EMBEDDING A PATIENT SAFETY CULTURE

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1 EMBEDDING A PATIENT SAFETY CULTURE October 2011 Robert J. Bell

2 The NHS (2005) DEPARTMENT OF HEALTH STRATEGIC HEALTH AUTHORITIES PRIMARY CARE TRUSTS ACUTE CARE TRUSTS Manage and integrate primary care for medical, dental, pharmaceutical and optical services Contract for (commission) hospital care Manage and provide Medical and Surgical care in Teaching, District General Hospitals and Specialist hospitals Contract with PCTs for services to patients on a local/national basis THE LOCAL HEALTH ECONOMY

3 The NHS (2011) The Evolution...?

4 Regulatory, Quality & Safety landscape is complex Over 60 different regulatory and licensing bodies to deal with Potential for over 1,600 different compliance orders! A recipe for confusion.. leading to heightened safety risks

5 Organisational values 1. We care We believe our patients deserve the best possible specialist treatment for their heart and lung condition in a clean, safe place. 2. We are not SMUG 3. We are constantly Dynamic..and improving

6 Promoting a safety culture at RBHFT: Four key elements to our Patient Safety Culture: Visibility Complexity Ambiguity Professional Autonomy

7 Our Story.. THE VISIBILITY JOURNEY Highly specialised organisation operating from two hospital sites 450 beds, 285M turnover, 3,000 staff Founder member of QUEST group and Patient Safety First group A long history of focusing on patient safety and quality improvement driven from the top: CE, Medical Director and Director of Nursing & Governance driving the agenda. Supported by a senior clinical lead at both sites: Drs Haxby and Mitchell. Quality and Safety Plan for integrated into Trust business plan Review currently underway to align Trust processes with the Quality Governance Framework

8 Our Story.. THE VISIBILITY JOURNEY Leading to a robust patient safety culture and impressive safety performance High levels of incident reporting, investigation and management "Can do attitude" with engagement in patient safety and quality improvement activities HSMR currently : 83 Extremely low HAI rates - MRSA (Nil) - C Difficile (Threshold of 7 cases/year!) Surgical site infection rates reduced to less than the national benchmark.

9 Quality and Safety Plan Create a culture within the organisation which promotes patient safety and continuous quality improvement at every level and ensures that leaders create an appropriate environment and model behaviours which facilitate safe care and motivate staff to improve the experiences of patients. Improve the reliability of care by increasing the capability of staff to undertake safety and quality improvement work through development of appropriate skills and application of best practice. Ensure transparency so that data on quality and safety is readily available to staff and patients and is used to drive change and improvement

10 Leadership Intervention 1. Promote a patient safety culture 2. Put patient safety as first item on every agenda 3. Encourage Patient Safety WalkRounds: Walk the Talk 4. Understand improvement methods 5. Ensure Executive Accountability

11 Robust governance Structure with high degree of scrutiny Trust Board Executive Assurance and Risk Management Patient and staff experience Clinical effectiveness Quality and Safety Research and Education Finance and Information E.g. National surveys Safety Climate Survey Health & Safety HR / sickness CQUINS Incidents Complaints/ Claims E.g. NICE guidelines Infection control E.g. Improvement strategy SUIs E.g. Clinical audit and research E.g. Monthly reviews Oversight committees chaired by Non Executive Directors Executive leads are nominated responsibility for each division Trust committees chaired by Board Executive, with mandatory division leadership participation and voluntary non-exec attendance

12 Most patient safety activities devolved to divisions Small central team support divisions via coordination, standardisation and information support Corporate governance & risk team Divisional structure Head of Quality & Safety Band 7 support Chief Operating Officer Health & Safety Quality improvement Divisional Director Divisional General Manager Legal Lead Clinician in Clinical Risk AGM s Safety Manager / Q&S Lead Senior Nurse Complaints & PALS Safeguarding Security 3 clinical divisions, each with clinical governance role Roles well established from previous structure long history of risk roles in place at previous directorate level Small corporate team for risk management Maintains responsibility for aggregating data Decides on audit priority for organisation Holds weekly meetings with divisional governance leads Ensure actions plans in place Support to resolve issues Key responsibility to facilitate risk management and governance e.g. monitor all green-amber-red incidents and ensure action plans lead to improvement Now evolving to more proactive roles e.g. CQC self assessment

13 Trust Success stories Cross-site multi disciplinary Wound Infection and Prevention effort Surgical Site Infection (SSI) data reviewed at monthly Clinical Governance day Changes to; Theatre access Hand hygiene, scrub up and surgical prep Dress code Dressings Wound management Vein harvest Re-enforced antibiotic policy Feedback to individual surgeons on SSI incidents

14 Building on our success Challenge is to sustain improvements and go further with a new divisional structure Ensure a change of emphasis from current top-down focus to empowering the safety agenda at clinical service line level

15 Risk Assessment : The Complexity Issue We have consolidated all the risks we have identified as part of our internal audit planning process in the following process: Diversity and Equality Compliance with legislation and terms of authorisation Improving patient experience Public Involvement / Role of governors Stable / Known Core work: Financial management and Financial Reporting Management of Human Resource Strategic planning VAT Recovery Statutory and mandatory training Patient Property and monies Sustainability reporting and the CRC Specialist Commissioners FOI requests Collaborative arrangements for back office functions Strategy formation IT Controls Business Continuity Contract management and coding Board Assurance Framework / Risk Management Clinical leadership Information Governance arrangements Partnerships for the provision of services Publicity, reputational risk and stakeholder management PBR Core external risk Core operations Governance arrangements Business planning Performance Management Health and Safety Management of Inventory Medicines management Procurement External The The Enterprise Trust Internal Changing Commissioners Branding and marketing Research Governance Emerging areas Business change CQC registration Service line reporting Delivery of clinical strategy IT benefits realisation Real time patient feedback Ward/ specialty based reviews Overall Quality Governance Arrangements Quality Accounts Implementing NICE guidance Delivery and Impact of the Efficiency programme Medical devices Board development Theatre and laboratory productivity Unit based reviews Tender waivers Economic Regulator Changes to the private patient cap Changing / New Data quality management Incident reporting Clinical Audit performance Estates Strategy Management and delivery of the capital programme Hospital refurbishment Single sex accommodation Head of Internal Audit opinion review Regulator driven review Local risk based review

16 So what about the Ambiguity and Professional Autonomy Issues? In hospitals, chief executives have to be guided: by five key principles: Be Accountable : Must be able to justify decisions and to be subject to public scrutiny. Be Consistent : Decisions need to be joined up, broadly consulted and implemented fairly. Be Transparent : Accessible and open (open minded) keep things simple, user friendly. Be Focused : Focus on the problems, exploit the opportunities, minimise the collateral effects. Be Balanced and Intervene when necessary. Delegate proportionate : and hold responsible. Clearly identify and empower innovation and professional initiative.

17 The final word The hospital has been almost a second home to me over the years, in child and adult life, and I feel safe, which I believe is priceless.