Patient Safety Guidance Implementation:
The challenge for organisations - Burning Platform or Information Overload?
Making health care safer: learning from social and organisational research conference conference
St Andrews University Scotland 27th June 2011
Pauline Cumming
Risk Manager, NHS Fife
First do no harm …
Burning Platform…Burning Platform…
Information overloadInformation overload
Information overload?Information overload? (Alvin Toffler, Future shock…1970)(Alvin Toffler, Future shock…1970)
NPSANPSA
SIGN
NICE
NHS Institute for Innovation and Improvement
MHRA
HSE
HTA
MRCPATIENT SAFETY 1ST WHO
IHI
The Health Foundation
NPSA output - a flavourNPSA output - a flavour
Patient Safety Alerts:Patient Safety Alerts: advice on patient safety advice on patient safety issues that are important issues that are important and have a specific timeline and have a specific timeline for implementationfor implementation
Safer Practice Notices:Safer Practice Notices: guidance on patient safety guidance on patient safety issues that contribute to issues that contribute to improving patient safety improving patient safety
Rapid Response Reports:Rapid Response Reports: advice on patient safety advice on patient safety issues that need immediate issues that need immediate local attentionlocal attention
Patient safety alerts on issues:
•That are a serious threat to patient safety, usually based on data showing repeated harm or loss of life
•That can be addressed through practical, evidence based actions
or
‘‘An Evaluation of NHS Quality Improvement An Evaluation of NHS Quality Improvement Scotland’s Dissemination Process of NPSA Alerts’ Scotland’s Dissemination Process of NPSA Alerts’ ((NHS QIS, July 2010)NHS QIS, July 2010)
Main challenges for NHS Boards : Main challenges for NHS Boards :
Knowing which alerts to prioritise and implement Knowing which alerts to prioritise and implement locallylocally
The current status of NPSA guidance in Scotland The current status of NPSA guidance in Scotland
The expectations of NHS QIS and SGHD on how The expectations of NHS QIS and SGHD on how NHS Boards should respond to NPSA NHS Boards should respond to NPSA information information
How guidance from England can be applied to How guidance from England can be applied to ScotlandScotland
Healthcare Quality Strategy 2010Healthcare Quality Strategy 2010
Quality AmbitionsQuality Ambitions
Mutually beneficial partnerships between patients, families and those delivering services
No avoidable harm or injury from healthcare and care within a clean & safe environment
Most appropriate treatments, interventions, support & services and no wasteful or harmful variation
Effective
Timely
Quality
Patient as partner…Patient as partner… ““We need to move, over time, to a more inclusive We need to move, over time, to a more inclusive
relationship with the Scottish people; a relationship relationship with the Scottish people; a relationship where patients and the public are affirmed as where patients and the public are affirmed as partners rather than recipients of care. We need to partners rather than recipients of care. We need to move towards an NHS that is truly publicly owned…move towards an NHS that is truly publicly owned…where ownership and accountability is shared with where ownership and accountability is shared with the Scottish people and the staff of the NHS…where the Scottish people and the staff of the NHS…where we think of the people of Scotland not just as we think of the people of Scotland not just as consumers– with only rights – but as owners – with consumers– with only rights – but as owners – with both rights and responsibilitiesboth rights and responsibilities” (” (A Participation Standard for the NHS in Scotland, August 2010, Scottish Health Council )
Keys to implementationKeys to implementation Quality of the evidence - who produced it Quality of the evidence - who produced it Relevance to practice Relevance to practice Effectiveness of dissemination Effectiveness of dissemination Strong leadershipStrong leadership Timing & importance - Opportunity costsTiming & importance - Opportunity costs Facilitation – Champions- someone to help Facilitation – Champions- someone to help
keeps up impetus & boosts chances of successkeeps up impetus & boosts chances of success Reliable measurement Reliable measurement AccountabilityAccountability Ownership: Is it about making it personal? Ownership: Is it about making it personal? CultureCulture
Patient Safety….Patient Safety….
“Patient safety should no more be seen as a programme for the NHS than breathing should be seen as a programme for human beings…” (Don Berwick, Institute for Healthcare Improvement Chair, Patient Safety Congress, 2008)
What is safety culture?
The shared beliefs and values of staff working in an organisation that determine the commitment to and quality of an organisation’s health and safety management
Alternatively….the way we do things around here (Dr Harry Burns, CMO, May 2007, NHS Fife)
Levels of maturity with respect to a ‘safety culture’
Pathological
Why waste our time on
safety?
Reactive
We do something
when we have an incident
Calculative
We have systems in
place to manage all like risks
Proactive
We are always on the alert for risks
that might emerge
Generative
Risk management is an integral
part of everything that we do
Levels of organisational culture Levels of organisational culture
(Westrum)(Westrum)
PathologicalPathologicalInformation is hiddenInformation is hidden
Messengers are Messengers are “shot”“shot”
Responsibilities are Responsibilities are shirkedshirked
Bridging is Bridging is discourageddiscouraged
Failure covered upFailure covered up New ideas are New ideas are
actively crushedactively crushed
Bureaucratic
Information may be ignored
•Messengers are tolerated•Responsibility is compartmentalised•Bridging is allowed but neglected•Organisation is just and merciful•New ideas create problems
Generative
Information is actively sought
•Messengers are trained•Responsibilities are shared•Bridging is rewarded•Failure causes inquiry•New ideas are welcomed
Paradigm shift - the grass is greenerParadigm shift - the grass is greener
Consider….Consider….
What do you think are the factors which enable uptake, What do you think are the factors which enable uptake, implementation and sustainability of patient safety guidance? implementation and sustainability of patient safety guidance?
What do you think are the factors which hinder uptake, What do you think are the factors which hinder uptake, implementation and sustainability of patient safety guidance? implementation and sustainability of patient safety guidance?
Is there is a moral imperative to act on such alerts?Is there is a moral imperative to act on such alerts?
Does non-mandatory status confuse, weaken the message Does non-mandatory status confuse, weaken the message and undermine the need to act?and undermine the need to act?
How do you think HIS and the Quality Improvement Hub might How do you think HIS and the Quality Improvement Hub might help patient safety knowledge management locally and help patient safety knowledge management locally and nationally? nationally?