Transcript Document

Safety Express
A New Journey in Patient Safety for the NHS
Dr Ailsa Brotherton
Ms Sally Deacon
What is Safety Express
• Safety Express is the name of the mobilisation vehicle for the QIPP Safe Care
work stream
• The programme aims to reduce harm in four defined areas using collaborative
techniques and improvement methodology:
Pressure ulcers
Falls
Catheter acquired urinary tract infections
VTE
• The programme is named ‘Safety Express’ because we aim to move together at a
pace and scale which is previously unprecedented in English healthcare.
• Safety Express is a ‘call to action’ for NHS staff who want to see a safer more
reliable NHS with improved outcomes at significantly lower cost
• Safety Express is a partnership with existing programmes (in particular Energising
for Excellence, High Impact Actions, Patient Safety First, the Productive Series and
the National VTE Implementation group) and each SHA region
Safety Express programme plan
•
Phase 1 - pilot phase (January to June 2011)
 Comprising of 3 Learning sessions 60 - 90 days apart January-June
 New knowledge will be archived into simple bundles and change packages
•
Phase 2 - (September to Feb 2012)
 Safety nodes will replicate the Safety Express Programme supporting the new
teams testing in pilot areas
•
Phase 3 - spread (February to August 2012)
 Scale up activity to the whole system
 Regional learning and sharing sessions will take place and exemplar CQUINS
will be developed
The Model
for Improvement
The Model for Improvement
We need to use our resources wisely.
•
•
•
Rapidly improving locally
Testing out the improvement
Rolling out good ideas
This should provide the best services, eliminate waste and adopt the best practice.
What are we trying to accomplish?
Level 1
Level 2
Level 3
1. 80% reduction in hospital
acquired category3 or 4 pressure
ulcers
2. 30% reduction in community
acquired category 3 or 4 pressure
ulcers (patients not in a hospital bed)
3. 50% reduction in serious harm or
death from falls
4. 50% reduction in the proportion of
patients with catheters being
treated for UTI
5. 50% reduction in avoidable VTE
events
To deliver the
HARM FREE [4]
for 95% patients
by Dec 2012
To deliver the
HARM FREE [6]
for 95% patients
by Dec 2012
‘HARM FREE’
defined by
absence of
pressure ulcers
harm from falls,
CA-UTI,
and VTE for all
patients
‘HARM FREE’
defined by
absence of
pressure ulcers
harm from falls,
CA-UTI, VTE,
bloodstream
infection & C diff for
all patients
by Dec 2012
What is the Safety Thermometer?
• The Safety Express measurement strategy focuses on Measurement for Improvement
• This approach differs from measurement for performance which many clinicians and
commissioners are most familiar with
• The Safety Thermometer is the survey tool which is used to measure for improvement
• The measures used are fundamentally about PROGRESS OVER TIME.
Improvement measures are usually a sample data (50% patients on specified
units of a single day,) the definitions are pragmatic working definitions
• Data collection systems are designed to minimise the data collection burden and
maximise on the benefit of the ‘act of measurement’.
• The Safety Thermometer is designed to help participants and the NHS build up a
picture of patient safety issues and to help you see the impact of actions implemented
• Each measurement location will measure small numbers of patients often
Org (All)
Data
Data
Copy
Print
Safety Thermometer: Types of Harm
Types of Harm
CAUTI
Fall
Fall:CAUTI
Fall:VTE
PU
Harm Profile
PU:CAUTI
PU:Fall
PU:Fall:CAUTI
PU:Fall:VTE
PU:VTE
PU:VTE:CAUTI
Patients
100%
VTE
90%
80%
70%
60%
Pressure Ulcers
50%
40%
30%
20%
Falls
10%
Catheters & Infection
0%
Q2/10
Q3/10
Quarter
VTE
VTE:CAUTI
Data
Harm Free (by location)
Data
Harm Free (by location)
How will we organise our
improvement?
Local teams across the provider system
A. Community services
B. Host
HOST
GP network
Team composition
Dream Team
Team
Leader
AHP
Patient
Stores
Nurse
Doctor
Pharmacy Manager Clerk
C. Mental Health
Doctor
D. Nursing Home
Focus for Impact
Aim
Primary Drivers
Secondary Drivers
Local Clinical Leadership
To deliver
harm free
care defined by
the absence of
pressure ulcers
harm from falls,
CA-UTI
and VTE
in 95%
of patients
By Dec 2012
Leadership
&
Safety Culture
Executive Support
Walk rounds & rounding
Clinical
Care
95% reliable
Active risk management
Continence, skin & moisture
Nutrition / Hydration
Medication reconciliation
Supporting
Infrastructure
Equipment
Education and Training
Ward Level Driver
A breakthrough series collaborative
Jan 2011
March
June
Sept
Supportive Framework
Supported Regionally and Nationally
National Coalition
Mobilised patients
10 regional teams
in SHAs
National Leadership - Safety Express
Sponsor
Department of Health
• Jim Easton
• Bruce Keogh
• Christine Beasley
Director
Maxine Power
Day to day leadership
Improvement Leader (s)
Maxine Power
Kevin Stewart
Technical expertise in
improvement and BTS
model
Coordinator
Ailsa Brotherton
Leads collaborative
administration with director
Chair
Kevin Stewart
Expert in Safety & practical
experience with safety
improvement
Faculty
Leadership Team
MP, KS & AB
National Faculty (steering group)
•
•
•
•
•
•
•
•
•
•
•
•
•
David Oliver / Francis Healey
Janice Stevens / Sally Batley
Mike Duerden & Carole Fry
Anita Thomas and Tim Browne
Katherine Fenton / Julie Halliday
Caroline Lecko
Mike Stroud
Ashley McKimm
Joan Sadler
John Madsen / Martin Orton
Bernard Crump / Kate Jones
Mike Durkin
Jane Cummings
Falls
Infection
CA-UTI
VTE
Pressure Ulcers
Pressure Ulcers
Nutrition
Junior doctors
PPI
Measurement
Improvement
Medical lead
SHA lead