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NES April 2009

NES April 2009. How many people are harmed in our healthcare system?. Global Trigger Tool Reviews. McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

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NES April 2009

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  1. NES April 2009

  2. How many people are harmed in our healthcare system?

  3. Global Trigger Tool Reviews

  4. McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%

  5. Jean Boal

  6. 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 • Bloodstream Infection: 30% reduction • Crash Calls: 30% reduction

  7. 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

  8. Total reported events • Number of reported events: high and medium risk • High/medium risk events • Total events 140 9000 8000 120 7000 100 6000 80 5000 4000 60 3000 40 2000 20 1000 0 0 1994 1995 1996 1997 1998 1999 • British Airways air safety reports, 1994-99 Source: British Airways (NPSA adapted)

  9. Theory of transformation

  10. Our Theory (Part 1) Build a compelling case for change Involve patients and carers Work on processes and outcomes that engage the hearts and minds Work at the coal face and at the executive level Data feedback, data feedback, data feedback Set the tempo!

  11. Our Theory (Part 2) Changes in process and outcomes are directly connected. The changes beginning tested, when fully implemented, will lead to large system aims.

  12. Boards Endorse Safety as Key Strategic Priority Deliver the programme Build a Sustainable Infrastructure for Improvement Align SPSP with national improvement programmes and measures Scottish Patient Safety Alliance (SPSA) Driver Diagram Primary Drivers Secondary Drivers National leaders openly endorse SPSP aims, failure is not an option for execs - Time and space given for improvement (not a target) -Royal Colleges serve in official capacity -Safety is an element of all programmes Scottish Government Sets PSA as Strategic Priority - -National Board development strategy -Ownership of agreed upon set of outcomes and measures -Quality and safety comprises 25% of agenda --Development of infrastructure that supports improvement and measurement -Clear improvement aims in strategic plan Improve Safety of Healthcare Services in Scotland -Segment hospitals , customize approach -In-country support for Boards -Spread strategy community hosp., primary care -One Team -”Everyone in the tent” -One Team -Develop experts in imp. methods and coaching -In-country measurement system, culture survey -Safety work migrates to appropriate agency -Training programmes developed in Scotland - Work with IST, QIS and HES to develop unified improvement approach -Align aims and measures with national programmes -Develop a portfolio and execution model -Build connection to safety in national work -Define within clinical governance framework

  13. Integration

  14. Judgement vs Improvement

  15. Prototype and Spread

  16. Successes from Action Period Two No central line bloodstream infections since July Shift

  17. Successes from Action Period Two Trend

  18. Successes from Action Period Two Shift Trend

  19. NES? • What is NES already doing that relates to this agenda? • How can NES help inform those working on this agenda? • What can NES do in addition to present activities?

  20. Who needs to know and what do they need to know? • Patients, carers and the public • Executives • Non-executives including chairs • Middle managers • Clinicians • Senior • Middle grade • Trainees • Administrators • Health professional students – Cab. Sec promise

  21. “NHS Scotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety.  The dedication of NHS leadership at all levels to this endeavor is apparent to me, and bodes well for success.  In its scale and ambition, the Scottish Patient Safety Programme marks Scotland as leader – second to no nation on earth – in its commitment to  reducing harm to patients dramatically and continually.” Don Berwick June 2008

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