In Scotland, hospital mortality rates are at their lowest level since records began. In this interview, Professor Jason Leitch, Clinical Director for NHS Scotland, shares the lessons his country has learned that could apply to other large-scale patient safety efforts.
To what do you attribute the success of NHS Scotland in reducing hospital mortality rates? Assuming there are many contributing factors, what has been crucial?
Scotland’s hospital standardized mortality ratio (HSMR) has fallen dramatically in the last few years. It’s not a perfect statistic, and it’s only one gauge, but we have used HSMR as a measure of our patient safety work. Cause and effect are hard to prove, but what we do know is that many things have contributed to the reduction in mortality.
The Scottish Patient Safety Acute Adult Programme, which began in 2008, focused on critical care, general wards, operating theaters, medicines, and leadership. There are a host of interventions, now implemented at scale, and in among these interventions are doubtless some that have contributed to mortality reductions:
- The surgical safety checklist is now embedded across the country, and we have seen a significant reduction in surgical mortality.
- Healthcare-associated infections (HAIs) are at their lowest levels since the country started keeping records.
- The work on sepsis has been crucial, particularly a robust application of reliable design processes to ensure the “Sepsis Six” — especially antibiotic provision — are carried out fast.
- The culture of safety is more difficult to attribute, but elements such as Leadership WalkRounds, early morning site-based safety huddles, and board prioritization have doubtless been crucial.
Scotland is the first country to establish a nationwide patient safety program. What have you learned about coordinating a quality and safety agenda on a large scale that might apply to other countries or large health systems?
There are many. In summary, here are the three key contributors to our work:
- Method — We chose the IHI Breakthrough Series Collaborative method underpinning the Triple Aim. We stuck with it; we were relentless with our focus and still are today, as we expand into other areas of work.
- Measurement — We measured a lot. Microsystems counted falls and pressure ulcers. Regional systems counted infections and number of people trained in quality improvement. Nationally we counted mortality and harms.
- Leadership — We identified and developed leaders, both at the board level and in the clinical and management communities. Thousands of people, including politicians, can now explain run charts and testing. We continue to invest in improvement capacity and capability as a crucial ingredient for change.
Is there anything you would do differently if you were starting the Scottish Patient Safety Programme today?
We have fantastic Programme Managers, some still with us after eight years, and they are largely self-taught and unsung. If we were starting again, we would systematically choose and train them as the work began, and invest in their management skills. The mid-tier leadership is so important that you have to treat them differently.
We have learned how important it is that leaders know how to do improvement, so that they can foster the best conditions possible for improvement work to be carried out by their teams, departments, and boards. Understanding improvement methodology, data, and the vital role of transparency is imperative for leaders at every level.
I wouldn’t try to convince the whole clinical community to jump on-board on day one. We tried that and it didn’t work. At the start, you need three critical care clinicians, not 600, and three are a lot easier to find. They will test and prototype and others will follow them.
What strategies keep up the momentum for continuous improvement?
This is probably the question that now troubles us the most. We’re building on the lessons learned from the acute hospital work as we expand to new areas, such as dentistry and community pharmacy. We’re building improvement capacity.
We have outgrown the Breakthrough Series Collaborative model for our more mature work, so we have had to think differently: we do more regional work, more campaign-style changes, and even some top-down edicts. We now have the 10 Essentials of Safety that we expect everyone in Scotland to do.
Is there a story that helps illustrate what it has meant for NHS Scotland to see these results?
In 2015 a pregnant woman in her 30s had an uneventful birth by caesarean section in a Scottish hospital. She was discharged a few days later and the mother and son were doing well. She became ill and ended up hospitalized with sepsis. She recalls waking up in critical care and hearing a nurse boast to a colleague how they managed to “Do the Sepsis Six in 37 minutes.” The Safety Programme saved her life.
The punchline to the story is that this woman works in the National Health Service and was one of the team who gathered the evidence for the sepsis work. She helped save her own and many other lives.