National Patient Safety Collaborative Programme Launch EventTuesday 14 October 2014 - The Montcalm, 34-40 Great Cumberland Place, London, W1H 7TW

NHS Improving Quality and NHS England

NHS

TheAHSNNetworkIn partnership with

3

Contents

Patient Safety Collaborative Programme Agenda

Speaker Biographies

Breakout Session One

Breakout Session Two

Academic Health Sciece Networks’ Safety Plans

Research Project Summary

Hello My Name Is....

4

6

15

18

20

38

40

TIME

10am - 10.20am

10.20am - 10.50am

SESSIONLeadership for Quality Improvement and SafetyChair - Lisa Butland, Director of Innovation,North West Coast AHSN

The leadership difference - Jan Sobieraj,Managing Director, NHS Leadership Academy(15 minutes).

The Board’s role in leading for qualityand safety - a regional approach andprogramme - Lesley Massey, Director ofthe Advancing Quality Alliance (AQuA) (15 minutes).

Leadership for safety – learning fromScotland - Joanne Matthews, Head ofSafety - Healthcare Improvement Scotlandand Jane Murkin, Head of Patient Safetyand Improvement, NHS Lanarkshire (15 minutes).

Panel discussion & questions(10 minutes).

Measurement for ImprovementChair - Tony Roberts, Deputy Director,Quality Assurance Team, South Tees HospitalsNHS Foundation Trust

Is healthcare getting safer? - ProfessorCharles Vincent - Patient Safety Lead,Oxford AHSN (15 minutes).

‘A system based on continual learning: a guide to using measurement forimprovement’- Phil Duncan, PatientSafety Collaborative Lead, NHS ImprovingQuality and Ian Chappell, ImprovementManager, NHS Improving Quality (15 minutes)

The Safety Thermometer andmeasurement for improvement -Abigail Harrison, Senior ProgrammeManager, Measurement and Innovation atHaelo (15 minutes).

Panel discussion & questions(10 minutes).

Collaboratives great and small -learning from experienceChair - Julie Neethling, AHSN BusinessSupport Lead for NHS England

Integrating patient safety into theAHSN’s - Anna Burhouse, Director ofQuality, West of England AHSN, ElizabethDymond, Deputy Director, Enterprise &Translation, West of England AHSN, AnnePullyblank, Clinical Director, West ofEngland AHSN (15 minutes).

Learning from working regionally withcollaboratives - Corinne Thomas,Programme Director, South West Quality andPatient Safety Improvement ProgrammeSouth of England Improving Safety in MentalHealth Collaborative (15 minutes).

Sign up to safety campaign – Nationalconsiderations - Dr Suzette Woodward,Campaign Director for the ‘Sign up to Safety’campaign (15minutes).

Panel discussion & questions(10 minutes).

11.05am - 12 noon

BREAKOUT SESSION ONE: DELEGATES CHOOSE ONE SESSION TO ATTEND:

10.50am - 11.05pm

9am - 10am Registration and coffee

Welcome and the NationalPatient Safety Plan - Dr MikeDurkin (Chair), Director for PatientSafety, NHS England

A facilitated discussion:Patients as partners

Miss Priscilla Chandro, PatientLeaderDr Kate Granger, SpecialistRegistrar in Geriatric MedicineSuzie Shepherd, Chair, RoyalCollege of Physicians PatientInvolvement Unit, Lay Vice Chair,Clinical Services AccreditationAlliance

Coffee and transition to breakoutsession

Breakout session one

National Patient Safety Collaborative Programme Launch Event

4

TheAHSNNetwork

Sharing best practiceChair - Philip Dylak, Director ofTransition, North West Coast AHSN

Achieving behaviour changefor patient safety - JudithDyson, Lecturer Mental Health,University of Hull (20minutes).

Delegate questions(10 minutes).

Sharing best practiceChair - Nigel Acheson, RegionalMedical Director, NHS EnglandSouth

Enhancing quality andrecovery - Acute kidney injury -Kay Mackay, Director ofImprovement, Kent, Surrey andSussex (KSS) AHSN and EdKingdon KSS AKI Clinical Lead,Enhancing Quality (20 minutes).

Delegate questions(10 minutes).

Sharing best practiceChair - James Scott, RegionalMedical Director, NHS EnglandSouth

South of England ImprovingSafety in Mental HealthCollaborative - Shaun Clee,Chief Executive, 2gether NHSFoundation Trust and Dr HelenSmith, Co-Medical Director andClinical Lead, South of EnglandImproving Safety in Mental HealthCollaborative (20 minutes).

Delegate questions(10 minutes).

12.05 - 12.35 - BREAKOUT SESSION TWO: DELEGATES CHOOSE ONE SESSION TO ATTEND:TIME

1.20pm - 1.45pm

2.10pm - 2.55pm

3.10pm - 3.30pm

2.55pm - 3.10pm

SESSION

4.20pm - 4.30pm

4.00pm - 4.10pm

1.45pm - 2.10pm

12.00 noon - 12.05pm - Delegates transition to break out session two

3.30pm - 4pm

4.10pm - 4.20pm

12.35pm - 1.20pm Lunch

Sir Bruce Keogh, National Medical Director, NHS England

Patient Safety Collaboratives - Dr Liz Mear, Chief Executive,North West Coast AHSN and Dr Chris Streather, ManagingDirector, South London AHSN

AHSN local meetings

Coffee break

Supporting and developing Patient Safety Collaboratives -Phil Duncan and Fiona Thow, Patient Safety CollaborativeDelivery Leads, NHS Improving Quality

The national picture - The Rt Hon. Jeremy Hunt MP,Secretary of State for Health

Sign up to Safety - Sir David Dalton, Chief Executive, SalfordRoyal NHS Foundation Trust & Dr Suzette Woodward, CampaignDirector, Sign up to Safety

Summary and next steps - Steve Fairman, Interim ManagingDirector, NHS Improving Quality

Chair: Final remarks and close – Dr Mike Durkin, Director forPatient Safety, NHS England and Professor Norman Williams,Chair, National Patient Safety Collaborative Programme Board

5

Anna BurhouseDirector of Quality, West of England Academic Health Science Network

Anna Burhouse leads on the Quality Improvement programmes, Evidence intoPractice and Evidence into Commissioning and is supported by the QualityImprovement Team.

Anna is a Health Foundation Improvement Fellow, and a Consultant Child andAdolescent Psychotherapist. Throughout her career Anna has specialised inroles which combine clinical and leadership skills to improve the quality andsafety of services.

Priscilla ChandroPatient Leader

Priscilla Chandro suffered a heart attack at the age of 37 and has since gone onto become what she terms as a “professional” patient and publicrepresentative. Her heart attack went undetected for three days, as she wasmisdiagnosed as having flu. Through her “work”, she is conscious ofhighlighting misdiagnosis and “stereotyping” when necessary, as she feels thatthese are not issues solely related to cardiac cases.

Coming from a corporate background, she is now self employed andpassionate about helping others to achieve the “better health outcomes for all”and “no decision about me, without me” straplines.

She is an Ambassador for the British Heart Foundation and has been involved inmany activities, including media work to raise awareness of Women and HeartDisease, member of grant committees, the Cardiovascular Disease OutcomesStrategy and the Keogh Mortality Rapid Response Reviews, amongst others.

She is currently involved as a lay member for the new style CQC hospitalreviews. Her “fixed” positions are as Public Governor for the South East CoastAmbulance service, Secretary for Cardiovascular Care Partnership UK, co-optedmember of council, being the first female patient, for the British Association of

Cardiovascular Prevention and Rehabilitation and as a lay member for the SouthEast Coast Cardiovascular Strategic Clinical Network and Clinical Senate. She isalso part of the national Women’s Health Patient Safety Committee.

“Whether you want to help shift change locally or nationally, there are anumber of ways you can get involved on different levels. I am very fortunate tohave been involved in some amazing opportunities and seen real change as aresult and I would urge anyone to consider helping to shift change wherechange is needed..”

She feels that partnership working between healthcare professionals and thepublic/patients is paramount on many levels. More importantly, when bothsides are “working as one” towards a common goal, this serves as a greatbenefit to the end user.

Shaun CleeChief Executive, 2gether NHS Foundation Trust

Shaun Clee is an experienced NHS Chief Executive with a clinical backgroundand track record of getting things done and successful partnership working.

Shaun has presented at numerous national and international conferences, is anactive member of the International Initiative for Mental Health Leadership, analumni of the Leadership Trust and places a great deal of emphasis onleadership skills development. He chairs the NHS South of England ImprovingSafety in Mental Health Clinical Faculty, has represented the National MentalHealth Network on the Care Quality Commission's Provider Advisory Group andis currently Chair of the NHS Confederations National Mental Health Network,(MHN), a Trustee of the NHS Confederation, a Non-Executive Director of theNHS Confederation, the Health representative on the National Criminal JusticeCouncil, and Chair of Kids Like Us, a Midlands based charity for children, youngpeople and their families who experience Juvenile Arthritis. In his role as Chairof the MHN he has grown the membership to include Social Housing providersand championed a joint statement between the MHN and the National HousingFederation on Mental Health and Housing

Speaker Biographies

6

His organisation, 2gether NHS Foundation Trust, was one of the first 10 MentalHealth Trusts to achieve Foundation Trust status. 2gether NHS FT has sustainedhigh performance since its inception built upon greater engagement andinvolvement internally and externally with partners. His organisation was one ofonly 37 from over 370, to be awarded Excellent for both quality of services andquality of financial management by the CQC in 2009 and has retained aGovernance rating of Green, a Mandatory Services rating of Green and aFinancial Risk Rating of 4 every quarter since authorisation in July 2007.

