Sheffield Microsystem Coaching Academy

Network Event3rd October 2013

AgendaTopic Time

Welcome – Steve Harrison 12.00

NHS England, Overview and Patient Safety Priorities - Bruce Warner 12.05

Questions & Discussion 12.45

Informal Networking 13.00

Close 13.30

Microsystems Coaching Academy Aim

To improve the quality and value of care we provide in the Sheffield Healthcare system

Through the development of team coaching

To build improvement capability at the front line with knowledge, processes and tools including the Dartmouth Microsystem Improvement Curriculum.

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It’s about redesigning the system

“Every system is perfectly designed to get the results it gets.”

Paul B. Batalden, MDCo-Founder The Institute for Healthcare Improvement

Founding Director, Center for Leadership and Improvement,

The Dartmouth Institute for Health Policy and Clinical Practice

Founding Director, Healthcare Improvement Leadership Development

The Dartmouth Institute for Health Policy and Clinical Practice

Co-Founder Institute for Healthcare Improvement

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Team Coaching

Improvement Science

Microsystem

Improving Microsystems - Elements

QI

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Want more information?www.sheffieldmca.org.uk

• Stories & case Studies

• Events (Open Invite)

• Apply to be a Coach

• Apply to have your team coached

Dr. Bruce WarnerDeputy Director of Patient SafetyNHS England

NHS England Overview and Patient Safety Priorities

NHS England Overview and Patient Safety Priorities

Dr. Bruce WarnerDeputy Director of Patient SafetyNHS England

OLD! Flowchart For Problem Resolution

Don’t Mess About With It!

YES NO

YES

You Daft PratNO

Will it Blow UpIn Your Hands?

NO

Deny All Knowledge

Anyone ElseKnow? You’re stuffed!

YESYES

NO

Hide It under a deskCan You Blame Someone else?

NO

SORTED!Yes

Is It Working?

Did You Mess About

With It?

International and National Recognition of Patient Safety

11

1999 2000 2001

2001 National Patient Safety Agency Established

• Collect and analyse information on adverse events

• Assimilate other safety-related information

• Learn lessons and ensure that they are fed back into practice

• Where risks are identified, produce solutions to prevent harm

June 2012 - National Patient Safety Agency Abolished

2

“We propose to abolish the National Patient Safety Agency”

“The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board…… covering the whole function from getting evidence to working up evidence-based safe services.”

Time to Move On

NPSA Patient Safety

Division

Patient Safety Function

to NHSCB(A)

NRLS to

ICHT

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What is NHS England?

Create the culture and conditions for health and care services and staff to deliver the highest standard of care and ensure that valuable public resources are used effectively to get the best outcomes for individuals, communities and society for now and for future generations

6,500 people in new roles in national, regional, and local offices across England

Role of NHS EnglandNHS England has three distinct but interconnected roles:

Directly commissi

oning primary

care, specialised, armed

forces and justice health

services System

wide leader for quality improveme

nt

Supportin

g and enabling the local

commissioning

system (CCGs

and Area Teams)

£26bn in 2012/13CCGs were

allocated £65bn in 2012/13

Working with partners: CQC,

Monitor, NHS TDA, NICE,

HSC IC, HEE

CCGs, CSUs, NHSIQ, NHS Leadership

Academy, Local Gov

The Mandate

Government sets annual objectives that NHS England are legally obliged to pursue, but NHS England is independent in pursuing those objectives

NHS England is held accountable to the government against the achievement of those objectives, and the level of continuous improvement

First Mandate for NHS England

•Sets out what the Government expects in return for handing over £95bn of tax payers money to NHS England

•The NHS Outcomes Framework sits at the heart of this Mandate. NHS England is expected to demonstrate progress across the entire framework

NHS Outcomes Framework

We need to make this vision a reality, translating it into how patients care looks and feels

NHS Outcomes Framework

Preventing people from

dying prematurely

Enhancing quality of life

for people with long-

term conditions

Helping people to

recover from episodes of ill

health or following

injury

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and protecting them from avoidable

harm

Domain 1 Domain 2 Domain 3

Domain 4

Domain 5

Effectiveness

Experience

Safety

Structure

Domain teams priority action areas

• Maximising the contribution that the NHS can make to preventing disease• Finding the ‘missing millions’ and diagnosing earlier and more accurately• Treating people in an appropriate and timely way • Addressing unwarranted variation in mortality and survival rates• Reducing deaths in babies and young children

