Patient Safety Collaboratives Plans on a page 2016
What are Patient Safety Collaboratives? The Patient Safety Collaboratives identify and spread safer care initiatives from within the NHS, as well as draw on the best ideas from industry, ensuring these are shared and implemented throughout the system. There are 15 Patient Safety Collaboratives in England, run by the Academic Health Science Networks.
Where are the Patient Safety Collaboratives? There are 15 PSCs across England, hosted by the AHSNs.
The Patient Safety Collaborative approach Place the quality of patient care, especially patient safety, above all other aims. Engage, empower and hear patients and carers at all times. Foster the growth and development of all staff, including their ability to improve the processes they are part of. Embrace transparency, unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.
Shared Patient Safety Collaborative priorities
Plans on a page The 15 Patient Safety Collaboratives have created plans on a page to highlight their local activities. Find out more about what's happening in your area in the following pages.
Patient safety: a national and local priority Our Patient Safety Collaborative aims to make East of England the safest place to grow old We have two inter-related aims: Across the AHSN system: To develop a QI infrastructure that will support continued service improvement and innovation. To be driven forward by: A Board Quality and Safety leadership programme A regional faculty of QI leaders A suite of QI capability building programmes At the point of care: To address the safety concerns of frail older patients in the community, in hospital and in care homes. The improvement programme will encompass; Medications safety Safer transfers in care Reliable identification and response to deterioration Our Partners EAHSN Patient Safety Clinical Study Group East of England Citizens Senate NHSIQ / Advancing Quality Alliance (AQuA) NHS Leadership Academy/Health Education East of England/CLAHRC EAHSN Academia HIGH LEVEL PLAN To make the East of England the safest place to grow old Strategic leadership priorities Point of care interventions Infrastructure development Ensure safety and quality are organisational priorities Actively develop a safety culture Partner with staff, other sectors, patients and users to improve care Ensure action to remedy any safety or quality concerns Provide leadership & oversight to ensure delivery of the PSC programme To respond to safety concerns of the frail in community, hospital & care homes, by improving: Medications safety Transfers in care Identification and response to deterioration Develop & utilise local QI capacity & capability Develop effective improvement measurement Develop more comprehensive metrics through which to monitor safety Enable and support local teams to learn and share at EAHSN learning events Ensure effective communications systems Contacts: Susan Went, Improvement Director: susan.went@eahsn.org Russell Dunmore, PSC Programme Manager: Russell.Dunmore@eahsn.org
EMAHSN Patient Safety Collaborative EMAHSN consulted and engaged with our partners to develop consensus on key patient safety priorities. We will: build alliances to optimise and share existing best practice support and enable organisations to accelerate the pace and scale of improvement activities. Improving Safety Building on best practice in shared areas of priority e.g. falls, medicines managements, suicide and self harm Organisations Co-produced with patients, health and social care; industry; higher education Staff Staffing dimensions in safety; human factors; translating research into practice; culture Patient Patient led programme; patient and carer perceptions of safety
Potentiating: existing initiatives, making the most of what is happening already Supporting: staff and patients to articulate their views Connecting: our partners in order to spread their best practice evidence and activities cheryl.crocker@nottingham.ac.uk 07772 353 046 www.emahsn.org.uk @EM_AHSN
Patient Safety: Greater Manchester Academic Health Science Network (GM AHSN) local priorities. Developing QI capability and capacity across the GM system through collaboration and partnership Aim: to support a whole system approach to medicines optimisation Capacity building Leadership Medicines Optimisation Capability and QI modules; Advanced Team Training, human factors, resilience, measurement and safety culture. Delivered in partnership with AQUA Grant awards for GM teams to develop Improvement for Science 4 Patient Safety with our partner HAELO Thematic based improvement programmes with GM teams IHI Expert Practitioner training places for Q Alumni Support remaining 6 CCGs to Sign up to Safety, Integrate GM AHSN Public Experience Group to inform and supporting our work programmes Populate GM wide Executive Boards places to influence and translate evidence into practice e.g. GMMMG, NIHR, Primary Care Patient Safety Translational Research Centre (GMPSTRC), MAHSC Co-ordination of GM Q nominations and local network Facilitate a GM wide Medicines Safety Officers group, identifying local priorities Project delivery on 3 key CVD pathways Atrial Fibrillation, Chronic kidney Disease and Familial Hypercholesterolaemia Support adoption and spread of tools such as e.g. PINCER / Refer to Pharmacy which enhance safety in prescribing and transfers of care Our partners Contact: Jane Macdonald, Director for Nursing and Improvement jane.macdonald@gmahsn.org or Dr Dai Roberts dai.roberts@gmahsn.org 01/07/2016 10
Our priority projects Patient Safety Collaborative Medications safety (initial focus on insulin) Patient Safety Handbook (South London projects, resources and expertise) Is working together across the whole healthcare system from hospitals to patients own homes to co-design interventions and initiatives to reduce avoidable harm, save lives and embed a patient safety culture. We will: Ensure that patients and carers are actively involved in both design and delivery of projects Develop improvement capability within organisations and leaders Identify evidence-based and reliable practice, and to scale up and spread this in a sustainable way Help staff analyse, monitor and learn from safety and quality information Embed a safety culture for safer care through staff involvement #hinstopcauti #patientsafetysouthlondon For more information: http://www.hin-southlondon.org/ Pressure Ulcers Patient-led co-design No Catheter, No CAUTI IHI improvement collaborative - scale up and spread of a bundle of interventions to reduce catheter associated urinary tract infections by 30% Dementia falls (screening, access, referrals) Communities of Practice Medications Safety Sepsis Deteriorating Patient Duty of Candour Delirium Research Inter-professional Interventions Supporting Patient Safety Medicines Optimisation Maternity
