Patient Safety At the heart of all we do
Introduction from our Medical Director Over the last 15 years it has been recognised that patient safety problems exist throughout the NHS as they do in every health care system in the world. This was brutally exposed in the Francis Report and then in the aftermath of that Francis report, Professor Don Berwick described how the NHS should change to address the previous failings. Berwick s report had 4 key messages: 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 support and improve the processes within which they work. Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge. Portsmouth Hospitals Trust has already adapted many of these principals with innovations such as the Listening In to Action programme of staff engagement, along with a consistent drive towards an open, honest and transparent culture. The Trust is one of the early adopters of the Sign up to Safety campaign which encapsulates the Berwick principals through 5 Safety pledges, easily recognised by all members of staff 1. Putting safety first. Commit to reduce avoidable harm in the NHS by half 2. Continually learn. Make our organisation more resilient to risks, by acting on the feedback from patients and staff and by measuring and monitoring how safe our services are 3. Being honest. Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong 4. Collaborating. Take a lead role in supporting local collaborative learning, across all services 5. Being supportive. Help people understand why things go wrong and how to put them right. The Trust has committed to increasing awareness of the role that Human Factors play in hospital errors and what can be done to mitigate these as much as possible. We aim to roll out a trust-wide human factors learning programme, similar to that used in other high risk industries, aimed at increasing understanding and awareness of this vital issue. This Safety Strategy outlines the principals that we will adhere to in the next 3 years during which we will continuously review these priorities and our progress in the delivery of improvement aims. Simon Holmes Medical Director 1
Patient Safety Despite our intentions patients are sometimes harmed as a result of the care that was meant to heal them or keep them well. The impact of this on patients, their families, and the burden to society cannot be underestimated. Organisations and individual healthcare workers are also impacted in many ways by such events. PHT s patient-centred strategic aims of safe, effective, caring and well led healthcare lead to us to think about the care we give to patients, and encourage us to reevaluate what we do and how we do it continually. To ensure patient safety, we need to build and maintain a genuine safety culture based on openness, honesty, fairness and accountability. Such a culture supports opportunities for learning and improvement and requires flexibility and resilience so that healthcare workers can deal with unexpected situations, learn from errors and manage priorities in a timely manner. New Model for Patient Safety at PHT Building on progress achieved over recent years in improving our patient safety record, PHT is embarking on a Trust-wide reconfiguration of its patient safety strategy over the next 3 years. We aim to be the best at what we do and to ensure that patient safety and quality is the highest priority for all our staff. As such we have signed up to the new NHS England Sign Up to Safety movement. As part of this we identified our 5 top organisational safety pledges in 2014 and, along with other health providers, we are now bound into a 3 year improvement plan which aims to reduce our level of patient harm by 50%. To underpin this we aim to align our quality improvement processes with our management structures so that responsibility and accountability for patient safety is firmly embedded at every tier of our organisation and is a priority for all PHT staff. To achieve this we need to foster an organisation culture that is committed to patient safety. 2
Reconfiguration of our safety culture Until recently the quality and safety agenda has focused predominantly on assurance. We need to evolve from a philosophy of assurance to a culture of increased awareness, involvement and proactive ownership of safety and quality improvement processes for all staff. This will enable all members of the PHT team to feel empowered and accountable for the care we provide to patients. The energy for this must flow from the Trust Board, through local management teams, to all ward and patient care areas so that there is no difference in commitment to the safety agenda from Board members to front line workers and support staff. This deep level of engagement will enable staff to reflect carefully and meaningfully on what they see, to learn and to direct solutions for improvement. The Board will set the structure and framework for this cultural change by aligning Trust objectives, behaviours and attitudes towards patient safety. We aspire to develop a truly no blame culture which encourages all staff to share errors and near miss events with the positive expectation of enhancing learning across clinical boundaries and preventing recurrence. Human error should be recognised as a feature of complex healthcare, but one that can be actively discussed, learned from and reduced. Staff should be supported by a Trust-wide system that celebrates adverse incident reporting, discourages risky behaviour, sanctions against recklessness and embraces every opportunity to learn and improve. Trust Board and Senior Managers Behaviour Alignment (leading ideas and strategy) CSCs, Local Directorates, Clinical Teams Leadership & local responsibility Business Intelligence Data to support accurate measurement 3
PHT and Sign up to Safety Sign up to Safety is a national campaign launched by NHS England aimed at reducing avoidable harm by 50% and saving 6,000 lives over the next 3 years. The campaign is designed to make the NHS the safest healthcare system in the world by creating a system devoted to continuous learning and improvement. The main message of the campaign is; Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients. PHT joined the Sign up to Safety campaign in September 2014. The campaign is based around organisations committing to specific pledges and we have based our pledges on 3 criteria;-our most frequent causes of moderate to severe patient harm, our NHSLA litigation data, our obligations under national and local quality contract schemes. The table below summarises the national campaign pledges and our specific in-house pledges which will constitute our safety priorities for the coming 3 years. 1. PUTTING SAFETY FIRST We will focus on: falls medication errors pressure ulcers patient deterioration healthcare associated infections mental health provisions 2. CONTINUALLY LEARNING We will focus on: open, pro-active, positive safety culture human factor training to be embed learning understand and reduce variation in practice focus on areas of poor patient outcomes 3. BEING HONEST We will: embrace the Duty of Candour requirements encourage openness and transparency introduce a Safety website for staff and public 4. COLLABORATING We will: within our organisation, share learning across CSCs work with partners to share knowledge and learning empower staff to play active roles in reducing patient harm 5. BEING SUPPORTIVE We will: develop embedded human factor programme integrate the complaints and serious incident investigation procedures engage and empower patient safety leaders, who are frontline clinical, staff to mentor and assist others 4