With over 36 years’ experience in Mental Health services and exposure to someof the best performing teams in America, New Zealand, Canada and Europe,Shaun is always looking to reduce the time from idea to positive impact.He is married, has 3 children in their mid 20's and when asked about hisproudest achievement said "that my kids will call us when we are out to see ifwe fancy a pint with them - even if it is me getting the round in"!

Ian ChappellImprovement Manager – Patient Safety, NHS Improving Quality

Ian Chappell BA (Hons), has worked in quality improvement within the NHS forthe past five years. A qualified Improvement Advisor (IA IHI ProfessionalDevelopment Programme), Ian has worked locally, regionally and nationally onlarge scale change programmes and held improvement roles in a number ofleading North West organisations e.g. AquA, Haelo. Ian has been involved innumerous Breakthrough Series (BTS) collaboratives in an IA capacity and has abackground in measurement for improvement.

Ian is currently an Improvement Manager within the Patient Safety Team at NHSIQ where he leads on Measurement, supporting the National Patient SafetyCollaborative programme and other NHS IQ initiatives.

Sir David DaltonChief Executive, Salford Royal NHS Foundation Trust

Sir David Dalton has been a Chief Executive for 19 years – 12 of these atSalford Royal. He has a strong profile, both locally within Greater Manchester,and also nationally in the areas of quality improvement and patient safety.

Under Sir David's leadership, the Trust set out its clear ambition to be the safestorganisation in the NHS and has adopted a disciplined approach of applied'improvement science' coupled with deep staff involvement.Sir David's other interest is in sustaining an organisational culture which delivershigh reliability of clinical standards, this has included supporting clinical leadersand creating a new framework for aligning an individual's contribution to thegoals and values of the organisation.

Sir David chairs a network organisation of Foundation Trusts - NHS QUEST -which aims to achieve unprecedented levels of quality improvement and he isVice Chair of the Greater Manchester Academic Health Science Network, whichaims to improve health through better adoption of evidence of best practice.Sir David received his knighthood in the New Year's Honours List 2014 for hisservices to the NHS.

Sir David has been chosen by the Secretary of State for Health, the Rt HonJeremy Hunt MP, to lead the Dalton Review into how leading NHS hospitals canexpand their reach to benefit more patients.

Phil DuncanNational Patient Safety Collaborative Lead, NHS Improving Quality

Phil Duncan BSc (Hons), has worked in the NHS for nearly 25 years, firstqualifying as a Registered General Nurse in 1992. Following experience in arange of clinical settings, Phil moved into acute trust business and generalmanagement and then to the Modernisation Agency in 2002. Formerly Directorof the Lung Improvement Programme with NHS Improvement, Phil has alsoworked on other national improvement programmes including those for Heartand Stroke Improvement.

His work interests lie mainly with designing clinical processes that sustainimprovements as well as mainstreaming best practice within organisations. Heis on a personal mission to seek new ways of working and empower staff to‘have a go at change’, but also to think differently about current systems usingthe variety of tools and techniques available.

7

Dr Mike DurkinDirector for Patient Safety, NHS England

Dr Mike Durkin is the National Director of Patient Safety at NHS England. Priorto joining NHS England Mike was the Medical Director of the South of EnglandStrategic Health Authority since 2006.

He qualified at The Middlesex Hospital and has held research and teachingappointments in London and Bristol. He was appointed to the faculty at YaleUniversity School of Medicine where he was also an AttendingAnaesthesiologist. He was Medical Director of Gloucestershire Royal NHS Trustfrom 1993 to 2002 where he has a consultant post in Anaesthesia. He wasappointed as Medical Director and Director of Clinical Quality for Avon,Gloucestershire and Wiltshire Strategic Health Authority in 2002. He has ledclinical performance and governance reviews for Royal Colleges and in NHS andIndependent hospitals in the United Kingdom, for other Strategic HealthAuthorities in England and in 2003/04 for a Ministerial Review in Gibraltar. Hewas on the core team for the Patient Safety Campaign for England as anadvisor on leadership interventions. He sits on Advisory Boards for The HealthFoundation and British Medical Journal Group. He chairs the ManagementBoard of the NICE National Clinical Guidelines Centre.

Elizabeth DymondDeputy Director of Enterprise & TranslationWest of England Academic Health Science Network (WEAHSN)

Elizabeth Dymond has over 10 years of experience within innovation, mostrecently holding the post of Innovation Manager at North Bristol NHS Trust andUniversity Hospitals Bristol NHS Trust. She is part of the innovation workinggroup of Bristol Health Partners. She is a medical engineer by background, andhas worked in the NHS in the areas of Ambulatory ECG and AssistiveTechnology for people with complex disabilities.

Judith DysonLecturer in Mental Health, University of Hull

A qualified General and Mental Health Nurse with a Masters degree in PublicHealth and a PhD investigating the use of psychological theory in influencingthe adoption of best practice by health care practitioners Judith is currently aLecturer in Mental Health. Judith’s research interests include behaviouralpsychology, the implementation of evidence based practice and usingpsychological theory to change behaviour. She is actively engaged inimplementation of evidence based practice in her work as an AcademicImprovement Fellow for the Improvement Academy of the Yorkshire andHumber Academic Health Science Network.

Recent publications: Dyson, J., Cowdell, F., (2014). Development and psychometric testing of the‘Motivation and Self-Efficacy in Early Detection of Skin Lesions’ Index Journal ofAdvanced Nursing (impact factor 1.527).

Büscher, T.P., Dyson, J., Cowdell, F., (2013). The effects of hoarding disorder onfamilies: an integrative review. Journal of Psychiatric and Mental Health Nursing(impact factor 0.795) Jul 21. Doi: 10.1111/jpm.12098.

Dyson, J., Lawton, R., Jackson, C., & Cheater, F. (2013). Development of atheory-based instrument to identify barriers and levers to best hand hygienepractice among healthcare practitioners. Implementation Science, (impactfactor 2.31) 8, 111

Dyson, J., Lawton, R., Jackson, C., Cheater, F., Does the use of a theoreticalapproach tell us more about hand hygiene Behaviour? The barriers and leversto hand Hygiene. Journal of Infection Prevention, 12(1), 2011

8

Steve FairmanInterim Managing Director, NHS Improving Quality

Steve Fairman is the Managing Director of NHS Improving Quality, the nationalbody which supports the NHS to improve the efficiency and effectiveness of itsservices for patients.

Steve joined the NHS following significant spells in Local Authorities and asocial research unit. Trained initially as a demographer and more recently as ahealth economist, he has led a number of complex multi-organisationalimprovement programmes to successful conclusion. His work is based aroundbuilding successful, and influential, partnerships for change – particularly withclinicians.

Steve has previously held Board level positions to Regional level in the NHS andspecialises in improving the quality and cost-effectiveness of public services forend users. Most recently, as Director of Business Improvement & Research forNHS England, he led nationally on the establishment and licencing of AcademicHealth Science Networks (AHSNs), and was a key leader in the NHS Englandapproach to advancing Telecare and Telehealth initiatives.

Dr Kate GrangerSpecialist Registrar in Geriatric Medicine

Hello my name is Dr Kate Granger and I am a final year Elderly MedicineSpecialist Registrar working in Leeds. I graduated from Edinburgh University in2005. My main clinical passion is improving how we look after older peoplewho are dying in the acute hospital setting. I live in Wakefield with my husbandChris. What makes me unusual is that I am also a terminally ill cancer patient,diagnosed with a very rare and incurable form of sarcoma in summer 2011. Ihave shared my illness on the other side through books, my popular blog andfrequent tweeting. I am also the founder of the global #hellomynameiscampaign which aims to encourage and inspire all healthcare workers tointroduce themselves to every patient they meet.

Although I face my impending mortality in the coming months I am also verybusy living a full and happy life as we complete my Bucket List.

Abigail HarrisonSenior Programme Manager – Measurement and Innovation, Haelo

Haelo is an Innovation and Improvement science centre focussed on improvinghealth and healthcare. Abigail Harrison has expertise in improvement scienceand delivery of measurement and change at scale. She leads Haelo’sMeasurement and Innovation teams and leads a number of programmes ofwork including the NHS Safety Thermometer national programme, the MakingSafety Visible programme which builds on the ‘Measurement and Monitoringof Safety’ framework and a programme of work to improve Medications Safety.

Abigail previously managed the NHS Safety Thermometer pilot for the QIPPSafe Care programme and worked with NHS QUEST on building measurementcapabilities, specifically around measuring harm. Before that she worked in anumber of NHS organisations including the Greater Manchester CancerNetwork, Salford Royal NHS Foundation Trust, and Lancashire TeachingHospitals NHS Foundation Trust.

Abigail studied at the University of Manchester for a Masters in EnglishLiterature and before that studied drama, drawing on this learning whenthinking about how we best communicate and share knowledge to improvehealth and healthcare.

The Rt Hon Jeremy Hunt MPSecretary of State for Health

Jeremy Hunt was appointed Secretary of State for Health in September 2012.He was elected as MP for South West Surrey in May 2005.

