Safe from harm

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.

“At the most basic level, if healthcare providers can’t ensure that patients who are admitted to hospital with a non-life threatening condition will come out alive, then none of the other treatments or services they provide will matter.” Carol Haraden, Institute for Healthcare Improvement

“We should be deeply concerned about the avoidable deaths happening in our hospital. There should be nothing more important to a chief executive than saving lives and demonstrating to staff that they are interested in this.” Stephen Ramsden, Luton and Dunstable Hospital NHS Foundation Trust 

2 Sources: Vincent, Neale and Woloshynowych. Adverse events in British hospitals: preliminary retrospective record review. 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.

Working out how to tackle patient safety issues in hospitals presents some really tough problems. The Health Foundation launched its Safer Patients Initiative in 2004 as a practical way of approaching these problems and offering some solutions. We commissioned the US-based Institute for Healthcare Improvement to work with hospitals across the UK to help them implement changes in the way they work, in order to improve safety for their patients.

We asked Carol Haraden, Vice President of the Institute for Healthcare Improvement with responsibility for patient safety initiatives, about her vision for patient safety and what healthcare organisations need to do to implement it.

Bottom of the pile

Carol describes patient safety as being at the bottom of a hierarchy of patient considerations. “If you were taking a flight and I said ‘what would you like to see in an aeroplane?’, you wouldn’t even say ‘my first priority is that we’d land’,” she explains. “You would take that for granted. You might say ‘bigger seats, better service or arriving on time’.” So when patients are asked what aspects of healthcare they’d like to see improve, their replies are more likely to be around improved access to services and the state of the hospital buildings and less likely to be about the fundamental basics of safe care, although concerns about the risk of infection is now firmly on the patients’ agenda.

Unlike the airline industry, however, people now have to ask questions about some of the most basic assumptions about healthcare. “Patients will rarely say ‘I want to be prescribed the right medication’,” Carol continues. “That’s an assumption, but it’s an assumption that frighteningly does not hold. More and more patients are having to say ‘I want to be sure I don’t have the wrong leg cut off’ when they never would have considered that before. We’ve always done wrong site surgery, it’s just now we’re talking about it publicly.

“People are really having to go back and think about their most basic requirements from healthcare,” she says. “At the most basic level, if healthcare providers can’t ensure that patients who are admitted to hospital with a non-life threatening condition will come out alive, then none of the other treatments or services they provide will matter.”

Hand hygiene

Carol points to the Safer Patients Initiative as a good model for how to measure hand hygiene. “As a simple way to know how a ward is doing we need an estimate of how many times they should have washed their hands versus how many times they did, such as in between seeing different patients or after entering a new ward. Staff anonymously observe each other, for just five minutes a day, and by the end of the day you have a pretty good sense of how many times that day you did wash your hands, against the number of times you should have done it. You’re looking to see that ratio improving.

“We’ve learnt from experience that this is not just about putting up alcohol dispensers,” Carol says. “You can put a dispenser next to every bed and theoretically that should make a difference but if people don’t recognise this as a problem, it won’t make any difference.

“So we try to build that will by helping people to understand their accountability and helping them see the link between things like MRSA and what they do on a daily basis. What we need to do is change habits. It needs to be automatic, just like when you get in the car and you put on your seatbelt.”

The Health Foundation set up the Safer Patients Initiative to work with acute hospitals across the UK on ways of making care safer for patients. We aim to provide the hospitals participating in the scheme with the knowledge and expertise to change practice, measure the effects and embed patient safety improvements.

The initiative has been run in two phases. The first phase began in 2004, when four hospital sites were selected to take part following a highly competitive selection process. We wanted to demonstrate that a large number of changes could be successfully tested simultaneously across a range of clinical areas. We also wanted to show that the improvements could be sustained and spread across the hospital and the wider Trust or board. Our overall aim was for the hospitals to make patient safety a priority and to bring about a change in the culture of the organisations.

In November 2006, we made ten further awards to 20 hospitals, which are now working in pairs to provide mutual support for the hospitals involved and to help accelerate and embed the improvements in clinical practice.

The Safer Patients Initiative works in four clinical areas: medicines management; peri-operative care; critical care; and care on general wards. A focus on preventing infections is included across all of these areas. This clinical improvement work is supported by an organisation-wide effort to bring about a change in culture, with senior leaders playing a key role in prioritising patient safety, supporting the work and initiating and participating in leadership walk-rounds to hear and respond to patient safety concerns.

What are the results?

This new approach is already showing dividends. Recently released results from the Safer Patients Initiative, show impressive safety improvements at the first four UK hospitals that joined the scheme in 2004. After just two years, they had on average halved their number of adverse events.

NHS Tayside has seen its adverse event (unintended harm to patients) rate fall by almost three quarters. In addition, the hospitals are seeing some knock-on improvements in their mortality rates. For example, Luton and Dunstable Hospital NHS Foundation Trust’s standardised mortality rate has improved from being 11 per cent worse than average (in 2005) to being 11 per cent better than average (last quarter 2006).

