Evidence Based Patient Safety

1. Evidence Based Patient Safety Suzette Woodward Head of Patient Safety Improvement National Patient Safety Agency

2. NPSA Guidance • Seven Steps… • http://www.npsa.nhs.uk/health/resources/7steps

3. Seven Steps 1. Build a safety culture that is open and fair 2. Lead and support your staff in patient safety 3. Integrate your risk management activity 4. Promote reporting 5. Involve patients and the public 6. Learn and share safety lessons 7. Implement solutions to prevent harm

4. Producing document • Brief: • Provide guidance for the health service which will help them improve patient safety • Simple, clear messages, for all care settings, for all staff • Actionable points • Practical tools and techniques • Signpost NPSA ‘products’

5. Gathering the information • Literature search, review and analysis • Needed examples of what worked with evidence to back this up • Wide trawl – divide into themes

6. Language • Standard definitions • Audience – main clinical governance and risk managers • Patient and public • Role of editor

7. Format • Electronic documents need an alert system to inform when to check the website. • Not everyone has internet access; therefore we • For larger documents prefer hardcopy • Want to be able to download as a series of smaller documents

8. Approval stages • Chief Medical Officer • Department of Health • Welsh Assembly Government • NPSA Board • NPSA Management team • NPSA staff • External reference group – international experts in patient safety

9. Dissemination • Communication Strategy • Publicly launched at NPSA conference • Patient Safety Managers • Used as a framework for all NPSA work • Presentations – all steps or focused step • Articles • Endorsement from experts – mentioned in various bulletins/articles/presentations by others outside NPSA

10. Spreading the message • Not mandatory – no ‘you must’ simply ‘we suggest’ ‘evidence tells us that..’ • Selling a message that connects to the reader – what is in it for them • Put yourself in the place of the implementer • Influencing the standard setters – NHSLA, Healthcare Commission • And the monitors - StHAs

11. Lessons • Clear about brief • Know the audience and the context • Justify length • Expert lots of delays • Need strong endorsement

12. Spin offs ! • Adopted by other countries e.g. Spain, Holland, Australia, Singapore • Chief Executive Checklist • Primary Care Version • Training for Non-Executive Directors and Chairs • Training for clinical leaders

13. Review • Evaluation of NHS users • “critical that they continue to be updated over time” • “the overview guide was so useful that we have put it on our Intranet so that it is easily accessible for all staff” • “fantastic to be able to send something that all staff can pick up and read” • “we are doing lots of this already, but nice to have reassurance that these are the right things” • “the overview guide gave practical examples of what to do, not just definitions. The new risk management strategy is all based on Seven Steps”