sheffield microsystem coaching academy network event 3 rd october 2013
TRANSCRIPT
Sheffield Microsystem Coaching Academy
Network Event3rd October 2013
Agenda
Topic Time
Welcome – Steve Harrison 12.00
NHS England, Overview and Patient Safety Priorities - Bruce Warner
12.05
Questions & Discussion 12.45
Informal Networking 13.00
Close 13.30
Microsystems Coaching Academy Aim
To improve the quality and value of care we provide in the Sheffield Healthcare system
Through the development of team coaching
To build improvement capability at the front line with knowledge, processes and tools including the Dartmouth Microsystem Improvement Curriculum.
4
It’s about redesigning the system
“Every system is perfectly designed to
get the results it gets.”
Paul B. Batalden, MDCo-Founder The Institute for Healthcare Improvement
Founding Director, Center for Leadership and Improvement,
The Dartmouth Institute for Health Policy and Clinical Practice
Founding Director, Healthcare Improvement Leadership Development
The Dartmouth Institute for Health Policy and Clinical
Practice
Co-Founder Institute for Healthcare Improvement
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Team Coaching
Improvement Science
Microsystem
Improving Microsystems - Elements
QI
18
Want more information?www.sheffieldmca.org.uk
• Stories & case Studies
• Events (Open Invite)
• Apply to be a Coach
• Apply to have your team coached
Dr. Bruce WarnerDeputy Director of Patient SafetyNHS England
NHS England Overview and Patient Safety Priorities
NHS England Overview and Patient Safety Priorities
Dr. Bruce WarnerDeputy Director of Patient SafetyNHS England
OLD! Flowchart For Problem Resolution
Don’t Mess About With It!
YES NO
YES
You Daft Prat
NO
Will it Blow UpIn Your Hands?
NO
Deny All Knowledge
Anyone ElseKnow? You’re stuffed!
YESYES
NO
Hide It under a deskCan You Blame Someone else?
NO
SORTED!
Yes
Is It Working?
Did You Mess About
With It?
International and National Recognition of Patient Safety
11
1999 2000 2001
2001 National Patient Safety Agency Established
• Collect and analyse information on adverse events
• Assimilate other safety-related information
• Learn lessons and ensure that they are fed back into practice
• Where risks are identified, produce solutions to prevent harm
June 2012 - National Patient Safety Agency Abolished
2
“We propose to abolish the National Patient Safety Agency”
“The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board…… covering the whole function from getting evidence to working up evidence-based safe services.”
Time to Move On
NPSA Patient Safety
Division
Patient Safety Function
to NHSCB(A)
NRLS to
ICHT
14
What is NHS England?
Create the culture and conditions for health and care services and staff to deliver the highest standard of care and ensure that valuable public resources are used effectively to get the best outcomes for individuals, communities and society for now and for future generations
6,500 people in new roles in national, regional, and local offices across England
Role of NHS EnglandNHS England has three distinct but interconnected roles:
Directly commissi
oning primary
care, specialised, armed
forces and justice health
services System
wide leader for quality improveme
nt
Supportin
g and enabling the local commissi
oning system (CCGs
and Area Teams)
£26bn in 2012/13CCGs were
allocated £65bn in 2012/13
Working with partners: CQC,
Monitor, NHS TDA, NICE,
HSC IC, HEE
CCGs, CSUs, NHSIQ, NHS Leadership
Academy, Local Gov
The Mandate
Government sets annual objectives that NHS England are legally obliged to pursue, but NHS England is independent in pursuing those objectives
NHS England is held accountable to the government against the achievement of those objectives, and the level of continuous improvement
First Mandate for NHS England
•Sets out what the Government expects in return for handing over £95bn of tax payers money to NHS England
•The NHS Outcomes Framework sits at the heart of this Mandate. NHS England is expected to demonstrate progress across the entire framework
NHS Outcomes Framework
We need to make this vision a reality, translating it into how patients care looks and feels
NHS Outcomes Framework
Preventing people from
dying prematurely
Enhancing quality of life
for people with long-
term conditions
Helping people to
recover from episodes of ill
health or following
injury
Ensuring people have a positive experience of care
Treating and caring for people in a safe environment and protecting them from avoidable
harm
Domain 1 Domain 2 Domain 3
Domain 4
Domain 5
Effectiveness
Experience
Safety
Structure
Domain teams priority action areas
• Maximising the contribution that the NHS can make to preventing disease• Finding the ‘missing millions’ and diagnosing earlier and more accurately• Treating people in an appropriate and timely way • Addressing unwarranted variation in mortality and survival rates• Reducing deaths in babies and young children
