Achieving success in the area of patient safety requires leaders to adopt a new approach.
Estimates suggest that one in ten patients admitted to hospital, experience an incident which puts their safety at risk. These incidents may result in harm and in some circumstances death. A stark reality is the fact that about half of these events could have been avoided. In England alone there are over 100,000 cases of hospital acquired infections per year, which are estimated to cause over 5000 deaths and cost £ 1 billion. It is evident that patient safety needs to be placed high on the leadership agenda.
In 2005, in a response to this growing international problem, the Health Foundation launched the ‘Safer Patient Initiative’ (SPI), a UK-wide programme designed to bring about radical improvements in patient safety through the implementation of a range of specific interventions using improvement methodology. The pilot involved four UK National Health Service Hospital Trusts and runs over a four-year period. This paper will describe the progress made through the pilot but principally the work undertaken in the Welsh site, Conwy & Denbighshire NHS Trust, a large health organisation providing acute community and mental health services for a population of 250,000 in Wales, UK.
Supported by the Institute of Healthcare Improvement from Boston, USA, the SPI pilot hospitals were given some specific objectives to achieve:
The programme also focussed on some cross cutting themes such as medicines management and infection control.
A formal evaluation of SPI is due for completion in late 2008. However, early results released by the Health Foundation in November 2006 showed impressive safety improvements at the four pilot hospitals. In the first two years of the programme the four sites had on average halved the number of adverse safety events. In addition some hospitals are already seeing improvements in their mortality.
At Conwy & Denbighshire NHS Trust the implementation of a Ventilator Associated ‘bundle’ saw the ventilator associated pneumonia rate being virtually eliminated. The Average Length of Stay (ALoS) in the Intensive Care Unit (ICU) was reduced significantly as patients were weaned from ventilators at an earlier stage (see Figure 1). Over £ 78,000 cost savings were identified in the ICU in the first 18 month of SPI.
Hand hygiene compliance in all sites has increased by more than 95 per cent and associated reductions in MRSA rates have also been observed.
Down Lisburn Health and Social Service Trust reduced the number of medication errors to below 10 per cent, following the development of system to track and manage the drugs that patients take. This system is helping to reduce mistakes in the primary care setting.
A reduction in cardiac arrest calls has been observed with the introduction of outreach teams (rapid response teams) and an early warning scoring system. The scoring system enables staff to effectively monitor patient’s condition and to take rapid action if they go into a decline.
The breadth and depth of change involved is significant, and the introduction of such an initiative requires a new approach in leadership for patient safety. There is emerging evidence that success in this area, is dependent on hospital leaders enhancing the priority given to patient safety and taking a real and continuing interest in patient safety within their organisations. Often the pressures placed on Chief Executives and their Boards relate to financial stability, or satisfying government and other regulatory targets. It is generally accepted that it takes a significant change of emphasis by leaders to affect organisational culture.
In this initiative, Chief Executives were expected to introduce a set of initiatives in leadership, which included three key aspects:
Establishing clear executive accountability for patient safety Firstly, the Board of directors formally recognised patient safety as their number one priority. The Board signed up to this within its corporate objectives, and by directing more of their time and attention to quality and safety matters. Non-executive directors actively participated in some aspects of the Safer Patient Initiative, e.g. Patient Safety Walk-rounds.
Whilst in principle SPI was a finite ‘project’, leaders were expected to ensure that the work was fully integrated into their organisation’s wider quality performance management and governance arrangements. The concept was to build a more sustainable infrastructure to support the quality and safety agenda. The Chief Executive took a leading role in SPI by chairing the implementation team. Key responsibilities were to get the right team on board; a team containing not only enthusiastic local champions for specific clinical areas but also individuals who could be trained as ‘Improvement Leads’ by IHI. ‘Go with the willing’ was a mantra IHI encouraged organisations to use. Rather than waste time trying to convince the ‘laggards’ to get on board with the initiative, change was driven through enthusiasts from across most professional groups.
