Overview
Around 16 million people are admitted to hospital each year in the UK¹. The majority are treated safely and successfully. However, a disturbingly high number will find that something goes wrong with their treatment or care, resulting in unnecessary harm, pain and suffering, sometimes leading to death. Estimates suggest that one in ten patients in hospital experiences an incident which puts their safety at risk, and that about half of these could have been prevented².
The Health Foundation’s Safer Patients Initiative (often known as SPI) was set up in 2004 to find practical ways of making acute hospitals safer for patients. It ran until 2008 and demonstrated the health service’s potential to ensure patient safety. The majority of the sites are continuing to work together in the Health Foundation’s Safer Patients Network.
The initiative has influenced the national safety initiatives across the UK, spreading the approach across the UK health services.
How did it work?
The Safer Patients Initiative ran in two phases – the first starting in 2004 and including four hospitals, the second in 2006 which brought another 20 hospitals on board. The sites worked together with the Health Foundation and safety experts from the Institute of Healthcare Improvement.
The Safer Patients Initiative:
- concentrated on five clinical areas, each containing multiple interventions that had an established and accepted evidence base in the UK (such as better management of patients in intensive care, infection control, preventative antibiotics for surgery and medicines safety)
- provided training in quality and safety improvement
- ensured safety was a strategic priority by ensuring full involvement of the chief executives and senior executive teams.
The success is due to SPI’s recognition that processes are the key to ensuring consistently high-quality care. By acknowledging the scale of the challenge, SPI built a system-wide approach. It shifted the culture away from individual blame; focused leaders’ attention on safety as a first priority; used evidence to make routine care processes more reliable; and built the will and skills of staff to support these strategies.
References
- Yuen P. Office of Health Economics Compendium 17th Edition, 2005–06 London: Office of Health Economics, 2005
- Sources: Vincent, Neale and Woloshynowych “Adverse events in British hospitals: preliminary retrospective record review” in British Medical Journal Vol 322 3 March 2001 and Emslie, Knox and Pickstone (eds), Improving Patient Safety: Insights from American, Australian and British Healthcare ECRI Europe, 2002
Phase one – 2004 to present
The first
phase of the initiative, brought four UK hospitals together to test ways of
improving safety on an organisation-wide basis and develop their expertise in
patient safety. These sites were: Luton and Dunstable Hospital NHS Trust; Conwy
and Denbighshire NHS Trust; Down Lisburn Health and Social Services Trust (now
South Eastern Health and Social Care Trust); and NHS Tayside.
Phase two – 2006 to present
In 2006, the Safer Patients Initiative brought a further 20 hospitals on board (see page 2 for the sites involved). The phase two hospitals worked in pairs to take forward safety improvements in their sites building on the learning from phase one. They also had the support of the Institute for Healthcare Improvement.
The sites tested ways of making care safer in three areas of their hospitals – on the wards, before, during and after operations and in critical care. In each of these settings staff looked at ways to improve infection control, the management of drugs and communication between staff teams and patients. The teams implemented interventions that worked in their setting, examples of these can be found in our Safer Patients factfiles.
The 20 hospitals that joined the scheme in 2006 are:
| England | ||
| Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust | working with | Airedale General Hospital, Airedale NHS Trust |
| Huddersfield Royal Infirmary, Calderdale and Huddersfield NHS Trust | working with | York Hospital, York Hospitals NHS Trust |
| Musgrove Park Hospital, Taunton and Somerset NHS Trust | working with | Torbay Hospital, South Devon Healthcare NHS Trust |
| Southmead Hospital, North Bristol NHS Trust | working with | Bristol Royal Infirmary, United Bristol Healthcare NHS Trust |
| Royal Free Hospital, Royal Free Hampstead NHS Trust | working with | The Royal London Hospital, Barts and The London NHS Trust |
| Wales and England | ||
| Maelor Hospital, North East Wales NHS Trust | working with | Countess of Chester Hospital, Countess of Chester Hospital NHS Foundation Trust |
| Wales | ||
| University Hospital of Wales, Cardiff and Vale NHS Trust | working with | Royal Gwent Hospital, Gwent Healthcare NHS Trust |
| Scotland | ||
| Dumfries and Galloway Royal Infirmary, NHS Dumfries and Galloway | working with | The Ayr Hospital, NHS Ayrshire & Arran |
| Northern Ireland | ||
| Antrim Area Hospital, Northern Health and Social Care Trust | working with | Causeway Hospital, Northern Health and Social Care Trust |
| Royal Victoria Hospital, Belfast Health and Social Care Trust | working with | Mater Hospital, Mater Hospital Trust |
Example results by clinical area
General ward care
Crash calls - Luton and Dunstable NHS Trust
There are now 1.5 fewer cardiac arrests per week following the introduction and reliable use of an early warning score
system on the wards (based on data from 2005 to December 2008). The system allows staff to monitor patients and take action if they
go into decline. It
has led to a fall in the crash call rate as staff can now take action
sooner to avoid patients developing serious life threatening conditions.
C Difficile infections - Torbay Hospital, South Devon Healthcare NHS Trust
Down from 3 infections per 1000 patient days (early 2006) to 0.5 per
1000 patient days (late 2008).
