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Safety Express. A New Journey in Patient Safety for the NHS Dr Ailsa Brotherton Ms Sally Deacon. Safety Express is the name of the mobilisation vehicle for the QIPP Safe Care work stream

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safety express

Safety Express

A New Journey in Patient Safety for the NHS

Dr Ailsa Brotherton

Ms Sally Deacon

what is safety express

Safety Express is the name of the mobilisation vehicle for the QIPP Safe Care work stream

  • The programme aims to reduce harm in four defined areas using collaborative techniques and improvement methodology:
    • Pressure ulcers
    • Falls
    • Catheter acquired urinary tract infections
    • VTE
  • The programme is named ‘Safety Express’ because we aim to move together at a pace and scale which is previously unprecedented in English healthcare.
  • Safety Express is a ‘call to action’ for NHS staff who want to see a safer more reliable NHS with improved outcomes at significantly lower cost
  • Safety Express is a partnership with existing programmes (in particular Energising for Excellence, High Impact Actions, Patient Safety First, the Productive Series and the National VTE Implementation group) and each SHA region

What is Safety Express

safety express programme plan
Phase 1 - pilot phase (January to June 2011)

Comprising of 3 Learning sessions 60 - 90 days apart January-June

New knowledge will be archived into simple bundles and change packages

Phase 2 - (September to Feb 2012)

Safety nodes will replicate the Safety Express Programme supporting the new teams testing in pilot areas

Phase 3 - spread (February to August 2012)

Scale up activity to the whole system

Regional learning and sharing sessions will take place and exemplar CQUINS will be developed

Safety Express programme plan
slide4

The Model

for Improvement

the model for improvement
We need to use our resources wisely.

Rapidly improving locally

Testing out the improvement

Rolling out good ideas

This should provide the best services, eliminate waste and adopt the best practice.

The Model for Improvement
what are we trying to accomplish
What are we trying to accomplish?

Level 1

Level 2

Level 3

To deliver the

HARM FREE [6]

for 95% patients

by Dec 2012

‘HARM FREE’

defined by

absence of

pressure ulcers

harm from falls,

CA-UTI, VTE, bloodstream infection & C diff for all patients

  • 80% reduction in hospital acquired category3 or 4 pressure ulcers
  • 30% reduction in community acquired category 3 or 4 pressure ulcers (patients not in a hospital bed)
  • 50% reduction in serious harm or death from falls
  • 50% reduction in the proportion of patients with catheters being treated for UTI
  • 50% reduction in avoidable VTE events
  • by Dec 2012

To deliver the

HARM FREE [4]

for 95% patients

by Dec 2012

‘HARM FREE’

defined by

absence of

pressure ulcers

harm from falls,

CA-UTI,

and VTE for all patients

what is the safety thermometer

The Safety Express measurement strategy focuses on Measurement for Improvement

  • This approach differs from measurement for performance which many clinicians and commissioners are most familiar with
  • The Safety Thermometer is the survey tool which is used to measure for improvement
  • The measures used are fundamentally about PROGRESS OVER TIME.
      • Improvement measures are usually a sample data (50% patients on specified units of a single day,) the definitions are pragmatic working definitions
  • Data collection systems are designed to minimise the data collection burden and maximise on the benefit of the ‘act of measurement’.
  • The Safety Thermometer is designed to help participants and the NHS build up a picture of patient safety issues and to help you see the impact of actions implemented
  • Each measurement location will measure small numbers of patients often

What is the Safety Thermometer?

harm profile
Harm Profile

Data

VTE

Pressure Ulcers

Falls

Catheters & Infection

slide10

Data

Harm Free (by location)

local teams across the provider system

B. Host

A. Community services

Dream Team

AHP

Patient

Stores

Doctor

Team

Leader

HOST

Team composition

GP network

Nurse

Doctor

Pharmacy

Manager

Clerk

C. Mental Health

D. Nursing Home

Local teams across the provider system
slide14

Aim

Primary Drivers

Secondary Drivers

Leadership

&

Safety Culture

To deliver

harm free

care -

defined by

the absence of

pressure ulcers

harm from falls,

CA-UTI

and VTE

in 95%

of patients

By Dec 2012

Local Clinical Leadership

Executive Support

Walk rounds & rounding

Clinical

Care

95% reliable

Active risk management

Continence, skin & moisture

Nutrition / Hydration

Medication reconciliation

Supporting

Infrastructure

Equipment

Education and Training

Ward Level Driver

supported regionally and nationally
Supported Regionally and Nationally

10 regional teams

in SHAs

Mobilised patients

National Coalition

national faculty steering group
David Oliver / Francis Healey Falls

Janice Stevens / Sally Batley Infection

Mike Duerden & Carole Fry CA-UTI

Anita Thomas and Tim Browne VTE

Katherine Fenton / Julie Halliday Pressure Ulcers

Caroline Lecko Pressure Ulcers

Mike Stroud Nutrition

Ashley McKimm Junior doctors

Joan Sadler PPI

John Madsen / Martin Orton Measurement

Bernard Crump / Kate Jones Improvement

Mike Durkin Medical lead

Jane Cummings SHA lead

National Faculty (steering group)