The Chief Executive gained the personal commitment of his executive team which included the Director of Finance (an important and often overlooked resource / champion in improvement projects). Each executive director took on the role of executive champion for different aspects of the work streams.
Measurement was a key element of the programme. However, unlike other national target-driven projects, the data collection in SPI was designed to get the frontline teams to understand their own performance. They used the data to improve their processes of care, as opposed to the familiar system of using data to judge performance or to benchmark and compare teams. The concept in SPI was to understand your own performance and work to improve it, rather than shift your attention outside the organisation and lose focus on what matters. Teams began to measure compliance with agreed processes of care. They were able to monitor whether any of the changes they were implementing were actually resulting in improvement.
The hospitals developed a communication strategy to ensure that patient safety was promoted at every opportunity.
This ranged from specific ‘News-sheets’ to ‘Open days’ which involved employees, patients and the public. Promotion through local media was an important aspect.
On a practical level, ‘Patient Safety Walk-rounds’ were introduced. These consist of leaders drawing up a schedule of dates where an executive visits a ward/department to meet informally with staff to discuss safety issues. A standard set of questions was designed to ensure consistency of approach, and the results of discussions are recorded by a scribe. Where safety concerns are highlighted, the corrective actions are suggested and concerned individuals are assigned with the responsibility.
A feedback / follow-up system is also put in place to ensure the actions happen. Key themes from the Safety Walk-rounds are fed back to the Board.
Staff from all levels and professions, from senior doctors to volunteers, are encouraged to attend the discussions. Typical discussions to start proceedings include:
When was the last patient harmed in your unit / ward and how?
What have you done to prevent this happening again?
These walk-rounds have been enormously successful. They not only enabled staff to see patient safety as a priority but also empowered and encouraged them to solve operational issues that can cause harm. Additionally, executives were requested to identify examples of good practice in patient safety. Instead of the focussing on the negative aspects of safety, good ideas were captured, celebrated and spread.
Whilst executives resisted the temptation to resolve operational problems, it was quickly recognised that the role of leadership is to remove barriers that prevent frontline staff doing their work effectively and safely.
As the Board begins to shift its way of doing business by channelling more attention to quality and safety, there is a need to demonstrate this throughout the organisation. One simple and effective means of achieving this in Conwy & Denbighshire was to make Patient Safety the first item on the Board’s agenda. All monthly Board meetings commence with a Patient Safety issue which in turn becomes the first item on staff briefings and routine management meetings throughout the organisation. Nurses have now adapted this idea and incorporated safety items into their handover meeting on shift changes. Summarised examples of such items are given in Table 1.
These practical steps encourage staff to pay more attention to patient safety issues and as a result the culture is gradually changing. As part of SPI there was a requirement to measure any shift in culture, all sites were expected to carry out a baseline culture survey. Figure 2 is an illustration of change in culture at Hand Hygiene.
The Health Foundation has demonstrated through the Safer Patients Initiative that significant improvements in patient safety can be realised with focussed effort. Leadership is an essential ingredient in the battle to reduce harm to patients.
There is still much to do in order to achieve a global reduction in the current levels of harm within healthcare and to implement programmes such as the Safer Patients Initiative. In the UK in November 2006, following on from the early successes of SPI, a second programme was launched involving a further 20 NHS organisations across the UK. This second programme is building on the learning from the original sites but the core elements of the programme remain the same.
The initiative has generated important discussions and activity at UK level. It has also promoted the introduction of national patient safety campaigns in England, Scotland, Wales and Northern Ireland. The initiative has changed our way of thinking about safety and quality and has reaped many rewards for patients, staff and organisations as a whole. The journey is not over by any means. The constant and relentless drumbeat of improvement needs to be continued.
To conclude, we will leave you with a simple yet profound quote. It was received from a member of the public who participated in a competition to find a slogan that captured what we were trying to achieve across the organisation: Patient safety is contagious—Pass it on!
*Sites taken from www.health.org.uk