Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on...

35
Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad HOPE_ Madrid May 2013

Transcript of Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on...

Page 1: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Spanish Strategy on

Patient Safety

Yolanda Agra MD, PhD

Ministerio de Sanidad, Servicios Sociales e Igualdad HOPE_ Madrid May 2013

Page 2: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

2006: Council of Europe Recommendations

(Committee of Ministers)

Ensure that patient safety is the cornerstone of all relevant

health policies

2004: Patient Safety Programme “Primum non nocere”

2009: Council of the European Union Council Recommendation on patient safety,

including the prevention and control

of healthcare associated infections

International framework

Page 3: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Culture To improve

PS

In NHS

Education Research

Reporting

and learning

systems Patients

Safe

Practices

Page 4: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Alliances

Ministry of Health 17 Health

Regions &

INGESA

Agreements

PROFESSIONALS

140 associations

supporting PSS

PATIENTS AND

CONSUMERS

22 associations

supporting PSS

PUBLIC AND PRIVATE

ORGANIZATIONS

•Universities

•Agencies

•Schools of health

•Others

Agreements and contracts

Collaboration

Page 5: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

ENEAS Professional statement

Statment with WHO

2005 2006 2007 2008 2009

2011 2010

APEAS

Bacteriemia zero (ICU) Patients Network

Hand Hygiene Programme EuNeTPaS

BZ results

Strategy indicators

Pneumonia zero

EARCAS

IBEAS

SINASP (N&LS)

Patient statement

Medication errors

SYREC

Expert recommendations

I Conference

II Conference III Conference IV Conference

V Conference

EU Presidency VI Conference

2012

PaSQ

Medication evaluation

Neonatology

PaSQ meeting

2013

UPDATE

Development of the Strategy

Page 6: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Main actions

1. Patient safety culture

Information

Teaching programme

Patient safety research

2. Safe clinical practices

HCAI

Medication

Procedures

3. Notification & learning system

4. Patients participation

Page 7: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

www.seguridaddelpaciente.es

Page 8: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Setting Questionnaire # of professionals

Problems

detected

Hospital

Hospital Survey

on PS Culture

(AHRQ)

22 Hospitals

(n= 2503)

.Managers support

.Communication

between Units

.Human resources

ICU Hospital Survey

on PS (AHRQ)

Pilot BZ

192 ICU

(n=438)

. Managers support

. Workload

. Human resources

Primary

care

Medical Officer

Survey on PS

(AHRQ))

15 Regions

(n=4344)

. Workload

Patient Safety Culture Professional perception of organizational climate in the NHS

Page 9: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Education is the first

step to change

Professionals’ culture

OBJECTIVES:

Prevent, detect, analyze and minimize AE.

Evidence and safe clinical practice

METHOD:

Multifaceted approach

CONTENTS:

AE Epidemiology and prevention

Risk management

EBM

Effective communication

Education and Training Promotion of culture and knowledge on Patient Safety

Page 10: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

2005 2006 2007 2008- 2012

Master Degree (5 editions, 150 professionals)

Basic Course at Regional level

Risk Management Online Course (22 editions, 1500 professionals)

Specific courses: Hand hygiene,BZ, NZ, SINASP

Teaching programme on PS

Page 11: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

APEAS (n=96047)

1,1% (1,05- 1,18)

48 PC centers

452 professionals

96.047 visits

Prevalence

ENEAS (n=5624)

9,3% (8,6-10%)

24 hospitals

5.624 patients

42.714 stays

Incidence

SYREC 40% Risk

Medication,

devices, catheters

acceses.

ICU

Prospective

2006

EARCAS AE related with: .Medication .HCAI .Evaluation Long term care facilities Qualitative study

2007 2008 2009-10

Research: frequency of AE

More than 50% of the AE would be preventable

Page 12: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

HCAI

NURSING CARE

SURGERY AND ANAESTHESIA

MEDICATION USE

PATIENTS INVOLVEMENT

COMMUNICATION

ZERO

INFECTION

ICU

HAND

HYGIENE

Safe Practices: Funding areas

STOP

HCAI

PATIENT IDENTIFICATION

Page 13: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

PREVENT AND CONTROL HCAI

Han

d H

yg

ien

e

Bacte

riem

ia z

ero

Pn

eu

mo

nía

zero

AM

R

Su

rvelilla

nce s

yste

ms

New

bo

rn in

fectio

n

HCAI

Sesp

sis

Co

de

Page 14: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Specific objectives

in coordination with

the Health Regions

To agree on common basic

activities

To select indicators at different

levels

To improve professionals’ HH

education and training

Hand hygiene program

Improving HH to reduce HCAI

Page 15: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Hand Hygiene Indicators 17 health Regions; 300 hospitals

Page 16: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

SECONDARY OBJECTIVES

-To promote and strengthen PS culture in ICUs throughout the NHS.

