Delivering safer care for every patient in Wales

1000 Lives Plus, a new national programme, seeks to improve patient safety and reduce avoidable harm across NHS Wales, building on the work of the 1000 Lives Campaign, which ended in April 2010. The Campaign aimed to save an additional 1,000 lives and prevent 50,000 episodes of harm in Welsh healthcare during its two-year period.
    
Focusing on patients
“It has enabled us to focus more closely on our patients and reminds me of why I went into the NHS – to save lives.” These words from a frontline member of staff show how the improvement agenda has captured the imagination of staff in NHS Wales.

1000 Lives Plus will align with several other national programmes in the five year Strategic Framework for NHS Wales. The programmes are the central delivery mechanisms for the Welsh Assembly Government’s vision for world class healthcare by 2015.

The inclusion of 1000 Lives Plus indicates just how far the patient safety and improvement agenda has come since the original Campaign was launched in 2008. Patient safety is now an integral part of the mainstream long-term plans within NHS Wales.

With an increased emphasis on patient-centred care, a commitment to working across primary and secondary care and several new clinical areas targeted for improvement, 1000 Lives Plus will have a transformational impact on Welsh healthcare.

A year on from an extensive reorganisation of the NHS in Wales, its seven Health Boards and three Trusts are all committed to 1000 Lives Plus. At the launch of the programme, medical directors outlined their local aims to reduce mortality and harm in their organisations.

This has been made easier by the emphasis on measuring and reporting on mortality. “In the old days, hospitals would not have known what their death rates were,” says Mr Hamish Laing, director of Acute Care at Abertawe Bro Morgannwg University Health Board.

“But everyone knows that in order to make improvements you have to be able to benchmark where you are and identify areas of concern. Only then can you begin to measure the quality of the services you are delivering.”

Spreading and embedding best practice
“The new programme is committed to accelerating the pace of change to spread the new ways of working introduced by the Campaign from ward to ward, practice to practice and organisation to organisation,” says Dr Alan Willson, director of 1000 Lives Plus.

“Every Health Board and Trust is involved, with the focus on patients having the right to expect the same high quality of care – wherever they receive their treatment in NHS Wales.”

Many of the proven success stories have become mandatory in healthcare settings across Wales, including measures to tackle pressure ulcers, the introduction of the WHO safer surgery checklist, and measures to address normothermia.

1000 Lives Plus is supporting clinical staff in making these mandatory changes. For example, over 200 frontline staff from across Wales attended a conference on reducing hospital acquired pressure ulcers in June 2010.

Conference delegates were shown how pilot wards in Wales had virtually eliminated pressure ulcers – the treatment of which, makes up four per cent of the entire NHS budget. They were encouraged to implement best practice in their workplaces to end the lottery that made it more likely to develop a pressure ulcer in one hospital than another.

New areas of work – and ways of working
1000 Lives Plus incorporates several new areas of work which will minimise waste, harm and variation. In total, there are over 20 programme areas which are being phased in over the next 12 months. These include:
• preventing falls in community care
• enhanced recovery after surgery
• improving maternity services
• offering better treatment to those suffering from depression
• improving quality of life and care for those with dementia
• reducing patient identification errors

Much of this work is preventative, such as installing new practices to prevent thrombosis, reduce the likelihood of chronic heart failure, prevent harmful medication mix-ups, and treat the warning signs that precede stroke.

Many of these areas involve both primary and secondary clinical organisations, with a definite agenda to institute quality “from board to ward to home”. In patient-centred care, consideration needs to be given to every interaction with patients, including preparing for surgery before hospital admission, and after discharge, for example by continuing treatment.

One of the newest areas being developed in 1000 Lives Plus is providing better mental health services. This includes engaging GPs to screen for depression during consultations as a preventative measure. Mental health initiatives also take the concept of patient-centred care to a wider level; involving the family of dementia sufferers is an integral part of improving care, both during hospitalisation and in coherent discharge planning.

The work to improve stroke services also focuses on preventative and post-event services. Action is being taken to initiate prophylaxis after Transient Ischaemic Attacks to mitigate against subsequent full-blown strokes.

There are also attempts to improve acute stroke care and start stroke rehabilitation early; again, with an emphasis on robust transfers of care into the community setting. Patients are expected to be involved in the planning stages for their transition back into the community, based on individually tailored treatment plans.