Professor Sir Bruce Keogh National Medical Director, NHS England

Professor, Sir Bruce Keogh became the National Medical Director for NHSEngland in April 2013. He is responsible for the clinical and professionalleadership of doctors, dentists, pharmacists, scientists and allied healthprofessionals; improving clinical outcomes and promoting innovation. Between 2007-2013 he was the NHS Medical Director at the Department ofHealth. Before taking up his national leadership role he was an associate

9

medical director at University Hospital Birmingham prior to becoming Directorof Surgery at The Heart Hospital and Professor of Cardiac Surgery at UniversityCollege London.

In a distinguished career in surgery, he has been President of the Society forCardiothoracic Surgery in Great Britain and Ireland, Secretary General of theEuropean Association for Cardiothoracic Surgery and a Director of the USSociety of Thoracic Surgeons. He has served as a Commissioner on theCommission for Health Improvement and the Healthcare Commission and wasknighted for his services to medicine in 2003.

Ed KingdonClinical Lead EQ-AKI Pathway, Kent, Surrey and Sussex Academic Health Science Network

Consultant nephrologist at Brighton and Sussex University Hospitals NHS Trustand clinical lead for the AKI pathway for the 11 acute trusts in KSS. Trained inNorth Thames in medicine and nephrology. Lead consultant for the SussexKidney Unit and chair of the Sussex collaborative renal clinical reference group.

Kay MackayDirector of ImprovementKent, Surrey and Sussex Academic Health Science Network

A nursing background; clinical experience in a range of acute and communityspecialities and then at Board level as Director of Nursing and Operations.Continued at Board level in commissioning and service redesign before movingto regional level in 2009 to establish the enhancing quality and recoveryProgramme (EQR) across Kent Surrey and Sussex which has been an incredibleprivilege to lead. (www.enhancingqualitycollaborative.nhs.uk) Next excitingchallenge is to establish the Kent, Surrey and Sussex patient safetycollaborative.

Lesley MasseyDirector of the Advancing Quality Alliance (AQuA)

Lesley Massey is a founder member and Director of the Advancing QualityAlliance (AQuA) an NHS North West of England based membershiporganisation with a focus on quality and safety improvement.

Before joining AquA, Lesley had undertaken a NW regional review of qualityimprovement capability and capacity within NHS care systems. Lesley hasworked in the NHS since qualifying as an Occupational Therapist in 1985; shehas an MA in Health Care Management and has undertaken a number ofsenior leadership positions. Lesley has a passion and commitment to makingimprovements in care quality and patient safety and has designed and ledseveral large scale regional and national improvement programmes particularlyin the areas of reducing avoidable hospital mortality, patient safety campaignsand patient experience programmes, including shared decision making/self-management support. Lesley leads the AquA Academy, overseeing the strategyfor and delivery of training and development for QI, providing the tools andmethodologies for building capability and capacity from boards to the front lineof care delivery. Lesley has particular interest and experience in working withsenior clinical leadership and executive teams as they build their systems forimprovement within integrated quality and safety strategic plans.

Joanne MatthewsHead of SafetyHealthcare Improvement Scotland

Joanne Matthews joined Healthcare Improvement Scotland in April 2013 asHead of Safety for the Scottish Patient Safety Programme following a careerspanning a number of years in the South of England. A nurse by background,Joanne trained and worked in Scotland before moving to England carrying outa number of clinical roles across acute care and NHS Direct.

Following this Joanne moved to the Primary Care Trust (PCT) in Brighton to leadservice improvement across community and acute services before taking on aStrategic Commissioner and Joint Commissioner (Adult Social Care) role across,acute and community care for adults and children. During this time Joanne alsoparticipated within the Department of Health, Long Term Conditions QualityInnovation, Productivity and Prevention (QIPP) leading the Sussex Programme.

Prior to returning to Scotland Joanne successfully led the CCG authorisationprocess for Brighton and Hove PCT and the close down of the PCT in line withthe recent changes to the NHS in England.

10

Dr Liz MearChief Executive, North West Coast Academic Health Science Network

Dr Liz Mear the Chief Executive of The North West Coast Academic HealthScience Network and a Board member of the Health Services ResearchNetwork.

Prior to joining the AHSN Liz was Chief Executive of the Walton Centre NHSFoundation Trust, an acute neurosciences trust in Merseyside, which operates ahub and spoke model of service across a foot print of 3.5 million residents. Lizwas also Chair of the Cheshire and Merseyside Comprehensive Local ResearchNetwork.

Before working at the Walton Centre Liz held a number of Director roles in avariety of NHS organisations including the acute sector, mental health andambulance service.

Liz worked in local government for 17 years, holding a variety of seniorcustomer service roles. Liz has also worked as a Senior ManagementConsultant, specialising in public sector business performance improvementand change management.

Jane MurkinHead of Patient Safety and Improvement, NHS Lanarkshire

Jane Murkin is an experienced change leader with extensive experience in bothnational and local senior leadership roles where she has led on the design andimplementation of improvement programmes to transform health and care. These have included:

• Patient safety and reducing harm • Person centred health and care • NHS Scotland’s Quality Improvement Hub • Whole system patient flow• Planned Care

Jane led on the initiation and early implementation of the Scottish PatientSafety Programme from 2007 till 2010 and the design and initiation of NHSScotland’s Quality Improvement HUB. Having spent several years working in the

Scottish Government, where she also lead on the design and establishment ofimprovement programmes for both patient flow and the Person CenteredHealth & Care Programme for NHS Scotland. Jane worked as a ProfessionalAdvisor for the Chief Nursing Officer on Quality Improvement.

Jane has many years experience teaching, coaching and facilitatingimprovement and supporting organisations and teams to drive a culture of safe,effective and person centred health and care and embedding a culture ofcontinuous quality improvement.

Jane is a nurse and midwife by background.

Anne PullyblankClinical Director, West of England Patient Safety CollaborativeWest of England Academic Health Science Network (WEAHSN)

Anne Pullyblank is the Clinical Director of the West of England Patient SafetyCollaborative.

Anne is also Clinical Director for Surgery at North Bristol NHS Trust, responsiblefor urology, plastic and burns surgery, dermatology, breast, transplant andgeneral surgery. She has a number of years’ experience leading on projects forthe trust and is passionate about improving patient safety.

Dr Helen SmithCo-Medical Director and Clinical Lead South of England Improving Safety in Mental Health Collaborative

Dr Helen Smith is the Co-Medical Director and Consultant Forensic Psychiatristat the Devon Partnership NHS Trust. She is the clinical lead for the QualityImprovement Academy in the Trust and the South of England Improving Safetyin Mental Health Collaborative.

Helen’s first consultant post was within the Forensic Services in the WestMidlands, before moving to Devon in 2004. She has a Master’s degree inCriminology from the University of Cambridge (1996). Helen completed thePatient Safety Officer training at the Institute for Health Improvement (IHI) inBoston USA (2008) and has a Post Graduate Certificate in Patient Safety andClinical Risk Management for the University of Leeds (2010).

11

Jan SobierajManaging Director, NHS Leadership Academy

Jan Sobieraj was appointed Managing Director of the NHS Leadership Academyshortly after its launch in April 2012.

The Academy’s vision is to be a centre of excellence and beacon of goodpractice on leadership development. It is a strategic intervention for the NHS,designed to make sure the health system develops the leadership it needs tomeet the challenges it will face in the coming years.

Jan was appointed after having served in the post of Managing Director forNHS and Social Care Workforce at the Department of Health from July 2011. In 2011 he was seconded from NHS Sheffield where he was Chief Executivefrom 2006 to the Department of Health as Director of Leadership.

He has been a Chief Executive in different NHS organisations for 13 years,including taking Barnsley Hospital to a first wave NHS Foundation Trust. Jan is a Honorary Professor of De Montfort University and a visiting SeniorFellow at Sheffield Hallam University and has held a number of senior roles onnational bodies and in local organisations including Trustee of the HealthFoundation and Local Government Association Leadership Centre.

Over the last 30 years of his management career, Jan has been passionateabout working in partnership with leaders, staff, patients and trade unions toimprove healthcare.

Suzie ShepherdLay chair and RCP Patient and Carer Network

Suzie Shepherd is the current lay chair of the RCP Patient and Carer Network(PCN) and lead for patient involvement in the Future Hospital Programme. ThePCN consists of patients, carers and members of the public from a wide rangeof backgrounds, who have opted to help the RCP develop and enhance itsrelationship with patients in the interest of improving healthcare. Suzie was akey contributor to the Future Hospital Commission through her role.

Suzie sits on several medical boards including the medical accreditation, healthinformatics patient records and revalidation boards, as well as chairingcommittees relating to patient involvement in health and social care includingthe public health agenda. Suzie also speaks regularly at external conferencesand events on behalf of the RCP.

Prior to ill health retirement Suzie worked within the NHS as a hospital traineddental nurse on an oral surgery unit and latterly as a strategic OrganisationalDevelopment and Improving Working Lives Lead in an SHA.More importantly Suzie manages two complex long term conditions and hasboth health and social care service needs in an ever changing, complicatedenvironment.

