Special report: leading on safety

Health Secretary Alex Neil is fond of talking about Scotland as a world leader in patient safety. “Scotland has some of the safest and best hospitals in the world,” he said recently. It isn’t a claim that is entirely unfounded. Don Berwick, the man who advised President Barack Obama on his health reforms and was appointed by David Cameron to spearhead a ‘zero harm’ agenda in NHS England said:

“The Scottish Patient Safety Programme marks Scotland as a leader, second to no nation on earth, in its commitment to reducing harm to patients, dramatically and continually.”

When offering advice to NHS England last year, Berwick said: “Far be it for me to suggest copying Scotland, but there you have it.”

The Scottish Patient Safety Programme (SPSP) was launched in 2008 to reduce mortality and adverse events in acute adult hospitals by the end of 2012. In that time mortality was reduced by 12.4 per cent across Scotland.

Furthermore, the programme’s successes cannot just be measured in mortality rates, according to its head of safety, Joanne Matthews: “Whilst  a reduction in mortality rates was one of the programme’s main aims and an important part of understanding the improvements being made, it is when you actually get into the specific areas that you see the impact that it is having for patients, such as reduced infection rates, and reliability in the completion of surgical checklists that are a key part of the care of patients receiving any surgical procedure. We have learnt over the last five years the key elements of the original acute adult patient safety programme within hospitals that work most effectively, and how to spread good practice across Scotland,” she says. An example of good evidence-based practice is the surgical pause – the practice of commencing a safety pause to ensure everyone is fully briefed before undertaking an operation. Matthews says: “Across Scotland we are showing 95 per cent reliability with the surgical pause. Within one month, 10,000 were recorded. It shows the real impact on the ground.”

From this learning, Healthcare Improvement Scotland, which co-ordinates the programme, identified the ‘ten patient safety essentials’ which were outlined  to all boards in September 2013, and represent a key part of the future development of the acute adult safety programme – they include: hand hygiene, leadership walk rounds, communication, and a number of steps to reduce infections related to ventilators and cannulas. The ‘surgical pause’ is included in the package of measures that are to be a “fundamental expectation of every person experiencing acute hospital care”, according to Professor Jason Leitch, Clinical Director of the Quality Unit at the Scottish Government.

The next stage of the SPSP aims to reduce hospital standardised mortality ratios from 15 per cent to 20 per cent and to provide 95 per cent harm-free care by the end of 2015. It has a significant focus on reducing infections, Sepsis/VTE, and preventing falls and pressure ulcers.  Sepsis, which is a life-threatening poisoning of the body which attacks the immune system, is being tackled by the SPSP’s ‘Sepsis 6’ bundle of measures. These measures ensure speedy intervention and treatment for those with sepsis. Use of the Sepsis 6 in pilot areas is up to 70 per cent, according to Matthews.

The safety programme has now expanded to include paediatric and neonatal care, maternity, mental health services and primary care.

A key element of the SPSP is that change is led by staff caring directly for patients monitoring improvements through the collection and analysis of data from within their own clinical area.

Matthews, herself a registered nurse, says staff have led the way in making the programme a success: “If we didn’t have the engagement, the ownership and the drive from clinicians and non-clinicians across the boards, this programme wouldn’t have been as successful as it has been. It is those individuals that are really making the difference. With this engagement we can continue to work with teams on a day to day basis to ask and answer key questions. For example, what’s the evidence and where do changes need to be made?”

Nurse Jen Rodgers introduced morning safety and flow huddles at Yorkhill Children’s Hospital in Glasgow, and won the nurse of the year award at the Scottish Health Awards for her efforts. She said: “The introduction of our hospital huddle at Yorkhill has not only improved our patient safety and flow, but also increased camaraderie between staff,” she said.

“SPSP has been a fantastic catalyst for change"

The implementation of SPSP has been supported by the Scottish Patient Safety Fellowship Programme, which established 75 fellows across Scotland to strengthen clinical leadership within quality and safety improvement projects across NHS boards and within the national patient safety programme. Seventy-eight improvement advisers have also been trained, working with the national patient safety team and within NHS boards. “Improvement advisers often will have a quality improvement  or clinical governance role within boards,” says Matthews.

As the SPSP expands out of the acute setting, one example where patient involvement has been crucial is in mental health. Matthews describes the patient safety climate tool, developed in the mental health safety programme, as a first: “No other health service is doing this. The safety climate tool is about capturing the experience from a patient’s perspective to help respond to their needs, as well as help change and develop the services that are delivered. It uses questions such as ‘Do you feel staff consider your safety when planning care?’ and ‘If you had to be restrained, do you feel that it was done safely?’ Since being developed, the tool has been tested in a number of areas, and we now have eight out of the 15 boards in Scotland having completed it. So, it is about the small steps: testing, making the changes then implementing that change across wards, units, practices within NHS boards, and ultimately to implement across the country.”

As well as mental health, primary care has been identified as an area for the SPSP to support. For Matthews, it is about focusing where the biggest impact can be made: “It is about ensuring that the patient moves seamlessly between services, and that avoidable harm is minimised.”

The primary care programme has three core areas: safety culture and leadership, safer medicines and reliable patient care within the practice and across the interface.

Matthews points out this “links nicely” with the acute adult programme. “The primary care programme has recently been awarded Closing the Gap money from the Health Foundation to test the expansion further into the community pharmacy arena,” she tells Holyrood. The safety climate survey in primary care is an online survey that looks at the whole GP practice. All members of the team can complete the survey and it will then provide feedback in the form of a report that measures teamwork, leadership and communication, as well as workload and the practice environment. Since the launch of the primary care programme in March last year, 86 per cent of practices have already signed up to complete it. Of those, 65 per cent have already done the survey for this year, Matthews says. “We know, for example, of a practice that has used its positive results as part of the advert to recruit a new doctor. It’s not just about the changes they need to make, it’s about saying that our safety climate is really good,” she says.

Despite obvious buy-in from clinicians across the country, cultural shifts are rarely rapid, and the SPSP continues to support this across all of the safety programmes. NHS Education Scotland (NES) have been working closely with Healthcare Improvement Scotland, raising awareness and providing online tools to support the safety work. Matthews says that NES will be playing a greater role in the capacity and capability building work that SPSP has developed and managed over the last few years.

Professor Philip Cachia, Postgraduate Dean and Patient Safety Lead for NES, says: “SPSP has been a fantastic catalyst for change and has delivered great benefits since the 2007 launch. Success in the long term, however, would be to move from a programme-based approach to a change in culture where safety is everybody’s business – and that it’s just the way we do things in Scotland. We remain committed to education as a key enabler of a culture of safety across health and social care in Scotland.”

Matthews says the cultural change will be exciting. “People in Scotland are spanning many different healthcare settings and have many different healthcare needs. It absolutely makes sense that we use the learning and experience of the previous five years to start shaping and building safety programmes within those areas.”