Non-clinical improvements can also enhance the quality of patient care. Work on improving data to ensure patients are correctly identified involves retraining staff to ensure data input is to the highest standard, and also that electronic data systems interface efficiently. Patient identification is an area where human and technological errors can be compounded.

Making sure the changes happen
The methodology introduced by the Campaign will continue to be used – applying small tests of change before wider implementation. The template for this evidence-based change movement is the 100,000 Lives Campaign developed by the Institute for Healthcare Improvement (IHI) in the US.

A collaborative model is bringing together staff from across the country, and across clinical and managerial settings, to learn new ways of working, which can then be put into practice and evaluated. These mini-collaboratives focus on distinct areas of improvement, seeking immediate change. They use learning sessions to discuss and plan activities (and later report back on progress), and action periods, during which the plans are enacted and tested.

Using the Model for Improvement, each change is tested through a Plan-Do-Study-Act (PDSA) cycle, which ensures the change is evaluated. At the end of the cycle, those introducing the change can choose to adapt it and retest, adopt it across the wider organisation, or abandon it and try something different. When the collaborative re-convenes, staff can learn from one another’s successes, and begin to spread the ideas that have proven
to work.

Frontline staff are well placed to identify solutions to problems and deliver the change that patients need. 1000 Lives Plus will continue to engage, support, equip and motivate frontline staff, recognising that NHS staff save lives every day and the programme will help them save even more.

This “hearts and minds” approach worked well for the Campaign. Ailsa Dunn, consultant physician in Powys Teaching Health Board, said: “The 1000 Lives Campaign is easily the best initiative that I’ve ever been asked to participate in. It’s exactly aligned with what we needed to do in Powys to ensure that our services were safe.”

Empowering patients
One of the key elements of 1000 Lives Plus is patient involvement. Patient stories are used at board level to keep patients central to the improvement work, and a new commitment to put the patient central is key to many of
the initiatives.

“We can, and will, be held to account by our patients, for it is our hands in which they place their trust and it is our obligation to hold it,” says Mary Burrows, chief executive of Betsi Cadwaladr University Health Board, which covers North Wales.

Patients also play a vital part in ensuring that improvements work – their compliance with treatment can be the determining factor in success. Educating patients about their treatments, and encouraging patients to feel able to question the care they receive is vital.

“Patients need to feel they can ask a doctor to wash their hands, or request a risk assessment for thrombosis,” says Dr Alan Willson. “When we begin to see patients as partners in treatment – someone we work with, rather than do things to – then we will see better recovery rates, and earlier discharges.”

Some programme areas are very reliant on patient-partnership. Enhanced Recovery after Surgery, for example, requires patients to follow nutritional guidelines and other preparatory measures in the run-up to surgery, in order for quicker healing afterwards.

Other interventions aim to shape patient behaviour in quite simple ways – one surgical initiative asks patients not to shave their body hair before surgery and another encourages people to report falls that have not resulted in injury, to help prevent further falls.

Since 1000 Lives Plus was launched, the need for substantial expenditure savings has become apparent. However, quality improvement does offer opportunities for greater efficiencies. In many cases, it is believed that higher quality can actually be achieved at a lower cost to the NHS.

Enhanced Recovery after Surgery is being funded on an invest to save basis, with savings gained from shorter hospital stays and fewer cancelled operations. This enables the investment to be paid back. However, there is a recognised need for whole system change to reflect the improvements in clinical care. In the case of pressure ulcer reduction, the potential savings are not being fully realised as the processes to discharge patients are not updated to reflect the improvement.
    
Wider system
1000 Lives Plus can help connect the dots to show how improvement must be integrated into a wider system. The clinical achievements will also offer an opportunity to generate financial savings for NHS Wales. These savings should escalate through embedded best practice that ensures that safer care and more cost-effective processes become the norm, and the benefits are felt in subsequent financial years.

“1000 Lives Plus is designed to ensure that new ways of working are embedded in everyday practice, enabling everyone to meet the shared vision of putting patients and patient safety above all else,” says Dr Tony Jewell, chief medical officer for Wales.

“We look forward to continuing the national effort to deliver improvements that will help deliver world class healthcare every time, to every patient wherever they live in Wales.”

For more information
Web: www.1000livesplus.wales.nhs.uk