-To create a network of ICUs implementing evidence-based safe practices

To reduce the mean national incidence of Catheter-Related

Bloodstream Infections per 1000 catheter-days in ICU to less than 4

BZ- MAIN OBJECTIVE

To reduce the mean national incidence of Peumonia related to MV per

1000 MV-days in ICU to less than 9

NZ- MAIN OBJECTIVE

Zero Infection - ICU

Page 17: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

SMoH

HR Department

HR Cordinating

Team Cordinator, ICU physician

ICU nurse, preventivist

ICU-1 ICU-2 ICU-n

Information, engagement

Managers commitment

Leadership

Organize: Functions

Resources distribution

Training

Monitoring

Evaluation reports: results

Structure & Process evaluation

Physician, Nurse, Executive,

infectious diseases comitee

Training

Implementation

Self-evaluation

Improvement

Cofinancing & coordination

Monitoring & spreading

National Organization

SEMICYUC

SEEIUC

Page 18: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

RESULTS 230 ICU (85% 0f the NHS)

- National rate <4

- 117 avoided deaths

- 130 mill € saved in hospitalization

54%

Page 19: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

RESULTS:

230 ICU (85% 0f the NHS)

-National rate <9

-280 avoided deaths

-143 mill € saved in hospitalization

DI NMV: NVM/1000 d MV (Mean)

40%

Page 20: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Criteria (increase)

4: Automatic

Communications (47%)

15: Continuos training

In PS (46%)

17: Programes to reduce

errors (49%)

18: Analysis of errors

By professionals (84%)

ISMP-Medication Safety Self-Assessment Questionnaire To identify the changes that ocurred from 2007 to 2011 in

medication safety practices in Spanish hospitals (105 hospitals in 2007 vs 165 in 2011)

Safe medication Use

Page 21: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

• 2006: Bibliographic review

• 2007: Meeting with HR and experts

Focus group with patients

• 2008: Survey to Scientific Societies

• 2009: Piloted in 2 hospitals

•

• 2010-11: Piloted in 4 HR

• 2013: 6 HR (68 hospitals, 9 primary care health centers)

Reporting and learning system

Objective:

To improve patient safety, learning from errors at local level

Page 22: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

• Voluntary

• Non punitive

• Confidential

• Anonymous (or not)

• Systems-oriented

• Expert analysis

R&LS: Characteristics

Page 23: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

SINASP Web page http://sinasp.msps.es

News

RCA

http://sinasp.msps.es/
Page 24: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Notifications received in one year

Notification by professional

0 500 1000 1500 2000

Enfermero

Médico

Farmacéuticos

Auxiliar de enfermería

Otros profesionalessantiarios

MIR

n=3.512

Medication 1214

Identification 528

Falls 440

Devices 355

Procedures related with treatmnent 279

Organization 286

Diagnosis 219

Surgical procedures 194

Others 149

Transport 125

Blood and blood products 125

Type of incidents

Nurses

MD

Pharmaceutical

Nurse assistant

Others

MD residents

Page 25: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

European Union Network for Patient Safety

and Quality of Care

- Support the Recomendation of the CoEU regardimg Patient Safety and Healthcare Associted Infections

- Strengthen cooperation between MS, stakeholders and International organizations on issues related to Quality of care, Patient Safety and Patient Involvement

April 2012 - March 2015

Sustainable Network

Exchange of PSP & GOP

Implementation PSP

PSP: patient safety practices

GOP: good organizational practices

Page 26: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

1 Coordination France (HAS)

4 Identification PSP

Exchange PSP Denmark (DSPS)

3 Evaluation

Greece (NKUA)

2 Communication Croatia (AQAH)

5 Identification PSP

Implementation PSP Germany (AQuMeD)

6 Description of QMS Identification GOP

Exchange GOP Spain (MSSSI)

7 Sustainability

Slovakia (MoH)

WP transversal

WP central

Exchange Mechanism

Page 27: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

www.pasq.eu

http://www.pasq.eu/
Page 28: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

What about the patients?

When we want your opinion we´ll give it to you

Page 29: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Patients participation in the PS strategy

2006

2007

2008 2009

2010

2013

NETWORK OF HEALTH SCHOOLS FOR CITIZENS

Page 30: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

Next steps

• Healthcare associated infections Hand hygiene Zero infection in ICU: resistance zero Antomicrobial resistance strategy Sepsis code

• Safe medication Medication errors High risk medication list for chronic patients Medication reconcilliation

• Notification and Learning System Primary Care

• Others Evaluation of teaching hospitals

Page 31: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

What we have achieved?

