Post on 30-Oct-2014
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Safety First and ForemostImproving Patient Safety in
England
Creating a system devoted to
continual learning and improvement
Todays session
• Touch on the context in which the NHS is operating and challenges faced
• Share the emerging plans for improving Patient Safety in England – Safety Collaboratives
• Explore essential components of large scale change and a framework for safety improvement
#saferNHS
NHS Improving Quality (NHS IQ)• NHS Improvement body - from 1 April 2013 and hosted by NHS England• Creation of one improvement organisation aligned with the needs and
challenges of the NHS• Provide improvement and change expertise to support improved health
outcomes• A core team working with a range of delivery partners
• Work with healthcare professionals to implement improvements• Across all sectors • Evidence based QI methods
• Bringing together and building on the wealth of knowledge, expertise and experience that has gone before:– NHS Institute for Innovation and Improvement, NHS Improvement,
National Cancer Action Team, National End of Life Care Programme, NHS Diabetes and Kidney Care.
#saferNHS
Focus on Quality
• Safety: Avoiding harm from the care that is intended to help• Effectiveness: Aligning care with science and ensuring efficiency• Patient-experience: Including patient-centeredness, timeliness and equity
#saferNHS#saferNHS
Stakeholders
Safety First and Foremost
Improving Safety in EnglandNational and Local Perspectives
Sarah TilfordImprovement Manager – Patient Safety
#saferNHS
The Francis Report - March 2013
Key messages from the Francis Inquiry 290 recommendations, 4,000 pages
MEDIA: Mid Staffordshire NHS Trust Public Inquiry report published Feb 13
Profits before patients:
Care home residents
subjected to horrific abuse
went to A&E 76 times in
three years - but private
owner did nothing
Follow us: @MailOnline
on Twitter | DailyMail
on Facebook
Julie Bailey of Cure the NHS Campaign stands outside Stafford Civic Centre
Key messages from the Francis Inquiry – 290 recommendations, 4,000 pages
• This was a system failure as well as failure of an individual organisation
• No single recommendation should be regarded as the solution to the many concerns identified
• A fundamental change in culture is required across the NHS
• We need to secure the engagement of every single person serving patients in the change that needs to happen
Post Francis ReviewsFrancis - Keogh and Berwick• Patient safety problems exist
throughout the NHS (14 Trusts)• NHS staff are not to blame• Incorrect priorities do damage• Warning signals abounded and were
not heeded• Concerns about leadership (boards)• Responsibility is diffused and not
clearly owned.• Improvement requires a system of
support• Lack of transparency • Fear is toxic to both safety and
improvement.
Berwick - Responding to Francis
“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”
Berwick Report, August 2013
QualityBetter
Old Way(Quality Assurance)
QualityBetter Worse
New Way(Quality Improvement)
Action taken on all
occurrences
Reject defectives
Old Way, New Way
Source: Robert Lloyd, Ph.D.
Requirement,Specification or
Threshold
No action taken here
Worse
National Reporting System
Source: NHS England Patient Safety Domain
2015/16 Further randomised systematic retrospective case note review – an indicator of problems in care resulting in preventable harm
Source: NHS England Patient Safety Domain
Nature of Harm
• Clinical Incidents – SUI, error, omission, failure to treat, failure to respond
• Never events• Complications arising from care intended to
help – HCAI, VTE, pressure ulcers• Patient accidents – falls• All sectors, all patient populations• Result -No harm, mild, moderate, severe, death
Context• Deliberate harm is rare
• System design and human factors contribute to failure
• NHS under pressure and financial challenges
• Rising demand - aging population, long term conditions better treatments & technologies
• Balance between target driven & quality outcomes and experience
We need to do more, with less... to improve standards and experience of care, with a real focus on prevention rather than counting past harm
#saferNHS
Cost of Harm
• Personal costs – patients & families and staff• 1 in 10 patients suffer harm, much of which is likely
to be avoidable• Lost capacity to treat others – affects waiting times• NHS Litigation costs £1.3bn / yr • Damage to institutions reputation• Financial costs – extra bed days, treatment cost• Getting a grip on safety = Economic good sense
#saferNHS
The Patient Safety Collaboratives Programme
2014-2019
Creating a system devoted to
continual learning and improvement
Supporting NHS England Safety Plan
#saferNHS
What will the programme look like?