Preventing people from dying prematurely

Enhancing the quality of life for people with long term

conditions

Helping people to recover from episodes of ill health or

following recovery

Ensuring that people have a positive experience of care

Treating and caring for people in a safe environment and

protecting from avoidable harm

1

2

3

4

5

DOM

AIN

S

• Helping patients take charge of their care• Enabling good primary care• Ensuring continuity of care• Ensuring a parity of esteem for mental health

• Keeping people out of hospital when appropriate• Effective interfaces between primary, secondary and community care • High quality, efficient care for people in hospital • Co-ordinated care and support for people following discharge from hospital

• Improving our understanding of the patient experience• Reduce inequality in patient experience • Enabling commissioners and providers to create a culture that puts good

patient experience and positive staff experience at the heart of services • Establishing clear lines of accountability for patient experience in the NHS

• Increase our understanding of the problem• Create the conditions for patient safety• Build capacity for safe care• Create a whole system response• Address our key patient safety concerns

NHS | Presentation to [XXXX Company] | [Type Date]

Domain 5Patient Safety

April 2013

To ensure that anyone accessing NHS-funded services is treated in an environment where their safety is the paramount concern and where the whole system actively seeks to reduce the risks, inherent in health care, to a minimum.

Our vision: What we want to achieve over the next decade

““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.”Sir Ian Kennedy, Chairman Healthcare Commission

Patient experience

Safety

Quality

Effectiveness

Safety is not a minimum threshold – all services can and should strive to excellence in safety

A. Why waste our time on safety?

B. We do something when

we have an incident

C. We have systems in place

to manage all identified risks

D. We are always on the alert for risks that might

emerge

E. Risk management is an

integral part of everything that we

do

PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVEThe Manchester Patient Safety Assessment Framework

The interplay between patient safety and clinical guidelines

It is about the way we safely deliver

care once the clinical decision on how

to treat has been made – the clinical

decision may be the right one but it is

not a given that we will deliver it without

error.

53,000,000+ people

The scale of the challenges

140,000+ different ways the human body can go

wrong

ICD10 codes

4,300+ ways of treating diseases

6000+ medicines for

treating diseases

BNF

and we wonder why people are harmed….?

The scale of the challenges

• Mid-Staffordshire – and the pockets of it that exist everywhere else• 1 in 10 patients admitted experience an adverse event • Half of adverse events are judged to be preventable• 5% of deaths in English acute hospitals had at least a 50% chance of being

preventable• Principal problems associated with preventable deaths

• poor clinical monitoring (31.3%), • diagnostic errors (29.7%), and • inadequate drug or fluid management (21.1%)

• Most preventable deaths (60%) occurred in elderly patients with multiple comorbidities and less than 1 year of life left

• 72% of all patient safety incidents are from the acute sector, 13% from Mental Health, 11% from Community, 2% from Learning Disability, 0.6% from Community Pharmacy and 0.4% from General Practice.

National Reporting & Learning System

NHS Trusts

Practitioners & Staff

PatientsCarers

NRLS

CQCMHRA

NHS ComplaintsNHS Litigation

Authority

InternationalCollaboration

AustraliaUSA

Europe

Standardised reportingCommunity

Pharmacy multiples

Commissioners

Searching by keywords: example

NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children

Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard

We need a trigger

Review of Deaths and Severe Harms

Local audit data

PCT audit of vaccine storage in

GP practices shared with NPSA

Significant proportion of vaccines

stored outside recommended

temperature range

NRLS Searched

National guidance produced

NHS | Presentation to [XXXX Company] | [Type Date]34

Media Reports, Coroners Courts etc.

By 31 March 2012

7,070,261 reports had been reported.

Approximately

3,700 incidents are reported to the NRLS per day.

Around 94% of incidents cause low or no harm

• The NHS leads the world in incident reporting, with the National Reporting and Learning System receiving nearly 8 million incident reports since late 2003 to date.

