The Scottish Improvement Journey: a nationwide approach to improvement

4. Scottish Patient Safety Programme

4.1 Pre-launch Phase

At the time, global evidence suggested nearly 1 in 10 patients admitted to a hospital would be unintentionally harmed and that over 40% of the incidents could have been avoided (de Vries et al., 2008, Weingart et al 2000, Crossing the Quality Chasm, 2001). Facing this evidence, leaders came together in Scotland to start working on the idea of a national Scottish Patient Safety Programme ( SPSP). The establishment of this work was a result of a combination of multiple triggers and factors: 1) robust research evidence of what needs to be done to achieve safer clinical care existed and was available; 2) the Safer Patients Initiative ( SPI) running since 2004 across 3 health boards and championed by NHS Tayside was getting excellent results demonstrating safety can be improved; 3) there was strong ministerial and governmental will and commitment to making healthcare better while focusing on evidence-based policy; 4) key senior leaders had an in-depth knowledge of, and passion for quality improvement. Thus far, no country had taken a national approach of quality improvement to make care safer.

As outlined in Better Health, Better Care: Action Plan (2007), improving the quality of healthcare is a strategic priority for NHSScotland. With a focus on safety and the aim to reduce harm in healthcare, the Scottish Patient Safety Alliance was established in 2007 by creating a partnership between the Scottish Government, NHSScotland, the Royal Colleges and other professional bodies, the Scottish Consumer Council and the Institute for Healthcare Improvement ( IHI). Building on the successes of SPI, the Alliance was to extend the work from the three NHS boards participating in SPI to all NHS boards in Scotland. It was formed to oversee and guide the development, launch and implementation of the Scottish Patient Safety Programme ( SPSP), the first-ever national undertaking of its kind.

The core of the team working on the programme development were: Derek Feeley, then Scottish Government Director of Healthcare Policy & Strategy and current President and CEO at IHI; Sir Harry Burns, then Chief Medical Officer; Professor Jason Leitch, then Scottish Government National Clinical Lead for Safety & Improvement; Jane Murkin, who became the National Coordinator for the SPSP; and Dr Pat O’Connor, who was brought into Scottish Government from NHS Tayside as a National Patient Safety Development Advisor. A team of committed and passionate individuals.

Recognising that NHSScotland did not have the depth and breadth of improvement skills needed, an international tender for a partner to support the work was announced. In August 2007, IHI was contracted as a technical partner for the SPSP and brought in their knowledge of improvement science together with experience from a broad range of international improvement programmes, including the 100,000 Lives Campaign. The planning and pre-work for a national programme started right away. IHI’s expertise was key at this stage – whilst the work came from the Scottish system, IHI was able to provide full support from initiation with the aim to phase out this support over time. IHI teams and local senior leaders set up meetings with health boards; visited different hospitals and professional organisations to help them understand where to start the work; met with academic entities to enable them to voice their concerns and raise their questions as well as to help understand best practices for implementation given the context. All this was designed to build will across these constituencies.

The SPSP Breakthrough Series Collaborative had a soft launch event in March 2007 but it wasn’t until January 2008 that the first learning session and an official launch took place in Tayside where the programme was announced by Ms Nicola Sturgeon, MSP, then Cabinet Secretary for Health and Wellbeing together with the Chairman of NHS Quality Improvement Scotland ( NHS QIS). Moving on from working only with volunteer teams, SPSP now included all health boards in Scotland. Interestingly, whilst the programme was not voluntary, it never needed to be officially mandated – the approach of quality improvement rather than performance management was appealing to both the professionals and to the health boards.

The introduction of the programme was not unchallenged. While the majority was supportive, there were of course doubters and criticism. Some felt this was just another project that would pass by, some were not so keen on the involvement of a US based company and others saw the ambitious goals as something they might never be able to achieve. It was a challenge to convince people they were not delivering evidence-based care reliably, 100% of the time. Tensions between the new methodology and previous improvement efforts were observed due to a misaligned understanding of how the new approach can add to the existing work and help increase its pace and scale. It was an important lesson for Scotland to not unnecessarily alienate certain groups of stakeholders by presenting the new QI method as the ‘golden chalice’ that would solve all problems. But people came together once they could see improvements in outcomes and safety.

On the political level, it was sensitive to admit people were being harmed within the national healthcare system and it took some time to accept the use of the language around harm and mortality. Needless to say, the political and governmental leadership embraced quality improvement as the way forward for Scotland.

Demonstrating this commitment to quality improvement since 2008, the SPSP has grown from Acute Adult Care and spread into areas of Mental Health, Primary Care, Maternity and Children, Healthcare Associated Infections, Medicines, and more recently the Primary Care programme is doing preparatory work in Community Dentistry, Community Pharmacy, and Community and District Nursing.