Patient safety programme Context Around 8-12% of hospital admissions are associated with one or more adverse events (injury caused during medical management). To prevent such incidents occurring and to create a proactive safety culture, the Berwick report recommends a number of actions including ensuring patient and carer voice is heard at all levels in organisations, that NHS organisations develop a learning culture and share best practice, and that patient safety data is transparent. Our programme in North West London (NWL) aims to address these areas. Proposed outputs Objective Quality and Safety Champion Network Standardising junior doctor communications System safety observatory Pressure ulcer prevention Teamwork and culture Foundations of Safety Forum For more information Develop network of patient safety champions to be involved with the work of our NWL partners and ICHP Support members to develop skills needed to be effective champions Create universal provision of NHS.net email for doctors throughout training in NWL, with the opportunity to roll this out nationwide Develop observatory of safety-relevant data across local health system to provide a holistic and predictive picture of system safety Diffuse pressure ulcer prevention and management best practice across NWL Engage with health and social care providers in a pressure ulcer prevention strategy / campaign Develop initiative to promote openness and candour at work amongst NWL staff Support leaders in NWL to confidently learn, share and understand principles of patient safety across their sector To ensure patient and carer views are heard at all levels as critical indicator of safety To develop strong ethic of team learning and a shared responsibility for patient safety To help develop transparent NWL-wide data on patient safety To support organisations to adopt and diffuse best practice in patient safety To provide a dedicated environment for leaders to discuss best practice and share learnings across organisations Desired outcomes Empower senior leaders to lead organisational change and to create system wide patient safety culture through Foundation of Safety activities Increase the number of partner organisations and care homes delivering best practice pressure ulcer prevention services/ strategies Develop patient safety champion capabilities within organisations Increase the number of member organisations with active patient safety engagement programmes Improve collaboration and opportunities for continual learning Spread adoption of the Health Foundation Patient Safety Framework Build an agreed best-practice set of measures to define patient safety Improve team working and culture, resilience and wellbeing, in order to reduce absenteeism and improve patient care Please contact Ronke Akerele, Director of Programmes and Performance T: 0207 960 6241 E: Ronke.Akerele@imperialcollegehealthpartners.com
Better safer care Patient safety collaborative 2016-2018 Vision Strategic aims Improving capacity and capability Safety Champion, learning networks, serious incident reporting tools Residential/ Care Home Building skills and knowledge Q- participants, Sign up to Safety, digital solutions, Telemedicine, apps, Innovation Scouts Respond to local cluster area needs Identify and explore the barriers to safer care in geographical sub-regions A focus on clinical areas Atrial fibrillation, muscular skeletal, mental health, alcohol, dementia, hydration, Emergency Dept. safe- Digital platform Leadership A focus on care homes National AHSN sepsis Leadership. Staff Health & Wellbeing Scope E-Learning, hydration, sepsis and Anticipatory Care, hospital avoidance, E- discharge, Medicines Optimisation Measurement, Evidence portal, Innovation assets, virtual communities of interest A focus on primary care. Values Diabetes care
Patient Safety and Quality Improvement plan-on-a-page 2016/17 Objective 1: Deliver impact through projects initiated in 15/16: Sepsis/Community Acquired Pneumonia (CAP) Acute Kidney Injury Hospital Mortality Monitoring and Reduction The Deteriorating Child Falls Prevention Pressure Ulcers ThinkSAFE Delivered through: Active management of contracts for delivery with each organisation leading on the project. Regular communication on the PSC funded projects across all Member Organisations ensuring broad stakeholder awareness and engagement. Facilitated collaborations between healthcare professionals across the region in key areas. Organisation of events with top regional and national speakers. Incentivisation of applications for matched funding. Collaboration with regional vanguards, especially the Urgent and Emergency Care Vanguard. Overseen through : Reporting to NHS Improvement/NHS England at a national level. An Executive Group for PSC/QI that are credible, engaged and active in support of the AHSN objectives. Robust management of SLAs and project-specific contracts for all funding. Clinical direction provided by the Medical Director. Objective 2: Build credible and visible QI capability in the North East and North Cumbria which has a focus on patient safety Objective 3: Collaborate and contribute nationally to learn and to share best practice Delivered through: Acting as the lead partner in Q-North East the new Quality Improvement infrastructure being developed in the region. Partnership working in developing Q-North East with Health Education England, particularly the Patient Safety Faculty. Investing in the region s participants in the Q Initiative (building on the 10 who participated in 2015/16) to deliver quality improvement leadership and training. Provide support to the Cumbria Leadership and Improvement Collaborative (CLIC) and ensure that experience from CLIC is utilised in developing Q-North East. Delivered through: Collaboration with PSCs and others beyond the region, particularly in the field of measurement of quality and safety, via the national PSC and QI forums. Interaction with similar national programmes on specific issues. Participation in PSC national events. Measured using the following success criteria: Quarterly progress reports showing project development and spread of improvement. Improvements in patient safety as measured by milestones and KPIs. External matched funding leveraged.
