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Patient safety seminar. Hester Wain, Head of Patient Safety Anne McDonald, Carl Waldmann, Emma Vaux, Marianne Sampson, Stathis Altanis. Trust Executive sign up to Patient Safety. What does Patient Safety mean to us?. - PowerPoint PPT Presentation
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Patient safety seminar
Hester Wain, Head of Patient Safety
Anne McDonald, Carl Waldmann, Emma Vaux, Marianne Sampson, Stathis Altanis
Trust Executive sign up to Patient Safety
What does Patient Safety mean to us?
Dr Emma Vaux: Doing the right thing in the right way every time for every patient; treating and caring for every patient as
if they were my mother/father/sister/husband/child
Dr Carl Waldmann: Prevent unnecessary harm
Dr Hester Wain: Ensuring that we have quality processes that help staff to avoid making errors, so that
we protect our patients and keep them safe
Anne McDonald: Doing the right thing for every patient every time
Our Patient Safety Aim
To provide safe, personal, and professional quality of care every time for every patient, by reducing the rate of harm and death by 50% by 2012, as measured using the trigger tool.
How can we do this?
Work harder
Learn more
Do better
Remember everything / Forget nothing
Does this work?
Quality Priorities 2011
Providing a positive patient experience by improving communication to inpatients, outpatients, and where appropriate to family and carers, particularly during the discharge process
Further reducing the numbers of patients who develop Clostridium difficile infection while in hospital
Improving care for patients with dementia
Reducing harm and mortality from VTE (blood clots), falls and sepsis
RBFT
Campaign for Preventing Harm,
Improving Safety
Board Leadership/ Executive Walkarounds
Care Bundles Infection Prevention & Control
Mortality ReviewsReducing Harm from
Deterioration Global Trigger Tool
Productive Ward Call 4 Concern
Patient Stories Medicines Management Monthly Hot Topics
Patient Safety Council
Patient Safety Federation Workstreams
Patient Safety First Campaign for England
Ed
uc
atio
n &
Tra
inin
g
Me
as
ure
me
nt fo
r Imp
rov
em
en
t
PDSA
Plan - the change to be tested or implemented
Do - carry out the test or change
Study - data before and after the change and reflect on what was learned
Act - plan the next change cycle or full implementation
Improvement process 1
Identify area where patient safety is at risk, by looking at complaints, incidents, audit reports
Create a process map of what actually happens on the ward
Develop ideas for change eg borrow innovations from other trusts, find published interventions, follow hunches, collate staff ideas
Work out how to measure success with “metrics”:
– immediate process measures (is the new idea being used)
– trustwide outcome measures (is the new idea creating safer care)
– remember to add balancing measures (does this new idea alter something else for the worse)
STUDY DO
ACT PLAN
Improvement process 2 Pick one area for a small step of change eg write procedure, change
procedure, write a checklist, use different staff/new equipment
Set up PDSA cycle with small defined group/area/ward with friendly staff who are committed to give it a go. Measure and record process, outcome and balancing metrics for a short time period eg 1 week
Repeat PDSA cycles to get improvement, and record each change, some will be useless, do not be afraid of failure this is a learning process!
Change needs to be 95% reliable. The best test of this is to ask 5 people on the ward how to do it, if they can all tell you, the process improvement works.
You need a working process that is 95% reliable, before you disseminate the change further.
STUDY DO
ACT PLAN
Neutropenic sepsis February 2010: 81% of antibiotics administered within 1 hour
Consultant Champions in ED, CDU, Oncology &
Haematology
Consultant Champions in ED, CDU, Oncology &
Haematology
Cancer electronic patient record system (RDS)
access available in CDU
Cancer electronic patient record system (RDS)
access available in CDU
STUDY DO
ACT PLAN
% patients receiving IV antibiotics within 1 hour
19
81
0
20
40
60
80
100
Jan Feb
Telephone line for patients discharged from
CDU/ED
Follow up by CNS
Audit of quality of advice/information given
Telephone line for patients discharged from
CDU/ED
Follow up by CNS
Audit of quality of advice/information given
Monitoring of stat. doses of antibiotics in patients who are not neutropenic
and not septic
Monitoring of stat. doses of antibiotics in patients who are not neutropenic
and not septic
STUDY DO
ACT PLAN
Neutropenic sepsis August 2010: 94% of antibiotics administered within 1 hour
% patients receiving IV antibiotics within 1 hour
19
94
82
9193
7681
0
20
40
60
80
100
PDSA cycle for WalkaroundsPlan
Set-up system for weekly Patient Safety Executive Walkarounds
Do
Visit ward areas with Executive Team
Study
Number of walkarounds – weekly rota maintained but challenging
Actions – resource intensive logging and report write-up
Feedback – all ward staff thanked, positive feedback included in report
Act
Weekly rota now coordinated by assistant
Actively delegate actions during walkaround
Include feedback in summary reports to Exec
PDSA cycle for WalkaroundsPlan
Develop Patient Experience Executive Walkarounds
Do
Amended paperwork, reviewed staff (added Matrons & PALS), visit ward areas with Executive Team
Study
Patients and family keen to talk – often challenging to talk to more than one in the visit
Actions – written up by each staff member with 3 key points
Feedback – given directly to ward at time to facilitate any problems identified
Act
Include these patient stories in Board Committees
Practising with PDSAs
4 facilitated workgroups
Patient Safety topic options are:
– Diarrhoea
– Falls
– Pressure ulcers
– Blood clots (VTE)
Review the information and discuss what system changes may reduce harm and increase safety
Identify one small change and create a plan to implement this
Feedback to all workgroups
STUDY DO
ACT PLAN
Our Patient Safety Aim
To provide safe, personal, and professional quality of care every time for every patient, by reducing the rate of harm and death by 50% by 2012, as measured using the trigger tool.
How? Identify the issues
Develop the solutions
Try small steps of change (PDSA)
Measure the success
Disseminate the practice
Monitor sustainability
Care Bundles
HSJ Patient Safety Award, November 2010Getting it right for every patient every time:Timely antibiotics for patients with Neutropenic Sepsis
Nursing Times & HSJ Patient Safety Award, March 2011Patient Safety in Critical Care: 'Call 4 Concern' helpline