Programme	Launch
Phase I
Acute Adult Programme	2008
Paediatrics Programme	2010
Phase II
Mental Health	2012 (September)
Primary Care	2013 (March)
Maternity and Children ( MCQIC)	2013 (March)
Healthcare Associated Infections	2015 (February)
Medicines	2015
Phase III
Community Pharmacy	2014 (November)	Prototyping work, exploring key areas of harm, and testing interventions with a small number of sites
Community Dentistry	2015
Community & district nursing (care homes)	2016

4.2 Phase I

The programme was initially introduced in Acute Adult healthcare settings with the aim to reduce inpatient mortality for any cause by 15% and to reduce hospital adverse events, as measured by the IHI Global Trigger Tool, by 30% across Scotland’s acute hospitals in 5 years (Haraden and Leitch, 2011).

IHI brought and introduced their tried and tested evidence-based clinical changes across 5 work streams: critical care, general ward, medicines management, peri-operative care, and leadership culture. They had content developed in each package together with plans for measurement and data collection. So the question was not what needs to be done; rather it was how to do it.

SPSP Adult Acute Change Package	Aim
1. Critical Care:	Improve Critical Care Outcomes (Reduce mortality, infections and other adverse events)
2. General Ward:	Improved general ward outcomes (Reduced infections, crash calls, pressure ulcers, AE in CHF and AMI patients)
3. Medicines Management:	Provide safe and effective medicines management (Reduce adverse drug events: r/t high risk processes and medicines e.g. medicines at the interface, anticoagulation)
4. Peri-operative Management:	Improved peri-operative outcomes (Reduced peri-operative adverse events: infections, cardiovascular events)
5. Leadership:	Provide the Leadership System to Support the Improvement of Safety and Quality Outcomes in your Board .

The SPSP was run using the Breakthrough Series Collaborative approach, with learning sessions every 3 months alternating with action periods. The learning sessions were notably well attended by chief executives and leadership teams from the health boards which allowed for break-out sessions and team meetings led by chief executives where the teams would plan how to efficiently and effectively put the change packages into place while adapting to their local settings. It was very helpful to have NHS Tayside, one of the strongest sites in SPI, leading by example.

Each NHS board had a nominated SPSP programme manager, who played a key role as part of the leadership and core coordination and the delivery team at Board level, with responsibility for embedding continuous quality improvement as an integral part of planning and delivery of care.

Not all work streams progressed at the same rate. Smaller units where multidisciplinary working was the norm, such as Intensive Care Units, were able to deliver improvements most quickly. Surgical theatres showed significant progress - surgical mortality had remained stagnant for the past 20 years but in 4 years of SPSP work it was reduced by a third. (Information & Services Division, 2012)

Data support was provided by IHI and the Information & Services Division ( ISD) at NHS National Services Scotland. In the early stages, the majority of the data was not routinely collected, and was generated through the work of SPSP.

Furthermore, a new model for measuring Hospital Standardised Mortality Ratio ( HSMR) exclusive to Scotland was developed by ISD in partnership with IHI. Monthly reports were produced for each of the teams in each of the hospitals showing them what they were doing well and what they could be doing better. Good quality data was crucial and as the programme was generating more data, it started creating credence and integrity of the programme which led to a greater belief that it was working.

However, the data measurement platform became a challenge. The IHI Extranet, designed to collect data, present data and share information, is a good tool for pilot stages, small scale projects or for small health boards. But once the SPSP was scaling up across more and more wards and surgical theatres and intensive care units, this tool could no longer handle the amount of data. It became difficult to bring the data together and feed it up the governance chain. Some attempts for new systems to better manage the data emerged locally in Lothian ( QIRNET) and in Lanarkshire ( LanQIP) with varying success rates. Unfortunately, this area has not yet been fully resolved and to date, and most health boards submit their data in modified excel spread sheets to HIS where the data get amalgamated into quarterly reports.

SPSP, together with NHS Education Scotland focused on building the infrastructure to support this emerging improvement work and building capacity and capability across Scotland to ensure that there were enough skilled people to manage the programmes locally. This included Improvement Advisors and the development of a clinical fellowship for quality and safety.

In 2010, the Healthcare Quality Strategy for NHSScotland was published and launched by the Cabinet Secretary for Health and Wellbeing. This was a revolutionary moment for Scotland as it set out the ultimate aim for NHSScotland “to deliver the highest quality healthcare services to Scotland, and through this to ensure that NHSScotland is recognised by the people of Scotland as amongst the best in the world” (The Scottish Government, 2010, p.1). It set out three quality ambitions – for care to be person-centred, safe, and effective. This government document places improvement at the heart of national healthcare strategy and set out its aim to expand the successful work of SPSP into other care areas.

