Leading for patient safety

Earlier this year eight studies were identified that had looked at 74,485 patient records. In these studies a median of 9.2 per cent of admissions had suffered an adverse event and it was determined that there was a median of preventability for 43.5 per cent of these patients. 56.3 per cent of these adverse events led to no or minor disability but 7.4 per cent of events were lethal.
    
For the PCT area with 200,000 inpatient admissions per year this would equate to the order of 18,400 patients experiencing an element of harm and that of the order of 7.4 per cent or 1,362 of these patients may die as a result of which 592 (at 43.5 per cent) were preventable.

Reducing risk of harm
Why is it that we are still so complacent when it comes to introducing new or even old models of care that would reduce the frightening probability that patients under care are very likely to experience harm as part of their journey?
    
Reports of these incidents are being collected from individuals and organisations in a systematic way by the National Patient Safety Agency and trends are beginning to emerge that demonstrate some significant risk areas, particularly with regard to medication errors, infection, falls, and perioperative care.
    
Why are we finding that reporting through the National Reporting and Learning System is improving in the acute and mental health settings but the response from general practice is still disappointing when we consider the number of episodes of care that take place outside hospital?

Safety campaign
The Patient Safety First campaign is the first of its kind in England that seeks to make the safety of patients everyone’s priority; its aim being that patients will experience no avoidable death or avoidable harm while in the care of the NHS. It is the brainchild of the Chief Medical Officer, Sir Liam Donaldson and Sir Ian Carruthers who outlined the future direction for patient safety in their Safety First paper in 2006.
    
It is funded and supported by a coalition of the National Patient Safety Agency, the National Institute of Innovation and Improvement, and the Health Foundation. It is led by Stephen Ramsden, chief executive of Luton and Dunstable NHS Foundation Trust.
    
These founding partners have brought together a Core Team of 20 ‘activist’ clinicians, managers and patients from across England who have been selected because of their commitment to change the way we deliver care so that harm and avoidable death is reduced, the patient experience is enhanced and that individual outcomes will improve.

Improving systems
The campaign seeks to deliver a scale change in the way that we bring about a radical improvement in patient safety. Using both a model of active engagement and participation of NHS staff and patients, as well as building on the foundations of evidence based medicine that will produce clinical system improvement through a rigorous attention to measurement, without losing ownership of the implications of variation.
    
The campaign is centred on a message that by the introduction of a number of key interventions the performance of clinical individuals and teams will focus on improving safety and that by doing so the patient experience will simultaneously improve. There are five interventions that form the first wave of evidenced based individual, team and bedside strategies:

• Leadership for safety
• Reducing harm from deterioration
• Reducing harm in critical care – which includes  specific central line and ventilator bundles
• Reducing harm in perioperative care – which includes preventing surgical site infection and implementing the World Health Organization (WHO) Surgical Safety Checklist
• Reducing harm from high-risk medicines – such as anti-coagulants, opiates, injectable sedatives and insulin.

These interventions have been developed through the experience of key initiatives and safety programmes led by the National Patient Safety Agency and supported within the Leadership in Patient Safety programme from the NHS Institute for Innovation and Improvement and the Safer Patient Initiative from the Health Foundation and the Institute for Health Improvement.
    
Although the core leadership intervention and many of the above are important for all organisations, the need for the development of key interventions that will support change and improvement in the Mental Health and Primary Care settings are well recognised and are also being actively developed for dissemination.
 
Signing up
In order for an NHS organisation to sign up to the campaign there must be a public pledge of commitment from the chief executive of a Trust and their Board to introduce at least two interventions; one of which must be the Leadership for Safety. Chief executives must signify that they are fully committed to leading the campaign locally with a written pledge to all staff within their Trust.
    
Trusts must also sign up to training in the Global Trigger Tool as the initial mechanism for audit and evaluation of current clinical harm. A further request is that the Trust will post its results demonstrating what changes have taken place.
    
The goal of the Leadership for Safety intervention is to ensure that a leadership culture at Board level exists that will promote quality and patient safety and provide an environment where continuous improvement in harm reduction becomes routine throughout the organisation.

Take action
The Patient Safety First campaign asks the leadership of the participating organisations to begin, at a minimum, by focusing on the following six actions to improve quality and reduce harm:

1. Develop explicit strategic priorities and goals
2. Provide demonstrable leadership
3. Ensure executive accountability
4. Establish and monitor explicit system level measures
5. Monitor progress and drive execution of plans
6. Build patient safety and improvement  knowledge and capability

The campaign was launched at the NHS Confederation Conference in Manchester in June when there was an initial sign-up from many chief executives and individuals. This momentum has been maintained since at many national and international events and also by using regional workshops, a master-class series of Web-EX sessions and by the development of a series of ‘How-to Guides’ for the interventions.
    
At the time of going to press, there are now more than 260 NHS organisations that have signed up including 78 per cent of all acute Trusts. Although the initial set of interventions has been focused towards the needs of this latter sector there has been an increasing sign-up from Mental Health, Ambulance and Primary Care Trusts.
    
The campaign is also supported by a field operations team led by Murray Anderson-Wallace. This team alongside the core members are now in position to support the development of both individual organisations and regional clusters, within which individuals and teams will be leading on the dissemination and training in the interventions. These clusters will also aim to set up a local approach to learning from current exemplar sites and regular learning exchanges.

Measuring quality
All the interventions have relevance across the provision sector, but it is becoming increasingly apparent to the commissioning function of PCTs that within the campaign there are some methods with which to identify not just elements of safety improvement. Some key and innovative tools can be used to show that not just measurement for improvement is taking place, but also that a vibrant and sustaining culture of quality and safety improvement is in place within their various providers.
    
As we move to a system that shares through posting of results and the increasing use of clinical dashboards, we should sustain our interest and support for the methodology employed by the Patient Safety First campaign. The development of the quality account is foremost in our minds as we demonstrate a public commitment to quality improvement across the NHS and there will be some early lessons learned from the campaign.

Will we step up to the challenge?
Will we really use the energy and commitment of our staff to reduce the numbers of patients suffering harm? Do we have a Board that has not just the ambition but the will and courage to see through the necessary changes? Will we really use the leadership position that we occupy to demand a reduction in avoidable harm and death? And if not… why not?

For more information
Try here first at www.patientsafetyfirst.nhs.uk.

This article originally appeared in the HSJ (Health Service Journal) 5 December 2008. It was written by Dr Mike Durkin, medical director, NHS South West, consultant anaesthetist, Gloucestershire Hospitals NHS Foundation Trust, and Core Team Member, Patient Safety First Campaign for England.