Safety, Collaboration and Spread Across Boundaries

1. Safety, Collaboration and Spread Across Boundaries Andrew Longmate National Clinical Lead for Patient Safety Ann Holmes Deputy Chief Nursing Officer and Chief Midwife

2. ♯nhsscot13

3. Safety is a dynamic non event

5. Our Constancy of Purpose Person Centred Safe Effective

6. Safe Ambition There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times

7. To transform the safety of acute care thereby improving care and radically reducing needless death and harm.

11. Extended ambition By December 2015 • 20% reduction in hospital mortality • 95% of patients will be free from avoidable harm in our hospitals

12. NHSScotland HSMR (up to December 2012) 0.93 0.97 11.8% - 9037 less than expected deaths

13. Reliable rescue MRSA C Diff SSI VAP CRBSI Prevent Hospital Associated Venous Thrombosis and Embolism Further increase safety in acute hospitals Reduce avoidable harm and death Reduce Hospital Associated Mortality Reduce HSMR by 20% 95% of people experiencing acute care free from harms in SPSI Medicines Safety Insulin: out of range glucose Anticoagulants Safety Briefings Team Working and Communication SBAR WHO Checklist Improve Management of Chronic Conditions CHF Stroke Sepsis MSSA Evidence based care bundles Heart Failure, Stroke, MI, PVC, Community Acquired Pneumonia Prevent HAI CAUTI E Coli No missed doses Best use of IT solutions Medicines Reconciliation High Risk Medicines Hospital Safety Brief Population Health Prevent harms Anticipatory planning Improve Flow and Demand-Capacity imbalance for unscheduled care Palliative and end of life care at home or in a homely setting Supported discharge and decision making Falls Pressure Ulcers Primary-secondary care collaboration

14. HAI Taskforce Scottish Patient safety Indicator SPSI By Dec 2015 95% of people experiencing acute care will be free from these avoidable harms

15. Scottish Patient Safety Indicator [SPSI] • Reducing key preventable harms • Centred on the person • Building on and integrating the SPSP, LBC, HAI work • Ward based (multidisciplinary) team work • Spread improvement science, expand capability and capacity • Catalyst for true improvement work to prevent some of our more important harms, focus on some harms not yet addressed • A specific aim for SPSP

16. Ayrshire and Arran Pressure Ulcer Data

17. Our change theory • A clear and stretch goal • A method • Predictive, iterative testing • Reliable implementation • Doing the common things uncommonly well

18. R.A.H. – GG&C

21. Psychological safety: create an environment where no one is hesitant to voice a concern and caregivers know that they will be treated with respect when they do. Organisational fairness; caregivers know they are accountable for being capable, conscientious and not engaging in unsafe behaviour, but are not held accountable for systems failures. A learning system where engaged leaders hear patients’ and front line care givers’ concerns regarding defects that interfere with the delivery of safe care and promote improvements to increase safety and reduce waste.

22. Every unit in a care system, clinical or otherwise should start the day or procedure with a briefing or huddle. “What are we doing today ? Here’s what we are thinking…..Who’s here to help us ? Do we have what we need ? And what barriers or constraints are in our way ?

23. Just the usual things from me…if everyone could pay attention during the pauses, that would be geatly appreciated… …and if anyone sees anybody doing anything daft; particularly if its me; then please speak up and let them know

25. Scottish Amalgamated HospitalPostoperative Surgical Mortality

26. Make your own saying

27. Just the usual things from me…if everyone could pay attention during the pauses, that would be geatly appreciated… …and if anyone sees anybody doing anything daft; particularly if its me; then please speak up and let them know

28. HOSPITAL HUDDLE AT YORKHILL- effects on delayed ICU discharges

29. What motivates people ?

30. Autonomy Mastery Purpose

33. Some Scientific Premises • Most people are trying hard most of the time to do a job they can be proud of. • All improvement is change (though not all change is improvement). • Fear is an enemy of improvement. • All measurement systems to assess performance will eventually come under the control of the measured. • It is very hard to improve unless you know how you are doing.

34. Some Rules of the Road • The needs of the patient come first. • Trust each other. • The key task is to learn. • Blame won’t help.

35. One thing • That you have seen today or seen at the posters ? • That you can contribute to the spread of ? • How are you going to do it ?

36. Create the Conditions (J Bloor) • Purpose • Leadership • Time (commitment, priority, resilience) • Connections to people • Connections to information

37. Leadership • Topic is a key strategic initiative • Goals and Incentives aligned • Executive sponsor assigned • Day-to-day managers identified • Spread aim statement developed WILL, IDEAS, EXECUTION, INFRASTRUCTURE... Measurement and feedback • Social System • Communication of awareness and technical knowledge • Key messengers • Peer-to-peer interaction • Technical support • Transition issues • Set up • Adopter audiences • Successful sites • Structured enhancements • Key partners • Initial spread plan • Better Ideas • Develop the case • Describe the ideas Knowledge management A Framework for Spread 2nd Edition the Improvement Guide Langley, Moen, Nolan, Nolan, Norman, Provost

42. What will it take ? • Integration, integration, integration • Winning the hearts and minds of the staff • Spread • Focusing on improvement not targets • Leadership • Measurement that has meaning • Integration into daily work • Creating infrastructure – people, IT • Creating capability and capacity

43. Three curves Co-production & assets Performance Improvement Performance Time

44. Avedis Donabedian “Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love.”

45. @AndyLongmate Andrew.Longmate@scotland.gsi.gov.uk Ann.Holmes@scotland.gsi.gov.uk