At Conwy and Denbighshire NHS Trust, pneumonia on the intensive care unit associated with assisted ventilation had been virtually eliminated by November 2006, from a previous level of 30 per cent. Patients were spending less time in the unit and needed fewer medications. This resulted in a saving of £78,000 in the medicines budget and allowed 350 more patients to be treated over the last two years.

Also by November 2006, NHS Tayside increased its hand hygiene compliance to 96 per cent on the general wards, which in turn helped to reduce hospital-acquired infections. Down Lisburn Health and Social Services Trust reduced the number of medication errors to below 10 per cent, following the development of a system for tracking and managing the drugs their patients take. The system is also linked to GP patient records and is helping to reduce mistakes in the primary care setting.

Luton and Dunstable Hospital NHS Foundation Trust estimates that there are 1.5 fewer cardiac arrests per week since the introduction of an early warning score system on the wards. The system allows staff to monitor patients’ conditions and to take rapid action if they go into decline. It has led to a fall in the crash call rate as the rapid response team can now take action sooner to avoid patients developing serious life threatening conditions. The fall in cardiac arrests has also had an impact on the site’s Hospital Standardised Mortality Ratio, which has shown a decline of 10 per cent since 2003.

With around 14,000 staff, NHS Tayside provides a comprehensive range of primary, community-based and acute hospital services for the populations of Dundee City, Angus, and Perth and Kinross in Scotland. Patient safety is literally at the top of the agenda at NHS Tayside. Rather than finance or performance management, safety is the first issue discussed at the executive team’s weekly meeting.

Pat O’Connor, Head of Safety, Governance and Risk at NHS Tayside, believes that this has speeded up the decision-making process. “We have team briefings on patient safety activity involving the executive team plus key frontline staff,” she says. “So we don’t have the linear decision-making process that most people identify with the NHS. This means decisions filter down much quicker and the organisation can be much more responsive in addressing a particular problem.”

The executive team’s role

Pat says that this high-level support for the patient safety programme has been integral to its success. “Certainly at times you do need a senior leader to lead from the front, particularly in the early days,” she explains. “But then at different times you need someone at the back encouraging people.

“We’ve been fortunate to have that support from the outset, but you will always get some resistance in large organisations such as ours,” she continues. “The Institute for Healthcare Improvement’s advice is to focus on the ‘early adopters’ who have the will to change and generate momentum that way. Perhaps before I would have concentrated first on the people who were less interested, but I know now that’s not necessarily the best way to implement change.”

Pat also believes that weekly walk-rounds involving senior leaders have been instrumental in embedding safety issues in the organisational culture. “We have one walk-round a week, where executive team members go to the frontline and meet with staff on the wards,” she says. “We find out what their major patient safety issues are and at the end of the conversation we agree three items to take forward. These might be the responsibility of the Chief Executive or other senior leaders, line managers or the front-line staff themselves.

As well as focusing on the senior executive team, the leadership development work at Tayside is focused around coaching and building skills for individuals who are improving safety on the front line. Clinicians are encouraged to find solutions to problems themselves, rather than taking issues up the management chain. As well as ensuring that management time can be focused on other priorities, this approach helps staff better understand the system in which they are working. They also feel greater ownership of the solution as a result.

There are numerous events throughout the year when clinicians can profile their achievements and an informal open monthly meeting called ‘Celebrating Success’. At these sessions, the monitoring data is reviewed and all staff have the opportunity to air their opinions on implemented changes. Each team raises two challenges they’ve faced that month and the group collectively helps resolve them.

Lessons in clinical leadership

Jean Balfour is a leadership development consultant who has been working closely with the patient safety team at NHS Tayside. She was asked to help the team work together more effectively and engage others in their safety improvement work. “A lot of my role was helping them work out how they were going to work with people who weren’t so engaged. How they were going to influence them, get them on board, teach them and help them to change their own practice,” she says.

On a practical level, Jean advises that a flexible approach is needed. “You can’t just pull people away from the wards, theatres and clinics at pre-defined times,” she says. “At Tayside, things started to work really well when clinicians came to me and said, ‘I’ve got half an hour free at this time,’ because you knew that if they suggested a convenient time, you would be more likely to get their full focus.”

In Jean’s view, the progress that NHS Tayside has made in patient safety has not just come about from improvements to systems and processes but also from a clear recognition that leaders need to be developed and empowered at all levels. This has enabled clinicians to test out their own solutions to problems, communicate the results and influence others to adopt them.

“Senior leadership used to be expected to have all the answers. Now people are saying: ‘This is my problem and I need to find a solution to it.’ Solving the problem then gives them confidence to share their experience with others,” Pat concludes.

Luton and Dunstable Hospital NHS Foundation Trust, which has been a Safer Patient Initiative site since 2004, has developed a system to identify rapidly patients whose condition is deteriorating, in order to prevent unnecessary deaths.

The National Confidential Enquiry into Patient Outcomes and Death has found that patients who died in hospital often showed signs that their condition was deteriorating long before they died. It recommended that hospitals should pay more attention to physiological signs of decline, put in place ‘track and trigger systems’ for all patients and link this to a response team skilled in managing acute clinical problems.

