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Safety Express

Safety Express. A New Journey in Patient Safety for the NHS Dr Ailsa Brotherton Ms Sally Deacon. Safety Express is the name of the mobilisation vehicle for the QIPP Safe Care work stream

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Safety Express

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  1. Safety Express A New Journey in Patient Safety for the NHS Dr Ailsa Brotherton Ms Sally Deacon

  2. Safety Express is the name of the mobilisation vehicle for the QIPP Safe Care work stream • The programme aims to reduce harm in four defined areas using collaborative techniques and improvement methodology: • Pressure ulcers • Falls • Catheter acquired urinary tract infections • VTE • The programme is named ‘Safety Express’ because we aim to move together at a pace and scale which is previously unprecedented in English healthcare. • Safety Express is a ‘call to action’ for NHS staff who want to see a safer more reliable NHS with improved outcomes at significantly lower cost • Safety Express is a partnership with existing programmes (in particular Energising for Excellence, High Impact Actions, Patient Safety First, the Productive Series and the National VTE Implementation group) and each SHA region What is Safety Express

  3. Phase 1 - pilot phase (January to June 2011) Comprising of 3 Learning sessions 60 - 90 days apart January-June New knowledge will be archived into simple bundles and change packages Phase 2 - (September to Feb 2012) Safety nodes will replicate the Safety Express Programme supporting the new teams testing in pilot areas Phase 3 - spread (February to August 2012) Scale up activity to the whole system Regional learning and sharing sessions will take place and exemplar CQUINS will be developed Safety Express programme plan

  4. The Model for Improvement

  5. We need to use our resources wisely. Rapidly improving locally Testing out the improvement Rolling out good ideas This should provide the best services, eliminate waste and adopt the best practice. The Model for Improvement

  6. What are we trying to accomplish? Level 1 Level 2 Level 3 To deliver the HARM FREE [6] for 95% patients by Dec 2012 ‘HARM FREE’ defined by absence of pressure ulcers harm from falls, CA-UTI, VTE, bloodstream infection & C diff for all patients • 80% reduction in hospital acquired category3 or 4 pressure ulcers • 30% reduction in community acquired category 3 or 4 pressure ulcers (patients not in a hospital bed) • 50% reduction in serious harm or death from falls • 50% reduction in the proportion of patients with catheters being treated for UTI • 50% reduction in avoidable VTE events • by Dec 2012 To deliver the HARM FREE [4] for 95% patients by Dec 2012 ‘HARM FREE’ defined by absence of pressure ulcers harm from falls, CA-UTI, and VTE for all patients

  7. The Safety Express measurement strategy focuses on Measurement for Improvement • This approach differs from measurement for performance which many clinicians and commissioners are most familiar with • The Safety Thermometer is the survey tool which is used to measure for improvement • The measures used are fundamentally about PROGRESS OVER TIME. • Improvement measures are usually a sample data (50% patients on specified units of a single day,) the definitions are pragmatic working definitions • Data collection systems are designed to minimise the data collection burden and maximise on the benefit of the ‘act of measurement’. • The Safety Thermometer is designed to help participants and the NHS build up a picture of patient safety issues and to help you see the impact of actions implemented • Each measurement location will measure small numbers of patients often What is the Safety Thermometer?

  8. Harm Profile Data VTE Pressure Ulcers Falls Catheters & Infection

  9. Harm Free (by location) Data

  10. Data Harm Free (by location)

  11. How will we organise our improvement?

  12. B. Host A. Community services Dream Team AHP Patient Stores Doctor Team Leader HOST Team composition GP network Nurse Doctor Pharmacy Manager Clerk C. Mental Health D. Nursing Home Local teams across the provider system

  13. Focus for Impact

  14. Aim Primary Drivers Secondary Drivers Leadership & Safety Culture To deliver harm free care - defined by the absence of pressure ulcers harm from falls, CA-UTI and VTE in 95% of patients By Dec 2012 Local Clinical Leadership Executive Support Walk rounds & rounding Clinical Care 95% reliable Active risk management Continence, skin & moisture Nutrition / Hydration Medication reconciliation Supporting Infrastructure Equipment Education and Training Ward Level Driver

  15. A breakthrough series collaborative Jan 2011 March June Sept

  16. Supportive Framework

  17. Supported Regionally and Nationally 10 regional teams in SHAs Mobilised patients National Coalition

  18. National Leadership - Safety Express

  19. David Oliver / Francis Healey Falls Janice Stevens / Sally Batley Infection Mike Duerden & Carole Fry CA-UTI Anita Thomas and Tim Browne VTE Katherine Fenton / Julie Halliday Pressure Ulcers Caroline Lecko Pressure Ulcers Mike Stroud Nutrition Ashley McKimm Junior doctors Joan Sadler PPI John Madsen / Martin Orton Measurement Bernard Crump / Kate Jones Improvement Mike Durkin Medical lead Jane Cummings SHA lead National Faculty (steering group)

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