scottish patient safety programme highlight report - NHS Lanarkshire

SCOTTISH PATIENT SAFETY PROGRAMME
HIGHLIGHT REPORT
Clinical Governance Group or Subject
Scottish Patient Safety Programme (SPSP)
Author:
Diane Campbell
Reporting Period (please click on appropriate box)
March and April 2011
√
Executive Clinical Lead
Dr Alison Graham
Date
March and April 2011
GENERAL COMMENT:
NHS Lanarkshire continues to make good progress with the Scottish Patient Safety Programme (SPSP).
SPSP HIGH LEVEL AIMS
AHO2: % unadjusted inpatient mortality – target: reduction by 15%
The Scottish Patient Safety Programme has monitored unadjusted mortality since the onset of the
programme; this is unadjusted and demonstrates variation. However, ISD is now producing HSMR on a
quarterly basis. which is influenced by a wide variety of factors such as age and diagnosis of patients
HSMR Data
One of the overall outcome measures of the SPSP is to demonstrate reduction in HSMR for each Board against
its own HSMR baseline from November 2007. The latest quarterly data demonstrates the following reduction
from the baseline period in relation to Hospital Standardised Mortality.
Data source: From December 2009 Information Services Division (ISD) The baseline quarters are
those from October 2006 to September 2007. The data used was linked SMR01 – Acute inpatient and day
case records and GRO death records. The outcome of interest was mortality within 30 days from admission.
• Hairmyres -6.6%
• Monklands -10.7%
• Wishaw -11.7%
Overall average (mean) reduction in HSMR for NHS Lanarkshire is -9.6%
Next Steps
The first meeting of the mortality review group has been undertaken and work agreed to include three main
reviews: the first to track all emergency patients admitted to Hairmyres Hospital for a 30 day period to
identify deaths and undertake ‘real’ time reviews. The second will be to review existing HSMR data to identify
unexpected deaths and undertake case note reviews. From this work, it will be intended that we identify
issues and themes and develop plans to address these. The third will be work in relation to sepsis and visits
to other areas of ‘best practice’ will be undertaken, with consideration also being given to a sepsis assessment
tool as part of our EWS. Early work has begun to progress.
AHO3: Adverse event rate – target: reduction by 30%. Improve patient safety by reducing
unnecessary harm by 30% for NHS Lanarkshire by 31 March 2013 (from a baseline of November
2007)
Twenty case notes are reviewed monthly from each acute site and assessed against the Global Trigger Tool,
which is a tool to review for adverse events against the main elements of the programme. Adverse event
rates continue to demonstrate random variation against target. However, there are general improvements
noted, with the most obvious in Early Warning Score compliance.

SCOTTISH PATIENT SAFETY PROGRAMME
HIGHLIGHT REPORT
Work stream Elements and Progress:
Blue – Completed
Green – On target
Amber – Delayed, but expected to recover in-year
Red – Delayed, not expected to recover in-year
CRITICAL CARE: All green, except Multidisciplinary rounds which is amber / green (depending on site).
Some excellent outcomes are being achieved.
CCP1 / CCP2: % Compliance with Ventilator Associated Pneumonia (VAP) Bundle: Compliance at
goal in all units. Variation remains with ALOS on mechanical ventilation – all sites. Reintubation rates low and
fairly stable. CCO1:Ventilator Pneumonia Rate: Nil at Wishaw since August 2009, Hairmyres since
December 2009 with isolated recent VAPs at Monklands
CCP3: % Compliance with Central Line Insertion Bundle and Central Venous Catheter Maintenance
Bundle: All at target for insertion bundle. All units at target with maintenance bundle. CCO2: Central line
bloodstream infections: Nil at Hairmyres since November 2008, nil at Monklands since September 2009
and nil at Wishaw since March 2010.
CCO6: Glucose Control: In place across all three critical care areas. All units at goal of >95% compliance
CCP4: Hand Hygiene: At goal in all three critical care units. CCO8:C.difficle associated disease rate: Nil
at Monklands since July 2010 with periodic individual cases at the other two sites over recent months
CCP5: % Achievement of multidisciplinary rounds: Making excellent progress at Monklands and Wishaw
with both at goal.
CCP6: Daily Goals: Daily goals sheet in place in all three areas and compliance good.
CCP8: Peripheral Vascular Cannula: All at goal. CCO4: SABs per 1000 AOBDS: Nil SABs at Hairmyres
since July 2010, nil at Monklands since August 2010 and nil at Wishaw since October 2010.
CCB1: ALOS: Reduced at Wishaw since programme onset
Process measure compliance target - ALL measures 95%
General Wards: All green: Excellent progress with all measures and spread throughout all general wards
and most associated hospitals (latter as relevant)
GWP1: Early Warning Scoring System (EWS): GWP2: % time respiratory rate recorded: GWP3:%
appropriate interventions: Compliance remains excellent and this is also seen at casenote reviews.
GWO1: Crash call rate: Crash calls rates reducing below baseline levels, especially Monklands, some
variation at other two sites.
GWP10: % compliance with hand hygiene: At target in the three sites and maternity. Spread to all
associated hospitals GWO4 C. difficle associated disease rate: excellent results.
GWP6: %compliance with Safety Briefings: All acute sites at target. Being used as a main vehicle for the
review of run charts and actions as well as other core questions and topics. Also being used to distribute
theme of the week.
GWP4: Rapid Response: Hospital Emergency Care Teams (HECT) in Place. Number of calls reducing
variation at Wishaw where there has been a recent rise (although not to baseline level). Overall reduction
may be in response to earlier identification of deteriorating patient (MEWS scoring).
GWP8: SBAR (reporting): All at target. Reporting % trained challenging as SBAR is now incorporated into