Preventing people from dying prematurely
Enhancing the quality of life for people with long term
conditions
Helping people to recover from episodes of ill health or
following recovery
Ensuring that people have a positive experience of care
Treating and caring for people in a safe environment and
protecting from avoidable harm
1
2
3
4
5
DO
MAI
NS
• Helping patients take charge of their care• Enabling good primary care• Ensuring continuity of care• Ensuring a parity of esteem for mental health
• Keeping people out of hospital when appropriate• Effective interfaces between primary, secondary and community care • High quality, efficient care for people in hospital • Co-ordinated care and support for people following discharge from hospital
• Improving our understanding of the patient experience• Reduce inequality in patient experience • Enabling commissioners and providers to create a culture that puts good
patient experience and positive staff experience at the heart of services • Establishing clear lines of accountability for patient experience in the NHS
• Increase our understanding of the problem• Create the conditions for patient safety• Build capacity for safe care• Create a whole system response• Address our key patient safety concerns
NHS | Presentation to [XXXX Company] | [Type Date]
Domain 5Patient Safety
April 2013
To ensure that anyone accessing NHS-funded services is treated in an environment where their safety is the paramount concern and where the whole system actively seeks to reduce the risks, inherent in health care, to a minimum.
Our vision: What we want to achieve over the next decade
““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.”Sir Ian Kennedy, Chairman Healthcare Commission
Patient experience
Safety
Quality
Effectiveness
Safety is not a minimum threshold – all services can and should strive to excellence in safety
A. Why waste our time on safety?
B. We do something when
we have an incident
C. We have systems in place
to manage all identified risks
D. We are always on the alert for risks that might
emerge
E. Risk management is an
integral part of everything that we
do
PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE
The Manchester Patient Safety Assessment Framework
The interplay between patient safety and clinical guidelines
It is about the way we safely deliver
care once the clinical decision on how
to treat has been made – the clinical
decision may be the right one but it is
not a given that we will deliver it without
error.
53,000,000+ people
The scale of the challenges
140,000+ different ways the human body can go
wrong
ICD10 codes
4,300+ ways of treating diseases
6000+ medicines for
treating diseases
BNF
and we wonder why people are harmed….?
The scale of the challenges
• Mid-Staffordshire – and the pockets of it that exist everywhere else
• 1 in 10 patients admitted experience an adverse event
• Half of adverse events are judged to be preventable
• 5% of deaths in English acute hospitals had at least a 50% chance of being preventable
• Principal problems associated with preventable deaths
• poor clinical monitoring (31.3%),
• diagnostic errors (29.7%), and
• inadequate drug or fluid management (21.1%)
• Most preventable deaths (60%) occurred in elderly patients with multiple comorbidities and less than 1 year of life left
• 72% of all patient safety incidents are from the acute sector, 13% from Mental Health, 11% from Community, 2% from Learning Disability, 0.6% from Community Pharmacy and 0.4% from General Practice.
National Reporting & Learning System
NHS Trusts
Practitioners & Staff
Patients
Carers
NRLS
CQC
MHRA
NHS Complaints
NHS Litigation Authority
International
Collaboration
Australia
USA
Europe
Sta
nd
ard
ised
rep
ortin
g
Community Pharmacy multiples
Commissioners
Searching by keywords: example
NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children
Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard
We need a trigger
Review of Deaths and Severe Harms
Local audit data
PCT audit of vaccine storage in
GP practices shared with NPSA
Significant proportion of vaccines
stored outside recommended
temperature range
NRLS Searched
National guidance produced
NHS | Presentation to [XXXX Company] | [Type Date]34
Media Reports, Coroners Courts etc.
By 31 March 2012
7,070,261 reports had been reported.
Approximately
3,700 incidents are reported to the NRLS per day.
Around 94% of incidents cause low or no harm
• The NHS leads the world in incident reporting, with the National Reporting and Learning System receiving nearly 8 million incident reports since late 2003 to date.
• Over 100,000 incidents are reported monthly.
