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Great expectations: a patient safety story …. Sue Smith Executive Director of Nursing & Patient Safety Director of Infection Prevention & Control. In 2008: HSMR 131 MRSA bacteraemia 12 C-difficile 158 So we Made patient safety, quality of care and experience our No.1 priority - PowerPoint PPT Presentation
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Great expectations: a patient safety story ….
Sue SmithExecutive Director of Nursing & Patient SafetyDirector of Infection Prevention & Control
• In 2008:– HSMR 131– MRSA bacteraemia 12– C-difficile 158
• So we – Made patient safety, quality of
care and experience our No.1 priority
– Signed up to national patient safety campaigns
The story begins….
Patient Safety First
Leading Improvements in
Patient Safety
Clinical leadership
• Monday SUI panel• Monthly GTT reviews• Mortality reviews• Time-out Drs and nurses
– one healthcare record• Shared learning & action• Role modelling
What will we do? By how much? How will we measure it?
Rationale Comments
Reduce mortality Top 25% nationally by 2014
Top 10% nationally = stretch target
Dr Foster
HED data
We aim to save more lives every
year
Year 10/11 11/12 12/13 13/14
Target 95 90 85 80
Stretch 85 80 75 70
Actual 95 92
How will we reduce mortality?
Min target Stretch target By when Trajectory
Reduce HA MRSA
bacteraemia
20% reduction against 2008/09
baseline of 9
50% reduction against 2008/09
baseline of 9
2014 Year 10/11 11/12 12/13 13/14
20% 6 6 5 5
50% 5 5 4 4
Actual 4 0
Reduce HA Clostridium Difficile
20% reduction against 2008/09 baseline of 158
50% reduction against 2008/09 baseline of 158
2014 Year 10/11 11/12 12/13 13/14
40% 127 120 115 110
50% 120 100 90 80
PCT 129 59 44
Actual 53 68
Reduce cardiac arrests year on
year
5% reduction against 2010/11 baseline of 129
30% reduction against 2010/11 baseline of 129
Yearly until 2014 Year 10/11 11/12 12/13 13/14
5% 129 123 117 111
30% 129 90 63 44
Actual 129 91
What will we do? By how much? How will we measure it?
Rationale Comments
Reduce mortality Top 25% nationally by 2014
Top 10% nationally stretch target
Dr Foster
HED data
We aim to save more lives every
year
Year 10/11 11/12 12/13 13/14
Target 95 90 85 80
Stretch 85 80 75 70
Actual 95 92
How will we reduce mortality?
Min target Stretch target By when Trajectory
Reduce inpatient fractures
50% = 17 less fractures
75% = 26 less fractures
2014 Year 10/11 11/12 12/13 13/14
50% 24 22 20 18
75% 20 18 15 9
Actual 24 20
Ensure no never events occur
Zero never events Zero never events 2014 Year 10/11 11/12 12/13 13/14
Target 0 0 0 0
Actual 0 3
Physiological observations recorded:At initial assessment
Cycle Heart Rate Respiratory Rate
Systolic BP
Conscious level
Oxygen saturation
Temperature
1
(n=490)83% 73% 81% 11% 74% 78%
5 (n=447)
99% 98% 98% 97% 98% 98%
6 (n=451)
98% 97% 98% 91% 98% 97%
7 (n=440)
99% 97% 99% 91% 98% 97%
Cardiac arrests
Quarter / Year Apr- Jun 10
Jul- Sept 10
Oct-Dec 10
Jan- Mar 11
2010 – 2011 cardiac arrests
22 28
[50]
38
[88]
41
[129]
2011 – 2012 cardiac arrests
29 12
[41]
28
[69]
22
[91]
InfectionYear 2008-2009 2009-2010 2010-2011 2011-2012
(Apr-Feb)
MRSA bacteraemia 9 5 4 0
Clostridium difficile 158 136 53 68
Complaints & complimentsYear 2009 2010 2011
Complaints 358 341 371
Compliments 2,212 3,786 5,087
The latest data available from the [March 2012] North East Quality Observatory System report the 2010-2011 overall inpatient experience measure for the Trust as
77.7 against a national mean score of 74.9.
Mortality
CQC Quality Risk Profile
Outcome Number Outcome Description
Previous Risk Estimate
Current Risk Estimate
Total Number of Items
Number of Qualitative Items
Number of Quantitative Items
1 (R17) Respecting and involving people who use services Low Green High Green 106 20 86
2 (R18) Consent to care and treatment High Green High Green 5 0 5
4 (R9) Care and welfare of people who use services Low Neutral Low Green 182 20 162
5 (R14) Meeting nutritional needs Low Neutral Low Neutral 21 6 15
6 (R24) Cooperating with other providers High Green Low Green 11 1 10
7 (R11) Safeguarding people who use services from abuse
Insufficient Data
Insufficient Data 1 0 1
8 (R12) Cleanliness and infection control Low Neutral High Green 63 4 59
9 (R13) Management of medicines Low Neutral Low Neutral 14 0 14
10 (R15) Safety and suitability of premises Low Green Low Neutral 46 2 44
11 (R16) Safety, availability and suitability of equipment Low Neutral Low Neutral 13 1 12
12 (R21) Requirements relating to workers Low Green Low Green 5 0 5
13 (R22) Staffing Low Green Low Green 30 0 30
14 (R23) Supporting staff Low Green Low Green 62 0 62
16 (R10) Assessing and monitoring the quality of service provision Low Green Low Green 40 0 40
17 (R19) Complaints Low Green Low Green 8 0 8
21 (R20) Records Low Green Low Green 66 0 66
November 2011data
• National / local financial climate• £40m challenge• New hospital• Operating framework• Commissioning for Quality and Innovation
(CQUIN) - £2,741,067 plus £405,700• Regulation – CQC/Monitor/CCGs….• Quality accounts / Quality Strategy
Where next?
So far, we know that clinical leaders and good teamwork….
Saves lives – What next?
