What is Improving Patient Safety in the England?

20th Annual International

Forum on Quality & Safety

in Healthcare

Carol Haraden &

Mike Durkin

24 April 2015

www.england.nhs.uk

The VTE Journey

2005 2006

APPTG

2007

HSC

Inquiry

CMO announces

national approach

NICE

CG46

2008

Exemplar

Centre

website

2009

Leadership

Summit

Risk

Assessment

template

NICE CG92

CQUIN

NICE QS3

Focal Point

for Change

2010

RA data

collectionCQUIN goal

reached

2011………….Present

Risk Assessment

figs now at 96%

New e-learning

modules

NHS Choices

Self-assessment

tool

National

Patient

Information

Leaflets

Commissioning

Toolkit

VTE in NHS

standard

contract

Information

Standard

2

www.england.nhs.uk

Comprehensive, systematic approach to VTE prevention

VTE Prevention Programme was the first national initiative of its kind

Key patient safety initiative:

Delivering high quality care

Reducing avoidable harm from VTE

Making hospitals safer

Leadership from patients and their families, the NHS, parliamentarians, charities….

Striving for excellence – VTE Exemplar Centres Network

Delivered change, enabled by levers provided by NHS

Risk Assessment rates have risen from <50% in 2010

Now stand at 96%

The NHS VTE prevention programme

3

www.england.nhs.uk

The impact of CQUIN

4

www.england.nhs.uk

Improving Outcomes

5

• QI data at trust level: increased risk

assessment, decrease in rates of HAT,

increased rates of appropriate TP,

reduction of inadequate prophylaxis,

• QuORU: 15% reduction in mortality

nationally when 90% risk assessment

goal reached

• Catterick & Hunt: in 2011 & 2012,

around 940 deaths owing to VTE have

been avoided in England. Impact of the national venous thromboembolism risk

assessment tool in secondary care in England:

retrospective population-based database studyDavid Cattericka,b and Beverly J. Huntc

Blood Coagulation and Fibrinolysis 2014, 25:00–00

ONS data shows 9% reduction in VTE deaths since 2010

Improvement corroborated by 3 studies:

www.england.nhs.uk

Case Study:

King’s College Hospital

• Thrombosis committee established 1999 – an instrument for clinical governance and driving change

• Leader of VTE Exemplar Centres Network established 2007

• Director King’s Thrombosis Centre is clinical lead for the National VTE Prevention Programme and chair of VTE Board

• Continuous monitoring of outcomes:

VTE risk assessment is key performance indicator

Regular audit vs NICE VTE prevention Quality Standard

Registry for RCA of cases of hospital-associated thrombosis

6

www.england.nhs.uk

Link Nurse/

MidwivesPatient

information

Thrombosis

team

Staff

education

RCA of

HAT cases

Electronic

VTEp

systems

Audit

programme

VTE

Prevention

Supportive

managers

Preventing VTE

www.england.nhs.uk Roberts et al – Chest 2013;144:1276 8

www.england.nhs.uk

• QI project at King’s College Hospital 2010-12

• Mandatory, documented VTE risk assessment, thromboprophylaxis guidance, mandatory VTE education, identification of hospital-acquired VTE with root cause analysis

VTE Prevention Programme Reduces

Hospital-Associated VTE

2010-11 2011-12 p

VTE risk assessment 63% (38-88) 93% (90-97)

HA-VTE 236

19.7/mo

189

15.8/mo

0.014

Inadequate prophylaxis

among HA-VTE

37% 21% 0.005

Anticoag prophylaxis in

high VTE/low bleeding

group

70% 89% 0.001

Roberts et al - Chest 2013;144:1276; Geerts 2014 9

www.england.nhs.uk

Acute Kidney Injury Programme

10

www.england.nhs.uk 11

www.england.nhs.uk

Southern Derbyshire CCG saw

Think Kidneys as a way to drive

quality & improvement locally

• NCEPOD ‘Adding Insult to Injury’ framed

AKI as driver for patient safety innovation

at scale

• Strong commitment from CCG

Chief/Deputy Nurse and Royal Derby

Hospital renal team

• CCG Board signed up inspired by patient

story & Board briefings

12

www.england.nhs.uk

Progress at Southern Derbyshire CCG

• CQUIN developed during January 2014

Secondary care assessment on admission & discharge information

£1 million funding attached gave high priority

Year 2 CQUIN agreed

• Primary care planning:

Locally Commissioned Service Framework signed up to by 56 practices

Baseline survey in general practice 467 + clinical respondents

Programme of education & awareness raising sessions in SC &PC

Strategic Clinical Network funded education & awareness raising sessions

Primary Care Quality Forum focus on AKI, RDH Academic Detailing & Peer Review supported by Renal Consultants, resource dissemination to GPs

Evaluation framework working in collaboration with Salford

AKI Policies, Procedures & Guidelines support care planning Shared Care Pathology website AKI guidance through RDG

Sick day rules – CCG Meds Management team

Read codes approved and being implemented

13

www.england.nhs.uk

Impact on

standards of

basic care

• Cases note audit of 306 pts.

