Changing the safety culture in Scotland

According to worldwide evidence, one in ten healthcare interventions causes harm to patients, and recent reports puts the figure even higher. In Scotland, aside from the personal impact on patients, adverse events are estimated to cost the NHS around £200m each year in providing extra treatment and in lost bed days.

Led and co-ordinated by Healthcare Improvement Scotland, the Scottish Patient Safety Programme (SPSP) started in Scotland in 2007 with the aim to turn this situation around and has produced impressive results.

System Breakdown
The starting point of SPSP was an acknowledgement that healthcare professionals do not go to work with the intention of causing harm, but that harm occurs because of failure in the systems within which those professionals work. Aiming to measure outcomes and the reliability of processes, the programme aims to ensure that hospitals in Scotland deliver safe and standardised care for every patient every time.

The application of evidence-based healthcare is widespread amongst health professionals, but turning evidenced-based thinking into the delivery of healthcare is not generally applied in a reliable manner – the programme aims to apply this way of thinking to how healthcare services are delivered in Scotland. This level of self-reflection has been supported on all levels across the NHS in Scotland. Very few countries in the world have publically stated that they share the same issues as Scotland, but the NHS in Scotland took the brave step of declaring publicly that its healthcare system causes harm to patients. Moreover, a commitment to tackling the issue was enshrined in a Quality Strategy produced by the Scottish Government that declared: “There will be no avoidable injury or harm to people from the healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.”

Achieving results
Four years on, the results of SPSP are making health authorities across the world sit up and take notice. Across Scotland, there has been a 73 per cent reduction in central line infections, a 43 per cent reduction in ventilator associated pneumonia, and a 72 per cent reduction in critical care C. difficile. There has also been a 14 per cent increase in ward hand hygiene, 58 per cent reduction in ward C. difficile, and a 31 per cent reduction in blood clotting less than six on the INR scale. In addition, the programme has seen a 23 per cent increase in safety briefings and a 15 per cent increase in on-time antibiotics.

A prime example of the kind of change being seen in Scotland is Crosshouse Hospital in NHS Ayrshire & Arran. Through visionary leadership and radical system changes, the hospital has witnessed a reduction of 18 per cent in their mortality rates.

Another example is the significant reduction in the number of avoidable infections – many intensive care units across Scotland are reporting reductions in critical care infections. For example, a significant proportion of units have not had a central line associated infection or ventilator-associated pneumonia for more than 400 days. These life-threatening infections were previously accepted as an unfortunate side-effect of delivering intensive care for critically ill patients and we are now demonstrating that they can be avoided, leading to a reduction in the length of stay in intensive care.

Culture shift
How have these results been achieved? Fundamentally, the programme is about changing the culture across the NHS in Scotland to ensure that it promotes safety. It promotes a culture where healthcare professionals actively learn from those occasions when things don’t go according to plan – a culture where there is a plan for making improvements, and that everyone knows not only what the plan is, but their role in delivering it for the benefit of their patient.

But SPSP found that there’s also a culture that surrounds the use of plans within NHS boards. In some systems, the plans will be different depending on who is in charge, or which element of healthcare is being delivered and monitored. Without changing this culture there will still be teams working in the old way, with no real understanding if their system is safe and delivering the best care.

Trial and error

At the beginning of the programme, SPSP explained the problems in healthcare in a stark manner that made the teams involved feel uncomfortable, deliberately unsettling the status quo. Teams looked at the evidence where patients had been harmed – and even killed – by the treatment provided to them.

At the same time, teams were trained in quality improvement techniques – a very different approach to traditional methods used to improve outcomes for patients. Clinical audit systems were the main focus to identify where improvements were needed. But often the output from these audits would be to tell people to try harder and then to repeat the audit in six months time. Unsurprisingly, many audits found not much would have changed.       

The approach now is much different. Real-time data is reviewed every week and small-scale rapid cycle tests of change are adopted to achieve sustained improvement for the patient. This new approach supports the organisational cultural change, ensuring that staff on the wards think about how to improve the healthcare delivery system by using small-scale tests of change, and measuring the impact of these changes to deliver reliable processes and improve outcomes.

Scoring goals
SPSP started out with a key goal of reducing hospital mortality by 15 per cent over the five-year first phase of the programme – this would be achieved by concentrating on key aims, such as preventing central line infections, preventing surgical site infections and reducing surgical complications, amongst others. What’s more, the SPSP aims to drive a change in the safety culture in NHS organisations.

Recognising the complexities involved in delivering modern healthcare, the programme has been designed to standardise approaches to care. There is good research to show which interventions make a difference when it comes to enhancing patient safety, through the programme these are now being implemented.

Such improvements cannot be made without carrying out the right investment in the people. NHS Scotland has invested in 34 Scottish Fellows, 36 Improvement Advisors, and 125 Improvement Science in Action delegates. Similarly, the leadership within NHS boards is targeted to ensure that they also understand the changes that are happening at ward level. Within hospitals, leadership teams walk round on a weekly basis, talking to staff and patients about safety and making the changes happen to deliver a safer environment. In addition, many board meetings have patient safety as a priority agenda item.

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