What we are aiming for The Safety Big 4 1. Patient Care based on clear criteria Patients receive care that has clear and specific aims, is governed by streamlined pathways and protocols to reduce the level of uncertainty and variability for our patients. Patientes are actively involved with and aware of the details of treatment 2. Patient Care is delivered in a complimentary infrastructure Our care protocols are aligned to the environment in which we deliver care, however simple or complex these may be and suitable infrastructure is developed and maintained as an integral part of care 3. Patient Care that can be readily assessed The quality of care we deliver can be measured easily by the healthcare worker to foster a culture of accountability and self-improvement through the measurement of patient outcomes in a routine and transparent fashion 4. Patient Care that allows comparisions The care we provide stands up to rigorous internal and external scrutiny, via analysis, validation and benchmarking 5
Improve Incident reporting It is an established fact that a well-functioning incident reporting system helps reduce adverse outcomes. Organisations with high levels of incident reporting are recognised as ones with a mature safety culture. In PHT patient safety incidents are reported electronically on the Datix system. Approximately 700 patient safety incidents a month are entered on Datix, which represents 72% of the total number of incidents reported on Datix. These incidents cover the whole spectrum of actual and potential patient harms from life threatening Never Events to near misses and minor medication errors. While these numbers may seem high, the Trust is in reality a relatively low reporter of clinical incidents comparing across the UK, with a perceived disproportionately high level of harm in reported incidents. As a result lower harm incidents, with potential to learn and reduce future risk, are being under-reported). As part of our patient safety improvement programme we would like to increase our rate of incident reporting. We aim to increase our reporting of incidents by 30% in the next 2 years and 50% within the next 5 years. Our plans to achieve this include:- Simplify Datix reporting- incident reporting needs to be simplified into a concise format to allow busy front line staff to use it with ease and speed and encourage reporting Make Datix more accessible-the Datix icon needs to appear automatically on each computer screen on log on, Datix app need to be made available for mobile phone users, Datix terminals need to be set out for staff who do not have access to the Trust log on, paper Datix reporting needs to be reintroduced for the small minority of staff and patients who are unable to access computers, Datix needs to be accessibale on the Trust internet page as well as Hospedia patient monitors to allow access to Datix reporting from the patients and public Reporter feedback- we need to feedback to reporters much more responsively after reporting incidents. This will in itself make the process of reporting incidents much more relevant and attractive to all staff. LiA sessions have highlighted the importance of this to PHT staff. Datix info shop- we would like to set up an open library of incidents so that clinical staff can research past incidents to increase organisational awareness and learning around patient safety incidents, open up channels for improvement programmes and increase the value of Datix reporting to front line staff. Datix says- we propose short summary reports set up by the ward, CSC, categorised by level of harm or incident type to allow benchmarking and discussions around improvement among CSCs and individual clinical areas. 6
Learning from Patient Safety Incidents The widespread use of a standard root cause analysis framework has greatly increased the impact of incident investigation within PHT. However, in common with other trusts, the dissemination of organisational learning has proved to be challenging. Many think that the supportive structures and process with the NHS are lacking and have not been conducive to embedding the changes required in practice to prevent similar incidents from reoccurring. We recognise the need to enhance multi-disciplinary contributions in our incident management so that the voice of all members of the patient team (including patients themselves) is heard in identifying when and why things go wrong. At the heart of this is the need to focus on human factors in incident investigation, to improve the quality (but reduce the bureaucracy of investigations) and ensure that recommendations are focussed on preventing similar incidents from reoccurring. Learning from incidents Using incidents to improve patient safety Based on the Canadian Incident Analysis Framework 7
Clinical Human Factors & Patient Safety Clinical Human Factors has been defined as Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities, and application of that knowledge in clinical settings In December 2003, PHT embarked on a journey to embed human factor (HF) training into the core of our safety strategy by opening a new high fidelity simulation training suite for healthcare workers. Whilst the medical simulation team are now well established, the nursing teams have started to play an active part and have had the opportunity to train internal and external members of staff in ways to improve how they identified, managed and have learnt from patient safety incidents. This body of work has gone from strength to strength and we have seen this diversify into almost every CSC within the Trust to a variety of staff groups. In 2015 a new patient safety initiative led by our medical director seeks to unify all the different human factor work streams at PHT under the patient safety umbrella. Harnessing the widespread interest in the use of human factors to improve patient safety will be instrumental to our success as an organisation in understanding and rectifying the causes of errorrs that lead to poor patient outcomes and avoidable harm. We believe that a multidisciplinary approach, integrating human factor science with clinical experience and knowledge, will ensure widespread dissemination of these valuable insights into team working. The approach outlined will form the basis for PHTs human factors training and awareness programs TEACH Corporate induction for all staff to include HF awareness Updates for existing staff, information websites and staff leaflets LEARN HF pratice development sessions, stimulation training, learning from incidents and sharing stories DEVELOP Best people programme, patient safety revolution events, Safety Culture 4 All and Peer Review model 8
Our Safety Future Over the next few months we aim to adopt many of the streams outlined below, some of which are novel initiatives, some of which will be strengthened and streamlined adaptations of existing processes. More details can be found on PHT Intranet webpage. "Safety Huddles" Multi-Disciplinary participation 24-hour Trust Board to mirror operational needs of the Trust Front line leadership Datix review and re-launch Patient Care 24/7 for all clinical services Integrated approach to Human Factors "SWARM" teams to improve root cause and analysis of incidents 9