Patient Safety Strategy - Gloucestershire Hospitals NHS Trust

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
PATIENT SAFETY STRATEGY
ANNEX A
1. Gloucestershire Hospitals has a key strategic objective – to maximise patient safety.
Promoting safety will save lives and reduce avoidable harm, the challenge for the Trust
is to get everyone to believe that it will and to support and engage clinical staff in
activities that take this forward and grow a safety culture.
2. Patient safety findings across the UK indicate that around 10% of patients experience
an adverse event during an acute admission. The overwhelming majority result in no
harm, however, around 50% are believed to be avoidable. This also indicates that
there are areas of care that are both ineffective and inefficient and lead to
unsatisfactory patient experiences.
3. Across the world in countries such as America, Canada, Japan, Denmark, Australia
and several European countries, direct action to reduce levels of avoidable mortality
has been initiated. Campaigns such as the “Saving lives” campaign have
demonstrated that any hospital can reduce its mortality rates by taking specific action
in key areas.
4. The English campaign “Safety First” was launched in 2008 with a focus on reducing
avoidable adverse events through key programmes of improvement. The campaign
builds on initiatives developed by the Institute for Healthcare Improvement (IHI) where
the evidence base has been scrutinised and measurements demonstrating improving
safety have been developed.
5. To meet the Trust’s objective, to maximise patient safety, a safety programme will be
established reflecting national and international experience and building on the
progress of the past year and the Leadership in Patient Safety programme.
6. Providing quality of care and safety will also lead to cost–effective care by
systematically reducing avoidable adverse events which result in extended hospital
stays and readmissions. The Trust must strive to be the best at providing quality of
care and safety which is both effective and efficient and provides patients with a
positive experience.
Culture, Values and Performance
7. To provide the right environment for a safety strategy it is important to foster and
support a just culture where staff are treated consistently and fairly at all levels. This
means that the Trust Board, managers and clinicians openly support staff and see any
adverse event and near miss, as an opportunity to learn and improve. A healthy
organisation “really” believes that it is better to invest its time and energy in
systematically learning from the 99% of incidents that don’t require any formal
disciplinary action rather than the 1% that might.
8. Consistently across the world, evidence shows that patients who have suffered
adverse events want an apology and reassurance that it won’t happen again. To
achieve this it must be the normal response to engage patients and their relatives in
investigations of all types and provide thoughtful and honest feedback.
9. A safety culture must be supported by visual safety leadership through executive
walkabouts and safety campaign leads, who, will engage front line staff and identify
champions to develop solutions. Individual initiatives will have the support of a
programme lead, and local clinical champions.
10. This process must be supported by good clinical measurement (metrics). These
metrics will be derived from the individual safety programmes and linked with the
performance framework of the Trust. The emphasis will be to provide initial
benchmarking, monitoring and assurance of performance throughout the Trust. Metrics
will be aligned with the PCT contract and other external monitoring needs. This
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information management process must be supported by effective data collection and
robust organisational information arrangements.
11. To deliver the safety agenda a comprehensive range of coaching and training must be
delivered, underpinned by an inclusive safety management system that is integrated
into the everyday work of all staff.
12. Patient involvement will be integrated into the work of all programmes so that
improvement of safety includes the patients interpretation of what is important and
improves the patient journey and experience within the Trust.
Trust Safety Aims
13. The Trust will reduce adverse events by developing a comprehensive range of safety
initiatives (see below) visibly supported by the Board, with the right culture, ownership
and safety management systems.
14. The Director of Safety will coordinate a safety campaign to engage clinical staff and
patients and to promote good practice and celebrate success.
15. The Trust aims will be to:
Reduce the number of patients who suffer avoidable harm
Grow a just safety culture
16. To demonstrate the long term success of the programme the Trust will develop the
following high level indicators. The Trust will also track the Hospital Standardised
Mortality ratio as a proxy indicator for the reduction of mortality.
