHS deaths • National panel of trained reviewers (multi-disciplinary)• Multiple reviewers per record

• Timetable: Invitation to tender via HQIP– http://hqip.org.uk/tenders/rcrr%20tender%202015/

The future• Direct comparison of Trusts based on avoidable X

deaths

• Develop notional avoidable death proportions ??• Use a coherent set of indicators known to be

associated with quality e.g. hospital acquired infections and measure as robustly as possible

• Develop indicators that reflect integrated care/ quality of care across health systems

Thank you

helen.hogan@lshtm.ac.uk

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk

Passing the Baton

29/09/15

Geoff Cooper – Patient Safety Collaborative Manager

Wessex Patient Safety Collaborative

Patient Safety Federation

Wessex and Oxford PSCs

Wessex and Oxford Patient Safety Collaboratives are part of a network of 15 Collaboratives established in 2014 by NHSE to tackle the leading causes of avoidable harm to patients.

The collaboratives aim to empower local patients and healthcare staff to work together to identify safety priorities and develop solutions.

These solutions will then be implemented and tested within local healthcare organisations before being shared nationally with the other collaboratives.

Patient Safety Federation

Patient Safety Federation

Collaboratives and Clusters

Patient Safety Federation Wessex PSC National Cluster

Sepsis (NW Coast)

Global Comparators (Sepsis)

Safe Medicines Pathway * (Meds Opt) (Wessex)

Anti-microbial prescribing * (Meds Opt (Wessex)

Local Priorities / Breakthrough Series

Wessex PSC Work Streams /Programme Model

Passing the Baton (Wessex)Patient Safety Federation

Wessex Patient Safety Collaborative

Safe Medicines Pathway

• Pharmacy and Transfer of care around medicines projects - Wessex AHSN Medicines Optimisation Programme

Anti-microbial prescribing

• Work programme being led by the Thames Valley and Wessex Antimicrobial Pharmacists Network

Sepsis • Dr Matt Inada-Kim (WPSC Faculty) working for PSF and WPSC• This programme will remain within organisations with Wessex PSC facilitation via

the current BTS Collaborative which includes teams from:• Dorset County Hospital NHS Foundation Trust• Dorset Healthcare University NHS Foundation Trust• Hampshire Hospitals NHS FT• NHS Dorset Clinical Commissioning Group• NHS West Hampshire Clinical Commissioning Group• Poole Hospital NHS Foundation Trust• Portsmouth Hospitals NHS Trust• The Royal Bournemouth & Christchurch Hospital NHS FT• Salisbury NHS Foundation Trust• Southern Health NHS Foundation Trust• South Central Ambulance Service NHS Foundation Trust• Wessex Paediatric Critical Care Network• University Hospital Southampton NHS Foundation Trust

PSF FINAL SHOWCASE EVENT

29TH SEPTEMBER 2015

http://www.patientsafetyfederation.nhs.uk