Dr Chris StreatherManaging Director, Health Innovation Network/South London Academic Health Science Network

Dr Chris Streather is a renal physician by training. He worked at Brighton,Kings, as a National Kidney Research Foundation Fellow, and Cambridge,before being appointed to St Georges as a Consultant in 1997. He becameMedical Director in 2004, later Director of Strategy and worked on the NationalPhysicians Assistant pilot, the RCP Acute Medicine Task Force and Lord AraDarzi’s Framework for Action. In 2008 he was the London Clinical Director asLondon’s Stroke services were comprehensively redesigned and worked on thePrimary and Community Care Advisory Board of the NHS Next Stage Review. Heis Deputy Chair of the London Leading for Health Partnership, a member ofLord Ara Darzi’s Health Commission and Mayor Boris Johnson’s London HealthBoard. From 2009-2012 he was the first CEO of South London Healthcare, andis now the Managing Director of the Health Innovation Network, leading forthe Networks Nationally on Patient Safety. He relaxes with his family, cycling orfollowing the fortunes of Reading FC.

12

Corinne ThomasProgramme Director, South West Quality and Patient Safety ImprovementProgramme, South of England Improving Safety in Mental Health Collaborative

Corinne Thomas, RN, BA (Hon), MA, is Programme Director for the South ofEngland Improving Safety in Mental Health Collaborative, the South WestStrategic Clinical Network Zero Suicide Collaborative and formally for the SouthWest Quality and Patient Safety Improvement Programme. Corinne has 13years experience as a Director of Nursing in organisations providing community,mental health and learning disability services as well as acute care. She hasbeen executive lead for the successful implementation of the Safer PatientInitiative 2, and has practical experience of leading change across a large,complex organisation.

Following her passion for patient safety, in March 2009 she completed thePatient Safety Officer Course at the Institute for Healthcare Improvement inBoston, and in 2010 she qualified as a Team Resource Management Instructorwith Global Air Training. In January 2015, Corinne graduates as anImprovement Advisor with the Institute for Healthcare Improvement.

Fiona ThowNational Patient Safety Collaborative Lead, NHS Improving Quality

Fiona Thow joined the Patient Safety Programme for NHS Improving Quality onthe 1st April 2014 where she will be working with colleagues to support thedelivery and co-production of the national Patient Safety Collaborative acrossEngland, in partnership with NHS England and the AHSNs. Other work willinvolve supporting capacity and capability building to support staff to makeimprovements in safety, based on the needs and choices of patients, theirfamilies and carers. In previous roles she has supported a range of improvementprogrammes across diagnostic services including radiology, audiology,endoscopy and physiology diagnostic services over the last 5 years. A recentinitiative included supporting the early work on 7 day service delivery models.

Following a clinical career as a radiographer and clinical manager, Fiona movedinto service improvement in 2001.She has held a range of service improvementposts across a range of specialties working at Trust, SHA and National level andhas undertaken several initiatives with the Department of Health. She gainedan MBA from Durham in 2000.

Fiona is very much looking forwards to working with staff, patients, theirfamilies and carers to support the design and delivery of a national safetyprogramme that will build on areas of excellence and create the conditions tospread and sustain best practice nationally. Creating a culture of openness,where staff and patients feel supported to raise concerns and shape their ownimprovement efforts locally, she believes will be key to success.

Charles Vincent M Phil PhDProfessor of Psychology, University of Oxford

Charles Vincent trained as a Clinical Psychologist and worked in the British NHSfor several years. Since 1985 he has carried out research on the causes of harmto patients, the consequences for patients and staff and methods of improvingthe safety of healthcare. He established the Clinical Risk Unit at UniversityCollege in 1995 where he was Professor of Psychology before moving to theDepartment of Surgery and Cancer at Imperial College in 2002. He is the editorof Clinical Risk Management (BMJ Publications, 2nd edition, 2001), author ofPatient Safety (2ned edition 2010) and author of many papers on medical error,risk and patient safety. From 1999 to 2003 he was a Commissioner on the UKCommission for Health Improvement and has advised on patient safety in manyinquiries and committees including the recent Berwick Review. In 2007 he wasappointed Director of the National Institute of Health Research Centre forPatient Safety & Service Quality at Imperial College Healthcare Trust. He is aFellow of the Academy of Social Sciences and was recently reappointed as aNational Institute of Health Research Senior Investigator. In 2014 he has takenup a new most as Health Foundation professorial fellow in the Department ofPsychology, University of Oxford where he will continue his work on safety inhealthcare.

13

Dr Suzette WoodwardNational Campaign Director, ‘Sign up for Safety’ Campaign

Suzette Woodward is the national Campaign Director for Sign up to Safety, acampaign to support the NHS in England to save 6000 lives and reduce harmby 50%. Suzette has worked at a national and international level in patientsafety for over 20 years. She is seconded from her executive director role insafety and learning at the NHS Litigation Authority. Previous to this Suzettewas Director of Patient Safety at the National Patient Safety Agency. Suzettespecialises in implementation of patient safety initiatives using campaigningand movement expertise and led the Patient Safety First Campaign. She has adoctorate in patient safety implementation and masters in clinical risk fromUCL. Suzette was named as one of the top 50 Inspirational women in the NHSin 2013 and named one of the top Nurse Leaders in the NHS in 2014.

14

Leadership for quality improvement & safety Chair – Lisa Butland, Director of Innovation, North West Coast AHSN

The Leadership differenceJan Sobieraj, Managing Director, NHS Leadership Academy

The Patient Safety Collaborative has set out two key enablers - measurementand leadership. Good leaders make a significant difference to the quality ofpatient care and the NHS Leadership Academy is an England wide agencydesigned to improve the leadership skills of leaders at all levels of the widerhealthcare system. The 15 minute presentation will outline: Why leadership isan important factor to safety improvement, How the NHS Leadership Academyis supporting the development of leaders, The opportunities that exist todevelop leaders through the Patient Safety Collaborative.

The Board’s role in leading for quality and safety- A regional approachand programmeLesley Massey, Director of the Advancing Quality Alliance (AQuA)

AQuA has been working with Boards and senior leadership teams for severalyears and has established a development programme aimed at building thecapability of those teams in the improvement, oversight and governance ofquality and patient safety. Our ambition is to support every organisation tobuild a system for improvement within a quality and safety strategy. A view intothat work is given and an insight into next stage developments for both acuteproviders and for CCG governing bodies.

Leadership for safety – learning from ScotlandJoanne Matthews, Head of Safety, Healthcare Improvement Scotland and Jane Murkin Head of Patient Safety and Improvement, NHS Lanarkshire

Scotland’s Patient Safety JourneyThis session will describe the safety work within NHS Scotland and share thekey leadership interventions and explore the leadership and cultural impact thishas had at both a national and local perspective.

Through Collective LeadershipScotland’s policy focus and commitment to a quality improvement approach todeliver safe, effective and person centred care within healthcareNational and local Infrastructure to support implementation Translated to care at the bed side.

Breakout Session One 11.05am – 12.00 pm (Delegates choose one of the following)

15

Measurement for improvementChair – Tony Roberts, Deputy Director, Quality Assurance Team, SouthTees Hospitals NHS Foundation Trust

Is healthcare getting safer’? Professor Charles Vincent, Patient Safety Lead, Oxford AHSN

Patient safety has been high on the national and international agenda in healthcare for over a decade. Studies around the world have shown that over 10% ofpatients experience an adverse event while in hospital. Considerable effortshave been made to improve safety, and it is natural to ask whether these effortshave been well directed. Are patients any safer? The answer to this simplequestion is curiously elusive. Although some aspects of safety are difficult tomeasure for technical reasons (defining preventability for instance), the mainproblem is that measurement and evaluation have not been high on theagenda. There is evidence of major safety improvements from specificprogrammes but it has been hard to demonstrate large scale improvements insafety. The presentation will reflect on the challenges for the new patient safetycollaboratives.

A system based on continual learning: a guide to using measurement for improvementPhil Duncan, Patient Safety Collaborative Lead, NHS Improving Quality and Ian Chappell, Improvement Manager, NHS Improving Quality

The purpose of this presentation is to explore what systems that learn look likeand how they ensure a learning cycle as opposed to one off encounters. Thissession aims to:

• Provide an overview of what continual learning looks like within healthcare, from national to local levels and offer insight into the opportunities for safety that continuous learning provides

• Outline the Safety Framework and explore how continuous learning underliesall aspects of safety improvement, from measuring improvement, providing evidence of where to focus improvement efforts and as one indicator of a safe working culture

• Review how we currently use data nationally to monitor patient safety and the challenges of national and local measurement of safety improvement

• Outline 5 key principles of measurement for improvement• Priority Setting and Baseline development• A small number of operationally defined measures• Understanding variation through regular measurement over time• Smart analysis: how to cut the data to provide learning• Qualitative Review: using regular reporting to provide theories of change.

The Safety Thermometer and measurement for improvementAbigail Harrison, Senior Programme Manager, Measurement and Innovation, Haelo

An overview of the NHS Safety Thermometer in the context of the AHSNPatient Safety Collaboratives including:

• Context and challenges with measuring improvement • What Safety Thermometers are available • What baseline data you and your members already have access to • How you can use the data for your Patient Safety Collaboratives

16

Collaboratives great and small – learning fromexperience Chair – Julie Neethling, AHSN Business Support Lead for NHS England

Integrating patient safety into the AHSN’sAnna Burhouse, Director of Quality, West of England AHSN, Elizabeth Dymond, Deputy Director, Enterprise & Translation, West of EnglandAHSN, Anne Pullyblank, Clinical Director, West of England AHSN

In the South West of England we have run a patient safety collaborative for 5years involving 18 trusts with workstreams on peri-operative care, medicinesmanagement, general ward, critical care and leadership. We have experience intraining for quality improvement, running themed workshops, developingfaculty and producing a system for measurement. We reduced HSMR sodelivered a real patient safety benefit. This was expanded from secondary careto include mental health. We will present how we plan to use this existingstructure to build the AHSN collaborative and how we will integrate the workwith primary care and other sectors.

