Scotland's

Patient Safety Journey

Leadership & Culture , National & Local perspective

Session Aims

• Share the safety journey in Scotland from a..

-national and local perspective

-reflecting a policy commitment to safe , effective and person centred care

-translating this to care at the bedside

http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme

2008 Launch

15 % Reduction in Mortality 30%

reduction in Adverse Events

Aims: To deliver the highest quality healthcare services to the people of Scotland For NHSScotland to be recognised as world-leading in the quality of healthcare it provides

Creating the conditions

5.2 million people £12 billion 14 Health Boards 8 Support Boards Emphasis on partnership and collaboration Moving to health and social care integration

“Safe, effective and person-centred care which supports people to live as

long as possible at home or in a homely setting.”

Sustainable delivery of the Quality Strategy

Quality of Care

Primary Care

Integrated Care

Safe Care

Unscheduled and Emergency Care

Person Centred Care

Care for Multiple and Chronic Illnesses

Health of the Population

Early Years

Health Inequalities

Prevention

Value & Financial

Sustainability

Innovation

Efficiency & Productivity

Workforce

12 Priority Areas for Action

ROUTE MAP TO THE 20:20 VISION

The SPSP Journey….

Compelling vision

Common goal - aim high

Evidence-based interventions

Model for Improvement Knowledge & skills

Collaboration

Leadership

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Roger’s Adopter Categories

Values

Behaviour Mindset

Quality Improvement & Methodology

Improvement Skills Model creating the conditions

Toolkit

Measurement for Improvement

Communication

Teams

• Local

• Board

• National

• International

Teams

Safety Culture

Safety Culture

National to local

• Rhetoric to reality

• No assurance

• Don't bring me bad news

• Infrastructure

• Leadership

• Spread to soon

• Culture

Stories and Culture

• Easy to focus on ‘failures’

And forget how often things go right

Out of adversity comes opportunity Benjamin Franklin

Lessons for Leadership in changing culture

Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.

•Berwick Report 2013

For improvement to flourish it must be carefully cultivated in a rich soil bed ( a receptive organisation), given constant attention ( sustained leadership), assured the right amounts of light( training and support) and water

( measurement and data) and protected from damaging.

Stephen Shortell

Culture

Progress towards our aims

90% of all practices in Scotland completed the Safety Climate Survey, by April 2014

Participate

Results

Feed-

back

Learning

Improvement

Safety

Climate

Survey

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Workload Communication Leadership Teamwork Systems

Scotland’s Safety Climate April 2014

Safety Climate Survey Results Clinical vs Non Clinical

00000

Success , Challenges & Learning

Local Success

Safety is a process of enquiry

Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2012.

www.health.org.uk/publications/the-measurement-and-monitoring-of-safety

Has care been safe

in the past?

Are our clinical systems &

processes reliable?

Is care safe today?

Will care be safer in the future?

Are we responding & learning

& improving?

It is not easy

It takes time

Achieve reliability before spreading

Measuring safety

Moving from scale testing to

universal spread

Expanding into other areas......

Learning

Spread

qihub.scot.nhs.uk

Older People in Acute Care

Spread

10 Patient Safety

Essentials Hand Hygiene

PVC Bundle

Surgical Brief & Pause

VAP Bundle

CVC Insertion

CVC Maintenance

General Ward Safety Brief

Early Warning Score

ICU Daily Goals

Leadership Walk rounds

Aim Primary Drivers Secondary Drivers

Through continually

improving

healthcare

delivered in

Scotland, we will

reduce events that

cause harm to

people.

Strategic Priority

Ensure safety and quality are organisational priorities

Provide leadership and oversight to ensure delivery

of programme

Actively develop your safety culture

Infrastructure

Develop and utilise local capacity and capability in QI

Effective measurement systems

Programme management

Effective communication

Manage transitions of care

Point of Care

Acute Adult

Maternity and Children Quality Improvement

Collaborative

Primary Care

Mental Health

Organising for the future

We have a Plan

At board level sufficient capacity and capability to delivery the safety aims

Capacity of the system to effectively use data to drive improvements

Capacity of the system to undertake large scale spread and sustain improvements

Effective systems to evaluate impact and capture key learning

A national infrastructure to ensure effective delivery and support locally

Integration across all safety programmes and wider

Questions

www.scottishpatientsafetyprogramme.scot.nhs.uk www.qihub.scot.nhs.uk

Joanne Matthews Head of Safety in Healthcare

Scottish Patient Safety Programme Healthcare Improvement Scotland

Jane Murkin

Head of Patient Safety & Improvement NHS Lanarkshire