17. The Global Trigger Tool for Measuring Adverse Events provides an easy-to-use
method for accurately identifying adverse events and measuring the rate of adverse
events over time. Tracking adverse events over time is a useful way to tell if changes
being made are improving the safety of the care processes. The Trigger Tool
methodology includes a retrospective review of a random sample of patient records
using “triggers” (or clues) to identify possible adverse events.
The success criteria will be a reduction of adverse events by 30% in three years
against the current rate.
18. To improve the ownership and culture of the organisation, the Director of Safety will
establish a programme of safety walkabouts with the executive team. Completion of
the walkabout programme and actions taken on the messages and issues received
from the workplace will be reported and monitored through to the Quality Committee.
18.1. The success criteria for this objective will be to complete 85 walkabouts a year
and to complete 70% of the actions agreed.
18.2. To improve the fairness and effectiveness rating for incidents reporting as
measured by the annual staff survey year on year.
Key Responsibility
19. The Trust Board should set the direction for effective patient safety systems which
should be an integral part of the organisation’s culture, of its values and performance
standards. All Board members should take the lead in ensuring the communication of
Safety programmes and benefits.
20. The Chief Executive is the Accounting Officer for Gloucestershire Hospitals NHS
Foundation Trust. He is accountable for ensuring that the Trust can discharge its legal
duty for all aspects of safety each year, and for the health & safety of staff, visitors and
contractors in the Trust.
21. A Non-executive Director must be identified and be assured that patient safety is
being addressed; the NED lead will act as a scrutinizer – ensuring the processes to
support and assure the Board facing significant patient safety risks are robust.
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22. The Medical Director and Director of Nursing, in partnership with the Director of
Safety will ensure organisational arrangements are in place for continuous monitoring
and safety improvements for patients.
23. Executive and Divisional Directors are accountable for the safety activities in their
areas of responsibility; their organisational structure must be able to discharge the
requirements of patient safety.
24. The Director of Safety has a particular responsibility for leading the Safety
programmes and risk management for both clinical and non clinical (health and
safety). He manages the risk teams which liaise closely with the Divisional teams to
support their activities. He will support and monitor the safety programmes and ensure
they are functioning and provide reports on the appropriate metrics.
25. All staff and managers are responsible for safety within their immediate environment
and for participating in wider governance, quality & risk management issues within
their department. In addition, all staff should have clear objectives set and documented
as part of their annual performance reviews.
Safety Programme
26. The Trust is partnering with the SHA and Health Foundation to establish and support a
safety programme. The programme will have five main streams:
Leadership Dr Frank Harsent Chief Executive
General Ward Mrs Maggie Arnold Director of Nursing
Critical care Dr Sally Pearson Director of Planning
Medicines Management Dr Sean Elyan Medical Director
Peri-operative Care. Ms Evelyn Barker Director of Service
Delivery
27. Each stream has an executive lead (see above), and will appoint a systems lead
(champions) and a day-to-day manager. The initiatives will be bench marked (self
assessed) with the support of the SHA and Health Foundation and a safety
programme established. Where possible the initiatives will be aligned with the PCT
requirements. (CQUIN) The metrics from these programmes will form part of the long
term assurance of the Trusts safety.
28. The programmes will form the basis of Divisional safety plans for quality and the
Quality accounts, infection control will be embedded within each programme.
29. The successful techniques and processes each year will form part of a database of
safety initiatives, so that in the following year clinical areas can adopt the practice on a
rolling programme of improvement. This information will be fed into the local annual
planning systems that contribute towards the Divisions annual plan.
30. Each initiative will establish a project plan and metrics to monitor and measure
improvements. The programmes will be regularly monitored by the Divisions quality
arrangements and shared with either the Patient Safety Forum or the Health & Safety
Committee and assurance will provided to the Quality Committee through the Quality
reports. Key operational concerns will be reported to Trust Management Team
meeting and overall performance to Trust Board.