Learning from working regionally with collaborativesCorinne Thomas, Programme Director South West Quality and Patient SafetyImprovement Programme, South of England Improving Safety in Mental HealthCollaborative

"Working collaboratively to achieve a common aim – my experience”

In this session your will hear about one methodology you may consider whendeveloping and running a collaborative. You will appreciate the factors criticalto success as well as understand some of the challenges you may face duringthe life of your collaborative.

‘Sign up to Safety’ campaign – national considerations Dr Suzette Woodward, Campaign Director, ‘Sign up to Safety’ campaign

A brief overview of the ‘Sign up for safety’ campaign.

17

Sharing best practice Chair, Philip Dylak, Director of Transition, North West Coast AHSN

Achieving Behaviour Change for Patient SafetyJudith Dyson, Lecturer Mental Health, University of Hull

Achieving Behaviour Change for Patient SafetyThe problems with implementing best practice are widely acknowledged.Interventions to change practice have had limited success. Two reasons havebeen identified for this:

• Implementation strategies are not based on prospective assessment of barriers and levers to practice and

• There is generally no theoretical basis informing the assessment of barriers and levers and the subsequent implementation strategies employed.

The Improvement Academy, embedded in the Yorkshire and Humber AHSN isworking with internationally recognised behaviour change experts to apply atheoretical approach to implementation through: i) regular, regional workshopsoffering instruction on this approach, ii) a publically available behaviour changetoolkit offering resources and examples for the adoption of this approach andiii) support for healthcare practitioners in clinical practice with applying thesetechniques to patient safety issues.

This presentation will offer a brief outline of the behaviour change techniquesemployed by the Academy and will demonstrate the feasibility andeffectiveness of this approach by giving examples of its application in practice.

Breakout Session Two 12.05pm – 12.35 pm (Delegates choose one of the following)

Sharing best practice Chair – Nigel Acheson, Regional Medical Director, NHS England South

Enhancing Quality and Recovery – Acute Kidney InjuryKay Mackay, Director of Improvement, Kent, Surrey & Sussex (KSS) AHSN and Ed Kingdon, KSS AKI Clinical Lead, Enhancing Quality

The Kent Surrey and Sussex Enhancing Quality and Recovery Programme is alarge scale clinical change programme aimed at embedding best practice andreducing variation in care and outcomes for patients. The vision was that thecare a patient received would comply with known best practice and should notdepend on what hospital they attended, which clinical team they saw, what dayof the week or what time of day they received their treatment. The AcuteKidney Injury (AKI) pathway began in 2011 with the aim of enhancedrecognition of AKI, implementation of simple responses to AKI in all clinicaldisciplines and to spread learning rapidly across all acute hospitals in KSS. Theprogramme relies heavily on systematic, rigorous measurement to producecredible, clinically-relevant benchmarking. Clinical leadership with local supportand ownership by each organisation is critical in achieving the goals.

18

Sharing best practice Chair – James Scott, Regional Medical Director, NHS England South

South of England Improving Safety in Mental Health CollaborativeShaun Clee, Chief Executive, 2gether NHS Foundation Trust and Dr Helen Smith, Medical Director, Devon Partnership NHS Trust

Taking to the floor and learning to dance: The highs and lows of settingup and running a Safety Collaborative in Mental HealthMental Health Trusts in the South West of England and more recently acrossthe South of England have been working with the Institute for HealthImprovements (IHI) breakthrough collaborative model since 2011.

Our experience over this time has taught us a lot about how to set up andrunning a collaborative and the fundamental building blocks that organisationsneed to have in place to benefit most from this approach and to developsustainable positive change.

Leadership attention and organisational infrastructure are crucial in developingthe fertile ground required to grow and propagate quality improvement acrossan organisation.

Our presentation will share with you the challenges and our attempts toovercome them and our successes.

19

20

Academic Health Science Networks’ Safety Plans

Patient Safety: A National and Local Priority

Contacts: Dr Robert Winter EAHSN Managing Director - robert.winter@eashsn.org Susan Went EAHSN PSC lead - susan.went@eahsn.org

Design Principles. We will seek to make our collaborative practical and helpful by: Building on the strength of our existing patient safety work; Working in partnership with staff, carers and users to design the work programme; Working in partnership with other organisations and networks involved in safety; Avoiding duplication for the service; Aligning interventions across care settings, reducing the number of unique or sector specific interventions; Advocating organisational, managerial and clinical leadership for safety and quality; Developing the capacity and capability of the system to use data and to drive improvements in quality and safety; Working across the continuum of improvement, testing innovative ideas, spreading good practice and encouraging reliable implementation; Ensuring evaluation is integral to the design and delivery.

Our Patient Safety Collaborative aims: Across the AHSN system: To develop a QI infrastructure which will support continued service improvement and innovation At the point of care: To listen to and address the safety concerns of older patients, their carers, and the staff caring for them

Our Partners EAHSN Patient Safety Clinical Study Group East of England Citizens Senate NHSIQ AQuA /NHS Leadership Academy/CLAHRC EAHSN Academia

Delivery method Adapted BTS collaborative model with twice yearly whole system learning events

HIGH LEVEL PLAN

21

EMAHSN has consulted and engaged with our partners to

develop consensus on key patient safety priorities [see below].

We will: build alliances to optimise and share existing best

practice support and enable organisations to accelerate the

pace and scale of improvement activities.

cheryl.crocker@nottingham.ac.uk

07808647120 www.emahsn.org.uk @EM_AHSN

22

23

Oct Dec ‘14 Jan March ‘15 Apr Jun ‘15 July Sept ‘15 Oct Dec ‘15 Jan Mar ‘16

Patientowned care

Identify what makes a patient feel safe when taking medicinces

Qualitativeexploration with patient groups

Utilise output to inform work streams e.g. what does good patient information look like, supporting mechanisms for on going

Patient access to their data

Link to connected healthcare monitoring below

Point of care testing Increase the uptake of point of care testing for anticoagulant monitoring – 3 CCGs participating

Patient decision aids Work with designer of NICE CG Patient Decision Aid to support evaluation andunderstanding of GP educational needs in using this tool

Supported self care & self management

From identified sites / CCGs support the uptake in self monitoring and selfmanagement – 3 CCGs participating

Solving problems

Understand baseline data

Utilising existing database sources tounderstand patient safety in terms of medicines utilization, linked to the harms in PSC safety topics

Governance GMAHSNwill co ordinate programme, source and analyze information andmeasurement from across the local health economy and provide feedback

Build leadership & workforce capabilities in safety

AQUA programme inc advanced team training (12 teams of 6), PS champions training (40 people), improvement practitioner modules 240 places) and Sign up to Safety Network launch and 6 month engagement for all AHSN members (up to 160 attendees) Health Foundation ’Closing the Gap’ programme for Board Level Collaborative on safety (10 localities), commencing in Feb 15

Connected healthcare monitoring

Utilise capabilities of existing systems that allow patients access to their records eg. Renal Pt View, and adapt, adopt and spread

Real timemonitoring & measurement

Increase uptake of FARSITE in GPpractices across AHSN footprint from 25% to 60% by March ‘15

Increase uptake of FARSITE in GP practices across AHSN footprint from 25% to 60% by March ‘15

Social networking & media

Working with FT to design and run aHackathon for young adults with Diabetes

New mechanisms

for care

Evidence the interventions which improve adherence

Work with colleagues in Primary Care Patient Safety Translation Research Centre to align current evidence, further advance research studies and spread of PINCER studies.

Drug safety monitoring in real world

Identify and work with 2 sites for utilisation of GP practice level safety dashboards designed by Primary Care Patient Safety Translation Research Centre, refine prior to spread of tool.

Early adoption of evidence, research & technology

Launch & deployInnovation Nexus (IN) review and support of SME developments

Ongoing IN delivery with evaluation of impact and return on investment. In partnership with NICE design an audit tool for the uptake of NICE guidelines for Medicines Management in Nursing homes

Identify unmet health care needs and support development

TechnologyInnovation Fund – Nutrition and Hydration £80k

TechnologyInnovation Fund – Medicines Optimisation £80£

Scope All members across GM e.g. Community hospitals, nursing homes, district nursing teams, acute hospitals, mental healthcare, commissioning

GMAHSN Patient Safety Collaborative – Plan on a Page

24

25

26

Health Innovation Network Patient Safety Collaborative -Patient Safety from Board to Bus StopThe Health Innovation Network (HIN) is embarking on a five-yearprogramme to support NHS organisations in South London in achievingtheir patient safety aims, from Board to Bus Stop. The HIN Patient SafetyCollaborative (PSC) will be built with over time with patients and carers,frontline staff, Board leaders and other stakeholders, working together acrossthe whole healthcare system - from hospitals to patients own homes - to co-design interventions and initiatives to reduce avoidable harm, save lives andembed a patient safety culture.

Our embedded aims are to support South London health and social careorganisations to:

• Develop strong leadership and to set an early collective tone and approach for improvement

• Ensure that patients and carers are at the heart of our programmes, actively involved in both design and delivery of projects

• Identify evidence-based and reliable practice (locally, nationally and internationally), and to scale up and spread this in a sustainable way

• Embed a safety culture and help spark social movements for safer care through broad staff involvement

• Develop improvement capability within organisations and leaders• Help staff analyse, monitor and learn from safety and quality information• Be a national exemplar of practice, and to create strategic partnerships with other exemplars

• Develop interventions and initiatives which can be applied or adapted to all care settings.

