Institute for Healthcare Improvement: Scottish Patient Safety Programme

Overview

"The Scottish Patient Safety Programme, marks Scotland as a leader, second to no nation on earth, in its commitment to reducing harm to patients, dramatically and continually."

—Donald Berwick, President and CEO, Institute for Healthcare Improvement

Watch an informational video on the Scottish Patient Safety Programme. [6:38]

The development of the Scottish Patient Safety Alliance links the NHS to the range of organisations which seek to secure and enhance the safety and quality of services provided to patients in NHSScotland; and, at the same time, improve patient experience. While acute care is the starting point, the overall approach reflects the totality of the patient journey and recognises that care will take place in a range of settings, with primary and community-based care becoming increasingly prominent in terms of the delivery of complex packages of care.

This approach reflects an evidence base that suggests one in ten patients admitted to Scottish NHS hospitals will be unintentionally harmed, and that around 50 percent of these events could have been avoided if lessons from previous incidents had been learned. A National Audit Office report published in November 2005 estimated that patient safety incidents cost the NHS in the UK an estimated £2 billion a year in extra bed days alone. That suggests costs in Scotland of £200 million per year.

Programme Objectives

The key objectives of the Scottish Patient Safety Programme are to:

Reduce healthcare-associated infection
Reduce adverse surgical incidents
Reduce adverse drug events
Improve critical care outcomes
Improve the organisational and leadership culture on safety

The intention is that by January 2011 there will be evidence of a 15 percent reduction in mortality, and a 30 percent reduction in adverse events. The level of achievement for a range of supporting aims such as ventilator-acquired pneumonia and crash call rates will also be quantified. Work continues with the NHS, professional bodies, and specialty societies to ensure the aims and implementation arrangements fully reconcile with NHSScotland organisational arrangements, which means there may be some further refinement.

These key aims are intended to be used to facilitate and drive improvement, rather than as a basis for measurement for accountability. An important part of our strategic approach is that these key aims are owned by those participating in the Scottish Patient Safety Programme and that the work done by front-line teams remains focused on improvements over time against their own baselines.

The Scottish Patient Safety Programme provides the support, the methodology for improvement, and analysis and reporting of the data generated as a result of the small tests of change instituted by each front-line clinical team. Good quality data will be fundamental to the credibility and sustainability of the programme. In addition to the work being undertaken by NHS QIS and IHI, further work is underway with the Information Services Division (ISD) to ensure a robust and sustainable measurement system is in place that will give consistent results across Scotland.

Programme to Date

The Programme is now underway, and since returning from the first learning session, Health Boards have been actively testing and implementing changes from each of the five workstreams. Staff are participating in the monthly conference calls for their workstreams, sharing experiences and learning form their Health Boards.

Health Boards across Scotland are organising events and information sessions to engage staff and help communicate the role staff have to play in the Programme. Scotland-wide networking events are also taking place, bringing together key people from across the country, with the aim of facilitating knowledge sharing and learning. The networking events will continue throughout the Programme, with an emphasis on providing specific events for workstream leads and staff.

Scottish Patient Safety Programme Fellowship

With support from The Health Foundation, five enthusiastic clinicians committed to the Scottish Patient Safety Programme have been selected to participate in this unique development opportunity.

The SPSP Fellowship is a 10-month programme of distance learning, coaching, and focused residential seminars covering:

Improvement theory, methods, and tools
Measurement for improvement
Reliability, systems, and design for safety
Working with people, motivation, and team building
Leading clinicians through change

Upcoming Events

Learning Session 4 is scheduled for May 19-20, 2009, in Glasgow. Senior leaders and teams from each Health Board will have the opportunity to share results, network with each other, and celebrate their successes thus far.