• Over 100,000 incidents are reported monthly.

• HES data suggests there are over 100,000 cases of VTE per year• NHS Safety Thermometer data suggests 6-7% of patients have a pressure ulcer• There were 326 never events reported to SHAs in 2011/2

Levels of Harm

Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11

NRLS limitations:very little reporting from general practice

All care settings: death and severe harm themes 2011/12

19%

17%

12%9%

8%

6%

6%

5%

5%4%

3% 2% 1% 1% 1% 1%Pressure ulcer grade 4 or above

Fall

Suicide/severe self harm

Treatment error or delay (excluding medication

Other or unable to theme

Obstetric-specific incident

Operation/ procedure

Clinical diagnostic error including delay of diagnosis

Deterioration not recognised or not acted on

Healthcare associated infection

Medication incident

Test results not seen or not acted on (any type of test)

Transfer or discharge incident

Pulmonary embolus - hospital acquired

Resuscitation (excluding medication)

Airway obstruction/ Aspiration pneumonia

Fixed prioritiesD

omai

n 5

of

the

NH

S O

utco

mes

Fr

amew

ork

Domain 5: embedded in all domain 1 – 5 work

Increase our

understanding of the

problem

Creating the

Conditions for Safety

Building Capacit

y for Safety

A whole system respons

e to safety

Tackling key

safety concern

s

Domains 1 – 4 are expected to build these safety themes into every programme/ project governance arrangement

Aim 1 – To increase our understanding of the safety problem

Increase our understanding of the problem

New methodology for measuring the safety of NHS services (indicator 5c) based on case note review of deaths in hospital

Further NHS Safety Thermometers (medicines, mental health, maternity)

Design and deliver the new single incident reporting and management system to replace/upgrade the NRLS and simplify reporting

Creating the Conditions for

Safety

Contract – SIs and HCAI

CQUIN and Quality Premium – Pressure ulcer improvement

Policy development – Serious incident management, deaths in custody

Aim 2: To create the conditions for safer care

Safety Expert Groups

Patient Safety Skills Strategy

Enhanced safety leadership

Building Capacity for Safety

Aim 3: To build capacity to deliver safer care

Patient safety collaboratives

Patient safety Improvement Fellows

Networks, champions and campaigns

A whole system

response to safety

Aim 4: To create an whole system response to safety

Outcomes framework priorities

Other key harms

Vulnerable groups

Tackling key safety concerns

Aim 5: To tackle key safety concerns

AIM 5: To address key areas of safety concernProgramme Objectives DeliverablesOutcomes Framework Safety Concerns

• Pressure Ulcers• VTE• Medication and devices• HCAI• CYP deterioration• Neonatal admissions

Key known harms • Falls (Older people in 1st 48hrs of acute illness)• Handover• Transitions• Nutrition and hydration• Deterioration• AKI

Vulnerable group safety concerns

• Primary Care strategy• Mental Health• Learning Disabilities Framework• Offender Health framework

Making the aims a realityFour key delivery streams will be used:

1. Central patient safety development team• Development of major initiatives such as reporting systems, safety

alerts, commissioning levers, etc

2. Patient Safety Collaboratives• Regional effort across boundaries to improve safety concerns

3. National community of interest networks• Led by the central patient safety team to link people together working

on key safety concerns across the country to accelerate sharing and learning, and support Patient Safety Collaboratives across England

4. Domain 1 – 4 Effectiveness and experience programmes• Linking into other developing NHS England programmes of work

Berwick ReportIm

plem

enta

tion

Aims for Improvement

Building Capacity through training, education, technical capability

Structural recommendations; Oversight, accountability and influence

Patient and Public Involvement

Measurement, transparency, tracking and learning

Legal penalties/criminal liability and their impact on safety

Implications for leaders at all levels

Staff and the work environment

Findings

Berwick - most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:

Placing the quality of patient care, especially patient safety, above all other aims:

Engaging, empowering, and hearing patients and carers throughout the entire system and at all times:

Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work:

Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

 

Thank you for listening

bruce.warner@nhs.net

www.sheffieldmca.org.uk