National alliances around Patient Safety

Dissemination of the safety culture in the NHS

Generation of a significant critical mass of professionals

involved in the strategy

Knowledge about security problems in the NHS

Knowledge of the tools to prevent and control them

Available data showing effectiveness and efficiency of

the practices implemented

Page 32: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

COMMITMENT

EDUCATION

IMPLEMENTATION

EVALUATION

FEEDBACK

Key elements for success

LEADERSHIP

Page 33: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

CHALLENGES

NHS SAFETY

Improve PS culture

Evaluation Patients Manager

leaders

Clinical

leaders

Page 34: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

We need more than ever leaders able to lead their teams

in the worst conditions, towards achievable goals

Page 35: Spanish Strategy on Patient Safety - PaSQ Strategy on Patient Safety2.pdf · Spanish Strategy on Patient Safety Yolanda Agra MD, PhD Ministerio de Sanidad, Servicios Sociales e Igualdad

[email protected]

mailto:[email protected]

Creating a Patient-Centered Digital Strategy

Creating a Patient-Centered Digital Strategy

Patient Experience Strategy: Rethinking the Fertility Journey

Patient Experience Strategy: Rethinking the Fertility Journey

Annual progress report for the NHS Patient Safety Strategy: year one€¦ · patient safety strategy to reflect the importance of promoting equality in patient safety. More detail

Annual progress report for the NHS Patient Safety Strategy: year one€¦ · patient safety strategy to reflect the importance of promoting equality in patient safety. More detail

Patient and Public Engagement Strategy 2014-17 · Patient and Public Engagement Strategy 2014-17 ... This is the final version of the strategy and includes an ... Patient and Public

Patient and Public Engagement Strategy 2014-17 · Patient and Public Engagement Strategy 2014-17 ... This is the final version of the strategy and includes an ... Patient and Public

Patient Involvement Strategy 2021-25

Patient Involvement Strategy 2021-25

Patient Experience and Involvement Strategy 2014-2017

Patient Experience and Involvement Strategy 2014-2017

CBD Strategy and Action Plan - Colombia (Spanish version)

CBD Strategy and Action Plan - Colombia (Spanish version)

Spanish PEI Settlement Strategy Summary

Spanish PEI Settlement Strategy Summary

Spanish Security Strategy

Spanish Security Strategy

WR Patient Prep Spanish Jan 2014 for web - Provider Portal

WR Patient Prep Spanish Jan 2014 for web - Provider Portal

Patient Safety Strategy

Patient Safety Strategy

Spanish PEI Settlement Strategy

Spanish PEI Settlement Strategy

Patient Experience & Involvement Strategy€¦ · 2 Foreword We are delighted to present our Patient Experience and Involvement Strategy for the next three years. This Strategy was

Patient Experience & Involvement Strategy€¦ · 2 Foreword We are delighted to present our Patient Experience and Involvement Strategy for the next three years. This Strategy was

Patient self-report section of the ASES questionnaire: a Spanish ...

Patient self-report section of the ASES questionnaire: a Spanish ...

Spanish Patient Guide - Carilion Roanoke Memorial and Community Hospitals

Spanish Patient Guide - Carilion Roanoke Memorial and Community Hospitals

Commonly Used Spanish Patient Forms: Consent, Refusal ......April 2015 Version 1 Commonly Used Spanish Patient Forms: Consent, Refusal, Instruction and Treatment . Provided as a courtesy

Commonly Used Spanish Patient Forms: Consent, Refusal ......April 2015 Version 1 Commonly Used Spanish Patient Forms: Consent, Refusal, Instruction and Treatment . Provided as a courtesy

Spanish input to the HEP European strategy update

Spanish input to the HEP European strategy update

ANEFAs Health and Safety Strategy for the spanish ... · Safety Strategy for the spanish aggregates industry César Luaces Frades General Manager. 2 Spanish Aggregates Sector ANEFA

ANEFAs Health and Safety Strategy for the spanish ... · Safety Strategy for the spanish aggregates industry César Luaces Frades General Manager. 2 Spanish Aggregates Sector ANEFA

Patient Handouts in English and Spanish

Patient Handouts in English and Spanish

Evaluation of the Mental Health Strategy of the Spanish National … · 2019-09-05 · 1. EXECUTIVE SUMMARY : The Mental Health Strategy of the Spanish National Health System (Spanish

Evaluation of the Mental Health Strategy of the Spanish National … · 2019-09-05 · 1. EXECUTIVE SUMMARY : The Mental Health Strategy of the Spanish National Health System (Spanish