National Patient Safety Programme

1. National Patient Safety Programme Jane Murkin - National Coordinator and Jason Leitch National Clinical Lead

2. Adverse Events in Hospital • 3.7% Harvard 1991 • 16.6% Australia 1995 • 10.8% London 2001 • 3 million bed days in UK • £1 billion per annum in UK • 50% PREVENTABLE

4. Reliability in Healthcare • Healthcare is a high hazard industry • Approx 10% ( 900,000 ) patients admitted to hospital experience an incident. • 72,000 of these incidents / adverse events contribute to the death of patients • Many go unrecognised

5. Patient Safety – A Global Issue

6. Current Reliability • Good people working hard will not be able to overcome the complexities of today’s systems of care to prevent errors • Studies show that human beings make errors • Misreading errors 3 in 1000 • Omission in the absence of reminders 1 in 100 (BMJ March 18 2005 Tom Nolan) • NCEPOD report on critical care (May 2005) shows: • 27% of hospitals have no early warning system • 44% of hospitals have no outreach • 66% of admissions to ICU were unstable for >12hrs (in hospital >24hrs) • 25% were not reviewed by consultant intensivist in first 12 hrs • In ICU frequent deficiencies in care: less than good in 47% • Deficiencies in care may have contributed to death in 11% (National Confidential Enquiry into Perioperative Death) • Consensus across many studies that

7. A Major Study of Reliability in American Health Care… • McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) • 439 indicators of clinical quality of care • 30 acute and chronic conditions • Medical records for 6712 patients • Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%) • Conclusion: The Defect Rate in technical quality of American health care is approximately • 45%

8. NHS QIS • established January 2003 by the Scottish Parliament • merger of six quality improvement organisations • special health board - independent in its advice, assessments and recommendations

9. Scottish Patient Safety Alliance- Key Partners • Scottish Government • NHS Scotland • QIS • Royal Colleges and Professional bodies • World leading experts on patient safety • Patients • NHS Education

10. The vision – Scotland leading the way in Patient Safety • Scotland at the forefront - a whole healthcare system approach • A strategic development priority for NHS Scotland • An explicit and tested approach to improving patient safety • Build on foundations laid through audit, clinical effectiveness and clinical governance • Alignment with wider NHS QIS Patient Safety work

11. Key Aims • Build on what's already been achieved • Tried and tested interventions • Improve safety and reliability of boards and a safety focused culture • Capacity and capability for improvement methodology • Spread and sustainability

12. How will we do this? • National approach – Advisory board CMO • National steering group • National Team / Clinical Lead • IHI • National learning sessions / site visits • Regional support • Evidence based interventions • Outputs from SPI 1 & 2

13. Outcome Aims • Reduce healthcare associated infections • Reduce adverse surgical incidents • Reduce adverse drug events • Improve critical care outcomes • Improve the organisational and leadership culture on safety • Reduce mortality by 15% in 3 years • Reduce adverse events by 30% in 3 years

14. Associated benefits • Reductions in length of stay • Reduction in complaints • Cost benefits • Care is given in the right place at the right time and in the right way • Increased improvement capability amongst staff

15. Key objectives

16. Integration of National work • HAI pilot work on care bundles • IHI / HPS bundle approach • Shared with IHI • IHI support in principal HPS bundle and definitions • Integration meeting planned 27/11/07

17. Programme / Learning sessions • Pre work period Oct – Dec • Jan 08 LS1 – 3 day event, work stream breakout sessions • Collaborative approach – Learn from faculty / colleagues Coaching from faculty Gather new information on the subject matter and process improvement Share information and build work on improvement plans

18. National Team • Experience , support, advise and guidance • Day to day contact • Site visits • Develop effective networks • Networking, sharing and learning opportunities

19. Communications • Letters to Chief Execs • Pre work • Networking event – Nov 20th • Learning session 1 – Jan 14th, 15th, 16th • Learning session 2 – May • Learning session 3 – Nov • Regular and ongoing throughout the programme

20. Questions ?