Looking for trouble!

Chief Executive Stephen Ramsden describes the work of the trust with the Safer Patients’ Initiative, to Jenny Kowalczuk, News and Features Editor, www.saferhealthcare.org.uk 

When did the Luton & Dunstable Hospital get switched on to safety?

You don’t change safety culture overnight and we’ve been working to improve our safety culture for years. But if I have to think of when we first addressed the safety agenda, it was back in 2002, when we wanted to tackle our mortality rate – which was 11% above the national average.

We took the step of investing in a full time executive director – Kate Jones - to create and lead a change team and use improvement science and transformational techniques to improve safety.  Following our experience with ‘Pursuing Perfection’ (a USA IHI led transformation initiative), Kate and our Medical Director, John Pickles, saw, at an IHI conference in San Francisco, that the Americans were using improvement science to improve patient safety.  

They came back fired with enthusiasm and persuaded me and our Trust Board to take on the importance of patient safety in the form of a new project supported by a full time project manager.

When the Safer Patients’ Initiative (SPI) was announced we saw it as a great opportunity to take our safety work forward, build on our existing investment and extend our work with IHI. And we were delighted to be one of the first trusts involved in the Health Foundation’s initiative.

Is safety improvement an expensive business?
 
You do need a modest investment for a comprehensive programme to promote safety and a safety culture.  Prioritising safety has meant some things have been displaced, but its not a big spend – it’s more time and effort - money just helps oil the wheels.

The SPI money – about £125,000 a year after fees are taken out - has allowed us to maintain a full time patient safety manager, to invest in data analysis, get a safety pharmacist on board and release a few doctors to involve them with this work which has proved a great investment. We’ve also invested in communication events, including patient safety evenings – and we get a fantastic response from doctors – usually have 15-20 consultants at each monthly event, which is really good. We also have a ‘Champions Collaborative’ for our front line, ward level staff – this is held off-site every two months.

We’ve made it our business to communicate safety everywhere in the trust – there are vast amounts of literature available, there are posters with key messages and as I’ve said, there are events happening regularly for staff. We’ve not had to go looking for clinical champions – we had clinicians more or less queuing to get involved – and there are lots of opportunities here with the SPI to get involved and make a difference to clinical practice and systems.

How involved are you in the safety improvement work in your trust?

For me, promoting safety has been a personal objective and I’ve made my support of safety visible. Every week, either myself or one of the Executive Directors visits a ward for an hour on a patient safety walkabout.  I’ve learnt from our staff - they don’t hold back! I think this kind of contact is essential to keep safety visible, at the top of the agenda and to identify the real barriers there are against improvement.

Are you seeing returns on your investment in safety?

Safety is a long journey and it takes strategic investment decisions from the board. As an example, we have just extended our critical care outreach team to run 24/7. We’ve done this because clinicians told us it was needed and would make a difference. We believe they are saving lives, and they are making more interventions since the extended service started two months ago.

From our experience, the biggest gain has been the combination of critical care outreach with our improved early warning system and improved basic observations. Together, we think these three things have reduced our mortality rates – we’ve seen a two step decrease in cardiac arrests – first one per week and now double – and even though these may not strike you as big figures, they translate into lives saved and deaths avoided.

In fact, we have now seen our death rates improve to 10% better than national average, after three years of the safety improvement work.

How is the Safer Patients’ Initiative different from the NPSA’s Seven Steps?

The Safer Patients Initiative has taken a completely different approach to the NPSA’s Seven Steps. While the NPSA’s steps are an impressive approach to quality assurance and learning, to me, from my experience with SPI, it’s not a proactive approach. We go looking for trouble. What we are trying to do is identify patients most susceptible to death or harm, and then put measures in place to safeguard them. At the moment throughout the trust we’ve got over twenty initiatives tackling issues in different settings to protect patient safety, and this is as well as having our reporting system in place feeding information back into the NRLS.

So how do you identify those at risk?

Our approach involves measurement! In the first twelve months of the SPI we had to create more than 35 new measures– things like numbers of cardiac arrests, and cardiac arrest patients who recovered, compliance with bundles in ITU – things we’d never even measured before – and it took us the best part of the year just to get the measures right. The goal of the SPI is to reduce adverse events in the trust by fifty per cent, but just measuring adverse events to get a baseline was new work. We’ve used case note review and trigger tools to identify adverse events. Using these measures has allowed us to chart our progress. And we’ve also been able to see increasing compliance with improvements and practices.

But what about meeting government targets, isn’t this work a distraction?

The relationship between government targets and safety is a tricky one. I don’t think we need a target for safety. I remember Ian Kennedy saying patient safety is more important than targets after the Stoke Mandeville report came out and that safety should always come first. We do need targets - target culture has made a difference to the quality of services and we have improved all kinds of important things not just waiting lists. But targets can never be more important than safety and safety should never be sacrificed to targets.

Who needs to lead safety improvement in a trust?

CEOs need to work with clinicians in partnership to deliver a safer healthcare service to patients. If safety came from management alone, it would be seen as a cynical activity. But, if it doctors promoted it without the support of managers, they wouldn’t be taken seriously. I believe it has to be a symbolic and joint partnership between doctors and managers. In our trust safety was first raised by our medical director and director of improvement who came to me for support - and I think that’s its important it happened that way round. 

What part does clinical governance have to play?

I think if you are coming to safety from a clinical governance perspective you need a change in attitude – safety demands a culture of improvement and goes beyond quality assurance – it is more than quality assurance. I also feel you must be sensitive to potential resistance from those who might see safety improvement as a cost saving exercise. I didn’t want that to be our message.

Why isn’t safety at the top of the healthcare agenda? What’s going to make the difference?

I hope the new report by the CMO, ‘Safety First’, will herald a new approach to patient safety in the UK.  One that combines the traditional approach of quality assurance, risk management, governance, regulation etc with the new approaches of transformational change, ‘moving people’ to want to improve, use of improvement science, proactively seeking problems to reduce errors, prevent harm and save lives.

Above all, CEOs need to be moved to engage with safety as a priority – I think we need to really understand the human cost of error. I regularly listen to patient stories – not just from our trust but at conferences and meetings. I can relate to the power of the patient story through a meeting with 40 Asian women who told me at their community centre, through interpreters, what it felt like to have a stillbirth at my hospital, with communication barriers playing a major role in compromising their care.  Once you’re moved by real lives, real experience and what’s happening to patients in your care, you can’t turn your back on safety.