Why It Matters
A decade of nationwide patient safety improvement offers many lessons about successful large-scale change.
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7 Questions to Guide Your Large-Scale Improvement

By Derek Feeley | Tuesday, June 5, 2018
Line of Sight

What can one relatively small country teach other health systems about large-scale quality improvement? Quite a bit, I believe.

People from all over the world are now studying and trying to replicate the progress Scotland has made — and continues to make — to improve health care nationwide. A small sampling of what the Scottish health care workforce has accomplished in the last decade helps explain why:

  • A drop in Hospital Standardized Mortality Ratio of more than 10 percent since 2014 — an estimated 7,800 fewer-than-expected deaths.
  • 21 percent reduction in sepsis mortality since 2012
  • 31 percent reduction in the cardiac arrest rate since 2012
  • 31 percent reduction in severe pressure ulcers since 2015

But the numbers are only part of the story. It’s been 10 years since the National Health Service (NHS) in Scotland and the Institute for Healthcare Improvement (IHI) first partnered on the Scottish Patient Safety Programme (SPSP), an unprecedented, comprehensive, and truly nationwide approach to improving patient safety. This anniversary is an opportunity for me — as former Chief Executive of NHS Scotland — to look back and reflect on some of the lessons I learned from the program.

Large-scale change of any kind is never easy. Scotland’s experience taught me that there are challenging questions health care leaders must ask themselves to determine if they and their organizations are ready to do what’s necessary to make large-scale improvement:

  • Are you willing to admit that your organization is doing avoidable harm to patients? — When we started, we had to face up to the fact that we had infections in our hospitals that were harming people and leading to unnecessary deaths. Just before SPSP started, we had a significant outbreak of difficile in one of our hospitals and people died. It was a shock that made it painfully clear to us that there was avoidable harm in our system.
  • Are you ready to be better than “good enough”? — Before SPSP, Scotland had a long tradition of performing clinical audits and publishing results in an open and transparent way. Scotland’s rates of surgical mortality weren’t bad by international standards, but they had stayed the same for about 10-15 years. In other words, people were being harmed who didn’t need to be harmed and people were dying who didn’t need to die. We decided this was unacceptable.
  • Are you making safety a top priority? — Every time I speak with leaders, I hear them say, “I’ve never been so busy. There are so many things competing for my attention.” It’s always tempting to prioritize the urgent over the important, but leaders have a responsibility to devote their attention to things like getting out and talking directly with teams. With the SPSP, we had a small central team, but we regularly sent dyads of our officials and an IHI representative out to meet the people doing the work in their own environment. We saw the challenges they faced up close and we committed ourselves to removing barriers to success.
  • Are you willing to be ambitious? — The ambition of the Scottish Patient Safety Programme inspired people. It was the first truly national program of its kind and we reminded people of this repeatedly. We said that a small country like Scotland was attempting something that no one had ever done before with the participation of every single clinical team in the country. People liked being part of something that was bold and truly national. You may not be taking on improvement on a national scale, but is there an initiative to which many, or all, of your teams can contribute, such as improving hand hygiene or co-designing care improvement with patients?
  • Are you building the skills necessary to make improvement? — Having a bold ambition without proper support sets teams up for failure. Telling people they need to improve isn’t enough. You need to show them how. We were fortunate that our teams liked learning about improvement science. They liked the practicality of it. And we paid special attention to identifying and developing the skills of the early leaders and celebrating their successes. This motivated others because they could see that we valued even incremental progress.
  • Can you stay focused if improvement doesn’t come quickly? — It took a little while for SPSP to get up and running. Although we knew it was a long-term program, and we were going to stick with it, holding our nerve was difficult in the early days. Staying focused when the results do not materialize as quickly as you’d hoped is crucial. You should anticipate doubters who will tell you your attention should be elsewhere, and commit to protecting people from disruptions and negativity. Former IHI Senior Vice President Jim Conway describes this beautifully: He talks about the “waterfall” of distractions and competing priorities that beat down on people constantly, and how leaders must provide shelter and shield their staff from things that get in the way of their real work.
  • Do you know how to capitalize on early success? — It’s important to learn from failure, but people are often motivated by success. In the first days of the SPSP, when we didn’t have outcome data to share, finding and sharing stories about early successes was part of our strategy. We talked about teams who were reporting promising increases in reliable implementation of the vent bundle. We joined in celebrating the teams who were getting to zero. They’d go 100 days without a central line infection, and they’d buy a cake. They’d go 200 days, and buy a bigger cake! Being part of those celebrations was important. It called attention to the pioneers. It’s easy to forget now that it was unheard of to go for days or months without health care-associated infections. Stories and celebrations of these successes inspired people.

Improving patient safety is never a quick fix. It takes courage to get started and it takes persistence to make progress. Making care safer takes cultural, behavioral, and leadership changes just as much as it needs improvement science and methods.

The Scottish Patient Safety Programme wasn’t an instant success. But, now, 10 years later, some would say it’s become a way of life.

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@derekfeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.

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