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Safer Clinical Systems

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elcome to the first SCS newsletter. This newsletter is aimed at all those involved in the SCS programme to ensure we all have a common and clear view of the programme and also to ensure that issues of interest are communicated across all the SCS teams. Throughout this newsletter I have given my views in many areas. These have not been developed alone and are my interpretation and collation of many people’s views. Please feel free to add to or challenge anything in this newsletter. At this stage of the programme I thought it might also be helpful to review the aims and the objectives that we all signed up to a year ago.

Matthew Cooke

issue 01 www.warwick.ac.uk/go/safersystems

What is the safer clinical systems programme? As the programme has moved SCS is a programme that aims “to increase reliability in systems of care and reduce the number of failures in clinical systems that result in harm to patients by developing and applying targeted interventions widely across the UK”

forward, I think we have developed an approach that is working towards identifying and controlling all relevant risks to an acceptable level, by continuously measuring and monitoring performance levels and by creating resilience that allows the system to withstand unforeseen disturbances.

Clarifying ‘what is a system’? Several of you have raised concerns over the variety of definitions of a system, so hopefully I can clarify this issue. Academics will debate issues like this forever, but a simple definition that I like is “the arrangement of resources to achieve objectives that have a single goal which can exist at many levels”. The bottom line is that a system can be as large or as small as you want but for SCS we are definitely looking to expand beyond the simple microsystems (a small group of people

who work together to provide care and the individuals who receive that care). This has been clearly reflected in the choice of topics which apply across a massive range of microsystems in your organisations and are influenced by factors at a variety of levels in the local health economy. I think the choice of the size of the system in SCS is a balance between being large enough to be able to detect and control risks common to many circumstances but small enough to be manageable.

Why is SCS different from previous initiatives? Many previous safety initiatives have focussed on the microsystem, such as introducing care bundles in one department. Change could often occur in a well localised area of care and the care bundle could be utilised more widely but often the underlying risks were not addressed. Hence it would solve one known problem but not decrease the risks of other errors. In SCS we are looking at a wider system, so that changes have a

much wider impact. Our projects may be based on a clinical microsystem, but they also look to include facilitators for change such as information systems, supplies management, staffing etc.  Within the central SCS project there is learning within team members (intra-team) as there is in a care bundle project. But I believe one of the features of SCS is that there is also horizontal learning to other projects, and also to other teams/ people (inter-team). The vertical

learning is about a change in management approach as well as the approach of many previous initiatives of just gaining executive engagement. But then there is the centrifugal spread which relates to the culture and readiness, which non-health sectors agree is not a planned spread but less welldefined, linking to social movement within an organisation as well as the large array of networks that exist in any health organisation.

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Reflecting on our Reflect progress A

series of objectives was included in the original tender; I think it is now a good time for us to take stock and see where we are in achieving these. Each site coordinator will be having these discussions with you, so that we are all clear of the work needed before May 2010. My impression is that we have all tried out new approaches and identified risk that previous approaches may not have detected. We are now starting to put controls in place. However, I do not believe that we can yet demonstrate the improvement in reliability of the process being studied and we do not have regular measures consistently in place to monitor and demonstrate the safety improvement.

The support team are now going to put a lot of focus on measurement and developing the safety improvement case for each site (see later) as without this we cannot show others what we have achieved. At this stage it is far too early to be seeing change in culture or in organisational approach but I think we are seeing the first signs that this may occur. Resilience will only develop once we have stability and common risks are managed, so again it is very early days. We will be discussing resilience more in future newsletters and at the December event. As a reminder, our objectives were: a) Identify areas where systems breakdowns are contributing to compromised patient safety. b) Develop understanding of what contributes to failures in patient safety from a clinical systems perspective, stretch and apply existing skills and expertise in systems and process improvement to patient safety problems, and build a deeper understanding of what works and how it is working.

Co-design The concept of ‘co-design’ has provoked significant debate and perhaps confusion during the programme to date. This is actually a much more simple concept than might be ‘feared’! Co-design simply means that the support team and award holders (site teams) will work together to design (co-design) the interventions to be tested during Phase 1 (as opposed to the support team designing interventions and then presenting them to award holders). Co-design of interventions will only operate in Phase 1; the award holders for Phase 2 will be implementing the interventions that are being codesigned during Phase 1. Leadership and management of the programme is provided by the support team.

c) Co-design strategies to deliver high reliability systems to underpin safer care in the specific areas identified and record what works and why and how it works. d) Develop metrics for safety and reliability in the areas that each team is working on, using a robust measurement system to monitor the impact of the interventions against these metrics. e) Capture the knowledge being generated in order to contribute to the defined set of evidence-based interventions that sites may be mentoring other organisations to implement in Phase 2. f) Lead work in your organisations to implement and test the approaches or interventions that we have developed. g) Collect regular/monthly data on agreed safety metrics and report this for analysis via a bespoke extranet which will be managed externally. Teams will share results and will use these as a resource for discussing improvements within the programme. h) Develop good working relationships and effective communication styles with the programme to fully enable mutual support and or problem solving in a collaborative manner.

Potential Phase 1 extension to December 2010 A reminder that you should have sent your responses back to Mary. THF will discuss these with the support team and we will aim to feed back in the next month.