We are working with our stakeholders to understand which patient safetyissues should be prioritised, and how a collaborative approach might be able toadd value to what organisations are already doing to meet nationalrequirements. The programme will also be closely linked with national and localinitiatives, including ‘Sign up to Safety’, Quality Accounts, Safety Thermometer,NHS Change Day, and King’s Health Partners Safety Connections programme.

Priorities identified for potential early action identified include: pressure ulcers,falls, catheter-associated urinary tract infection (CAUTI), deteriorating patient,and medications safety (insulin management). In year one, plans are under wayto scale up the following interventions:

• Right Insulin, Right Time, Right Dose – a breakthrough collaborative focused on reducing harm to diabetic patients through better insulin management.

• No Catheter, No CAUTI – a collaborative to reduce harm from CAUTIs by improving appropriate urinary catheter management in patients in hospital and following discharge.

• A range of interprofessional interventions are being explored, including a potential interdisciplinary ‘rounding’ offer and development of communities of practice.

All interventions will be underpinned by a strong measurement functionsupporting front line staff, and focused work with local educationcommissioners to scope educational needs in priority areas and to ensure thatthese needs can be met. A faculty of experts will act as critical friends for thePSC, advising on proposals, evaluating impact, and acting as coaches,facilitators and mentors for PSC projects and for HIN member patient safetyinitiatives. Over time, we will evaluate impact, and embed programmes,ensuring sustainability in the long-term. We will also deliver stretch targets(expanding work to cover additional priority areas), develop commercialpartnerships, and explore innovative technologies that support patient safety.

IMPERIAL COLLEGEHEALTH PARTNERSPatient Safety Programme

Our vision is to support organisations to embed safety in every aspect of their work. This means:

Patient and carer views are obtained and heard at all levels as a critical indicator of safety

There is a strong ethic of team working and shared responsibility for patient safety

Effective safety measurement and monitoring systems are in place in all clinical settings

Clinical processes, practices, equipment and environment are standardised and

Patient Safety Champion Network

Our programme will deliver:

involvement and participation in patient safety improvement initiatives across NWL

issues and protocols amongst senior staff

practice among partner organisations

doctors’ induction across NWL

and reduction in prescribing errors

to reduce variation

Foundations of Safety Best

Practice Forum

NWL wide series of expert forums for nominated Board executives, non-executives, senior leaders, commissioners and patient representatives. Participants will be able to foster shared best practice and innovation to deliver organisational and cultural change.

Safety measurement

and monitoring

Collaboration with NHS trusts to test and further develop – through application in practice – a holistic framework for measuring and monitoring safety, developed by the Centre for Patient Safety and Service Quality

Prioritisation of research

Research to identify clinician and patient views on the key priorities for patient safety in primary care, mental health and cancer care.

Provides crucial intelligence to support future initiatives within these domains.

Prescribing improvement

model

Pilot improving pharmacists’ provision of feedback to doctors on their prescribing errors, which aims to support better communication between pharmacists and doctors.

Standardising junior doctor

inductions

deaths associated with hospital care, in order to assess what proportion Avoidable mortality research

a single communication channel for key safety messages to be delivered to this group.

Contact us For more information contact our Patient Safety team on:ea@imperialcollegehealthpartners.comWebsite: www.imperialcollegehealthpartners.comTwitter: @ldn_ichp

VISION PROJECTS DESCRIPTION OF ACTIVITY MEASURING IMPACT

supporting and promoting their involvement in the design and delivery of the Partnership’s patient safety work programme.

27

-

-

28

Measured using the following success criteria

Having clear measurable objectives atprogramme and project levels

Improvements in patient safety asmeasured by milestones and KPIs

Bi monthly progress reports showingproject development and spread ofimprovement.

Match funding and wealth creation usedas a criteria for investment.

AHSN additional funding sought throughbusiness development opportunities.

Objective 1: Leadership and accountability

To ensure that there is leadership andaccountability for safety throughout the

system

Objective 3: Transparency, reliability,resilience, learning and improvement

To foster a safety culture of transparency,reliability, resilience, continual learning and

improvement, based on sound safetyscience

Objective 4: Working in genuinepartnership

To develop genuine partnerships betweenthose who give care and those who receive

care to improve their safety

Delivered through:• Effective governance at project, Academic Health Science Network and national levels• Membership of national Steering group• Membership of Measurement and communications sub groups• Delegation to national launch event.

NENC Patient Safety Collaborative plan on a page 2014/15

Delivered through:• Systematic spread of quality improvements across health and social care.• To be innovative, whilst grounded in evidence and using tried and tested methods• To build upon existing initiatives and stimulate new ideas linked to national and local

priorities

Overseen through the following governancearrangements:

Accountable to NHS ImprovingQuality/NHS England at a national level.

A Board and Exec Team that arecredible, engaged and active in supportof the AHSN objectives

Clear leadership from SRO, supportedby a small core team

A well run Steering Group,representative of and responsive toconstituent stakeholders and projects

Robust management of SLAs andproject specific contracts for all funding

Proactive and vibrant communicationensuring broad stakeholder awarenessand engagement

Objective 7: Sign up to Safety

To align with and complement theambitions of the ‘Sign up to Safety’

campaign

Delivered through:• Locally owned and structured quality improvement initiatives leading to transformational

change• Active management of the circa £465k of Patient Safety Collaborative funding (£275 from

national pot and £190k from existing AHSN budget)• Ensuring improvements are measurable and sustainable

Delivered through:• Building system wide capability for staff and patients in patient safety improvement science.• Creating environments and opportunities where people can come together to learn from

each other, including regional engagement and project learning events

Objective 6: To collaborate

To enable NHS staff in the North East andNorth Cumbria to have the opportunity to:work together in a collaborative way, bothinside and outside their own organisations

and with national and internationalexpertise

Delivered through:• A focus on patient centred approaches, which engage the patient in understanding and

managing their own safety in accordance with their wishes.• To co produce solutions involving staff and patients

Delivered through:• People being supported to engage with all levels of the organisations within which they

work• Bringing together patients and carers, national and international safety expertise with

practical experience, in partnership with NHS England, NHS Improving Quality, and othernational, international and local bodies interested in improving safety

• Being inclusive of all health sectors, with parity of mental, physical and psychologicalhealth, in particular focussing on safety across care boundaries

• Working in partnership with other AHSNs where there are opportunities to share expertise

Delivered through:• Encouraging local organisations to sign up to the campaign and to develop credible plans to

achieve the campaign objectives• Help participants in the national patient safety fellowship scheme to achieve their

objectives locally, through networking and other support

Objective 2: Creating the conditions forsafety

To create the conditions that help preventpatient safety incidents from occurring in

the first place, engendering a sense of pride

Objective 5: Improvement programme

To deliver a system wide, locally ownedand led, programme that delivers year on

year improvements in safety

29

30

North West Coast Academic Health Science Network Patient Safety Collaborative

Organisations involved to dateNWC AHSN has involved all of its NHS partners – providers,commissioners and improvement bodies (AQuA, HAELO and NWLeadership Academy) in the development of its proposals and plans forthe PSC (please visit www.nwcahsn.nhs.uk for details of colleagueorganisations). On 17 September, NWC AHSN held a stakeholderengagement event to which all of its NHS and academic partners wereinvited. The event was designed to gain agreement on a number ofclinical and action priorities proposed by the AHSN. Organisationsunable to send representatives have been consulted on the outcomes ofthe day.

Priority areas of workNWC AHSN will ensure that all of the current NHS England requirementsare met. Based on outputs from its recent enagement event, its clinicalsafety priorities will be medicines optimisation; management of sepsis;transition between paediatric and adult care; and hydration. It hasalready agreed a contract with a provider for a significant element of itsmedicines optimisation work.

Its priority areas for action will be providing Board level development insafety; providing safety training and development to staff working atpatient care level; agreeing a regional policy on patient safety; setting uplearning networks around safety improvement themes; developingsafety champions or leads in each organisation; and undertakingtechnology reviews to identify solutions to safety issues.

High level workplan/approachNWC AHSN will continue to use the principle of working with existingstructres and resources, unless they are patently unfit for purpose.

To drive and accelerate the Patient Safety agenda, NWC AHSN hasissued, with a short turnaround, a number of Preferred SupplierAgreements to regional improvement bodies for support to itsimprovement themes (which will be at the heart of how the PSC bringsabout improvement); building leadership capacity and capability;networking; board development; and measurement and data analysis.NWC AHSN has asked all its suppliers to work within the establishedstructures for patient, carer and community engagement.

ContactNorth West Coast Patient Safety CollaborativeC/O North West Coast Academic Health Science Network, VanguardHouse, Daresbury Sci Tech, Keckwick Lane, Daresbury, Warrington,Cheshire, WA4 4AB

Philip Dylak, Programme Manager (Patient Safety) T: 01772 520282M: 07538 022771E: philip.dylak@nwcahsn.nhs.uk

North West Coast Patient Safety Collaborative

32

Oxford Academic Health Science Network Patient Safety Collaborative

Achieving safe health care has the potential to bring very great benefitsto patients, families and all involved in the delivery of care. The impactof even small improvements in patient safety is massive, both in terms ofreducing the disease burden and in the huge economic benefits of saferhealthcare. Many safety initiatives are in progress in the Oxford AHSNgeography in acute NHS hospitals, community and mental healthsettings and in the patient’s home. The bodies involved in this workinclude NHS acute trusts, NHS community trusts, NHS mental healthtrusts, care homes, social care bodies within county councils, carecommissioning groups, universities and pre-existing collaboratives andfederations.

