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Translating a safety programme

Translating a safety programme

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Translating a safety programme

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  1. Translating a safety programme The Great Ormond Street experience

  2. Aims of session A discussion of how GOSH has established an improvement and safety programme

  3. Great Ormond Street Hospital • CONTEXT • Paediatric specialist hospital • 120,000 outpatients / year • 30,000 inpatient / year • 2,800 staff • 16 transformation team staff • 3 Analysts Light therapy for the treatment of rickets in the 1930’s

  4. GOSH 2010 Strategy Working Together

  5. No Waits programme

  6. Zero Harm programme

  7. © GOSH All rights reserved

  8. © GOSH All rights reserved

  9. Building WILL

  10. Leadership for safety © GOSH All rights reserved

  11. © GOSH All rights reserved

  12. Executive WalkRounds

  13. Developing IDEAS and innovating

  14. The UK Paediatric Trigger Tool Safer Care Programme

  15. Co-production steering group Nicola Davey, Senior Associate, and Dr Robert Varnum, Associate, Safer Care Programme, NHS Institute for Innovation and Improvement Dr Peter Lachman, Consultant for Service Redesign and Transformation Great Ormond Street Hospital for Children Dr Derek Burke, Medical Director, John Reid, Director of Nursing and Dr Janet Cumberland Associate Specialist, Emergency Care, Sheffield Children’s NHS Foundation Trust Co-Production Teams Alder Hey Children’s NHS Foundation Trust Birmingham Children’s Hospital Great Ormond Hospital for Children NHS Trust Royal Manchester Children’s Hospital Sheffield Children’s Hospital The Royal Free Hospital NHS Trust University Hospital Bristol NHS Greater Glasgow Clyde Royal Hospital for Sick Children, Edinburgh

  16. UK Co-production • 9 Hospital worked together to co-produce the tool • The tool was based on the UK Adult GTT, The Canadian Paediatric GTT, The CHCA recommended tools • 3 meetings to work together to debate each trigger • Each team asked to test tool 4 times on 20 sets of notes • At each meeting triggers adjusted or modified • Definitions clarified and refined • Results were then analysed

  17. GTT comparison

  18. Creating & Refining a Trigger Tool Adverse event list Trigger long list Alpha version(s) Trigger Tool Beta version Trigger Tool Public version(s) Insert date/time

  19. Alpha testing data analysis Sample characteristics Patients 296 Triggers 503 = 1.70 per case (95 CI 1.5-1.9) Adverse events 127 = 0.43 per case (95% CI 0.3-0.6) ie 43% harm rate

  20. Our early results

  21. Alpha testing data analysis

  22. The Paediatric Early Warning Score SBARD

  23. PEWS: 24 PDSA Cycles in 9 Months

  24. Situation: I am (band X nurse) on (ward X) I am calling about (patient X) The reason I am calling is because I am concerned as the…. (e.g. Resp. is XXX, Pulse is XXX, Temp is XXX, CEWS is XXX) S Background: Patient X was admitted on (date) with (e.g. seizure/chest infection) They have had X operation / procedure / investigation… Patient X’s normal condition is (e.g. alert/drowsy/confused/pain free) Assessment: I think the problem is:….. Or I am not sure what the problem is but patient X is deteriorating Or I don’t know what’s wrong but I am really worried And I have….. - (e.g. given O2/ given analgesia/ stopped the infusion) A B Recommendation: I need you to….. Come and see the patient in the next XXX minutes/hours And is there anything I need to do in the meantime?;…… (e.g. stop the fluid?/ repeat the obs.) R Decision: The recipient agrees with your recommendation The recipient understands the SBAR and you on agree a plan (e.g. and will attend within the next xxx minutes/hours) D Acknowledgement to the Institute of Healthcare Improvement ( and to NHS Institute for Innovation and Improvement (

  25. EXECUTIONAdapting bundles and measures

  26. Measure the whole system

  27. © GOSH All rights reserved

  28. © GOSH All rights reserved

  29. Programme measures

  30. Peri-operative Care Driver Diagram © GOSH All rights reserved

  31. October © GOSH All rights reserved

  32. Infection driver diagram © GOSH All rights reserved

  33. Infections Dashboard © GOSH All rights reserved

  34. Adapted from Scotland Safety Programme

  35. © GOSH All rights reserved

  36. Dashboard medicine management early days © GOSH All rights reserved

  37. Dashboard for the wards © GOSH All rights reserved

  38. Challenges Business case for quality Clinician Engagement Culture change Wiring this into the system