Overview of SPSP

Wendy Sayan, Acting Patient Safety Development Manager

Aims of the Session

Morning Session• Overview of the current Patient Safety Programme• New Patient Safety Programmes• Implementation, Sustainability & Spread• Developing a Patient Safety Culture

Afternoon Session• Data and Measurement• Failure to Rescue and SEWS

Scottish Patient Safety Programme

Vision

“To transform the safety of acute care in Scotland thereby improving care and radically reducing needless death and harm”

Every Patient Every Time!

DVD

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

Key objectivesWork Area Change Package Element

Critical Care Establish infrastructure•Daily goal sheets•Daily multi-disciplinary rounds

Infection Prevention•Ventilator bundle•Central line bundle•General infection prevention practices•Glucose control (ITU then to HDU)

General Ward Risk Identification and Response•Rapid response (Outreach) teams•Early warning system

Infection Prevention -MRSAReliable care for Congestive heart failureCommunication and Teamwork

•Safety briefings•Communication tools (e.g. SBAR)•Prevention pressure ulcers

Leadership Infrastructure to support safetyWalkroundsSafety a strategic priority

Medicines Management ReconciliationAnticoagulation , Insulin,Conduct an FMEA on a high risk medication process

Perioperative DVT ProphylaxisContinuity of Beta blockersSSI bundleTeam culture - briefings

Scottish Patient Safety Programme

SPSP Aims Primary Drivers Secondary Drivers

•Mortality: 15% reduction

•Adverse events: 30% reduction

•Ventilator associated pneumonia: 0 or 300 days between

CL CR-BSI: 0 or 300 days between

Staph aureus bacteraemias: 30% reduction

Crash Calls: 30% reduction

Surgical site infections: 50% reduction (clean)

GENERAL WARD Reduced infections,crash calls, pressureulcers, AE in CHF and AMI patients

PERI-OPERATIVE

Reduce peri-operative adverse events: infections, cardiovascular events

LEADERSHIP

Provide the Leadership System to Support the Improvement of Safety and Quality Outcomes in your Board

CRITICAL CARE

Reduced Mortality, Infections, & OtherAdverse Events

Provide reliable, timely, care using evidence-based therapiesCreate a collaborative team and safety cultureEnsure patient and family centred careDevelop infrastructure that promotes quality care

MEDICINES MANAGEMENT

Reduce adverse drug events: r/t high risk processes & medicines e.g. medicines at the interface and anticoagulation

Provide appropriate, reliable and timely care to patients using evidenced-based therapies to prevent surgical site infectionsCreate a team culture attuned to detecting and rectifying intraoperative errorsProvide appropriate, reliable and timely care to patients using evidenced-based therapies to prevent peri-operative cardiovascular events

Provide reliable, timely, care using evidence-based therapiesIntegrate patient and family into careDevelop infrastructure that promotes quality careCreate a collaborative team and safety culture

Provide reliable medicines management processesCoordination of carePatient and family involvement

Develop the infrastructure to support quality and safety improvementProvide oversight to programmePromote the position of safety and quality in the organisation

NHS Tayside Patient SafetyFive years on…..

Implementation of Mental Health Patient Safety Interventions

Implementation of Women & Child Health Patient Safety Interventions

Implementation of Primary Care Patient Safety Interventions

Medication Safety

Develop Infrastructure to Support Quality and Safety Improvement, Promoting the Position of Safety and Quality within NHS Tayside

Building Capacity, using data at the frontlineContinue spreading Patient Safety and Quality Improvement to non-clinical areas:

Sterile Services Department Mortality & Morbidity ReviewsEmbedding Patient Safety and Quality Improvement in Medical CurriculaFurther develop the NHST Framework for Spread and sustainabilityReview of further development of existing Walkround Process

180 Day Rapid Improvement Collaborative – focus on Medicines Reconciliation admission & discharge in Medicine for the Elderly

