Healthcare quality and patient safety: Conceptual aspects

1. Healthcare quality and patient safety: Conceptual aspects International Workshop on Quality and Safety in Healthcare, Brasilia, Brazil Jonathan Riddell Bamber, 13 August 2013

2. www.health.org.uk - jonathan.bamber@health.org.uk By the end of this session you will have... • brief introduction to a UK perspective on quality and safety improvement • an overview of the Health Foundation’s involvement in quality improvement for over 10 years; and • reflections on potential relevance for the Brazilian context

3. www.health.org.uk - jonathan.bamber@health.org.uk The Health Foundation • An independent health charity • Working to improve the quality of healthcare in the UK: England, Scotland, Wales, and Northern Ireland • International links (e.g. the US Institute for Healthcare Improvement and Proqualis; work in Nepal and Malawi) • All information on our website in English; available through Proqualis (Fundaçao Oswaldo Cruz) in Portuguese soon • Established 1997; focus on quality 2003; my work on knowledge translation since 2007

4. www.health.org.uk - jonathan.bamber@health.org.uk The UK National Health Service • Created 1948 as universal free health provision • Paid for by universal employment tax (public share 82% in 2007*) • Four countries manage separately NHS England • R$171bn 2001/2 increased to R$364bn 2010/11 ** • R$7,000per head 2010/11 (R$833 in Brazil, R$7,000US ***) * OECD website cited Paim et al Lancet 2011; 377; 1778-97 ; ** 10 Aug 2013: http://www.nhsconfed.org/PRIORITIES/POLITICAL-ENGAGEMENT/Pages/NHS-statistics.aspx; *** 10 Aug 2013: United Nations Development Program, cited www.worldpolicy.org/blog/health-care-brazil-300-year

5. www.health.org.uk - jonathan.bamber@health.org.uk Development of quality and safety (NHS) • First organisational review of healthcare associated deaths in UK was by Florence Nightingale in 1856 • History of enquiries into failure and response, often around infection control, or maternal or child death • To err is human (IOM, 1999) • An organisation with a memory (Sir Liam Donaldson, 2000)

6. www.health.org.uk - jonathan.bamber@health.org.uk Our approach and strategy • Foundation approx. R$2.5bn; spend R$85-100m a year • Approach: IDENTIFY research and expert advice INNOVATE improvement projects and research DEMONSTRATE large-scale improvement initiatives ENCOURAGE joint working and promotion • Strategy • Target resources selectively (meeting current UK needs) • Combination of knowledge development AND direct improvement to patient care

7. www.health.org.uk - jonathan.bamber@health.org.uk 1) Selective Targeting to meet UK needs

8. www.health.org.uk - jonathan.bamber@health.org.uk 2) Best evidence AND direct improvement to patients • Evidence needed from all improvement project of outcomes and explanation of why • 10-15% on evaluation on any improvement project • Lining up - Michigan Keystone and UK • Applied research – making practice change, not just publication • Improvement Science: • Capacity development (post doctorial and PhDs) • Global consensus • 50% ownership of BMJ Quality and Safety • Monthly research scan of 40,000 journals to provide a sweep of 50 articles on health care improvement

9. www.health.org.uk - jonathan.bamber@health.org.uk Reflections • Improvement must be relevant and engage professional and policy audiences • Adapting solutions for specific situation – local history, context and experience • e.g. 328 obstetrics guidelines; 35,000 pages!! • Consider the side effects of change

10. www.health.org.uk - jonathan.bamber@health.org.uk 3) Consider the side effects of change: Incident reporting in healthcare • National Reporting and Learning System (NRLS) 2003 • Emulating rapid response in aviation for incident reporting: • aviation 10,000 • Identify problem and investigate • NHS: 1.4m per year • Data driven epidemiological tool…little investigation

11. www.health.org.uk - jonathan.bamber@health.org.uk Reflections • Improvement must be relevant and engage professional and policy audiences • Adapting solutions for specific situation – local history, context and experience • e.g. 328 obstetrics guidelines; 35,000 pages!! • Consider the side effects of change

12. www.health.org.uk - jonathan.bamber@health.org.uk Thank you for listening Contact: jonathan.bamber@health.org.uk Acknowledgements: Professor Claudia Travassos, National School of Public Health, Fundaçao Oswaldo Cruz Dr CamilaLajolo,Proqualis, Fundaçao Oswaldo Cruz Professor Mary Dixon-Woods, University of Leicester Professor Charles Vincent, Centre for Patient Safety and Service Quality (CPSSQ), Imperial College London Dr Tim Draycott, Improvement Science Fellow, the Health Foundation Dr Carl MacRae, Improvement Science Fellow, the Health Foundation Professor Nick Barber, Director of Research, the Health Foundation

13. A framework for measuring and monitoring of safety • Has patient care been safe in the past? • Ways to monitor harm include: • mortality statistics (including HSMR and SHMI) • record review (including case note review and the Global Trigger Tool) • staff reporting (including incident report and ‘never events’) • routine databases. • Are we responding and improving? • Sources of information to learn from include: • automated information management systems highlighting key data at a clinical unit level (e.g. medication errors and hand hygiene compliance rates) • at a board level, using dashboards and reports with indicators, set alongside financial and access targets • Are our clinical systems and processes reliable? • Ways to monitor reliability include: • percentage of all inpatient admissions screened for MRSA • percentage compliance with all elements of the pressure ulcer care bundle. • Will care be safe in the future? Possible approaches for achieving anticipation and preparedness include: • risk registers. • safety culture analysis and safety climate analysis • safe safety training rates • sickness absence rates • frequency of sharps injuries per month • human reliability analysis (e.g. FMEA) • safety cases. • Is care safe today? • Ways to monitor sensitivity to operations include: • safety walk-rounds • using designated patient safety officers • meetings, handovers and ward rounds • day-to-day conversations • staffing levels • patient interviews to identify threats to safety.