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VTE Showcase Maintaining the Momentum. Mike Durkin Director of Patient Safety 16 September 2013 Portcullis House, London. The scale of the challenges. c58,000,000+ people. 140,000+ different ways the human body can go wrong. 6000+ medicines for treating diseases.

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vte showcase maintaining the momentum

VTE ShowcaseMaintaining the Momentum

Mike DurkinDirector of Patient Safety

16 September 2013

Portcullis House, London


The scale of the challenges

c58,000,000+ people

140,000+ different ways the human body can go wrong

6000+ medicines for treating diseases

4,300+ ways of treating diseases


ICD10 codes

and we wonder why things go wrong….


The scale of the challenges

  • Mid-Staffordshire – and the pockets of it that exist everywhere else
  • 1 in 10 patients admitted experience an adverse event
  • Half of adverse events are judged to be preventable
  • 5% of deaths in English acute hospitals had at least a 50% chance of being preventable
  • Principal problems associated with preventable deaths
    • poor clinical monitoring (31.3%),
    • diagnostic errors (29.7%), and
    • inadequate drug or fluid management (21.1%)
  • Most preventable deaths (60%) occurred in elderly patients with multiple comorbidities
  • 72% of all patient safety incidents are from the acute sector, 13% from Mental Health, 11% from Community, 2% from Learning Disability, 0.6% from Community Pharmacy and 0.4% from General Practice.

The scale of the challenges

  • The NHS leads the world in incident reporting, with the National Reporting and Learning System receiving nearly 8 million incident reports since late 2003 to date.
  • Over 100,000 incidents are reported monthly.
  • HES data suggests there are over 100,000 cases of VTE per year
  • NHS Safety Thermometer data suggests 6-7% of patients have a pressure ulcer
  • There were 326 never events reported to SHAs in 2011/2
the journey so far

NHS Prioritisation

The Journey so far

Adaptive strategy and consistent pressure prioritises VTE prevention across the UK


2004 2005 2006 2007 2008 2009 2010 2011


VTE: Delivering Improvement

National VTE Prevention Programme - collaboration of clinical experts, NHS leaders

and dedicated health professionals with the aim of ensuring that VTE prevention

strategies are fully integrated in to NHS systems and processes for the future

  • NICE CG92: Venous thromboembolism
  • VTE Prevention Quality Standard (QS3)
  • NICE CG144: Venous thromboembolic diseases
  • Technology appraisals of oral anticoagulants for use in VTE
  • Pathways for VTE
  • National VTE Risk Assessment Tool
  • Mandatory collection of VTE risk assessment data
  • National CQUIN goal

2010 - only 41% of patients were being risk assessed

Q1 2013/14 – 95.4% of admitted patients received a VTE risk assessment on admission

Significant reduction in VTE –associated mortality (unpublished draft data )



Data sourced from Hospital Episode Statistics (HES) for the period April 2007 – October 2012. The data is presented by rate (U prime chart) of patients with VTE per 10,000 Finished Consultant Episodes in inpatients in England. The numerator is calculated from a count of episodes of VTE recorded in any diagnostic position (diagnostic codes I80.1, I80.2, I80.3, I80.9, I82.9, I26.0, I26.9) by month. The denominator is the number of finished clinical episodes by month. The mean rate for the latest re-based period is 111.6 VTE’s per 10,000 FCE’s, an 8% increase from the first period centre line. There appears to be a seasonality effect in January (although it appears to a lesser extent in 2012). There is some evidence of this trend in the literature – partly explained by changes in coagulation factor levels – see http://www.ncbi.nlm.nih.gov/pubmed/19542893; http://www.ncbi.nlm.nih.gov/pubmed/22901545; http://www.ncbi.nlm.nih.gov/pubmed/21725580 . During the reported period there has been an increase (before and after, first (Aug-Oct) and last three data points) of 248,420 FCE’s.


EU comparisons

  • Postoperative pulmonary embolism or deep vein thrombosis, 2009 (or nearest year)
  • OECD Health Data 2012.