The Oxford Academic Health Science Network Patient SafetyCollaborative (PSC) will initially focus on a small number of clinicalprogrammes but also act as an umbrella and coordinating centre for themany important patient safety initiatives, both practice and research,within the Oxford AHSN geography of Berkshire, Buckinghamshire,Bedfordshire and Oxfordshire. The PSC will work alongside the clinicalnetworks within Oxford AHSN’s Best Care programme and ultimately beaccountable to the Oxford AHSN Partnership Board on which all NHSproviders, CCGs and Universities are represented.

The principal aims of the PSC will be to:• Develop safety from its present narrow focus on hospital medicine to embrace the entire patient pathway

• Develop and sustain clinical safety improvement programmes within the Oxford AHSN

• Develop initiatives to build safer clinical systems across the Oxford AHSN

• Collaborate and support sister safety programmes both nationally and internationally.

Early priorities are:• The active engagement of patients and carers• The development of a safety information system for the PSC• Establishment and support of programmes on acute kidney injury, medication safety, pressure ulcers and safety in mental health

• Developing capacity and capability in leadership for safety improvement.

The PSC has chosen to focus on a small number of core areas in the firstinstance. We are conscious that further consultation needs to take placewith a wide range of partners and that the full programme of work willonly emerge gradually. The priorities set out here should be seen as astarting point and not a definitive account.In time we hope to develop programmes which will address risks andsystems vulnerabilities across the system and which are oriented towardsbuilding a safer healthcare system. Our longer term aim must be todesign safe systems of care rather than address individual safety andquality issues.

33

34

UCLPartners’ Patient Safety Programme: A collaborativeapproach to sustained improvement in patient safety The aim of the UCLPartners programme is to build, develop and supportimprovement capabilities for front-line staff and to improve patientsafety outcomes for a population of six million people across ourpartnership. Our focus is on progressively reducing avoidable harm andembedding safety through an ethos of building continuous improvement intoroutine practice at scale; establishing safety as normal practice acrossUCLPartners. Nine design principles inform our approach. These are:• To have meaningful patient, carer and family involvement• To make partnership initiatives relevant to local priorities; embedding safety into mainstream delivery

• To make safety relevant to the mainstream front line of care• To build networks across the partnership and promote shared learning • To ensure educational and trainee involvement and build leadership capacity in safety

• To ground work in authentic and rigorous time series measurement • To support partner organisations to build improvement capacity and capabilityat scale

• To implement core informatics enablers for safe care• To ensure robust evaluation.

Our approach to measurement will align teams’ understanding of where theyare currently and where the highest priority areas for attention lie. This isrooted in four simple questions:• Do you know how good you are?• Do you know where you stand relative to the best?• Do you know how much variation exists, and at what level in your system?• Do you know your rate of improvement over time?

UCLPartners will ensure the safety and improvement work draws from andinforms/supports work in other regions and AHSNs wherever it usefully can.We are focusing on informing commissioning priorities and approaches tobetter align the whole system in supporting safety and improvement mosteffectively.

Building on existing foundationsUCLPartners’ patient safety programme builds on improvements and learningsgained from existing UCLPartners collaborations including, the DeterioratingPatient Initiative, which over the last three years has grown to involve 16 acutetrusts across UCLPartners’ geography.

Our priorities are derived from patient and population need matched to partnerorganisations’ current safety priorities and their views on where partnershipworking can add most value to local safety efforts. A small team, rooted in theefforts of clinicians and front line teams across the partnership, will report to theUCLPartners Executive, via a Programme Board chaired by Clare Panniker, ChiefExecutive of Basildon and Thurrock University Hospitals NHS Foundation Trust.

The initial priorities include sepsis and acute kidney injury (AKI). Discussions areongoing with partners regarding other partnership-level priority areas, forexample, falls and pressure ulcers. Each of these areas contributes to our overallaim of reducing mortality across the partnership, and, crucially, each is alsoamenable to a whole health system approach – i.e. relevant in all settings fromcare homes/usual place of residence to the acute hospital.

Each of UCLPartners’ integrated AHSN programmes is placing further and moreexplicit emphasis on patient safety. These programmes include: cardiovascular,mental health, neuroscience, children and young people, cancer and complexpatients. Their priority areas are currently being determined.

About UCLPartnersUCLPartners is an academic health science partnership with over 40 highereducation and NHS members, including 23 acute, mental health andcommunity NHS organisations. Through UCLPartners, members collaborate toimprove health outcomes and create wealth for a population of over six millionpeople in north east and north central London, south and west Hertfordshire,south Bedfordshire, and south west and mid Essex. Tel: 020 7679 6633 www.uclpartners.com

UCLPartnersAcademic Health Science Partnership

35

West of England AHSN – Patient Safety ‘Plan on a page’2014/15 – 15/16 (Draft v0.3)

Patient safety as‘everybody’s business’

• Leadership at all levels

• Map current quality/patient safety improvement capability• Development of patient safety Faculty/Fellows cohort• WofE AHSN Improvement Academy• Human factors (comms) training for Bands 1 4 & their managers• Foundation Doctor QI training and project support network

• Development of a measurement strategy to identify local needsand priorities using data that is already collected wherepossible, and using metrics that are meaningful to local people

• Identification and set up of a suitable measurement system• Measurement & evaluation strategy

Focus on local needs andpriorities

• Measurement capability & capacity• Provision of measurement for improvement capability training

to build capacity in the WoE health system ?analysts? MDs?

• Engagement and involvement of staff, peoplewho use services and members of the public

• Multi method engagement and involvement programme tosupport priority development, conversations about patientsafety, and communicating with the WofE community

• STAR Emergency Department (supported by THF Shine)• Maternity tbc• Single West of England Early Warning Score to identify and

respond to patients whose health deteriorates

• New ways of working to enhance patient safety

Innovating & developingnew approaches

• Primary care and community incident reporting and adverseevent response and analysis process (based on work in Cornwall)

• Incident reporting and multidisciplinary response

Matching leading practice • Programme of workshops on falls, medications optimisation,VTE, pressure ulcers, CAUTI, critical care, peri operativepractice (based on work of Safer Care South West)

• South of England Mental Health Collaborative• PINCER/ECLIPSE medications (based on work in other AHSNs)• Sepsis (from national priorities)• Emergency laparotomy (spreading from the RUH/RSCH pilot)• Acute kidney injury

• Condition specific safety programmes

• Map current quality/patient safety improvement successes• Developing approaches to optimise speed of spread and

adoption of leading practice across the West of England

• Spread methodology

36

Wessex Patient Safety CollaborativeWorking to improve safety for patients in Hampshire, Dorset , Isle of

Wight and South WiltshireWessex Patient Safety Collaborative Support TeamWessex AHSN Chief Executive – Martin Stephens

Director of Patient Safety Collaborative – Keith LincolnClinical Lead for Patient Safety Collaborative – Professor Jane Reid

Patient Safety Collaborative Manager – Geoff Coper(emails to: first name.lastname@wessexahsn.net)

Priority Safety Topics

Subject to a Launch and Listen event on 11 Nov 14 where the emphasis will be on codesign and co production, the Wessex Patient Safety Collaborative will look toaddress the following areas in the first instance:

The ‘essentials’Leadership and Measurement

Other sources of potential harmMedication ErrorsTransfers of Care – to include reduced readmissions, improved patient and carerexperience, reduced out of hours referrals and fewer specific harms e.g. AKI.

Current PositionPriority areas of work• Engage with members, partners and wider stakeholders to achieve awareness of

the PSC and buy in to the programme• A successful Launch and Learn event for Wessex PSC (11th Nov) to identify areas

of work and achieve participation from all stakeholders. Also, to highlight thealignment to Sign up to Safety to support organisations in complimentary activity.

• Baseline patient safety topics across WessexHigh Level Work planOct 14 National PSC launch event. Develop overarching PSC plan including aims,objectives, strategic delivery plans that align with the national programmemeasurement strategy.Nov 14 Wessex PSC launch event – identify areas of patient safety to be addressedby the PSC. Consolidate information and learning from launch event. Establish PSCSteering Committee. Communicate launch event outcomes with stakeholders.Dec 15 Identify initial areas for PSC to tackle and start to co ordinate interestedstakeholders for quality improvement events. Engage support to build qualityimprovement capability within Wessex.

