Transcript The Scottish Patient Safety Programme

Scottish Patient Safety
Programme –
Paediatric Update
Jane Murkin, National Co-ordinator, Scottish Patient Safety Programme
Julie Adams, National Facilitator, Paediatrics
National Delivery Plan Implementation Group – 10th March 2010
Our vision – Scotland leading the way in
Patient Safety
• Scotland at the forefront - a whole healthcare system
approach
• A strategic development priority for NHS Scotland
• An explicit and tested approach to improving patient
safety
• Build on foundations laid through audit, clinical
effectiveness and clinical governance
• Alignment with wider NHS QIS Patient Safety work
Background
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SPSA launched by CMO March 2007
SPSP first programme of work
Strategic priority for all NHS boards
Improvement programme – process / outcome
Five work streams
Designated Board PM and Exec Lead
LS1 Jan 2008, LS6 May 2010
National Facilitators appointed – Sept 2008
Board trajectories
Scottish Patient Safety Programme Driver Diagram
Primary Drivers
Scottish Government Sets
Patient Safety as
Strategic Priority
Improve Safety
of Hospital
Healthcare
Services in
Scotland
Boards Accept Safety as
Key Strategic Priority for
Effective Governance
Robust, evidence
based proven
clinical changes
Secondary Drivers
Demonstrable results to community
Clear, shared measurement set
Visible on all senior leader agenda
PSA represents & demonstrates cohesive, united
programme
National Policy alignment
Ownership of agreed upon set of outcomes
Review of outcomes at each meeting
Quality and safety comprises 25% of agenda
Recovery plans for unmet outcomes
Infrastructure supports improvement and measurement
Involve patients in safety
Acceptance of pragmatic science
Royal College Supports PSA Programme
IHI/QIS Team Expert at
Content, Coaching and
Programme Management
International expert clinical faculty
Faculty expert at improvement methods and coaching
Programme design and structure
Align SPSP with national
improvement programmes
and measures
Inventory national programmes and measurements
Meet with programme leader to understand
programme intent, audience, history
Harmonize our metrics
Outcome Aims:
• 15% reduction in mortality
• 30% reduction in adverse events
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Reduce healthcare associated infections
Reduce adverse surgical incidents
Reduce adverse drug events
Improve critical care outcomes
Improve the organisational and leadership culture on
safety
• Data for improvement
Work Area
Critical Care
Change Package Element
Establish infrastructure
–Daily goal sheets
–Daily multi-disciplinary rounds
Infection Prevention
Key objectives
General Ward
–Ventilator bundle
–Central line bundle
–General infection prevention practices
–Glucose control (ITU then to HDU)
Risk Identification and Response
–Rapid response (Outreach) teams
–Early warning system
Infection Prevention - MRSA
Reliable care for Congestive heart failure
Communication and Teamwork
–Safety briefings
–Communication tools (e.g. SBAR)
–Prevention pressure ulcers
Leadership
Infrastructure to support safety
Walkrounds
Safety a strategic priority
Medicines Management
Reconciliation
Anticoagulation , Insulin,
Conduct an FMEA on a high risk medication process
Perioperative
DVT Prophylaxis
Continuity of Beta blockers
SSI bundle
Team culture - briefings
Paediatric Programme
• Steering Group established August 2009.
• National Facilitator appointed November 2009.
• National Event November 2009 – provide access
to expert learning:
– Cincinnati Children’s Hospital;
– Great Ormond Street Hospital.
Develop paediatric aims, goals and
measures
• Ensure aims are ‘best in class’
• Paediatric evidence-base
• Relevance to improving the safety of paediatric
hospital healthcare in Scotland;
• Same workstream infrastructure as SPSP.
• Additional paediatric aims – child protection.
Next Steps……
• Confirm aims, goals and measures:
– Steering Group meeting 30th April 2010.
• Launch event June 2010:
– publicise the programme;
– opportunity for specific paediatric training, i.e.
paediatric trigger tool;
– capacity building within paediatric community.
• Develop strong patient links.
• Establish infrastructure to deliver safe and
reliable paediatric care.