1Extending safety beyond narrow acute hospital focus to embrace entire patient pathway 2Developing and sustaining patient safety programmes with our partners Sepsis Maternity Mental health Pressure damage improve reduce Never reduce failure to reduce pressure antibiotic events: retained return to acute damage across the use swabs psychiatric wards patient pathway Acute kidney injury improve data improve prevention, recognition and management Gastric buttons improve safety in positioning and replacement Further information Phone 01865 784964 Email charles.vincent@psy.ox.ac.uk jill.bailey@oxfordhealth.nhs.uk Web www.patientsafetyoxford.org www.oxfordahsn.org Twitter @PS_Oxford @OxfordAHSN 3Enhancing regional leadership, capability and capacity Develop skills in Develop capability Develop leadership clinical human in measurement for patient safety factors for improvement improvement skills Develop capability in quality improvement methodology Further reading: Haidrani, L. (2016). Project reduces self-harm in children and adolescents. Mental Health Practice, 19(6), 8-9. Bailey, J., et al (2016). Reducing self-harm in young peoples services. Interview manuscript submitted for publication. Vincent, C., (2010). Patient Safety (2nd ed.) Chichester: John Wiley & Sons. Introduction here: http://www.patientsafetyoxford.org/wp-content/uploads/2015/04/vincent-essentials-of-patient-safety-2012.pdf Vincent, C. & Amalberti R. (2016). Safer Healthcare: Strategies for the real world. Springer open. Available at http://link.springer.com/book/10.1007%2f978-3-319-25559-0 Warren O., Dean Franklin B., & Vincent, C. (2015). Going into hospital? A guide for patients, carers and families. UK: Eastdown Publishing. http://www.goingintohospital.co.uk/
UCLPartners Patient Safety Programme Embedding safety into organisational culture across the partnership to reduce avoidable harm and improve quality of care for patients and their carers Aims To have meaningful patient, carer and public involvement and engagement to contribute to making safety relevant to the frontline of healthcare delivery. To support partners to develop and sustain patient safety approaches by embedding safety into organisational priorities and mainstream delivery. To support organisations in the understanding and use of measurement including the embedding of times series measurement practices. To build networks across the partnership to promote learning whilst supporting and developing local leadership capacity in safety, as well as developing capability and capacity in quality improvement to sustain clinical safety. Programme activities Patients and staff Involvement, human nature and change events to involve patients and staff to increase awareness of safety. Improvement networks Sharing and communicating building networks, communities of practice and sharing approaches to sustainably to improve patient safety systems. Safety collaboratives Understanding variation specific work streams to measure and test improvement change packages across pathways. Capability Learning and development building improvement knowledge to develop capability and capacity in quality of care across the UCLPartners geography. Appreciation of systems Human nature and change Understanding variation Building knowledge Aligning with local and national priorities Whole system focus Patient/carer/family involvement Relevance to frontline staff Time series measurement Informatics for safer care Build networks Leadership capability Improvement capability and capacity uclpartners.com @UCLPartnersPSP
Wessex Patient Safety Collaborative 2016 - the Wessex Logic model as a Plan on a Page SITUATION There are many examples of good care being delivered across the health and care system, however we cannot yet be confident that safe, effective and person centred care is consistently delivered across Wessex. ACTIVITIES Breakthrough Series 1 Breakthrough Series 2 Primary Care Project Human Factors & Ergonomics Patient Safety Support Fund Medicines Safety Cluster (Lead) Community of Safety and Improvement Practice Emergency Laparotomy Collaborative Mental Health Collaborative Potential Projects SHORT TERM OUTCOMES These are the local projects representati ve of activity occurring or planned for 2016/17. The PSC work plan is driven by local drivers and our PSC Steering Group and will be reflective of Wessex organisation al priorities and national initiatives. Established faculty expertise for Sepsis, & Transfers of Care 13 organisations actively engaged in the Collaborative Four learning events delivered to over 200 participants Multiple PDSA tests of change completed by improvement teams with ongoing measurement Planning to move both teams into Networks at close of the Collaborative Improved spread of best practice via national PSC clusters Establish faculty expertise for the (physically) deteriorating patient Acute, community and care home sectors to be invited to engaged Deliver four learning events in 2016/17 to approx. 