The Scottish Patient Safety Programme

1. The Scottish Patient Safety Programme Jane Murkin, National Co-ordinator

2. Session aims • Outline NHSScotland strategic approach to patient safety and improvement • Progress to date • Early examples of success

3. Scottish Patient Safety Alliance Key Partners • The Scottish Government • NHS Scotland • NHS QIS • Royal Colleges and Professional bodies • World leading experts on patient safety • Patients • NHS Education for Scotland • Health Protection Scotland

4. Delivery • National team, based within NHS Quality Improvement Scotland (NHS QIS) and led by National Co-ordinator • Scottish Government • National Clinical Lead for Safety and Improvement • National Patient Safety Development Advisor • A technical partner: Institute of Healthcare Improvement • Faculty

5. Our Theory Build a compelling case for change Work on processes and outcomes that engage hearts & minds Reduce waste and redundancy Work at the coal face and at the executive level Data feedback, data feedback, data feedback Set the tempo! Changes in process and outcomes are directly connected The changes being tested, when fully implemented, will lead to large system aims

6. Primary Drivers Secondary Drivers Scottish Patient Safety Programme Driver Diagram Demonstrable results to community Clear, shared measurement set Visible on all senior leader agenda PSA represents & demonstrates cohesive, united programme National Policy alignment Scottish Government Sets Patient Safety as Strategic Priority Boards Accept Safety as Key Strategic Priority for Effective Governance Robust, evidence based proven clinical changes IHI/QIS Team Expert at Content, Coaching and Programme Management Align SPSP with national improvement programmes and measures Ownership of agreed upon set of outcomes Review of outcomes at each meeting Quality and safety comprises 25% of agenda Recovery plans for unmet outcomes Infrastructure supports improvement and measurement Involve patients in safety Improve Safety of Hospital Healthcare Services in Scotland Acceptance of pragmatic science Royal College Supports PSA Programme International expert clinical faculty Faculty expert at improvement methods and coaching Programme design and structure Inventory national programmes and measurements Meet with programme leader to understand programme intent, audience, history Harmonize our metrics

7. Aims • 15% reduction in mortality • 30% reduction in adverse events • Reduce healthcare associated infections • Reduce adverse surgical incidents • Reduce adverse drug events • Improve critical care outcomes • Data for improvement • 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

8. Key objectives

9. SPSP Engine and Timeline Organisational Self Assessment P P P A A D D D A S S S 2 day Kickoff 2 day LS 2 day LS 2 day LS Continued Supports Alignment with national work Supports Expert clinical faculty Networking events Listserv Site Visit Phone conf Assessments Monthly Reports via web Key Changes Improvement Measures Jan 11 Jan 09 Oct 07 Jan 08 Jun 08 Jun 09

10. Building a sustainable infrastructure for improvement • Learning sessions • National capacity and capability events • Patient Safety leadership course • Fellowship programme • Developing Scottish Faculty • Improvement Advisors

11. Programme Integration • Multilevel collaboration – national initiatives / programmes • Building a sustainable infrastructure embedding SPSP methodologies • Integrated work programmes and measurement strategies • Joint messaging • Joint presentations and events

14. Progress so far • Over 600 Leadership walkrounds have now taken place throughout Scotland. • 52 pilot wards throughout Scotland have implemented daily safety briefings as a routine part of their work. • Critical Care teams are able to demonstrate significant periods of time without central line infection in ITU.

15. VAP rate, Royal Alexandra Hospital, Paisley

16. “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