Meeting National Safety Standards
31. In parallel to the safety programmes, the Trust will also aim to meet all relevant
national standards. This will demonstrated by aiming for NHSLA level 3 for General
and Maternity Standards over the next 3-5 years. To effectively implement all safety
solutions recommended by the National Patient Safety Agency and the wider Safer
Alert Bulletins, and each year demonstrably build on the Healthcare Commission
standards relevant to safety.
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Summary
32. The Trust will aim to become the best at reducing unnecessary harm to patients with a
comprehensive safety programme led by the Board, with an open and learning culture,
engaging front line staff and patients to develop solutions supported by effective
information management.
Andrew Seaton
May 2009
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Appendix 1
Nationally agreed Safety Measures
Critical care
The recommended measures are:
Ventilator bundle compliance
Days between Ventilator associated pneumonias (VAP)
Central Line bundle compliance
Days between central line infections (CLI)
Additional measures are:
VAP rate per 1,000 ventilator days
CLI rate per 1,000 central line days
Ventilator length of stay
Length of stay in ICU
These measures are in use with the 1000 Lives campaign in Wales and also used by the Safer Patients Initiative.
Peri-operative care
The recommended measures are:
SSI rate 30 days post operation
SSI bundle compliance
% antibiotics administered on time
% antibiotics discontinued on time
% surgery with appropriate hair removal
% of surgical patients with perioperative normothermia
% diabetics with controlled glucose
% patients with appropriate hair removal
% compliance with use of the WHO Surgical Safety Checklist
Some of these measures are in use with the 1000 Lives campaign in Wales and also used by the Safer Patients Initiative.
Deterioration
The recommended measures are:
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The number of cardiac arrests per month
The number of Rapid Response calls per month
The percentage of Rapid Response team communications performed with your chosen communication tool. We have created measures
for SBAR and RSVP, simply select the one you are using. If you use another tool, you will need to create a custom measure. Please
contact the campaign team for further guidance on how to do this.
If you want more information on where your process for dealing with deteriorating patients is working or not working, you might like to
consider the following process measures:
The percentage of patient observations complete
The percentage of patients who triggered that had an appropriate reaction
These can both be picked up while doing the GTT audit. We also strongly recommend performing a mortality case note review to get a
handle on the issues surrounding unexpected death.
High risk medicines
The campaign is focusing on 4 drugs or drug groups: Anticoagulants, Opiates, Insulin and anaesthetic sedatives. Ideally we would want to
measure compliance with treatment protocol (a process measure) and adverse drug events related to these drugs (an outcome measure).
However these are extremely labour intensive to collect and so we recommend a series of proxy outcome measures as follows because
they are more straightforward to collect:
% of inpatient warfarin doses administered according to protocol *
Number of patients receiving Warfarin with INR >6
Number of patients receiving Warfarin with INR >5 *
Number of patients receiving Warfarin with INR >8 *
% of patients receiving low molecular weight heparin outside protocol limits *
Number of patients receiving flumazenil to counteract effects of midazolam *
% of patients with no INR recorded on inpatient warfarin prescription *
Additional measures
There are additional measures contained in the How To Guide that participants may want to use to assess compliance with protocols and
measure real outcomes. They are:
The number of patients who received opiates who receive subsequent treatment with naloxone *
Number of patients who received 25%/ 50% glucose to correct insulin induced hypoglycaemia
Reported anticoagulant adverse event rate *
Adverse event rate associated with use of low molecular weight heparin and unfractionated heparin
Injectable sedative adverse event rate *
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% of patients treated within opiate protocol *
Opiate adverse event rate *
Insulin adverse event rate *
* These measures are in use with the 1000 Lives campaign in Wales.
There are 4 other interventions VTE, falls, surviving sepsis bundle, and peripheral lines that are under development.
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Appendix 2
Ward\Department
Involved
Safety
Project
Safety
Theme
i.e. Wards
Clinical
Champion
Target
Metric(s)
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