SCOTTISH PATIENT SAFETY PROGRAMME
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the ‘way we do things’ within NHS Lanarkshire e.g. is becoming routine as part of our culture - now features
on much of our documentation and our safety briefs.
GWP10: Peripheral Vascular Bundle: All at target GW02: SABs per 1000 occupied bed days
Although all acute sites have demonstrated considerable improvement since baseline, there have been
small SAB increases and slight variation noted although general targets met. Work has begun testing CVC
insertion and maintenance bundles in general wards.
Heart Failure Bundle: Testing has begun against the bundle and will be reported in due course
Progress demonstrating compliance and spread for General Wards. Also, includes some
associated hospitals
Hand Hygiene

PVC
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MEWS

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Peripheral Vascular Bundle (PVC)

SBAR
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SAFETY BRIEF

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Medicines Management Amber to Green. Very good progress in medicines reconciliation in Older Peoples
Receiving at Monklands Hospital and sustained improvement achieved. Further tests of change being
undertaken at Wishaw and improvement being noted there too. Increasing medical staff involvement.
MMP3c: Anticoagulation: INR >6, while scale has been altered, the results are demonstrating some
variation and greater understanding continues to be sought re same with review of case notes and early
notification from labs to facilitate this process.
MMP2: FMEA: Repeat / recalculated FMEA at Wishaw demonstrating improvement with a decrease of 46%
and 30% at Monklands. This work is shared across NHS Lanarkshire.
MMP1: Medication Reconciliation: Medicines reconciliation continues to have challenges within acute
receiving units as this continued to be viewed as Pharmacy led. An improvement team focussing on Wishaw.
MMP1 Custom Measure: Parallel work has been undertaken in Older Peoples Receiving at Monklands
Hospital and this is seeing some excellent results and sustained improvement. Lessons are being learned
from this unit.
Peri operative All green, except surgical brief which is amber to green. Data now beginning to be reported
as per general ward and excerpts from this data demonstrating spread and improvement following peri
operative dialogue.
POP1:DVT prophylaxis: All sites at target
POP2: Antibiotic prophylaxis: Excellent progress - at target.
POP3: Glucose control: Still some difficulty in achieving this – type 2 diabetic patients and normal level of
control and emergency activity. Clinical decision focussed.
POP4: Beta blockers: Sustained improvement Monklands although slight recent dip. At target Hairmyres,
not yet at target Wishaw.
POP5: Normothermia: At target at three sites
POP6: Skin preparation / hair clipping: 100% compliance. Fully spread and no razors available.
POP7: Surgical brief: Monklands and Wishaw at target with progress at Hairmyres. Surgical Pause: All
theatres, all sites. Excellent progress and sustaining same
All data being reported as per general ward to more easily inform improvement plans

SCOTTISH PATIENT SAFETY PROGRAMME
HIGHLIGHT REPORT
Walkrounds: Forty nine executive leadership walk rounds have been undertaken to date. Excellent
representation from Executive and Non Executive Directors. Walk rounds scheduled at two per month for
next calendar year. Emerging themes remain HAI, storage, clinical environment and small equipment issues.
Data is entered to demonstrate actions completed on an ongoing basis now. New system in place to track %
of actionable items resolved and Extranet updated. Very good relationships with PSSD to resolve Estates
issues.
Quarterly Leadership work stream meetings are scheduled to enable direction to be given to the work streams
and practice to be shared as relevant
Paedriatic
Initial work has begun and making good progress. Of note is the EWS are being posted outside bedded area
which acts as an alert to all staff if necessary.
Heart Failure
Initial work has begun and this will be reported in due course
Relevant Bundle Spread
This well underway in associated hospitals and mental health to include safety brief and SBAR. Efforts are
being made to firmly align with other quality measures such as food fluid and nutrition, pressure area care,
etc.
Data Management
We have now obtained funding from the Scottish Government eHealth Department to enable us to further
develop our data management system: Lanarkshire Quality Improvement Portal (LanQIP), which brings
together all of our quality measure via a web based portal. Along with other support funding, this enables us
to appoint three system developers to further develop and ‘roll out’ to most of the other NHS Scotland Boards
who have indicated interest.
Comments on variations from plan (where exists):
• No variation from plan.
• Funding secured for one year for SPSP Clinical Facilitators to ensure spread capability and capacity as
this programme moves outwith acute hospitals.
• Funding achieved centrally to spread our data management system – Lanarkshire Quality
Improvement Portal (LanQIP) to interested NHS Boards who have requested this system.
Actions planned for the next 6 months:
• Begin reporting Paediatric Work stream progress
• Begin reporting Heart Failure bundle progress
� Develop capacity within areas not yet participating in SPSP. Improvement teams (SPSP, Leading Better
care, Better Together, HAI) to visiting areas such as attached hospitals to continue spread and
improve monitoring for all NHS Lanarkshire Hospitals
� Refine Spread plan as per above
� Develop reporting system further to have in place as per general ward
� Continue review of data to target improvement
� Complete LanQIP and begin to spread this to other interested NHS Boards.