4.3 Phase II

The second phase of the programme is defined by building on the successes achieved in Acute Adult Care and spreading the approach into other areas of care. Planning was already under way for safety collaboratives in mental health, primary care, and maternity and paediatrics. In comparison with the early days of scepticism about ‘another programme’, these new areas were pulling the programme towards themselves.

It was however, also recognised that the work on acute care was still to be continued. In 2012, the Cabinet Secretary for Health & Wellbeing announced the new aims for the Acute Adult programme to be to further reduce mortality and harm experienced by patients in Scotland’s acute hospitals and to ensure that 95% of patients receiving care are free from harms such as pressure ulcers, falls, cardiac arrest and catheter acquired infections by the end of 2015.

Each of the new programmes had its specificities as they needed to undergo some adaptation to the context of their care setting. It was harder for local Primary Care teams to attend national learning sessions and so more was done regionally and virtually. It was also recognised this is different type of care that will require new solutions. The aim of the Primary Care programme within SPSP was for all NHS boards and 95% of primary care clinical teams to be developing their safety culture and achieving reliability in three high risk areas by 2016. At the launch of the programme in 2013, the focus was on General medical services but since, prototyping and testing in Community pharmacy, Dentistry, and Community and district nursing (care homes) have been under way with plans to expand to further professional services in the future.

In Paediatrics, the challenge was trying to take interventions from an adult setting and shift them to a children setting. Moreover, the patients in maternity and paediatric care are most often not sick. The aims of the Maternity and Children Quality Improvement Collaborative ( MCQIC) are three-fold: maternity, neonatal, and paediatric care. All the streams had the aim to reduce avoidable harm in women and babies/ neonatal care/ paediatric care by 30% by 2016 with a focus on different relevant interventions ( HIS, 2016c). While provisional national outcome data for 2015 indicated a 19.15% reduction in the rate of stillbirth compared with 2012, the data also indicated that more work needed to be done on neonatal mortality and postpartum haemorrhage to demonstrate improvement.

Mental Health Safety had a very particular journey marked by more freedom as the research evidence in this area is limited and often contested, there were no existing interventions, and it was the first time improvement was used in a setting with patient interaction and with such a focus on the service user. Often seen as a ‘Cinderella service’ that gets left behind, there was tremendous will once Mental Health services were included in the SPSP. The Mental Health stream of Patient Safety built on the work done in the Mental Health Collaborative run from QuEST. It became a natural extension rather than a new initiative and had a continuity of approach as the focus remained on in-patients. The work on interventions had to be designed from scratch and it was decided to co-design the programme priorities alongside the service users, carers, clinicians, and the evidence. This led to a sense of a bottom-up approach to building its own evidence which was based around safety principles of risk assessment, restraint, medicine safety, self-harm and violence reduction. The meaning of harm had to be redefined for the mental health context and two types were identified: Type 1 – harm that the system does to the individual, and Type 2 – harm that the individual does to themselves as a result of a complex mix of external factors. To help assess the fear of harm on a ward, the Patient Safety Climate Tool was developed by a service-user led focus group and supported by the programme team.

The work on Medicines was developed to bring together all improvement activity related to medicines from the existing programmes, allowing for more of a whole system perspective. The Healthcare Associated Infections ( HAI) programme works primarily in acute care and aims to develop and test approaches to reduce HAIs.

The national approach adopted in this phase by the new National Coordinator for the programme focused on introducing a structure and governance to programmes that had evolved in very individual ways over time. A stage of developing further support to organisations as a whole started emerging across programme commonalities: leadership, teamwork, communication, and strategic planning, all alongside the interventions. At team level, new processes for reporting data, assessing data, and reviewing data within governance structures were brought in to better the leadership’s understanding of what was happening and what needed further support. This also led to an increased confidence in Scottish Government that SPSP was delivering on its aims.

Aligned with a broader move to more local work and to access all those involved, national learning sessions of the Breakthrough Series Collaborative are now taking place once a year and are accompanied by local context-specific sessions and regional events. Another change has involved moving from traditional programme-specific site visits to a combined site visit in which the whole Patient Safety Programme visits the whole NHS board rather than conducting multiple visits by each strand of the safety work. This also gives the boards an opportunity to bring all strands of their safety improvement work together.

In 2012, IHI’s initial 5-year contract expired. Moving from the closer, safety-based support, towards a wider remit for both the progression of SPSP and the progression of quality improvement across public services, IHI won the tender for a new contract and became the Strategic Quality Improvement Partner for the Scottish Government in the summer of 2013. Since then, this wider remit has progressed the relationship between the two partners towards one of support that is sustainably co-designed and co-produced by the partners. IHI’s role was to work in partnership with SG, HIS, and NES to build sustainable capacity and capability to continuous quality improvement and deliver real and high impact improvements. They also worked on adding value and provided support to existing and emergent quality improvement activities across the NHS and wider public services in Scotland. IHI also facilitated connections with improvement organisations around the world. This 3-year contract has recently been extended to 2018.