Safer Clinical Systems News | www.warwick.ac.uk/go/safersystems


Project two Site coordinators will be discussing your plans regarding project two and how this links to your potential Phase 1 extension. I hope we can use the start of project two to test whether the approaches can be transferred to sites in Phase 2.

Measurement “Evidence without an appropriate argument is unexplained, just as an argument without evidence remains unfounded”

All of you will by now have discussed the future plans for measurement with the support team coordinators. So that we have clarity, I will highlight a few key points: • Each site is developing a safety improvement case which will contain quantitative data and narratives to show how risks have been identified, what control has been put in place and what improvements have resulted. The last item will be a combination of data (particularly a monthly run chart to demonstrate reliability changes) and narrative to describe the management of risk. The site coordinators have already spoken to you and, as you are aware, the first safety improvement case will need to be completed by 31st October. • Any measurement will be balanced to describe not just improvements in safety but narrative (and data if possible) to look at any possible impacts on clinical outcome, satisfaction, timeliness of care and cost. • These cases will be updated with new data each month and the support team will provide a mechanism to make this as easy as possible for you. • The safety improvement cases will include a two page executive summary which your CEOs have agreed will be useful for them to use at Board level. More details are available on the SCS web page.

Proposal for visits to other industries At the beginning of Phase 1 we discussed the possibility of trips to various manufacturing organisations. It was generally agreed that these may be time consuming and that many sites had already done such visits. As we enter the second year of the project, we wanted to look again at this issue. The change is, however, that we may want to look at alternative locations with more of a safety focus. We welcome your views on whether visits would add value for you. Things that you might like to consider: • What benefit would you get from visiting a site that you would not gain from a visiting speaker from the same site? • Would this be a good investment of time? • What would you hope to learn from the visit?  To help in considering this, there are three examples given below, but do let us know if you have other ideas of where we could visit. National Air Traffic Services (NATS) at Bournemouth: NATS provide air traffic services in the UK.  One of the main objectives is to maintain safety in the air space by ensuring adequate separation between aircraft (en-route) as well as suitable tower approach.  A visit to their experimental centre provides an insight into the use of realtime simulation and human factors assessment.  A speaker from NATS could outline their overall approach to managing safety.  To the novice, a real-time simulation may be difficult to comprehend. 

Transport for London / London Underground / Docklands Light Railway: Managing safety in the underground is a challenging task involving not only the management and control of rolling stock and signals, but also the safety on stations.  A visit to a London Underground control room can provide insights into the signalling on London Underground intended to ensure that trains are kept at a safe distance.   A speaker from London Underground could explain their safety strategy.  Docklands Light Railway is a driverless operation, posing novel safety challenges.  A DLR speaker could explain these challenges and outline how they are met.  West Midlands Fire Service: Being a fire fighter is a hazardous occupation, entering a hostile and uncontrolled environment. Team working and developing mutual trust is key to individual safety. Teams utilise standardised approaches and work strictly to standard operating procedures, even in this unpredictable environment. A speaker from WMFS could explain how they develop this team working and standardisation, but also how they cope with the variations of their work.

Human Factors training We are exploring how to provide more human factors training. We would welcome your views on what you would like if you were starting SCS. You might also like to have a look at the FAA e-learning

website http://www2.hf.faa.gov/ HFPortalNew/Training.aspx and let us have your views. If you know of other open access learning sites, please let us know. More details in the next couple of months.

www.warwick.ac.uk/go/safersystems | Safer Clinical Systems News


Responding to issues you have raised You have raised a number of issues in various formats including workshop feedback, interviews, site reports and Health Foundation interim reports. We have reviewed all your issues and have planned responses to each one. It isn’t possible to address the individual items in this newsletter, so we have uploaded the response onto the SCS website (sites>feedback to sites) and your site coordinators will also give you feedback.

Business case for safety A group of SCS finance directors is meeting in November to explore issues arising from SCS. We will let you know how this work progresses.

Over the next month, the support team will be asking your views on: The emerging SCS approach Proposals for the delivery of phase 2 Thanks in advance!

Upcoming courses or conferences: 2nd European Workshop on Education & Training for Patient Safety Wednesday 18th November at Warwick Medical School http://www2.warwick. ac.uk/fac/med/staff/sujan/ ws_etps09

Risk and Patient Safety 2009

Articles for distribution: Dr Foster Unit’s report on patient safety indicators http://www.cpssq.org/Publications/Resources/ Resources%20information/PSI%20report%20v2.pdf

National Patient Safety Agency Safety in doses: improving the use of medicines in the NHS. Published 3 September 2009. http://www.library.nhs.uk/GuidelinesFinder/ ViewResource.aspx?resID=324971&tabID=288

Latest NRLS site reports for England and Wales http://www.nrls.npsa.nhs.uk/patient-safety-data/ organisation-patient-safety-incident-reports/

Tuesday 24 - Wednesday 25 November 2009 Church House, London

Patient Safety First:

http://www.healthcare-events.co.uk/conf/booking. php?action=home&id=327

Creating a Business Case for the Patient Safety First Campaign. This document is available from the SCS website.

Feedback on all aspects of the programme is vital for us all to get maximum benefit from participation. Please do let us have feedback by e-mailing us at safersystems@warwick.ac.uk It would be great to have contributions from you for future editions. Please let us have your ideas or articles. This newsletter is also available (with built in hyperlinks) on the SCS website, www.warwick.ac.uk/go/safersystems

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SCS Newsletter No. 1 November 2009