Improving Patient Safety at the RD&E Council of Governors January 2010, Item 9

1. Improving Patient Safetyat theRD&ECouncil of GovernorsJanuary 2010, Item 9 Respond, Deliver & Enable

2. Florence . . . “It may seem a strange principle to enunciate that a sick patient in hospital will come to harm” Harm can be defined as anything unwanted or unexpected

3. Why should we worry? • Estimated 900,000 incidents a year result in harm or near harm to NHS patients (2006) • 25% of incidents and 39% of near misses go unreported • 840 incidents where a patient will die • 400 will die due to medical device incidents • 27,000 extra bed days • Average cost of £7.4m per hospital • Adverse events cost £2b in hospital stays alone • £400m clinical negligence settlements (Source: NPSA)

4. Where are we at?

5. Reduction in Clostridium difficile Infection. . .

6. Clostridium Difficile Infections 72 hours post admission Total bed days saved per annum = 1815 @ £200 per bed day = £363,000

7. Patient safety The vision for theCampaign Previous Improvement andsafety initiatives: Pursuing Perfection 2003 Leading Improvement In Patient Safety (LIPS) Programme 2007 The campaign cause is: • To make the safety of patients everyone’s highest priority The campaign aim is to achieve: • No avoidable death, and no avoidable harm • Signed up to: • Patient Safety First Campaign in September 2008 • South West Quality & patient Safety programme Oct 2009 Respond, Deliver & Enable

8. Is patient safety our top priority? What have we signed up to We’ve made a public statement to our staff and promoted the use of a number of evidence-based interventions so we can track improvement over time • Leadership for Safety • Reducing harm from Deterioration • Reducing harm in Perioperative Care Surgical Site Infection WHO Surgical Safety Checklist • Reducing harm in Critical CareVentilator care bundle Central line bundle • Reducing harm to patients from Falls RD&E’s own Intervention (not yet part of Campaign)

9. SW Quality & Patient Safety Improvement Programme General Ward • Deterioration • HAIs • VTE • Safety briefings Perioperative Care • Surgical site infections • Team briefing • WHO surgical check list • Pe-op VTE Critical Care • Central line infections • VAP Medicines Management • Warfarin • Insulin • Medicine reconciliation LEADERSHIP

10. Leadership for Safety National & SW Campaign Expectations Six Actions to Improve Quality and Safety • Develop explicit strategic priorities • Provide demonstrable leadership • Ensure executive accountability • Establish and monitor explicit system level measures • Monitor progress and drive execution of projects • Build improvement knowledge and capability Number of Executive Walkrounds

11. The deteriorating patient SBAR Generic Communication tool Situation Background Action required Response needed Piloted and now in use Proposed new Observation Chart piloted and now in production one-day snapshot audit results “… significant improvement in the 08/09 recording of EWS across all areas compared to 2007 ” (over 80% of patients had EWS scores) • Aide memoire • Funded by the League of Friends • Issued to all staff on induction • EWS plus phlebitis score • Plans to link to self assessment and ESR

12. Annual Mortality Review Standards of Care Review of 50 sets of casenotes of patients who have died Comparison of October 2007 and November 2008 • Reviewing: • 2x2 mortality table • Process of care • Adverse events % Reduction inAdverse Event Rate: Mortality Notes • Management of • VTE treatment • GI bleeding • AF • Delay in antibiotic treatment • Missed deterioration Examples of some planning failures

13. Interventions Medicines Reconciliation • New clerking pro-forma Small Tests of Change underway Spreading tests in early 2010 Roll-out of pro-forma during Q2 2010 Audit standards of practice Q3 2010

14. Falls and Intentional Rounding • After fatalities, Lead Nurse led a ‘rebellion’ to achieve a change in staff attitudes and behaviours • Used tools from ‘improvement science’ and patient safety • Plan; Do; Study; Act (PDSA)small test of change • Checklist for staff • Intentional Rounding check patients hourly • Pace

15. The value of annoted run charts Weekly Number of Patient Falls Wards A and B - SPC

16. Reducing number of inpatient Falls Total number of inpatient falls in 10 medical wards April 2008 to July 2009

17. Patient Safety Structure Board of Directors Governance Committee Medicines Management Committee Patient Safety Steering Group Resuscitation Committee Infection Control Committee VTECommittee Falls Project Adverse Events Forum Learning Lessons Group These groups are existing sub-committees of the Governance Committee, but have reporting responsibilities on the national PSF & SWQPSFP interventions to the PSSG New group established March 2009 New group established October 2008 New group established July 2008 New group established March 2009 Information to be cascaded to Directorate Governance Groups (DGGs) via members who sit on each committee listed above

18. Quality Dashboard for the Board

19. Any questions? ?