4.4 Key results achieved across the various strands of SPSP as at March 2016

Acute Adult	Primary Care	Maternity & Children	Mental Health
End of Phase II in March 2016	End of Phase in March 2016	End of Phase in March 2016	End of Phase II in September 2016
- 16.5% reduction in Hospital Standardised Mortality Ratios ( HSMR) from the 2007 baseline - 21% reduction in 30-day mortality sepsis - 19% reduction in cardiac arrest rate for 11 out of 22 hospitals that have reported consistently from February 2012 to December 2015 - 8 out of 15 reporting NHS boards from March 2014 to February 2015 show the percentage of patients discharged from hospital without any of the Scottish Patient Safety Indicator ( SPSI) harms is exceeding the aim with a median of 99.2% (aim 95%) HIS (2016b)	- 93% GP surgeries across Scotland completed the safety climate survey during 2014-2015, an increase of 3% over the previous year - 74% of all GP surgeries are carrying out structured case note reviews - 83% of all GP practices have introduced the care bundles the programme developed, to improve reliability in at least one high risk area. - increased awareness of safety issues in the community and the importance of teamwork and culture in identifying and addressing these issues. HIS (2016e)	- a 19.5% reduction in stillbirth rates in 2015 (provisional data) compared with 2012. - More work on neonatal mortality and postpartum haemorrhage needs to be done to demonstrate improvement. - Currently data is insufficient to reliably demonstrate impact and improvement in the neonatal and paediatric care work streams. HIS (2016c)	- increasing number of wards and units showing improvements in rates of violence (17 wards) and restraint (13 wards), seclusion and percentage of individuals self-harming (6 wards) – there are examples of restraint reduction by 57%, self-harm reduction of 70% or violence reduction of 78%) - the Safety Principles in Mental Health have been identified as interactions, tools and processes that can contribute to a reduction of harm measurable through the SPSP- MH Outcome Measures - over 600 facilitated Patient Safety Climate Tool surveys completed and over 3,000 staff climate surveys undertaken - NHS boards are submitting their leadership reports every 2 months – these are aggregated and distributed to all SPSP- MH programme managers and leads for sharing of best practice and networking - increasing service user, carer, and third sector involvement in SPSP- MH, including attendance at learning sessions HIS (2016d)

4.5 Phase III

The Acute Adult and Primary Care programmes recently published a 90-day Process Report in which they agree the focus for the next stage for both programmes ( HIS, 2016a). Responding to the need to look at the whole patient journey rather than focusing on silos in service delivery, the overarching themes for the next stage of both programmes are: 1) prevention, recognition, and response to deterioration; 2) medicines; and 3) system enablers for safety. Other streams of work will continue to aim at reducing harm with Primary Care focusing on safety culture, safer medicines, and safety across the interface. The Acute Adult work will focus on pressure ulcers, falls, catheter-associated urinary tract infection ( CAUTI), deteriorating patient, including cardiac arrest and sepsis, and medicines reconciliation. New work streams of acute kidney injury and emergency laparotomy are also being developed.

An expansion into new care sectors is also proposed. Exploratory work to identify and test interventions to reduce harm across Community Pharmacy, and Community Dentistry, is under way. This new work is going through prototyping in a small number of boards in order to develop and test reliable changes and interventions before they are spread across the country.

Given the maturity of many of the programmes, Scotland now needs to focus on sustainability of the gains. Many leaders are highlighting the need to properly embed the work into the system before moving on to other areas. It is not enough to test and get reliable results, the work has to become day-to-day business. To avoid change fatigue, this work has to be built into the fabric of the organisation. To achieve that, outcome measures become more important than process measures at the stage of sustainable and sustained improvement. Some might argue that the national focus has been lost and the work is not as joint up, but others would say this just means the work has become embedded in the day-to-day business. Furthermore, to take sustainability forward, some argue that the focus needs to move from reacting to existing problems to proactively managing the threats and preventing them. With the help of a grant from the Health Foundation, Scotland is already well underway thinking about, and working on, prevention.

Various initiatives have emerged from or beside the SPSP. Using patient safety stories, the ‘What matters to you?’ initiative was launched to enhance patient safety and patient experience. Bringing a human side to patient safety work offers an opportunity to reflect on experiences. It led to activities such as nursery visits to old people’s homes because it was found that the two groups enjoy spending time together. Another important programme that emerged is the Person-Centred Health and Care Collaborative. It focuses on relationships and patient stories as a significant component of the big picture within quality healthcare. Taking the whole system approach, the Whole System Patient Flow Improvement Programme was launched by QuEST in 2013 with the aim to ensure that patients receive the right care, at the right time, in the right place, by the right team, every time.

The Scottish work on Patient Safety also inspired other large scale patient safety programmes across the world, including Norway, England, Portugal and Singapore.