National Medicines Management Collaborative June 2012 launch

SIPC 1 & 2Improve management of immunosuppressive drugs

Improve care for LVSD heart failureImprove Medicine Reconciliation processes

Patient Safety in Prison ServicesSPSP Primary Care 2013 launch

Scottish Patient Safety Programme in Paediatrics - SPSPPPaediatrics – appropriate, timely and reliable evidence-based critical care therapies.Improve medicines management processes and decrease harm from medicinesImprove paediatric perioperative outcomesImprove paediatric general ward outcomesSafety Beyond Acute – "Improving Maternity Services through teamwork solutions"

Maternity Care Quality Improvement Collaborative 2012 - 2015

Continued support to sustain Current levels of reliability in all Acute Adult Work streams Spread Plan development for all acute adult workstreamsImprove Patient Rescue – SEWS revision and implementation, Crash call reviews, mortality reviews Improve Sepsis and VTE – Sepsis/VTE Collaborative 2012 - 2014Antimicrobial ManagementPVC Insertion & Maintenance Bundle DevelopmentHeart Failure

HDU workstream DevelopmentTo improve the safety and reliability of care throughout NHS Tayside by Dec 2012

Outcomes:

Mortality (15% reduction across NHSS) Adverse Events (30% reduction across NHSS)

Aim

Sepsis Collaborative Background

• National collaborative launched by the Scottish Patient Safety Programme and Scottish Antimicrobial Management Group in January 2012

• Four pilot areas within NHS Taysideo Ward 15, Ninewells Hospitalo Ward 42, Ninewells Hospitalo Accident & Emergency, Ninewells Hospitalo Ward 4, Perth Royal Infirmary

• Aim to achieve 5% reduction in mortality by December 2012, rising to 10% by December 2014.

• Early spread to wards 5/6 and orthopaedics

How will we do this?

To improve the recognition and

timely management of Sepsis in acute

hospitals

Outcome:Reduction in

mortality in pilot population from

Sepsis

5% by December 2012 10% by

December 2014

Reliable Recognition &

Assessment

Reliable Care Delivery

Education &

Awareness

Culture of safety and Quality

Improvement

Patient & Family Centred Care

Reliable Sepsis screening (EWS + SIRS)Ensure reliable communication across clinical teams of at risk patientsEnsure timely rescue of deteriorating patient by competent teams

Ensure reliable delivery of Sepsis Six within 1 hourSource Control Ensure reliable escalation of septic patients to higher level of careImprove Antimicrobial stewardship - 3 day review

Education on burden of illness & current performanceProvide training to staff on clinical knowledge and improvement skills

Executive SponsorshipClinical LeadershipMultidisciplinary team working Develop measurement frameworks to guide improvement

Involve patients & families in treatment process and care planning

Sepsis Six Bundle

Sepsis Acute & SpecialtyData – Ward 42, Ninewells

Sepsis Acute & SpecialtyData – A&E, Ninewells

Sepsis Acute & SpecialtyData – AMU, Ninewells

Implementation & Sustainability

• 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

Our Theory

The Improvement Guide, API

To Be Considered a Real Test

• Test was planned, including a plan for collecting data

• Plan was carried out and data was collected

• Time was set aside to analyse data and study the results

• Action was based on what was learned

Move Quickly to Testing Changes

• Year• Quarter• Month• Week• Day• Hour

“What tests can we complete by next Tuesday?”

Select your pilot area to start to test:

• 1 patient

• 1 day

• 1 admission

• 1 clinician

Start Small ~ 1:3:5:All

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S DD S

P ADATA

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PVC Bundle, Orthopaedic Ward - PDSA PVC Bundle, Orthopaedic Ward - PDSA CycleCycle

DAT

A

Test SPSP PVC Bundle within orthopaedic clinical setting with one patient and one nurse. PVC maintenance was already carried out within this Major Joint Replacement Orthopaedic Ward. Testing was required around the implementation of the SPSP Bundle which differed slightly.