#saferNHS
Patient Safety Collaboratives
• AHSN footprint
• 2-5m population
• Locally owned and run
• Majority of funding devolved to support local improvement programme activity
• National support for;
• change packages/ interventions;
• knowledge sharing;
• consistent measurement;
• networks/communities.
Who will be involved?
#saferNHS
Patient Safety Improvement Programme
#saferNHS
Creating a mass movement for patient safety in England• A great Improvement Programme is just one small partWe intend to do “lots of lots” • Campaigns • Engage with Patients Groups• Use Social media Tweetchats WebEx MOOCs Hakathons• Engage Emerging Leaders and Trainees• Develop the role of champions / fellows, change agents • Connecting the dots, creating networks, building
capability
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Creating a patient safety movement: four things we can learn from the great social movements
Slides Courtesy of Dr Helen Bevan
Emerging themes in large scale changeFoundation Emerging direction
Organisation Community
Power through hierarchy Power through connection
Mission and vision Shared purpose
Making sense through rational argument
Making sense through emotional connection
Leadership-driven (top down) innovation
Viral (grass-roots driven) creativity
Led by expert opinion Allow all talent
Engaged patients Passionate users
Clinical networks Mass communities
Tried and tested, based on experience “Net Generation” principles
Transactions Relationships
Most large scale change efforts fail to achieve the objectives
Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey
70%
25%5%
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 1:Focus on the physiology of change as much as
the anatomy
Anatomy of change Physiology of change
Definition The shape and processes of the system; detailed analysis;
how the components fit together.
The vitality and life-giving forces that enable the system and its people to
develop, grow and change.
FocusProcesses and structures
to deliver health and healthcare
Energy/fuel for change
Leadership activities
measurement and evidence
improving clinical systems reducing waste and
variation in healthcare processes
redesigning pathways
creating a higher purpose and deeper meaning for the change process
building commitment to change connecting with values creating hope and optimism about
the future calling to action
Source: Crump and Bevan
Anatomy of change Physiology of change
Definition The shape and processes of the system; detailed analysis;
how the components fit together.
The vitality and life-giving forces that enable the system and its people to
develop, grow and change.
FocusProcesses and structures
to deliver health and healthcare
Energy/fuel for change
Leadership activities
measurement and evidence
improving clinical systems reducing waste and
variation in healthcare processes
redesigning pathways
creating a higher purpose and deeper meaning for the change process
building commitment to change connecting with values creating hope and optimism about
the future calling to action
Source: Crump and Bevan
Anatomy of change Physiology of change
Definition The shape and processes of the system; detailed analysis;
how the components fit together.
The vitality and life-giving forces that enable the system and its people to
develop, grow and change.
FocusProcesses and structures
to deliver health and healthcare
Energy/fuel for change
Leadership activities
measurement and evidence
improving clinical systems reducing waste and
variation in healthcare processes
redesigning pathways
creating a higher purpose and deeper meaning for the change process
building commitment to change connecting with values creating hope and optimism about
the future calling to action
Source: Crump and Bevan
@helenbevan #KPHsafety#KHPsafety#KHPsafety
Lessons for transformational change1. In order to sustain
transformational change, we as leaders need to move from a burning platform (fear based urgency) to a burning ambition (shared purpose for a better future)
2. We as leaders need to articulate personal reasons for change as well as organisational reasons
3. If the fire (the energy) goes out, all other factors are redundant
@PeterFuda
@helenbevan #KPHsafety#KHPsafety#KHPsafety
You get the best efforts from others not by lighting a fire
beneath them but by building
Source: Bob Nelson
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 3:Frame to connect with hearts and minds
@helenbevan #KPHsafety#KHPsafety#KHPsafety
Framing Is the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to action E.g. Civil Rights Activists 1950’sSnow D A and Benford R D (1992)
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 4:build shared purpose
@helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
NHS Change Model
www.changemodel.nhs.uk#saferNHS
@helenbevan #KPHsafety#KHPsafety#KHPsafety
We know that ...
