Tackling patient safety through team working

Around 16 million people are admitted to hospital each year in the UK (1). 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 prevented (2).

The Health Foundation’s Safer Patients Initiative was set up to address this problem and find ways of making hospitals safer for patients. It is a two-year programme designed to drive forward system-wide changes in order to reduce hospital mortality and adverse events – harm to patients related to or arising from the delivery of care.

A shared approach to safety

Torbay hospital (part of South Devon Healthcare NHS Trust) is one of 20 hospitals selected to join the Safer Patients Initiative in late 2006. The new hospitals are working in pairs, or couplets, each of which has five teams covering leadership, critical care, perioperative care, medicines management and the general wards. Torbay chose to pair up with Musgrove Park Hospital, based in the Taunton and Somerset NHS Trust.

“The concept of the Safer Patient Initiative is that if you get your systems and processes right, you will deliver an improved outcome,” Julie Branter, Head of Clinical Governance and Risk at Musgrove Park, comments. “We have a wealth of information within the NHS but we’re not very good at putting it together and using it to improve.”

The Safer Patient Initiative teams are working with patient safety experts from the US-based Institute for Healthcare Improvement to produce an extensive safety report every month. This contains 43 outcome and process measurements, including mortality, MRSA infections, hand washing compliance, surgical site infections and medicines reconciliation.

The hospitals are using these data to implement changes that result in improvements to their systems of working. Changes are piloted, implemented and spread on a one-three-five basis. This means the team starts with one patient, nurse, doctor or unit, then moves on to three, then five, then the whole hospital. This allows them to test ideas under different conditions, build a common understanding and adapt the changes to their local environment to make it part of routine operations.

“The Safer Patient Initiative is not an easy process,” Sue Holton, Governance and Patient Safety Lead at Torbay, says. “To have someone else who understands what we’re trying to achieve and what we’re going through is great. We also have the opportunity to exchange information. So if Musgrove Park is successful with their safety briefings, we find out how they did it.”

Torbay has piloted a ‘naked from the elbow down’ strategy, which means that staff are banned from wearing watches or jewellery that could carry infections on the wards. Sue says Torbay can now “smell success” in reducing hospital-acquired MRSA. Last year the hospital had 23 cases of MRSA bacteraemia but, as of November this year, they have had just 11. Hand hygiene compliance is also improving from 48 percent in May 2007 to 73 percent in August. “We’ve also shared our ‘naked from the elbow down’ initiative with Musgrove Park,” Sue comments.

The joint working also acts as a spur for further improvement. “Hospitals rise and fall with their couplet,” Julie says. “If I’m achieving really well in Musgrove Park and Sue’s not doing well in Torbay, then the lowest score will be the score that we get. It is actually quite good because it gives you an incentive to work closely together.”

Spreading the word

Enthusiasm for The Health Foundation’s Safer Patient Initiative is spreading. “I don’t like to use the language of infection but it’s organic, like bacteria,” Frank Hamill, Project Lead at Southmead Hospital, part of North Bristol NHS Trust, says.

Southmead’s partner in the initiative is the Bristol Royal Infirmary, United Bristol Healthcare NHS Trust. Their successes include working on a single patient observation chart that will be rolled out to most of Bristol’s hospitals to help identify patients who are deteriorating.

The Safer Patients Initiative is designed to be responsive to local needs and hospitals can choose the areas in which they want to look for improvements first. “The wonderful thing about the initiative is that there are no set, rigid routes,” Frank explains. “You can mould it and shape it to suit your own circumstances. For instance, the perioperative team at Bristol Royal Infirmary have been tracking and recording surgical site infections following discharge from hospital, whereas at Southmead we are tracking in-patients.

“We’re approaching the same problem – identifying and understand our surgical site infection rate – but from different ends. So ultimately we’ll have a unified system we can both utilise to track all our patients,” he adds.

Frank also highlights the use of data for improvement. “We’re extremely rich in the NHS with business management information like bed occupancy rates, but we have appallingly poor quality process measurement information,” he comments. “Now every single month we report back to the teams on compliance with their respective measures. We started off with hand washing data for staff dealing with ten patients. We’re now up to 1,400 – that’s 1,400 observations of staff washing their hands before and after handling a patient. We also capture the grade of staff member, to deal with the myths that it’s doctors or porters who don’t comply.”

It hasn’t all been plain sailing, however. Many of the trusts have had trouble getting the data in the form required by the Institute for Healthcare Improvement. “We were collecting data for the Department of Health’s Saving Lives Campaign, which is also around hand hygiene,” Phil Hall of Bristol Royal Infirmary comments. “But the Institute is more specific. It says you need to count the number of times people wash their hands before and after handling a patient, whereas the Department of Health only says before. So we knew we were pretty good at it but we were missing some key information.”

Leadership lessons

The role of a hospital’s senior leadership team is crucial to improving safety. “I cannot emphasise enough the importance of real leadership at Chief Executive and Board level, if you are serious about culture change,” Frank comments. “Our Chief Executive has led the leadership walk rounds, where senior executives go down to the wards and departments on a rolling basis, sit down with frontline staff and discuss their issues and concerns around the safety of their patients. They then take those issues away and draw up an action list to resolve them.”