Further adaptation of process, test with 3-5 patients and 3 nurses, parallel testing of locally developed audit tool to suit revised process.

Continue to test process and accompanying audit documentation with all patients and involving all staff to ensure all issues are discovered and resolved

Implement PVC Bundle all Wd 16 patients Ninewells Hospital

95% compliance with PVC Bundle Process by Dec 2009

Implementation of PVC bundle process and audit tool

Adapt and test existing PVC Bundle process carried out within ward 16 to align with SPSP PVC Bundle

5 Key Principles of Improvement:

• Knowing why you need to improve• Feedback mechanisms to tell if your improvement is

happening• Develop effective change that will result in improvement• Test a change before implementing• Know when and how to make the change permanent

Local Display and Feedback of Data

Developing a Patient Safety Culture

What is Quality in Healthcare?

• Quality is what we do

• Clinical effectiveness and safety

• Patients (populations)/people

• Standards delivered by high quality education

• Large scale ‘roll-out’ of evidence

• Quality is what we strive for

• Effective, Safe, Patient Centred, Timely, Equitable, Efficient

• Patients, populations, and Systems

• Continuous improvement through learning

• Small scale testing and context-specific spread

Attitude

Scope

Focus

Requisites

Scale

Content adapted from a presentation from Professor Peter Davey, University of Dundee

Traditional Approach New Approach

Bureaucratic: Standardise, don’t paralyse

Supporting frontline staff is Supporting frontline staff is criticalcritical

Solberg et al Journal on Quality Improvement 1997, 23:135-147.

We are increasingly realising not only how critical measurement is to the quality improvement we seek but also how counterproductive it can be to mix measurement for accountability or research with measurement for improvement

Patient Safety Dashboard – this is audit of everyone’s work

Patient Safety Executive Walkrounds

“I found it a very interesting experience

and valued the opportunity to spend time

with senior staff from the management

side of NHS Tayside, who had time to

listen to me and share their experience

and knowledge.”

Staff Comment on experience of Walkround

Patient Safety Executive Walkrounds

Quality Improvement & Safety• Both parties willing to discuss relevant issues, and being focussed on

continuous improvement regarding patient care & safety.• Interaction with staff and patients and the completion of the quality loop.• Visible reminder for staff of the importance of the safety agenda• Openness of process and opportunity to see evidence of patient safety &

improvement work.• Opportunity to look for compliance with safety processes

Communication• Discussion with the Senior Charge Nurse after the walk around the ward is

particularly useful.• Positive engagement with staff team and service leads• Opportunity to talk with patients and staff• Open discussions• Giving staff the opportunity to showcase what they are doing well and receive

recognition for their hard work.

Scottish Government, May 2010

The Healthcare Quality Strategy

for NHSScotland

Institute of Medicine’s6 Dimensions of Quality

• What does high quality healthcare look like for you, your team and your service- and what gets in the way of achieving this, all the time?

• What is the first simple thing you have the power to change, immediately, or in the very short term, which would improve the reliability of the quality of the service deliver today?

• What other practical ideas do you have that would improve the experience and outcomes of care for patients, carers and for us all?

• What prevents you from putting this idea into practice?

• What else would it take to make this happen?

What are your learning objectives?

1. What are human factors and why are they important?

2. Understanding systems & complexity in health care

3. Being an effective team player

4. Understanding and learning from errors

5. Understanding and managing clinical risk

6. Use of quality improvement methods

7. Engaging with patients and carers

Data & Measurement

Measurement for Improvement

• Improvement is not about measurement however, effective measurement and data collection plays an important role.

• Improvement is about making changes to

processes and systems, with measurement playing a key role in the process.

The Improvement Guide, API

Why are you measuring?

The answer to this question will guide your entire The answer to this question will guide your entire

quality measurement journey!quality measurement journey!

Improvement?Improvement?

Judgment?

Judgment?Research?

Research?