70 delegates per day Aim to increase participant knowledge, skills and confidence around both topic and quality improvement Establish Primary Care Focus Group to focus PSC on relevant areas of work Develop Framework for a Model Safety Practice (MSP) Develop support pack for MSP Practices to pilot MSP in early 2016 Measure MSP impact with option to rollout to all 10 CCGs Deliver 2 awareness raising events for senior managers and clinicians Deliver 1 awareness raising event for CEOs, Executives and NEDs Conduct scoping exercise for future Human Factors work based on evaluation of the 3 events Establish a fund to support appropriate local patient safety initiatives across Wessex Launch application and award process First projects to commence in 2016 Review uptake and project impact Provide medicines safety focus as part of the AHSN Medicines Optimisation Network Enable national learning and sharing around medicines safety across AHSNs and PSCs Facilitate 4 cluster events per year 2016 work focused on mapping medicines safety work across PSCs and insulin safety Leadership: Establish Leadership Faculty; Support the development of a Just Culture; Scope and deliver a bespoke leadership programme Measurement: Establish Measurement Strategy; Increase monitoring of safety across the system; Improve understanding and use of measurement at PDSA, project and regional levels Patient Engagement: Engage Patient Representation in Collaborative Faculty; Develop operational model for Patient Engagement Surface individuals, teams and networks working in patient safety, innovation and improvement Establish the Community of Safety and Improvement Practice (CSIP) Launch and manage the on-line database (LIFE) to support CSIP members Deliver a Wessex Quality and Improvement Conference in June 2016 Reduce mortality post emergency laparotomy by up to 15% Work with Kent, Surrey and Sussex and West of England AHSNs to deliver Learning Events across the 2 year Collaborative Establish a Wessex leadership team to support Wessex teams Deliver regular Wessex QI events Support one Trust to engage in an elderly care subproject Support the South of England Mental Health Collaborative (MHC) to improve the safety of patients with mental health Work with South of England, KSS, Oxford and West of England AHSNs to fund the Collaborative and provide strategic direction 2016 work focused on reducing self harm, violence and early mortality Link Wessex MHC teams with other Wessex networks 1. Maternity, stillbirth and Neonatal Scope the need for a Wessex Maternity, Neonatal and Stillbirth project Engage with stakeholders 2. Frailty Forum Engage in discussions around frailty work across Wessex MEDIUM TERM OUTCOMES These are national aspirational aims and the PSC will work with the local health system to make gains in key areas. Reduced variability in safety practices across the health and care systems Safety Improvement Capability embedded across the health and care systems Increased collaboration across whole systems, transparency, sharing and collective improvements Team based approach and team working the norm at all levels Culture of continual learning is embedded and maintained Communications platform (including website) established to provide Support and Development expertise and resources to Safety and Improvement Community Increased alignment of system priorities and policies with improvement goals Greater levels of larger scale improvement which is sustainable and measurable Patient safety is everyone s priority LONG TERM OUTCOMES Patients and service users across the health and care system experience and receive safer and higher quality care GOAL By 2019 care is safer for patients based on a culture of openness, continual learning and improvement ASSUMPTIONS Continued political backing and available funding for the initiative Continued recognition through the system of the importance of the Berwick report AHSNs will continue and maintain a positive leadership role for patient safety Transfer of patient safety function to NHS Improvement will retain consistency of leadership Hospitals have safe staffing levels across the NHS in England Improvement training of staff actually makes a difference Staff have capacity and time to do improvement even if they have the skills and knowledge Leadership team will flex and change over the five years
Leadership and Human Factors Measurement Medicine Safety Cluster Patient Safety Support Fund Breakthrough Series Collaborative 2 Physical Deterioration Patient Engagement Annual Conference LIFE Information platform Community of Safety and Improvement Practice Primary Care Mental Health Collaborative Emergency Laparotomy Collaborative Breakthrough Series Collaborative 1 Transfer of Care Network Sepsis Network Wessex Patient Safety Collaborative
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Patient Safety Collaboratives Plans on a page 2016