“ Every Patient, Every Time”

1. Scottish Patient Safety Programme “Every Patient, Every Time” Joint SEPSIS/VTE Collaborative 18/01/2012 Dr Stewart Lambie Consultant Nephrologist Maryanne Gillies SPSP Manager

3. Change Package – Secondary Drivers VTE Bundle • Assessment of patient and admission related risk of VTE • Assessment of contra-indications to anti-coagulant and mechanical Interventions • Treat according to outcome of assessment and recommended action • Plan for timely re-assessment • Documented evidence that the risks and benefits of thromboprophylaxis have been discussed with the patient

4. Change Concepts Develop Risk Assessment Tool • Prompts/Careplan/Care Pathways/White Boards /Drug Kardex Cultural Change • Executive Sponsorship • Clinical Leadership • Patient Safety Walkrounds/Safety Briefs • Display of Data Locally • Multi-Disciplinary Team /Use of Consultant Checklists • Education and Awareness Patient and Family Involvement: • Patient Information on pre-admission/admission and discharge • Patient Empowerment • Self-administration

5. In March 2011 - A large multi-disciplinary team meeting todiscuss the concept of an NHSH wide cross-specialtyThromboprophylaxis protocol Team agreed – to attempt one pan Highland cross-specialty thromboprophylaxis protocol Ascertain level of patient information currently available

6. Background – NHS Highland

7. Scottish Patient Safety Programme • AIM:95% or > patients will be assessed for the risk of VTE and will have the correct treatment prescribed and administered by end December 2014. • MEASUREMENT: • Was there a documented VTE assessment protocol completed correctly? ( to include patient and admission related risk and assessment of contra-indications to pharmacological/mechanical intervention • Was the correct treatment prescribed and administered? • Was there a documented re-assessment of VTE? • CHANGE IDEAS

8. Current Situation – NHS Highland VTE Assessment Protocol

9. Scottish Patient Safety Programme

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17. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S What are we trying to accomplish? Clear Aim statement AIM:95% or > patients will be assessed for the risk of VTE and will have the correct treatment prescribed and administered by end December 2014. General surgery ward 5c Pre-assessment Partner with Urology/ Gynae/ENT Theatres

18. Aim:95% or > patients will be assessed for the risk of VTE and the correct treatment will be prescribed and administered 95% or > by end December 2011 Describe your first (or next) test of change: Test the detail and the effectiveness of the newly designed cross-specialty thromboprophylaxis assessment protocol with one doctor/one nurse/one patient Person responsible When to be done Where to be done List the tasks needed to set up this test of change Person responsible When to be done Where to be done Predict what will happen when the test is carried out Measures to determine if prediction succeeds  Feedback from Fy1- assessment protocol easy to follow and complete Review by associate medical director Plan AMAU RH 09/06/11 Version 0.7 (June 9 11)Thromboprophylaxis assessment protocol One Consultant to discuss with doctor/nurse planned PDSA test One Doctor/nurse to test new protocol One patient selected for test Doctor/Nurse offers feedback from test and outcome of assessment to Consultant RH MG 09/06/11 AMAU Fy1 will find the assessment protocol easy to follow, will complete it accurately DoDescribe what actually happened when you ran the test Did not notice Bolded item single high risk, did not notice Specialty specific criteria, got mixed up on reverse of form, couldn’t understand duplication. Too busy, too complicated and took too long to complete Study Describe the measured results and how they compared to the prediction FY1 found assessment protocol very difficult to follow, did not complete it correctly and did not prescribe the correct treatment. ActDescribe what modifications to the plan will be made for the next cycle from what you learned*Complete review of assessment protocol *Reduce any redundant steps *take out unnecessary text*Use colour to highlight key areas * Simplify back page to avoid any unnecessary duplication * include further options at assessment outcome section. Make changes and test small scale again.

19. Surgical pilot site Shift Sustained Improvement Periop careplan No form/Not scored Not signed Introduction of CAD Sustained Improvement Shift Periop careplan No Teds New Docs Introduction of CAD

20. What change can we make that will result in Improvement? Change ideas……

21. Assessment – Challenges • Capacity • Accepting usefulness rather than seeking perfection – understanding and accepting levels of Risk • Testing, implementing and spreading • Data systems • Consideration of different types of Drug therapy/Dosage and Timing • Consideration of continuing therapy and patient involvement

22. Next steps….. • Look at Electronic Systems/Solutions • Theatreman Upgrade • Consultant Checklist • Data tools – web based through e health • Patient involvement • DVT /PE Outcomes • National Collaboration

23. DASHBOARDREPORT

24. NHS Highland team… Secrets of our success….