teesside patient safety conference presentations

Safety First and ForemostImproving Patient Safety in

England

Creating a system devoted to

continual learning and improvement

Todays session

• Touch on the context in which the NHS is operating and challenges faced

• Share the emerging plans for improving Patient Safety in England – Safety Collaboratives

• Explore essential components of large scale change and a framework for safety improvement

#saferNHS

NHS Improving Quality (NHS IQ)• NHS Improvement body - from 1 April 2013 and hosted by NHS England• Creation of one improvement organisation aligned with the needs and

challenges of the NHS• Provide improvement and change expertise to support improved health

outcomes• A core team working with a range of delivery partners

• Work with healthcare professionals to implement improvements• Across all sectors • Evidence based QI methods

• Bringing together and building on the wealth of knowledge, expertise and experience that has gone before:– NHS Institute for Innovation and Improvement, NHS Improvement,

National Cancer Action Team, National End of Life Care Programme, NHS Diabetes and Kidney Care.

#saferNHS

Focus on Quality

• Safety: Avoiding harm from the care that is intended to help• Effectiveness: Aligning care with science and ensuring efficiency• Patient-experience: Including patient-centeredness, timeliness and equity

#saferNHS#saferNHS

Stakeholders

Safety First and Foremost

Improving Safety in EnglandNational and Local Perspectives

Sarah TilfordImprovement Manager – Patient Safety

#saferNHS

The Francis Report - March 2013

Key messages from the Francis Inquiry 290 recommendations, 4,000 pages

MEDIA: Mid Staffordshire NHS Trust Public Inquiry report published Feb 13

Profits before patients:

Care home residents

subjected to horrific abuse

went to A&E 76 times in

three years - but private

owner did nothing

Follow us: @MailOnline

on Twitter | DailyMail

on Facebook

Julie Bailey of Cure the NHS Campaign stands outside Stafford Civic Centre

http://ec.tynt.com/b/rw?id=bBOTTqvd0r3Pooab7jrHcU&u=MailOnline



http://ec.tynt.com/b/rf?id=bBOTTqvd0r3Pooab7jrHcU&u=DailyMail

http://ec.tynt.com/b/rf?id=bBOTTqvd0r3Pooab7jrHcU&u=DailyMail

Key messages from the Francis Inquiry – 290 recommendations, 4,000 pages

• This was a system failure as well as failure of an individual organisation

• No single recommendation should be regarded as the solution to the many concerns identified

• A fundamental change in culture is required across the NHS

• We need to secure the engagement of every single person serving patients in the change that needs to happen

Post Francis ReviewsFrancis - Keogh and Berwick• Patient safety problems exist

throughout the NHS (14 Trusts)• NHS staff are not to blame• Incorrect priorities do damage• Warning signals abounded and were

not heeded• Concerns about leadership (boards)• Responsibility is diffused and not

clearly owned.• Improvement requires a system of

support• Lack of transparency • Fear is toxic to both safety and

improvement.

Berwick - Responding to Francis

“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

Berwick Report, August 2013

QualityBetter

Old Way(Quality Assurance)

QualityBetter Worse

New Way(Quality Improvement)

Action taken on all

occurrences

Reject defectives

Old Way, New Way

Source: Robert Lloyd, Ph.D.

Requirement,Specification or

Threshold

No action taken here

Worse

National Reporting System

Source: NHS England Patient Safety Domain

2015/16 Further randomised systematic retrospective case note review – an indicator of problems in care resulting in preventable harm

Source: NHS England Patient Safety Domain

Nature of Harm

• Clinical Incidents – SUI, error, omission, failure to treat, failure to respond

• Never events• Complications arising from care intended to

help – HCAI, VTE, pressure ulcers• Patient accidents – falls• All sectors, all patient populations• Result -No harm, mild, moderate, severe, death

Context• Deliberate harm is rare

• System design and human factors contribute to failure

• NHS under pressure and financial challenges

• Rising demand - aging population, long term conditions better treatments & technologies

• Balance between target driven & quality outcomes and experience

We need to do more, with less... to improve standards and experience of care, with a real focus on prevention rather than counting past harm

#saferNHS

Cost of Harm

• Personal costs – patients & families and staff• 1 in 10 patients suffer harm, much of which is likely

to be avoidable• Lost capacity to treat others – affects waiting times• NHS Litigation costs £1.3bn / yr • Damage to institutions reputation• Financial costs – extra bed days, treatment cost• Getting a grip on safety = Economic good sense

#saferNHS

The Patient Safety Collaboratives Programme

2014-2019

Creating a system devoted to

continual learning and improvement

Supporting NHS England Safety Plan

#saferNHS

What will the programme look like?

#saferNHS

Patient Safety Collaboratives

• AHSN footprint

• 2-5m population

• Locally owned and run

• Majority of funding devolved to support local improvement programme activity

• National support for;

• change packages/ interventions;

• knowledge sharing;

• consistent measurement;

• networks/communities.

Who will be involved?

