The Patient Safety Collaborative Programme

2014-2019

World Stop Pressure Ulcers Day

Fiona Thow20 November 2014Network

Responding to Francis and Berwick

“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

Berwick Report, August 2013

For NHS staff and clinicians:

• Participate actively in the improvement of systems of care

• Acquire the skills to do so• Speak up when things go wrong• Involve patients as active partners and co-

producers in their own care

Patients as leaders and true partners

Co- producing the safety programme

“Following Don Berwick’s recommendation, NHS England will establish a new Patient Safety Collaborative Programme across England to spread best practice, build skills and capabilities in patient safety and improvement science, and to focus on actions that can make the biggest difference to patients in every part of the country. They will be supported to systematically tackle the leading causes of harm to patients. The programme will start in April 2014.”

The government’s response to Francis, November 2013

Responding to Francis and Berwick

• AHSN footprint• 2-5m population• Locally owned and run• Majority of funding devolved

to support local improvement programme activity

• National support for;• change packages/

interventions;• knowledge sharing;• consistent measurement;• networks/communities.

Patient safety collaboratives

#saferNHS

A Different kind of Collaborative

• Locally driven and led• Designed in partnership• Provide support, co-ordination & rapid

spread and adoption• Developing capacity & capability for QI &

Safety

Framework for Operational Excellence

©Alan Frankel and IHI 2013

A system devoted to continual learning and improvement

Using the principles of the Safety Framework

• Patients, families and carers involved in agreeing and designing priorities

• Focusing on creating the right culture• Creating a system that continues to learn• Using appropriate quality and safety

improvement methodology• Measurement & Leadership are key !

Progress to date• NHS England Public Board signalled support for the programme• Design Day held for 120 experts on 15 January 2014• NHS England funding allocation process finalised• Governance structures and processes agreed with AHSNs• Collaborative Programme Board established • Patient Safety Leads group convened• 1:1 meetings with AHSN’s• Baseline data packs in development• Establishing links to other initiatives• National Launch Day - 14th October• Operational model & initial “cluster groups” agreed

Topic area Patient Safety Topic

The ‘essentials’

Leadership Measurement

NHS Outcomes Framework improvement areas

Venous Thrombo-embolism

Healthcare Associated Infections

Pressure Ulcers Maternity

Medication Errors

Deterioration in children

Other major sources of death and severe harm

Falls Handover

and Discharge

Nutrition and hydration

Acute Kidney Injury

Missed and delayed

diagnosis

Deterioration of patients

Medical Device Errors

Sepsis

Vulnerable groups for whom improving safety is a priority

People with Mental Health

needs

People with Learning

Disabilities Children Offenders

Acutely ill older people

Transition between

paediatric and adult care

Collaborative priorities - proposals

The ‘operational model’National Patient Safety Collaborative Programme - Operational Model

Pressure Ulcers VTEMedication Errors HCAI Maternity Falls

AHSN

1 x x x2 x x x3 x x x4 x x5 x x6 x x x7 x x8 x x9 x x

10 x x x11 x x x12 x13 x x x14 x x15 x x

Leadership and Measurement

NHS IQAcceleratedLearning Groups

EvidenceToolkitsSocial mediaCampaignsSpread

Cluster groups• Primary focus: leadership, measurement and quality

improvement and safety capability• Medicines Optimisation, AKI, Mental Health, Pressure

Ulcers, deterioration of the patient (Incl. sepsis)• Group focus on topic specific improvement• Bringing expertise together with practical application• Peer support and problem solving• Accelerate and share learning across the NHS

Pressure Ulcers• 5 AHSNs have identified it as a priority area• Interest in working in care homes, community

and supporting people in their own homes• Developing skills and training resources for care

homes• Linking it to work on hydration, falls and AKI• Plans are still being developed – cluster group

input, master classes, sharing good practice, resources

Key principles• Build on existing good work• Establish ‘how’ to implement current evidence• Test and refine new ways of working – where evidence

may be lacking• Influence levers and drivers in the system to support safer

care• Align initiatives – making safety everyone’s business• Staff and patients – tools, skills and support• Aim for large scale and transformational change• Share learning across the NHS

NHS IQ Role – what we have heard

• A small national supporting / coordinating function• Build on pockets of excellence and communities of interest• Developing joint approaches with partners to:

• Measurement - expert group, baseline metric development and national aggregation

• Leadership & Culture - expert group• Capability building programme - workshops• Programme evaluation & ROI• Partner with patients and carers

• Provide QI and programme support materials and guidance • Co-produce - avoid duplication and share best practice and resources• Do only what adds value nationally - help align work, connect and

join up the dots

#saferNHS

Fiona.thow@nhsiq.nhs.uk

www.nhsiq.nhs.uk

Improving health outcomes across England by providing improvement and change expertise.