Organisations engaged as of 30 Sep 14Provider TrustsIsle of Wight NHS TrustThe Royal Bournemouth & Christchurch Hospitals NHS Foundation TrustPoole Hospital NHS Foundation TrustSalisbury NHS Foundation TrustUniversity Hospital Southampton NHS Foundation TrustPortsmouth Hospitals NHS TrustDorset County Hospital Foundation TrustHampshire Hospitals NHS Foundation TrustDorset Healthcare University NHS Foundation TrustSolent NHS TrustSouthern Health NHS Foundation TrustSouth Central Ambulance Service NHS Foundation TrustSouth Western Ambulance Service NHS Foundation Trust

Clinical Commissioning GroupsNorth East Hampshire and FarnhamIsle of WightFareham & GosportNorth HampshireDorsetPortsmouthSouth Eastern HampshireSouthampton CityWest HampshireWiltshire (Sarum locality)

UniversitiesBournemouthSouthampton SolentPortsmouthSouthamptonWinchester

Local AuthoritiesDorset County CouncilHampshire County CouncilIsle of Wight CouncilPortsmouth City CouncilSouthampton City CouncilWiltshire County Council

Other StakeholdersLocal Medical CommitteeHealth watch HampshireHealth watch Dorset

Wessex Academic Health Science Network, Innovation Centre, SouthamptonScience Park, 2 Venture Road, Chilworth, Southampton SO16 7NP

Tel: 02382 020 840

37

hhsskkrr

ooYY

etSaf

ntie

Pat-up

bbmmuu

HHddnn

aaeerrii

1420

(ive

taor

bla

Coly

etup,

e topht

om

fr

rreebb14-2019)

safet patient

Our

eryv

eg

invl

ovin

learnid

ealth anhM

ono

frgn

isiil

bs, w

noisati

anrg

os f

mate

e tlin

nfro

xperienatient e

practical su

odil

l buil

we

ativro

abll

o c

ysafet

suln

coo

eaners tcl

m fro

eno

eryes.

icerv

styi

ilb

disagn

learni

fto

s ma

tee

tlinn

seoh

tno

cus o

e s, w

mar

ht atien

pce

will redu

pm i

yafet

ent sdn

eped

r ino

s fec

xperien,

o acr

gnare learni

shd

antners be

helptt

noru

oessful

succ safe

atientp

andyit

num

moth c

o b

ints,

tansul

me

arat

h tafety

sfs o

arease

of o

ityil

abcap

e ht

ase e

, incrm

ent,me

vro

patient

pe

vorp

imer.

bm

Hud

anre

rkshio

Yss

oisatio

Oity

ileliab

Rh

Hig

rko

wty

safew

ithm

eat

e tlin

nofr

indu

incls,

gtin

al sett

spio

h and

er partn

ru o

tot

anrt

opmi

st o

ms and

noisati

anrg

otner

r paruo

turecul

ty safe

atienttaff, i

sgn

oma

ane

encid

eve

uso t

s im

aiO

ursafety

foisatio

, iin

sm

,l

taen

mg

iner eir

h ts and

e vo

rpm

taff, idan

opp

ractical sup

-

rO

udo

Mf Patien

ole

cotners be

r paruo

helpot

t ro

St f Patien

men

evm

pro I

y t

fea

isatioan

rg O

ityil

eliab R

h Hig

em

cot

CQC

edi

Wlb

up

safetyr

fosn

isatiov

rop

m, i

gin

rec i

EN

HS

care

skro

tw ne

ecne

diEv

-de

sabenes

Effectiv safeatient

P patien

gAssessin

entme

vro

pIm

tg

Accessineasurem

yfet

Sa

rfo

secr

uose

rd

tyfe

asor

mp

i

srrse

tta

Ms enes

reff

oes

arim

sumles

dd hu

ty safe

ate

e tlin

nro

frfo

st patien

tyafe

cture lu

mate

at etlin

n fro

ote

sclo

data ent

e.g (

y in safet

eic

ovt

atienp

e h t

frag

rintoi

nom

andent

measure

tm

enev

o

eenc

idv

earch es

sma

elev

lm

)ERAS

. Pe.g

rko

wem

fra

5:14092

eff:R

easurem

yfet

Sa t

gin

agan

Min

Onl

safete

frag

rintoi

nom

andent

measure

andgn

learnine

we

s betno

ensi t

rcesuo

s re

gin

trainy

safet

Act

rko

wem

fraec

anmr

perfo and

ImNS

HAte

utti

s In

rdfo

Brad

vro

p.im

ww

we

ons si

ussc

diise

abloundt

Rts

Seng

niLear

on i

Acteer r

P

reth

ruF

nom

atiro

fni

:m

ye

adc

t An

me

vero

p,

arches

e R

thr Heal

fote

26 : 01274 3839

leT

rg o.

yme

cadta

neme

sesas

lerc

teM

asods

thw

me

evi

eeer r

38

39

BackgroundApproximately 10% of hospital patients are harmed by the care they receive,leading to many approaches to improving safety, including an internationalemphasis on patient involvement.

Within a previous programme of research funded by the National Institute forHealth Research the project group developed ThinkSAFE, a user-informedrobust approach supporting patient and family involvement in improving in-patient safety. There are four components to ThinkSAFE which address theneeds of both service-user and frontline healthcare staff:• a patient safety video• a patient-held Healthcare Logbook, containing tools to facilitate patient/staff interactions and the sharing of information

• ‘Talk Time’, a dedicated time to discuss queries and concerns with staff• a theory and evidence-based educational session for staff.

The approach has generated international interest and has twice received aPatient Experience Network National Award. Our recent pilot work has shownthat the approach is acceptable and feasible, that it can improve patient safetyand positively influence both patient and staff interactional behaviours. Theunderlying concepts of the approach are generic, making it adaptable to localcontext and varying needs of patients. ThinkSAFE has the potential to support afundamental shift in the way patients and staff work together, to deliverimproved patient experience and safety across whole organisations.

The current project will run for 12 months, starting in the autumn of 2014,culminating in the development of an implementation package that includes adetailed user-guide and implementation toolkit. This, and all ThinkSAFEmaterials, will then be made freely accessible to NHS Trusts and patients via adedicated website, to encourage broad, effective and rapid dissemination andimplementation of ThinkSAFE.

Research Project Summary - Information for Trusts

AimTo develop a package to support and promote dissemination andimplementation of ThinkSAFE across the North East AHSN region and beyond.

Objectives1. To develop a package to include a detailed user manual, implementation

toolkit and promotional materials.2. To make ThinkSAFE materials freely available to NHS Trusts and patients

through a dedicated website3. To establish dissemination and promotional processes.

Who is leading the project?The project is funded by the Academic Health Science Network North East &North Cumbria (AHSN NENC) and is also part of the newly established NENCPatient Safety Collaborative. The project is led by Richard Thomson, Professorof Epidemiology and Public Health, and Dr Susan Hrisos, Senior ResearchAssociate, who are both based in the Institute of Health & Society at NewcastleUniversity.

Who can participate?We are looking to recruit four acute Trusts across the North East region.• Northumbria Healthcare and City Hospitals Sunderland NHS Foundation Trusts have already agreed to take part

• We are now inviting participation of a further two acute TrustsInterested Trusts should contact Susan Hrisos or Richard Thomson for further information.

Contact details can be found on the following page.

“Supporting patients and healthcare staff to improve patient safety:Developing an implementation package for ThinkSAFE”

40

What will Trusts be expected to do to deliver this project? Participation includes:Identification and support of a dedicated implementation team, including aproject (ThinkSAFE) Champion. This team will drive the project locally through:• Promotion and engagement activities within the Trust• The development of an implementation action plan, including small scale (PDSA) pilot studies

• Regular team and networking meetings, including participation in an online support forum to share learning across the four participating teams

• Delivery of staff training sessions about ThinkSAFE• Implementation of ThinkSAFE• Participation in co-design workshops to develop and refine the study implementation package, ThinkSAFE resources and dedicated website

• Participation in dissemination and launch events.

What support is available to help Trusts deliver this project?• A full time project manager will oversee and co-ordinate the project, providing on-going guidance and support to each of the four participating Trust teams

• Implementation teams will receive full training in the ThinkSAFE approach and the implementation project aims and objectives

• A payment of £5000 is available to support Trust participation in the project as described above

• Continuous support will also be provided by the project leads and an expert Advisory Group

• All ThinkSAFE materials will be provided by the researchers.

If you are interested in involving your Trust in this project or would like moreinformation please contact Susan Hrisos, Senior Research Associate, Institute ofHealth & Society (IHS) on 0191 208 6774/6826 or by email at:susan.hrisos@ncl.ac.uk

Further informationwww.ahsn-nenc.org.uk/project/patient_safety.phpwww.ncl.ac.uk/ihs/research/project/5063www.ncl.ac.uk/ihs/research/project/4945www.ihi.org/resources/Pages/AudioandVideo/WIHIEngagingPatientsinSafety.aspx

ww

w.hellom

ynameis.org.uk

Hello, m

y name is D

r Kate G

ranger &

I'm the founder of the

#hellomynam

eis campaign.

.

I'm a doctor &

a terminally ill cancer patient. D

uring a hospital stay in Sum

mer 2013 I m

ade the stark observation that m

any staff did not introduce themselves.

I firmly believe a friendly introduction is m

uch more than

comm

on courtesy. It is about making a hum

an connection, beginning a therapeutic relationship and building trust.

Visit my blog &

pledge your support

drkategranger.wordpress.com

/hellomynam

eis

Tweet using

#hellomynam

eis

Consider launching your ow

n local cam

paign

What

Can I do?

Introduce yourself to every patient you m

eet &

encourage your peers to do the sam

e

41

NOTES

42

@NHSIQwww.nhsiq.nhs.uk

Improving health outcomes across England by providing improvement and change expertise

enquiries@nhsiq.nhs.uk

Published by: NHS Improving Quality - Publication date: October 2014© NHS Improving Quality (2014). All rights reserved. Please note that this product or material must not be used for the purposes of financial or commercialgain, including, without limitation, sale of the products or materials to any person.

To find out more about NHS Improving Quality: