We would like to thank Pfizer and Boehringer Ingelheim for the non-promotional Educational Grants that made the free nat

1. We would like to thank Pfizer and Boehringer Ingelheim for the non-promotional Educational Grants that made the free nature of this event possible 

2. Next Seminar: ½ day on June 1, 2009 Quality by Design: Achieving strategic outcomes in health care through Clinical Microsystem Development Marjorie Godfrey*, MS, RN The Dartmouth Institute for Health Policy and Clinical Practice; Director, The Clinical Microsystem Resource Group

4. James Adams

6. Global Trigger Tool Reviews

8. NHS Scotland £10.3 billion Integrated health and social care 14 territorial boards Special boards NHS Quality Improvement Scotland NHS Education for Scotland NHS Health Scotland NHS National Services Scotland Scottish Ambulance Service State Hospital

9. NHS Scotland Leadership Board Chairs meet with Cabinet Secretary monthly Board Chief Execs meet with NHS Scotland Chief Exec monthly Medical Directors meet monthly Finance Directors meet monthly Nurse Directors meet monthly

10. All cause mortality: Males 0-64, 2001

11. The wrong skills

12. from R Resar, Institute for Healthcare Improvement Current Improvement methods in healthcare are highly dependent on vigilance and hard work

13. from R Resar, Institute for Healthcare Improvement The focus on outcomes tends to exaggerate the reliability within healthcare giving clinicians a false sense of security

14. from R Resar, Institute for Healthcare Improvement Permissive clinical autonomy creates and allows wide performance margins

15. from R Resar, Institute for Healthcare Improvement The use of deliberate designs to articulated reliability goals seldom occurs

16. New skills Human factors Reliable design Evidence based care delivery Improvement science

17. LOX-GNH145-20071113-BVJM Eras of quality 1) The 1990s – Evidence based medicine

19. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461 Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design: Systematic review of randomised controlled trials Results: Our search strategy did not find any randomised controlled trials of the parachute.

20. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461 Conclusion: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

21. LOX-GNH145-20071113-BVJM Eras of quality 2) The 2000s – Add evidence based care delivery

22. The Leader’s Role

29. What Will it Take? Winning the hearts and minds of the staff Focusing on improvement not targets Leadership Integration into daily work Tying it all together Creating infrastructure Creating capability and capacity Measurement that has meaning

30. A “Project”

31. Moving a Big Dot

33. Sound impossible? – Here are some examples of success

35. “The Patient Safety Programme has captured the imagination of a wide range of staff. I believe it is beginning to have a major impact on organisational culture and is so perfectly aligned to our vision and values. It is proving to be one of the most professionally satisfying areas of work that most of us have ever done at senior exec level and it is already the day job rather than a programme or initiative.” NHS Board Chief Exec

36. 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 MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction

37. Interventions Critical Care Ventilator acquired pneumonia bundle, central line Ward Early rescue Communication Medicines Medicines reconciliation Theatres Surgical pause Infection prevention/control Leadership Safety walkrounds Executive leadership board patient safety profile

38. 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

40. Driver 5

41. Alignment Policy Programmes People Methodologies Aims Measures Education

42. What does real alignment look like? Vision Values

43. NHS Highland VAP Bundle Compliance

44. NHS Highland VAP Rate

45. NHS Grampian – Percent Compliance with Hand Washing in ICU

46. NHS Grampian – Percent Compliance with Peripheral Line Bundle

47. NHS Grampian – Compliance with Ward Safety Briefings

48. NHS Grampian – Percent Compliance with Theatre Briefings

49. NHS Fife - Percent Compliance with Early Warning Score

50. NHS Fife – Crash Call Rate

51. NHS Lothian – C.Diff. Rate

52. NHS GG&C – ICU Mortality, Glasgow Royal Infirmary

55. “The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science.  It harnesses the energies and wisdom of Scotland’s health care leaders –NHS executives, QIS experts, clinical professionals, civil servants, and more – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care.” Don Berwick

57. Key Components* Self-Assessment Will Ideas Execution Low Medium High Low Medium High Low Medium High

60. Jean Boal

61. jason.leitch@scotland.gsi.gov.uk “It is not necessary to change. Survival is not mandatory” W. Edwards Deming