• 132 cases baseline

• 156 cases post intervention• 77 in 2012 audit, 79 in 2013 audit

• Equal numbers in each AKI stage

Baseline 2012 2013 p value

Fluid balance assessed 36.4% 66.2% 79.7% p<0.001

Medication review 71.1% - 88.4% p<0.001

Renal imaging (AKI 2 & 3) 45.3% 54.2% 71.0% p<0.001

Nephrology referral (AKI 3) 37.8% 56.5% 78.9% p<0.001

Urinalysis performed 40.3% 57.1% 35.5% p=0.177

* **

*p<0.001

www.england.nhs.uk

Saving £millions through better

treatment of sepsis

• The UK Sepsis Trust estimates 35,000 deaths per

year in UK from sepsis (1,2,3)

• Treatment of sepsis costs the NHS an estimated £2.5

billion a year

15

1.Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European intensive care units: results of the SOAP study. Critical Care

Medicine 2006; 34: 344–53

2.Hall MJ, Williams SN, DeFrances CJ, et al.: Inpatient care for septicemia or sepsis: A challenge for patients and

hospitals. NCHS data brief Hyattsville, MD: National Center for Health Statistics 2011; 62

3. The Intensive Care National Audit and Research Centre (2006)

The reliable delivery of basic elements of sepsis

care could save an estimated 11,000 lives a year

across the country and £150 million annually

In a typical district general hospital could save an

extra 100 lives a year (approx £1.25 million)

The Sepsis Six

1. Give high-flow oxygen via non-rebreathe bag

2. Take blood cultures and consider source control

3. Give IV antibiotics according to local protocol

4. Start IV fluid resuscitation Hartmann’s or equivalent

5. Check lactate

6. Monitor urine output consider catheterisation

within one hour

..plus Critical Care support to complete EGDT

www.england.nhs.uk

What Doncaster and Bassetlaw NHS

Foundation Trust did to improve?1. Establish project lead and a multidisciplinary

sepsis team

2. Develop and implement a sepsis pathway

document (IPOC)

3. Educate staff about sepsis and the IPOC

(Quiz)

4. Sepsis screening as part of triage

5. Analyse and learn from failure to deliver

sepsis 6 within 1Hr

6. Treat all patients with sepsis in resuscitation

area

7. Give regular feedback on progress

8. Ongoing MDT education on sepsis and

improvement17

18

Sepsis 6

Sept-Oct 2013 March 2014

IPOC (n=71 58%)

Non-IPOC (n=50 42%)

IPOC (n=33 70%)

Non-IPOC (n=14 30 %)

Oxygen <1 hour

99% 94% 100% 95%

Antibiotics <1 hour

90% 67% 91% 72%

IV Fluids <1 hour

94% 37% 97% 81%

Blood cultures <1 hour

97% 47% 94% 72%

Lactate <1 hour 93% 39% 94% 72%

Urine measured <1 hour

84% 25% 97% 72%

Survival 87.3% 79.1% 93.9% 78.6%

21www.england.nhs.uk

Spread and Scale Up: Coverage and Completeness

These presenters have nothing to disclose

P22

“Up to 70% of improvement projects never spread.”

Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012;

53(4): 43-50.

Core elements included in the design: 1. Phased Approach

P24

PDSA “ramp” testing under different conditions (Langley, 2006)

Degree of Belief in Change Ideasd

eg

ree

of b

elie

f

Innovation Phase(set design targets, develop

Ideas and predictions, and draft

an initial conceptual model and

change package)

Pilot Phase(test and

revise/amend conceptual

model and

change package)

Adapt and Spread(implement and disseminate

a successful

change package)

High

Moderate

Low

Prototype development of a “slice” of the system (Massoud, 2004)

26

Core elements included in the design: 2. Adoption mechanisms

P27

IHI’s framework for spread (Nolan, Schall et al. 2005)

Core elements included in the design: 3. Existing concepts of “spread” and “scale up”

• “scale-up” - overcoming the system/infrastructure issues that arise during efforts to scale-up implementation (5x thinking)

• “spread” – the leadership, social, and environmental factors that promote adoption and replication, with little modification, of an intervention within a health system

P28

Unpublished document: Kurapati, Laderman, et al., 2011.

Adoption MechanismsP29

• Well-tested set of interventions are deployed at large scale, adopted with minimal further adaptation by frontline staff

• Focus on replication and sustainability • Strong reference to leadership, social networks,

communication and attributes of the intervention (IHI’s Spread Framework)

• Culture of urgency and persistence• Planned diffusion models (e.g. Mayo “managed

diffusion”, Kaiser Permanente “spread toolkit”)

Support SystemsP30

• Build human capability for scale-up . • Leadership team to guide the process • Reference to 5x thinking – phased training from volunteers to trained,

dedicated improvement specialists• QI-based programs for those who need additional training (start

before scale-up begins).• QI teams

• Build infrastructure for scale-up: • Balance targeted resource addition vs system redesign • reconfiguration of existing resources (e.g., on-site lab for lactate,

nephrology referral, thrombosis team) • Additional tools (e.g., checklists, data capture systems), • Communication tools, and • Key personnel (data capturers, quality improvement mentors)

Support SystemsP31

• Build reliable data collection and reporting systems• Track and provide feedback on the performance of

key processes

• Data systems for improvement vs monitoring

• Develop learning systems:• Mechanisms for collecting, vetting, and rapidly

sharing change ideas or interventions

Sustainability

• Key design feature in all phases (i.e., build into change package)

• Ensure high-reliability of the new processes (e.g., use failures to continually improve processes)

• Create monitoring systems to ensure desired results are being achieved

• Build support for structural elements (i.e., training, policies and procedures, standardize processes, etc.)

• Develop and use ongoing learning systems (i.e., opportunities for shared learning and support, refined change package and materials, etc.)

P32