Overall Project Measures vs. PDSA Cycle Measures

AchievingAim

Data for Project Measures: - Overall results related to the project aim (outcome, process, and balancing measures) for the life of the project

Adapting ChangesDuringPDSA Cycles

Data for PDSA Measures:- Quantitative data on the impact of a particular change- Qualitative data to help refine the change - Collect only during cycles

Data Management

• Initial local reporting using Microsoft Excel • National use of IHI SPSP Extranet• Development of NHS Tayside Data Dashboards

Can be filtered down to ward level

NHS Tayside ICU Ventilator Bundle Compliance

0

10

20

30

40

50

60

70

80

90

100

Date

Pe

rce

nta

ge

5th element introduced High % of agency/

bank nursesNew intake of anaesthetists, high usage of bank/agency staffEducation sheet developed.

4 element bundle on all patients

04/02/05-17/02/05 tests of change x 6 to implement sedation vacation and HOB on all patients

Presenting your data

VAP Rate - ICU, Ninewells Hospital

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Month

VAP

Rate

per 1

000 p

atien

t day

s

ICU now admitting all neuro patients following closure of neuro ICU

Implementation of daily goals

Chlorhexidine oral gel introduced over previous 12 months

median (13.89)

What happened here?

If you don’t understand the variation that lives in your data, you will be

tempted to ...

• Deny the data (It doesn’t fit my view of reality!)

• See trends where there are no trends

• Try to explain natural variation as special events

• Blame and give credit to people for things over which they have no control

Data Reporting Structure

• Data recorded locally using IT Dashboard System

• Reports created by each Directorate and Patient Safety Team for local and national reporting purposes

• SPSP reporting to Clinical Quality Forum, Executive Management Team and within local Clinical Governance Groups

Measurement Principles

• Develop aims before measuring• Design measures around aims• ‘How Good, By When’• Establish a reliable baseline• Track progress over time• The key purpose of measurement for

improvement is for learning. • Teams need measures to give them feedback

that the changes they are making are having the desired effect and are resulting in improvement.

FAILURE TO RESCUECRASH CALLS

& SEWS

Diane Campbell

Programme Director

Older Peoples Improvement Collaborative

Purpose of crash calls reviews

• Gather reliable & real time information

• Analysis to identify human factors & issues with SEWS

• Examine potential opportunities for earlier interventions and learning

• Reflection – individual & team

SBARtool

Crash Call review tool

Human factors

Crash call review tool page 2

SUMMARY OF CRASH CALL FINDINGS

NINEWELLS & PRI

Examples ofClinical

Excellence

Delayed Escalation

Lack of Documentation

Prolonged periodsWith No

Observations

No increased Frequency when

SEWS >2

Observationsperformed in

isolation

Underscoring

Overnight Observations

CommunicationTeam working

Prioritisation ofCare

DNA/CPR

SEWS DevelopmentDrivers for Change:

• Based on review findings there was recognised need to review the existing chart

• Local SEWS data

• National developments (NEWS)/NICE Clinical Guideline 50

SEWS journey

so far……

(Nov 2011-present)

Modification to oxygen recording

Additional score of 1 if Receiving supplemental

oxygen

Document Oxygen Code

on SEWS

Target saturationsAid appropriate

management

Modifications to Blood Pressure & Neurological

Assessment

Pain &

UnresponsiveScore a 3

BP < 80mmHgNow score a 3

Integrating Sepsis Triggers

SEWS ≥4: THINK SEPSISIf 2 or more of the following:• Temperature >38 or <36•Altered mental state•Respiratory Rate >20 breaths per min•Known/suspected neutropenia•White cell <4 or >12

AND clinical suspicion or confirmed Infection Commence ‘Sepsis 6 Bundle within 1 hour’

Clear monitoring plan

MonitoringGuide

Frequency Of

Obs

Escalations/Exclusion

Improving Nursing Documentation

‘Red Flag’

Pilot Ward CQI Data

Testing

Pilot ward

SEWS is fundamental to patient safety &

should guide safe monitoring forEVERY PATIENT EVERY TIME!