Surgical / perioperative care
Surgical briefings - Airdale General Hospital, Airedale NHS Trust
Since
introducing the briefing for urology patients in April 2007 they have reached 100%
compliance with surgical briefings for patients in this clinical area (Dec 08). For all surgical
patients across the hospital 90% now have a surgical briefing, this is from a
starting point of 20%.
Critical Care
Central line infection - Royal Free Hospital, Royal Free Hampstead NHS Trust
From a peak of 18 infections per 1000 bed days for ICU patients
(in March 2007) this has been reduced to zero by Aug 2007 and maintained at zero until last
reported data for 2008. Achieved
by reliable application of the bundle for central line care, this includes: compliance
with sterile technique, correct point of insertion, regular inspection and
assessment for removal.
Medicines management
Medicines reconciliation - Bradford
Royal Infirmary, Bradford Teaching Hospitals Trust
Has seen improvement in reliability of medicines
reconciliation from 50% (in Nov 07) to a constant level of 98-100% (over
period from Feb- Aug 08).The team achieved this by:
- Enforcing compulsory reconciliation on discharge
- Prescribers had to either explain any changes to medicines or confirm there had been no long term changes
Anticoagulant adverse drug events - Bradford
Royal Infirmary; Bradford Teaching Hospitals Trust
In
August 2008, Bradford Royal Infirmary saw a 41% reduction in adverse drug events or anticoagulation
medicines from the median line (established on July–Dec 2007 data). Achieved this through
highlighting the need to establish baseline coagulation rates for patients before
prescribing and regular monitoring of patient response to the drug.
Leadership
Executive ward rounds
'It was really important for people to see that those people who aren't
normally associated with clinical work, were actually coming out, sitting down and spending an hour with the guys that work and deliver every
day. And them saying to them "you know the process, you know the system, tell me
what the things are that worry you about safety".'
Liz Childs, Director of Nursing & Quality and Deputy
CE, Torbay
Hospital; South Devon Healthcare NHS Trust
'[Patient safety leadership walkrounds involve the] executive directors going around to all the different clinical areas, sitting down with frontline junior staff of all different disciplines and non-clinical staff and asking them what would make a difference to patient care.
We
asked them to talk us through the last clinical incident they had reported, then
we started get a sense of what things we needed corporately to take on board,
what things they should take responsibility for sorting out and what things
they should just get on and sort out. It
is important for leaders to be involved in SPI because it makes people feel
that it's real… it makes the frontline staff believe that you are going to do
something about it.'
Andrew Way, CEO (until June 2009), Royal
Free Hampstead NHS Trust
Board attention and priority at board level
'Another success factor for SPI is executive buy-in: having
non-medical senior people within an organisation who are expecting it to
happen so you’re not pushing against a closed door. If you’re having problems
or issues with a particular individual, they can help things happen, and
they’ll drive the whole process.'
Justin Phillips, consultant anaesthetist, Musgrove
Park Hospital, Taunton and Somerset NHS Trust
'In terms of tangible changes made through SPI, the big thing is the culture - safety is definitely seen as a priority across the organisations now from board to ward. At each board meeting now we start by listening to a patient’s story, this may have positive endorsements or some criticisms or issues about the care the patient’s received. This sets the tone for every decision we make around the board table, with the end result being to improve care.' Liz Childs, Director of Nursing & Quality and Deputy CE, Torbay Hospital; South Devon Healthcare NHS Trust
Priority at clinical directorate level
'SPI’s been enormously useful as a
teambuilding exercise. Patient safety has always been a priority at Torbay, but
SPI has really helped us to develop key team working between management and
clinicians and nursing staff and across lots of areas in the hospital because
it’s so far reaching.
Our learning from SPI
Our safety work to date has delivered many valuable insights:
Hospitals need better measurement systems
Across the NHS, there is a lack of real-time clinical performance data. In SPI hospitals, teams track safety improvements against a range of process and outcome measures. By collecting meaningful data, each team can see the real-time impact of their changes, and identify new areas for improvement.
Guidelines and standards are not the same as practice
There is a lack of knowledge about implementing change. While the quality agenda has focused largely on guidelines and standards, there has been little focus on how to introduce practical, reliable change. Our safety work has demonstrated the importance of starting changes on a small scale, only implementing them more widely once improvement has been shown and the steps are well established.
The right infrastructure is essential
Unless there’s an adequate infrastructure to support the improvement work, it will only ever have a basic and localised effect. It is important to plan and think about the impact changes will have across a wider system of care.
Clinical staff need training
Quality improvement methods should be part of clinical training. If students can be trained about quality improvement earlier, along with research methods and randomised controlled trials, they should find it easier to work with these systems throughout their careers.
Patients must be involved
While there’s a growing awareness of the need to involve patients in developing solutions, there’s little evidence that current patient engagement strategies are working.
We must develop inspiring leaders
Helping senior staff learn how to lead change has helped build an organisational focus for clinical work. High expectations and clear levels of accountability are both key to improving outcomes and driving the spread of improvements.
Patient safety must be a strategic priority
The chief executives participating in SPI played a unique role in building and sustaining the focus on patient safety. They have shown how essential it is for boards and senior executives to prioritise patient safety and embed it across their hospitals.
