Can we really learn from the past?

Transcription

1 Can we really learn from the past? Learning Lab Sunday 10 th December 2017 SL19

2 Dr Jonathan Kirk, National Clinical Lead Healthcare Improvement Scotland Professor Craig White, Divisional Clinical Lead, Scottish Government

3 3

4 4

5 5

6 Proposition Scotland's Context Your System Framework Take Home Plan

7

8 Aims

9 Our agenda Scotland as a case study A framework to organise our thinking Past Present Future Our proposition

10 Let s be the best #THFSMP #qff5 #IHIForum

11

12 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

13 Proposition: Learning through a focus on the past is only part of the story

14

15 What do you think about our plan for our time together?

16

17 Eric Hoffer

18 ...everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it. What is quality improvement and how can it transform healthcare? Batalden,P; Davidoff.F Qual Saf Health Care February; 16(1): 2 3

19 Scotland as a case study

20 Incidence rates of BSI, VAP and CR-BSI Scotland, Source: Scottish Intensive Care Society Audit Group 2015

21

22 Our wider context

23 5.37 million population 13.4 billion health and social care budget 14 territorial boards Integrated health and social care Healthcare Improvement Scotland 23

24

25 Involving people Improvement programmes Policy & Legislation

26

27

28

29 Healthcare Improvement Scotland strategic approach

30 Healthcare Improvement Scotland strategic approach

31

32 Proposition Scotland's Context Your System Framework Take Home Plan

33 What happens where you are?

34

35

36

37 How safe is our care? What is safe?

38

39 Could a framework help?

40

41 Proposition Scotland's Context Your System Framework Take Home Plan

42

43

44

45 Measuring and monitoring safety 45

46 Global impact of the report USA Canada Hong Kong UAE Oman Brazil Australia New Zealand Trinidad & Tobago UK Ireland France Netherlands India Myanmar Ghana Zambia South Korea

47

48 48

49 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

50 Proposition Scotland's Context Your System Framework Take Home Plan

51

52 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

53 The past

54

55

56 DISCUSSION 1. How do you know that care has been safe in the past? 2. How do you know your systems and processes are reliable?

57

58 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

59 The present

60

61 Royal Hospital for Sick Children, Yorkhill PICU Total Delayed Discharges (+ 4 hrs) Hospital Huddle started 7 th Jan 2013

62 How do you know if care is safe today?

63

64 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

65 The future

66

67 DISCUSSION 1. How do you know that care will be safe in the future? 2. How do you respond and improve?

68

69 Proposition Scotland's Context Your System Framework Take Home Plan

70 A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

71 Integration and learning Are we responding and improving? Past harm Has patient care been safe in the past? Reliability Are our clinical systems and processes reliable? Anticipation and preparedness Will care be safe in the future? Sensitivity to operations Is care safe today?

72 Past harm Has patient care been safe in the past? Anticipation and preparedness Will care be safe in the future? Integration and learning Are we responding and improving? Reliability Are our clinical systems and processes reliable? Sensitivity to operations Is care safe today? Adapted from Dr Jane Carthey

73 Past Harm Integration and learning MDT communicatio n Reliability Anticipatio n and Preparedness Sensitivity to Operations Past Harm Past Harm Integration and learning Safety Planning Reliability Integration and learning Safer Medicines Reliability Anticipation and Preparedness Sensitivity to Operations Anticipati on and Preparedn ess Sensitivity to Operations

74 What does good look like for you and for the people you serve? 74

75 Structure conversations about safety Surface gaps in understanding Identify barriers to improvement Enable learning

76 Whatever your point of concern, whether individual, team, or organisation what ought the totality of your efforts look like to give you the best possible chance of learning and improving

77

78 Consider what set of information you need. Do you have the collective wherewithal to gather, process, analyse, interpret and learn from that information? Have you got the right interactions in place from which to learn?

79 We believe you should learn from the past, but not in isolation

80

81 Thank you Dr Jonathan Kirk, National clinical lead Healthcare Improvement Scotland Professor Craig White, Divisional clinical lead, Scottish Government