Safer Clinical Systems. About Safer Clinical Systems June 2011

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1 Safer Clinical Systems About Safer Clinical Systems June 2011

2 Safer Clinical Systems A systems approach to building safe and reliable patient care through: proactively searching for and managing risk, ensuring feedback to create continuous learning, engagement and sustainable solutions 2

3 Harm continues Continuing harm of 1 in 10 in US and UK Despite many initiatives Failure to spread Failure to sustain Evidence on impact of systems factors Evaluation of Safer Patients Initiative February 2011 Patient Safety First Campaign report March

4 Our research shows poor reliability Failures in reliability pose real risk to patient safety 15% of outpatient appointments affected by missing clinical information Important clinical systems and processes are unreliable Four clinical systems measured had failure rate of 13%-19% Wide variations in reliability between organisations Unreliability is the result of common factors Lack of feedback mechanisms and poor communication. It is possible to create highly reliable systems The Health Foundation May

5 What is a safe clinical system? Our working definition of a safe clinical system is: A clinical system that delivers value to the patient, is demonstrably free from unacceptable levels of risk and has the resilience to withstand normal and unexpected variations and fluctuations 5

6 Building Safer Clinical Systems Understanding the system Identifying and managing the risk Systems thinking Designing for safety Ensuring valid standards and improving reliability Creating resilience 6

7 Key Features of the Programme You will be taken through a systematic approach which will involve: A tailored learning and development programme Expert help On-site support facilitated by a named person Peer-review Opportunity to review your progress at key intervals Central learning events 7

8 Learning and Development Learning and development will be provided by the Support Team through: Induction event Collaboration and training conferences Shared learning events On-site training needs analysis through site facilitators On-site and/or remote response through technical experts Communities of practice and learning sets 8

9 Phase 2 Interventions Many adverse events occur in patient pathways where handovers or prescribing are an issue. They can often be traced back to system design and contextual factors. In Phase 2 we will be working within patient pathways, focusing on these supporting processes and systems: Safe, reliable prescribing in patient pathways (e.g. prescribing by staff throughout the pathway, together with upstream processes such as information transfer and downstream administration) Safe, reliable clinical handovers in patient pathways (e.g. transfer of clinical information, tasks, responsibility and authority) 9

10 Timeline of the Programme Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept SCS Programme Steps Step 1 Step 2 Step 3 Step 4 Pathway definition and context System diagnosis Option appraisal and planning System Improvement Cycles Induction Launch event and Training and Human Factors event 1 Training and Human Factors event 2 Non-technical skills training event Shared learning event Shared learning event Shared learning event Collaborative and training events Next steps learning event Award holder Communities of Practice support Expert review (gates) Site plans & progress by TST Expert review (gates) Programme by external experts Award holder site support

11 Safer Clinical Systems A systems approach to building safe and reliable patient care through: proactively searching for and managing risk, ensuring feedback to create continuous learning, engagement and sustainable solutions 11

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