The methods used by the Safer Patients Initiative hospitals include such track and trigger systems, along with rapid response teams who will move in at the first signs of patient deterioration. Luton and Dunstable has already seen results from this work.

The hospital’s Chief Executive Stephen Ramsden, believes that saving patient lives must be at the top of all chief executives’ agendas. “As accountable officers we should be deeply concerned about the avoidable deaths happening weekly in our own hospital,” he says.

Saving lives

To tackle this problem, the patient safety team at Luton and Dunstable brought three key elements together: an analysis of deaths through case note reviews using trigger tools, the development of an early warning scoring system and a rapid response team to attend failing patients.

The Luton and Dunstable team, led by medical director John Pickles, consultant anaesthetist Michael Carter, and patient safety managers Jane Murkin and Anne Thomson, started off by examining patient records. The team examined patient records and reviewed 50 consecutive deceased patient records. The study highlighted a number of problems with patient observations – the respiratory rate was often missing and observations were often incomplete, absent or infrequent.

“It was apparent that almost no respiratory observations were being done,” Michael Carter explains. “We concluded that the respiratory rate had lost emphasis in training, due to developments such as dinamaps and pulse oximeters. Because of this, wrong assumptions have crept into medical and nursing practice.”

The team set about reintroducing this ‘lost’ skill and delivered cascade training to nursing staff in respiratory rate skills. At the same time as observation skills were refreshed, an Early Warning Score system was introduced to record observations, highlight when these signaled that a patient’s condition was in decline and trigger a response.

Colour coded warnings

The Early Warning Score system used by Luton and Dunstable is a colour banded card that removes the need for a score to be calculated. The information is explicit – if the patient’s condition is in decline, scores fall into red or yellow boxes. If two yellow, or one red box, are filled, the nurse must take action and respond to the patient’s condition.

Nurses can also call for assistance if they think the patient is showing signs of deterioration, even though they haven’t triggered a yellow or red score on the chart. “The first response can be informing the senior nurse on the ward,” Anne Thomson comments. “But if he or she can’t address the issues, the nurse must get a doctor to attend the patient within thirty minutes. If they can’t, then they call the outreach team.”

The final part of the jigsaw was to put in place a rapid response team. At Luton and Dunstable, this is called a critical care outreach team. “We now have a team of three critical care nursing staff who can be paged and have a dedicated phone line. We can either call them to assist on the ward or to give support to ward staff in delivering the appropriate care,” Anne says.

The service also delivers education to staff, advice and a follow up service for patients who’ve been discharged from the Intensive Care Unit back to the wards. “‘Getting the team onto the wards to offer their services has helped win hearts and minds in getting the system accepted,” Anne continues. “The team has become so valued by clinical and nursing staff that the decision has been taken to provide the service 24 hours a day, seven days a week.”

By using the Early Warning Score system and outreach together, it’s possible to reduce avoidable deaths in hospital. “From our experience, the biggest gain has been the combination of critical care outreach with our improved early warning system and improved basic observations,” Stephen Ramsden says. “Together, we think these three things have reduced our mortality rates.”

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 Patients 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 Patients 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.

A shared approach to safety

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

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.”

The Safer Patients Initiative work also has implications for national policy development.

1. Staff need data about their work

The Safer Patients Initiative encourages the collection and use of data that appeals to clinicians by demonstrating individual or team performance over time. There can be a useful meeting of top-down data, collected to meet national targets and/or to monitor performance, and bottom-up data, used as a tool for improvement.

2. Better measurement systems are needed

Most UK hospitals do not have systems that provide them with instant access to critical data such as MRSA infection rates, outcomes from emergency ‘crash’ calls or infection rates following surgery. The Safer Patients Initiative sites have developed data collection systems to track safety improvements over time.

3. There is a lack of knowledge about implementing change

There are very few hospitals in the UK that have sufficient people with the skills in improvement methodology, systems thinking and implementation needed to support improvement work. The Safer Patients Initiative has shown the importance of starting with small tests of change, implementing them more widely only once improvement has been shown and the steps involved are well established.

4. Adequate infrastructure to support improvement is essential but often lacking

Most of the changes that will work to improve patient safety require the ability to think and plan for the impact they will have across a wider system of care. Without an adequate infrastructure to support improvement work, services cannot move beyond rudimentary improvement.

5. Clinical staff need training in quality improvement

Medical students learn about research methods and randomised controlled trials. If we can introduce methods of measuring quality improvement earlier in their training, they should find it easier to work with these systems later on.

6. Patients must be involved in safety efforts

There is an increasing awareness of the need to involve patients in developing safety solutions. However, evidence about the effectiveness of current patient engagement strategies is limited.

7. Leadership development is crucial

Supporting senior staff to learn how to lead change has helped build an organisational focus for clinical work. Setting high expectations and ensuring levels of accountability is key to achieving improved outcomes and driving the spread of improvements.

8. Patient safety must be a strategic priority

Hospital boards and senior executives need to prioritise patient safety and embed it across the hospital. The chief executives participating in the Safer Patients Initiative play a unique role in building and sustaining the focus on patient safety issues throughout their trusts.