NHS Safety Thermometer

% of patients with new VTE

nhs outcomes framework to measure success and enhance accountability
NHS Outcomes Framework to measure success and enhance accountability

Overarching Indicators- selected to measure the breadth of each domain

i.e. the ‘comprehensive service’

Improvement Indicators- selected following analysis of multiple factors e.g. burden of disease, variation in quality , understanding what outcomes are most important to different groups e.g. children, working age adults, older people

our fixed priorities that contribute to our vision
Our fixed priorities that contribute to our vision

Domain 5 of the NHS Outcomes Framework

national patient safety dashboard
National Patient Safety Dashboard

Helping NHS England track progress towards achievement of improvement in Outcome Framework Domain 5 measures

don berwick s national advisory group on the safety of patients in england
Don Berwick’s National Advisory Group on the Safety of patients in England
  • Independent of Government, NHS management, or any other influence
  • Advised by senior advisers from across the NHS and elsewhere (Julie Bailey, Robert Francis, Ara Darzi, Liam Donaldson, Jeremy Taylor, Peter Walsh, HSE, CQC and others)
  • Small number of recommendations delivered to; the Prime Minister; the Secretary of State for Health; the NHS England Executive; other clinical and executive leaders in the NHS; and the public at large
  • The most important patient safety report in over a decade
  • Will set the agenda for patient safety in the NHS for the next 10 years or more
don berwick work streams
Don Berwick Work Streams

Aims for Improvement

Building Capacity through training, education, technical capability

Structural recommendations: Oversight, accountability and influence

Patient and Public Involvement


Measurement, transparency, tracking and learning

Legal penalties/criminal liability and their impact on safety

Implications for leaders at all levels

Staff and the work environment


1. Patient safety problems exist throughout the NHS: Like every other health care system in the world, the NHS experiences repeated defects in patient safety.

  • 2. NHS staff are not to blame: A very few may be exceptions, but most staff wish to do a good job, to reduce suffering, and to be proud of their work.
  • 3. Incorrect priorities do damage:In some organisations, goals of (a) hitting targets and (b) reducing costs have taken centre stage.
  • 4. Warning signals abounded and were not heeded:Loud, and urgent signals were muffled and explained away.  
  • 5. Responsibility is diffused, and therefore not clearly owned: With so many in charge, no one is.
  • 6. Improvement requires a system of support:. The most important single change in the NHS in response to this report would be for it to become a system devoted to continual learning and improvement of patient care, top to bottom and end to end.
  • 7. Fear is toxic to both safety and improvement:Fear impedes improvement in complex human systems.

1. Recognise with clarity and courage the need for wide systemic change:

  • 2. Abandon blame as a tool. Trust the goodwill and good intentions of the staff, and help them achieve what they already want to achieve:
  • 3. Reassert the primacy of working with patients and carers to set and achieve health care goals.
  • 4. Use quantitative goals with caution. Such goals, (i.e., “targets”) do have an important role en route to progress, but should never displace the primary goal of better care.  
  • 5. Recognise that transparency is essential, and expect and insist on it at all levels and with regard to all types of information (other than personal data).  
  • 7. Ensure that responsibility for functions related to safety and improvement are vested clearly and simply
  • 6. Give the people of the NHS – top to bottom – career-long help to learn, master, and apply modern methods for quality control, quality improvement, and quality planning
  • 8. Make sure pride and joy in work, not fear, infuse the NHS.

Our most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:

  • Placing the quality of patient care, especially patient safety, above all other aims:
  • Engaging, empowering, and hearing patients and carers throughout the entire system and at all times:
  • Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work:
  • Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

“You never get to safety through anger and blame. You get there through learning, curiosity and commitment”

Don Berwick


Features of a safe NHS

  • Create a learning safety culture; staff feel safe to report and act safety incidents; part of every role
  • Develop high reliability systems and processes to support the identification and management of risks to patient safety
  • Patient involvement and feedback recognised as an essential learning opportunity; our best warning system
  • Responsive Boards proactively manage safety of their organisations

Features of a safe NHS

  • ‘Displays’ of compliance are over; finance and safety are considered of equal importance
  • What matters is measured (hard metrics, soft intelligence), tracked and used.
  • Staff engaged, supported and empowered to deliver safe care; just and knowledgeable leadership.
  • Clear standards are set for minimum safety levels, failures to meet the sanctions are understood, and used appropriately; peer review
professor avedis donabedian
Professor AvedisDonabedian

“Systemsawareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love”

  • We prioritise patients in every decision we take.
  • We listen and learn.
  • We are evidence-based.
  • We are open and transparent.
  • We are inclusive.
  • We strive for improvement



Improvement through learning

  • Evaluation of outcomes is a priority work stream for the programme
  • Continue to improve our understanding of VTE metrics nationally, regionally and locally
  • Root Cause Analysis is an effective learning tool to drive improvement
  • RCA included in the current National VTE CQUIN – submission of quarterly report to commissioners
  • High quality VTE prevention should underpin commissioning of care
  • Important to include VTE prevention in commissioning contracts with providers
  • NICE Quality Standard provides as set of measures for performance management as regards best practice
  • More information can be found on the National VTE Prevention Programme website: www.vteprevention-nhsengland.org.uk
through the eyes of our patients
Through the Eyes of our Patients

Thank You