Safer Patients Network

Networks are increasingly seen as an effective lever in determining the way problems are solved and organisations are run. They influence the degree to which individuals and organisations succeed in achieving their goals. Social networks provide an efficient way to test new ideas and to move promising solutions from one organisational setting to another. This is particularly true when attempting to generate improvement in complex systems.

SPI organisations have demonstrated unprecedented success in improving both the processes and outcomes of care in their individual organisations. They have done so using a collaborative 'all teach, all learn' approach. Our experience is that quality improvement relies critically on a shared sense of experimentation. Teams learning from one another is a more effective approach to improvement than a traditional one whereby individual sites don’t know about others’ discoveries and ideas.

By working together SPI organisations have organically developed a social network that allows them to share data and methods transparently. They can also offer each other help and encouragement. In developing the Safer Patients Network, we aim to build on SPI by bringing together the qualities that are often seen in social networks and communities of practice to make healthcare safer for patients.

The network approach emphasises the nature of improvement as a sustainable journey rather than a project that comes to an end. The long-term goals of the network are to:

• build deep learning about improvement challenges
• build enhanced research and development capability aimed at furthering patient safety through innovation
• build organisational capability through the development of selected mentors, capable of helping creating results in other organisations.

The Foundation is no longer alone in championing quality improvement approaches to patient safety. Along with the variety of activities around the safety agenda across the UK, we see our unique contribution as providing:

• a focus for initiating, testing and developing new approaches to patient safety in a coordinated way
• an infrastructure to build skills, enhance capability and increase capacity for improvement in patient safety, without organisations having to rely on the enthusiasm of a handful of key individuals.

The network’s members have safety expertise through their involvement in SPI and are committed to working collaboratively to improve patient safety. The members of the Safer Patients Network are:

• Airedale NHS Trust
• Barts and The London NHS Trust
• Belfast HSC Trust
• Bradford Teaching Hospitals NHS Foundation Trust
• Calderdale and Huddersfield NHS Trust
• Cardiff and Vale NHS Trust
• Gwent Healthcare NHS Trust
• Luton and Dunstable NHS Foundation Trust
• NHS Dumfries and Galloway
• NHS Tayside
• North Bristol NHS Trust
• North Wales NHS Trust
• Northern HSC Trust
• Royal Free Hampstead NHS Trust
• South Devon Healthcare NHS Trust
• South Eastern HSC Trust
• Taunton and Somerset NHS Trust
• York Hospitals NHS Trust.

The sites working together in the Safer Patients Network first worked in couplets in the Safer Patients Initiative. This 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 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. 

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:

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

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. ' Justin Phillips, consultant anaesthetist, Musgrove Park Hospital, Taunton and Somerset 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. Chris Uridge, physician in elderly care & general medicine, Torbay Hospital; South Devon Healthcare NHS Trust

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.