#saferNHS

Patient Safety Improvement Programme

#saferNHS

Creating a mass movement for patient safety in England• A great Improvement Programme is just one small partWe intend to do “lots of lots” • Campaigns • Engage with Patients Groups• Use Social media Tweetchats WebEx MOOCs Hakathons• Engage Emerging Leaders and Trainees• Develop the role of champions / fellows, change agents • Connecting the dots, creating networks, building

capability

@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore

Creating a patient safety movement: four things we can learn from the great social movements

Slides Courtesy of Dr Helen Bevan

Emerging themes in large scale changeFoundation Emerging direction

Organisation Community

Power through hierarchy Power through connection

Mission and vision Shared purpose

Making sense through rational argument

Making sense through emotional connection

Leadership-driven (top down) innovation

Viral (grass-roots driven) creativity

Led by expert opinion Allow all talent

Engaged patients Passionate users

Clinical networks Mass communities

Tried and tested, based on experience “Net Generation” principles

Transactions Relationships

Most large scale change efforts fail to achieve the objectives

Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey

70%

25%5%


Factor 1:Focus on the physiology of change as much as

the anatomy

Anatomy of change Physiology of change

Definition The shape and processes of the system; detailed analysis;

how the components fit together.

The vitality and life-giving forces that enable the system and its people to

develop, grow and change.

FocusProcesses and structures

to deliver health and healthcare

Energy/fuel for change

Leadership activities

measurement and evidence

improving clinical systems reducing waste and

variation in healthcare processes

redesigning pathways

creating a higher purpose and deeper meaning for the change process

building commitment to change connecting with values creating hope and optimism about

the future calling to action

Source: Crump and Bevan

@helenbevan #KPHsafety#KHPsafety#KHPsafety

Lessons for transformational change1. In order to sustain

transformational change, we as leaders need to move from a burning platform (fear based urgency) to a burning ambition (shared purpose for a better future)

2. We as leaders need to articulate personal reasons for change as well as organisational reasons

3. If the fire (the energy) goes out, all other factors are redundant

@PeterFuda


You get the best efforts from others not by lighting a fire

beneath them but by building

Source: Bob Nelson


Factor 3:Frame to connect with hearts and minds


Framing Is the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to action E.g. Civil Rights Activists 1950’sSnow D A and Benford R D (1992)


Factor 4:build shared purpose


NHS Change Model

www.changemodel.nhs.uk#saferNHS


We know that ...

• Shared purpose is a common thread in successful change programmes*

• Organisations and change initiatives with strong shared purpose consistently outperform those without it.**

*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)**Management Agenda 2013 Boury et al (Roffey Park Institute)

Be part of a movement

#saferNHS

Campaign – Sign Up to Safety

#saferNHS

Culture and Learning System – creating the conditions for safety improvement

What does this mean?

#saferNHS

#saferNHS

The safety improvement needs to be built on sound evidence based method and theory - hope is

definitely not the plan!

A Theoretical Framework for Safety

©Allan Frankel and IHI 2013

Culture – the foundations• Culture is uniquely local - the social glue ‘the way we do things

round here’ • High performing teams have agreed norms of behaviour and

structures that create value for the patient, staff and the organisation.

• Measuring culture provides valuable (personal) insights into what it really feels like to work in that environment in a particular role

• Insights can be quite disparate - "the doctors or managers think it's fine, and no one else does"

• Evidence on culture - perceptions about teamwork, safety, and leadership correlate with the quality of care and ‘excellence’

Critical components of culture in healthcare are Leadership, Psychological Safety and Teamwork ©Alan Frankel and IHI 2013

A Theoretical Framework for Safety


Learning – a systemEvery day skilled healthcare professionals face challenges with basic defects and problems that make it difficult to deliver high quality care • A learning system provides a methodical way to visibly

capture concerns, act on them, introducing a cycle of learning and improvement

• This is an essential component of high performing organisations

Critical components of a learning system are Continuous Learning Processes,

Reliability and Improvement and Measurement©Alan Frankel and IHI 2013


In your work area• Learning boards• Defect Identification • Safety walk-rounds• Rapid action – PDSA, driver diagrams, small tests of change • Feedback mechanisms


Our Commitment to Patients

The NHS in England can become the safest health care system in the world.

That will require unified will, optimism, investment, and change.

Everyone can and should help. And, it will require a culture firmly rooted in continual

improvement.

Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the

power of pervasive and constant learning.

Berwick Note:

Berwick Report 2013

Berwick Note For NHS Staff and Clinicians:

• Participate actively in the improvement of systems of care.

• Acquire the skills to do so.• Speak up when things go wrong.• Involve patients as active partners and co-

producers in their own care.

Berwick Report 2013

Improving health outcomes across England by providing improvement and change expertise

Slides Courtesy of Dr Janet Williamson


If you can’t describe the pathway and walk it, you can’t change it.

I hear and I forget, I see and I remember, I do and I understand.

Confucius, Chinese philosopher & reformer

1.


Be clear what your ideal looks like2.

Be BOLD, be ambitious


Focus on the vital few things not long lists3.


Know your improvementmethodology4.

It does not matter which approach, but stick to it

Don’t move into doing until you have baseline, you have data and you are clear about the issues you aretrying to solve


Understand the context5.

Today is about doing more and differently but with the same or less money


Building relationships and building capability from the start

6.

Redesigning the process, the pathway and the structures is easy, the biggest challenge is winning hearts and minds and changing behaviour


Every day, seek to learn and continue to learn

7.


Improvement requirespersonal resilience

8.


Once you operationalise things you are not in an improvement role, so STOP

9.


Happy staff make happy improvers

10.

Thank-you [email protected]

visit: www.nhsiq.nhs.uk

@Sarah_Tilford#saferNHS

mailto:[email protected]

teesside patient safety conference presentations

Healthcare

roffey park

improving

values creating

safety allan

allan frankel

deliver health

components

change connecting