The Scottish Patient Safety Paediatric Programme, General Ward Workstream

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The Scottish Patient Safety Paediatric Programme,
General Ward Workstream

• Jane Murkin, National Co-ordinator
• Annette Henderson PM NHS Lothian

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Aims

• Complexity and challenges
• Overview of SPSP general ward aims and drivers
• Share successes
• Learning to date
• Overview of Paediatric General ward
• A local board experience of implementing PEWS
• Setting your first pdsa
• What else?

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Ward 1
Ward 2

• Joke pic

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Challenges

• complexity
• Too Busy
• Yet more work /audit
• We dont have a problem
• Variation
• Standardisation versus customisation
• Tools to test
• Tools to measure
• Knowledge to test and measure
• Motivation to change

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Content areas

• SBAR
• Early recognition
• Outreach teams / response system
• Hand hygiene
• Safety Briefings
• PVC Bundle
• Medicines reconciliation

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Learning to date

• Importance of linking process and outcome
• Challenges in relation to testing and
  implementing response systems
• Significant progress and successes
• Achieving reliability prior to spread
• Scale and challenge of spread
• Importance of data at the frontline
• Multidisciplinary engagement
• Infrastructure of support

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Percent trained in the use of SBAR within NHS
Ayrshire Arran Pilot Ward
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Percent using SBAR within NHS Grampian
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• In aviation 75 of accidents are caused by human
  factors
• whats the figure in healthcare?

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Percent compliance with EWS Assessment Golden
Jubilee National Hospital
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Percent of observations identified as at risk
that have appropriate interventions undertaken in
terms of EWS NHS Fife
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Percent compliance with hand hygiene with general
ward NHS Grampian
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NHS Scotland Hand hygiene
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NHS Scotland PVC Bundle Compliance
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NHS Fife 24 wards, PVC Bundle compliance
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SPSP Paediatric Ward Driver Diagram
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Questions?
Questions?
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Case study
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Remember
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Using the lens of Profound Knowledge
Appreciation of a system
Theory of Knowledge
Psychology
Understanding Variation
Aim or Values
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simple tool for staff to use test out ideas that
will improve healthcare systems and processes
The Improvement Guide, API
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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Hunches Theories Ideas
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Build on Small Scale Tests of Change

• One patient
• One doctor
• One nurse
• One day / shift

Seek usefulness, not perfection
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PDSA Worksheet
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Share your first tests
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What will it take to improve safety?

• Winning the hearts and minds of the staff
• Focusing on improvement not targets
• Leadership
• Integration
• Making it daily work
• Creating infrastructure
• Creating capability and capacity
• Measurement that has meaning

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