• Shared purpose is a common thread in successful change programmes*
• Organisations and change initiatives with strong shared purpose consistently outperform those without it.**
*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)**Management Agenda 2013 Boury et al (Roffey Park Institute)
Be part of a movement
#saferNHS
Campaign – Sign Up to Safety
#saferNHS
Culture and Learning System – creating the conditions for safety improvement
What does this mean?
#saferNHS
#saferNHS
The safety improvement needs to be built on sound evidence based method and theory - hope is
definitely not the plan!
A Theoretical Framework for Safety
©Allan Frankel and IHI 2013
Culture – the foundations• Culture is uniquely local - the social glue ‘the way we do things
round here’ • High performing teams have agreed norms of behaviour and
structures that create value for the patient, staff and the organisation.
• Measuring culture provides valuable (personal) insights into what it really feels like to work in that environment in a particular role
• Insights can be quite disparate - "the doctors or managers think it's fine, and no one else does"
• Evidence on culture - perceptions about teamwork, safety, and leadership correlate with the quality of care and ‘excellence’
Critical components of culture in healthcare are Leadership, Psychological Safety and Teamwork ©Alan Frankel and IHI 2013
A Theoretical Framework for Safety
©Allan Frankel and IHI 2013
Learning – a systemEvery day skilled healthcare professionals face challenges with basic defects and problems that make it difficult to deliver high quality care • A learning system provides a methodical way to visibly
capture concerns, act on them, introducing a cycle of learning and improvement
• This is an essential component of high performing organisations
Critical components of a learning system are Continuous Learning Processes,
Reliability and Improvement and Measurement©Alan Frankel and IHI 2013
©Allan Frankel and IHI 2013
In your work area• Learning boards• Defect Identification • Safety walk-rounds• Rapid action – PDSA, driver diagrams, small tests of change • Feedback mechanisms
©Allan Frankel and IHI 2013
©Allan Frankel and IHI 2013
Our Commitment to Patients
The NHS in England can become the safest health care system in the world.
That will require unified will, optimism, investment, and change.
Everyone can and should help. And, it will require a culture firmly rooted in continual
improvement.
Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the
power of pervasive and constant learning.
Berwick Note:
Berwick Report 2013
Berwick Note For NHS Staff and Clinicians:
• Participate actively in the improvement of systems of care.
• Acquire the skills to do so.• Speak up when things go wrong.• Involve patients as active partners and co-
producers in their own care.
Berwick Report 2013
Improving health outcomes across England by providing improvement and change expertise
Slides Courtesy of Dr Janet Williamson
Improving health outcomes across England by providing improvement and change expertise
If you can’t describe the pathway and walk it, you can’t change it.
I hear and I forget, I see and I remember, I do and I understand.
Confucius, Chinese philosopher & reformer
1.
Improving health outcomes across England by providing improvement and change expertise
Be clear what your ideal looks like2.
Be BOLD, be ambitious
Improving health outcomes across England by providing improvement and change expertise
Focus on the vital few things not long lists3.
Improving health outcomes across England by providing improvement and change expertise
Know your improvementmethodology4.
It does not matter which approach, but stick to it
Don’t move into doing until you have baseline, you have data and you are clear about the issues you aretrying to solve
Improving health outcomes across England by providing improvement and change expertise
Understand the context5.
Today is about doing more and differently but with the same or less money
Improving health outcomes across England by providing improvement and change expertise
Building relationships and building capability from the start
6.
Redesigning the process, the pathway and the structures is easy, the biggest challenge is winning hearts and minds and changing behaviour
Improving health outcomes across England by providing improvement and change expertise
Every day, seek to learn and continue to learn
7.
Improving health outcomes across England by providing improvement and change expertise
Improvement requirespersonal resilience
8.
Improving health outcomes across England by providing improvement and change expertise
Once you operationalise things you are not in an improvement role, so STOP
9.
Improving health outcomes across England by providing improvement and change expertise
Happy staff make happy improvers
10.
Thank-you sarah.Tilford@nhsiq.nhs.uk
visit: www.nhsiq.nhs.uk
@Sarah_Tilford#saferNHS