• HES data suggests there are over 100,000 cases of VTE per year
• NHS Safety Thermometer data suggests 6-7% of patients have a pressure ulcer
• There were 326 never events reported to SHAs in 2011/2
Levels of Harm
Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11
NRLS limitations:very little reporting from general practice
All care settings: death and severe harm themes 2011/12
19%
17%
12%
9%
8%
6%
6%
5%
5%
4%
3% 2% 1% 1% 1% 1%Pressure ulcer grade 4 or above
Fall
Suicide/severe self harm
Treatment error or delay (excluding medication
Other or unable to theme
Obstetric-specific incident
Operation/ procedure
Clinical diagnostic error including delay of diagnosis
Deterioration not recognised or not acted on
Healthcare associated infection
Medication incident
Test results not seen or not acted on (any type of test)
Transfer or discharge incident
Pulmonary embolus - hospital acquired
Resuscitation (excluding medication)
Airway obstruction/ Aspiration pneumonia
Fixed prioritiesD
om
ain
5 o
f th
e N
HS
O
utc
om
es
Fra
mew
ork
Domain 5: embedded in all domain 1 – 5 work
Increase our
understanding of the
problem
Creating the
Conditions for Safety
Building Capacit
y for Safety
A whole system respons
e to safety
Tackling key
safety concern
s
Domains 1 – 4 are expected to build these safety themes into every programme/ project governance arrangement
Aim 1 – To increase our understanding of the safety problem
Increase our understanding of the problem
New methodology for measuring the safety of NHS services (indicator 5c) based on case note review of deaths in hospital
New methodology for measuring the safety of NHS services (indicator 5c) based on case note review of deaths in hospital
Further NHS Safety Thermometers (medicines, mental health, maternity)
Further NHS Safety Thermometers (medicines, mental health, maternity)
Design and deliver the new single incident reporting and management system to replace/upgrade the NRLS and simplify reporting
Design and deliver the new single incident reporting and management system to replace/upgrade the NRLS and simplify reporting
Creating the Conditions for
Safety
Contract – SIs and HCAI
Contract – SIs and HCAI
CQUIN and Quality Premium – Pressure ulcer improvement
CQUIN and Quality Premium – Pressure ulcer improvement
Policy development – Serious incident management, deaths in custody
Policy development – Serious incident management, deaths in custody
Aim 2: To create the conditions for safer care
Safety Expert Groups
Safety Expert Groups
Patient Safety Skills Strategy
Patient Safety Skills Strategy
Enhanced safety leadership
Enhanced safety leadership
Building Capacity for Safety
Aim 3: To build capacity to deliver safer care
Patient safety collaboratives
Patient safety collaboratives
Patient safety Improvement Fellows
Patient safety Improvement Fellows
Networks, champions and campaigns
Networks, champions and campaigns
A whole system
response to safety
Aim 4: To create an whole system response to safety
Outcomes framework priorities
Outcomes framework priorities
Other key harmsOther key harms
Vulnerable groupsVulnerable groups
Tackling key safety concerns
Aim 5: To tackle key safety concerns
AIM 5: To address key areas of safety concernProgramme Objectives Deliverables
Outcomes Framework Safety Concerns
• Pressure Ulcers• VTE• Medication and devices• HCAI• CYP deterioration• Neonatal admissions
Key known harms • Falls (Older people in 1st 48hrs of acute illness)• Handover• Transitions• Nutrition and hydration• Deterioration• AKI
Vulnerable group safety concerns
• Primary Care strategy• Mental Health• Learning Disabilities Framework• Offender Health framework
Making the aims a realityFour key delivery streams will be used:
1. Central patient safety development team• Development of major initiatives such as reporting systems, safety
alerts, commissioning levers, etc
2. Patient Safety Collaboratives• Regional effort across boundaries to improve safety concerns
3. National community of interest networks• Led by the central patient safety team to link people together working
on key safety concerns across the country to accelerate sharing and learning, and support Patient Safety Collaboratives across England
4. Domain 1 – 4 Effectiveness and experience programmes• Linking into other developing NHS England programmes of work
Berwick ReportIm
ple
men
tatio
n
Aims for Improvement
Building Capacity through training, education, technical capability
Structural recommendations; Oversight, accountability and influence
Patient and Public Involvement
Measurement, transparency, tracking and learning
Legal penalties/criminal liability and their impact on safety
Implications for leaders at all levels
Staff and the work environment
Findings
Berwick - most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:
Placing the quality of patient care, especially patient safety,
above all other aims: Engaging, empowering, and hearing patients and carers
throughout the entire system and at all times: Fostering whole-heartedly the growth and development of all
staff, including their ability and support to improve the
processes in which they work: Embracing transparency unequivocally and everywhere, in
the service of accountability, trust, and the growth of
knowledge.
www.sheffieldmca.org.uk