Patient Safety Guidance Implementation:

The challenge for organisations - Burning Platform or Information Overload?

Making health care safer: learning from social and organisational research conference conference

St Andrews University Scotland 27th June 2011

Pauline Cumming

Risk Manager, NHS Fife

First do no harm …

Burning Platform…Burning Platform…

Information overloadInformation overload

Information overload?Information overload? (Alvin Toffler, Future shock…1970)(Alvin Toffler, Future shock…1970)

NPSANPSA

SIGN

NICE

NHS Institute for Innovation and Improvement

MHRA

HSE

HTA

MRCPATIENT SAFETY 1ST WHO

IHI

The Health Foundation

NPSA output - a flavourNPSA output - a flavour

Patient Safety Alerts:Patient Safety Alerts: advice on patient safety advice on patient safety issues that are important issues that are important and have a specific timeline and have a specific timeline for implementationfor implementation

Safer Practice Notices:Safer Practice Notices: guidance on patient safety guidance on patient safety issues that contribute to issues that contribute to improving patient safety improving patient safety

Rapid Response Reports:Rapid Response Reports: advice on patient safety advice on patient safety issues that need immediate issues that need immediate local attentionlocal attention

Patient safety alerts on issues:

•That are a serious threat to patient safety, usually based on data showing repeated harm or loss of life

•That can be addressed through practical, evidence based actions

or

‘‘An Evaluation of NHS Quality Improvement An Evaluation of NHS Quality Improvement Scotland’s Dissemination Process of NPSA Alerts’ Scotland’s Dissemination Process of NPSA Alerts’ ((NHS QIS, July 2010)NHS QIS, July 2010)

Main challenges for NHS Boards : Main challenges for NHS Boards :

Knowing which alerts to prioritise and implement Knowing which alerts to prioritise and implement locallylocally

The current status of NPSA guidance in Scotland The current status of NPSA guidance in Scotland

The expectations of NHS QIS and SGHD on how The expectations of NHS QIS and SGHD on how NHS Boards should respond to NPSA NHS Boards should respond to NPSA information information

How guidance from England can be applied to How guidance from England can be applied to ScotlandScotland

Healthcare Quality Strategy 2010Healthcare Quality Strategy 2010

Quality AmbitionsQuality Ambitions

Mutually beneficial partnerships between patients, families and those delivering services

No avoidable harm or injury from healthcare and care within a clean & safe environment

Most appropriate treatments, interventions, support & services and no wasteful or harmful variation

Effective

Timely

Quality

Patient as partner…Patient as partner… ““We need to move, over time, to a more inclusive We need to move, over time, to a more inclusive

relationship with the Scottish people; a relationship relationship with the Scottish people; a relationship where patients and the public are affirmed as where patients and the public are affirmed as partners rather than recipients of care. We need to partners rather than recipients of care. We need to move towards an NHS that is truly publicly owned…move towards an NHS that is truly publicly owned…where ownership and accountability is shared with where ownership and accountability is shared with the Scottish people and the staff of the NHS…where the Scottish people and the staff of the NHS…where we think of the people of Scotland not just as we think of the people of Scotland not just as consumers– with only rights – but as owners – with consumers– with only rights – but as owners – with both rights and responsibilitiesboth rights and responsibilities” (” (A Participation Standard for the NHS in Scotland, August 2010, Scottish Health Council )

Keys to implementationKeys to implementation Quality of the evidence - who produced it Quality of the evidence - who produced it Relevance to practice Relevance to practice Effectiveness of dissemination Effectiveness of dissemination Strong leadershipStrong leadership Timing & importance - Opportunity costsTiming & importance - Opportunity costs Facilitation – Champions- someone to help Facilitation – Champions- someone to help

keeps up impetus & boosts chances of successkeeps up impetus & boosts chances of success Reliable measurement Reliable measurement AccountabilityAccountability Ownership: Is it about making it personal? Ownership: Is it about making it personal? CultureCulture

Patient Safety….Patient Safety….

“Patient safety should no more be seen as a programme for the NHS than breathing should be seen as a programme for human beings…” (Don Berwick, Institute for Healthcare Improvement Chair, Patient Safety Congress, 2008)

What is safety culture?

The shared beliefs and values of staff working in an organisation that determine the commitment to and quality of an organisation’s health and safety management

Alternatively….the way we do things around here (Dr Harry Burns, CMO, May 2007, NHS Fife)

Levels of maturity with respect to a ‘safety culture’

Pathological

Why waste our time on

safety?

Reactive

We do something

when we have an incident

Calculative

We have systems in

place to manage all like risks

Proactive

We are always on the alert for risks

that might emerge

Generative

Risk management is an integral

part of everything that we do

Levels of organisational culture Levels of organisational culture

(Westrum)(Westrum)

PathologicalPathologicalInformation is hiddenInformation is hidden

Messengers are Messengers are “shot”“shot”

Responsibilities are Responsibilities are shirkedshirked

Bridging is Bridging is discourageddiscouraged

Failure covered upFailure covered up New ideas are New ideas are

actively crushedactively crushed

Bureaucratic

Information may be ignored

•Messengers are tolerated•Responsibility is compartmentalised•Bridging is allowed but neglected•Organisation is just and merciful•New ideas create problems

Generative

Information is actively sought

•Messengers are trained•Responsibilities are shared•Bridging is rewarded•Failure causes inquiry•New ideas are welcomed

Paradigm shift - the grass is greenerParadigm shift - the grass is greener

Consider….Consider….

What do you think are the factors which enable uptake, What do you think are the factors which enable uptake, implementation and sustainability of patient safety guidance? implementation and sustainability of patient safety guidance?

What do you think are the factors which hinder uptake, What do you think are the factors which hinder uptake, implementation and sustainability of patient safety guidance? implementation and sustainability of patient safety guidance?

Is there is a moral imperative to act on such alerts?Is there is a moral imperative to act on such alerts?

Does non-mandatory status confuse, weaken the message Does non-mandatory status confuse, weaken the message and undermine the need to act?and undermine the need to act?

How do you think HIS and the Quality Improvement Hub might How do you think HIS and the Quality Improvement Hub might help patient safety knowledge management locally and help patient safety knowledge management locally and nationally? nationally?