Patient safety collaborative launch delegate pack

NHS Improving Quality and NHS England
National Patient Safety Collaborative Programme Launch Event
Tuesday 14 October 2014 - The Montcalm, 34-40 Great Cumberland Place, London, W1H 7TW
NHS
In partnership with
TheAHSNNetwork

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Contents
Patient Safety Collaborative Programme Agenda
Speaker Biographies
Breakout Session One
Breakout Session Two
Academic Health Sciece Networks’ Safety Plans
Research Project Summary
Hello My Name Is....
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National Patient Safety Collaborative Programme Launch Event
TIME
9am - 10am Registration and coffee
10am - 10.20am
10.20am - 10.50am
SESSION
Leadership for Quality Improvement
and Safety
Chair - Lisa Butland, Director of Innovation,
North West Coast AHSN
The leadership difference - Jan Sobieraj,
Managing Director, NHS Leadership Academy
(15 minutes).
The Board’s role in leading for quality
and safety - a regional approach and
programme - Lesley Massey, Director of
the Advancing Quality Alliance (AQuA)
(15 minutes).
Leadership for safety – learning from
Scotland - Joanne Matthews, Head of
Safety - Healthcare Improvement Scotland
and Jane Murkin, Head of Patient Safety
and Improvement, NHS Lanarkshire
(15 minutes).
Panel discussion & questions
(10 minutes).
Measurement for Improvement
Chair - Tony Roberts, Deputy Director,
Quality Assurance Team, South Tees Hospitals
NHS Foundation Trust
Is healthcare getting safer? - Professor
Charles Vincent - Patient Safety Lead,
Oxford AHSN (15 minutes).
‘A system based on continual learning:
a guide to using measurement for
improvement’- Phil Duncan, Patient
Safety Collaborative Lead, NHS Improving
Quality and Ian Chappell, Improvement
Manager, NHS Improving Quality (15 minutes)
The Safety Thermometer and
measurement for improvement -
Abigail Harrison, Senior Programme
Manager, Measurement and Innovation at
Haelo (15 minutes).
(10 minutes).
Collaboratives great and small -
learning from experience
Chair - Julie Neethling, AHSN Business
Support Lead for NHS England
Integrating patient safety into the
AHSN’s - Anna Burhouse, Director of
Quality, West of England AHSN, Elizabeth
Dymond, Deputy Director, Enterprise &
Translation, West of England AHSN, Anne
Pullyblank, Clinical Director, West of
England AHSN (15 minutes).
Learning from working regionally with
collaboratives - Corinne Thomas,
Programme Director, South West Quality and
Patient Safety Improvement Programme
South of England Improving Safety in Mental
Health Collaborative (15 minutes).
Sign up to safety campaign – National
considerations - Dr Suzette Woodward,
Campaign Director for the ‘Sign up to Safety’
campaign (15minutes).
(10 minutes).
11.05am - 12 noon
BREAKOUT SESSION ONE: DELEGATES CHOOSE ONE SESSION TO ATTEND:
10.50am - 11.05pm
Welcome and the National
Patient Safety Plan - Dr Mike
Durkin (Chair), Director for Patient
Safety, NHS England
A facilitated discussion:
Patients as partners
Miss Priscilla Chandro, Patient
Leader
Dr Kate Granger, Specialist
Registrar in Geriatric Medicine
Suzie Shepherd, Chair, Royal
College of Physicians Patient
Involvement Unit, Lay Vice Chair,
Clinical Services Accreditation
Alliance
Coffee and transition to breakout
session
Breakout session one
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TheAHSNNetwork

12.05 - 12.35 - BREAKOUT SESSION TWO: DELEGATES CHOOSE ONE SESSION TO ATTEND:
Sharing best practice
Chair - Philip Dylak, Director of
Transition, North West Coast AHSN
Achieving behaviour change
for patient safety - Judith
Dyson, Lecturer Mental Health,
University of Hull (20minutes).
Delegate questions
(10 minutes).
Chair - Nigel Acheson, Regional
Medical Director, NHS England
South
Enhancing quality and
recovery - Acute kidney injury -
Kay Mackay, Director of
Improvement, Kent, Surrey and
Sussex (KSS) AHSN and Ed
Kingdon KSS AKI Clinical Lead,
Enhancing Quality (20 minutes).
Delegate questions
(10 minutes).
Chair - James Scott, Regional
Medical Director, NHS England
South
South of England Improving
Safety in Mental Health
Collaborative - Shaun Clee,
Chief Executive, 2gether NHS
Foundation Trust and Dr Helen
Smith, Co-Medical Director and
Clinical Lead, South of England
Improving Safety in Mental Health
Collaborative (20 minutes).
Delegate questions
(10 minutes).
TIME
12.35pm - 1.20pm Lunch
1.20pm - 1.45pm
1.45pm - 2.10pm
2.10pm - 2.55pm
2.55pm - 3.10pm
3.10pm - 3.30pm
SESSION
4.00pm - 4.10pm
4.20pm - 4.30pm
12.00 noon - 12.05pm - Delegates transition to break out session two
3.30pm - 4pm
4.10pm - 4.20pm
Sir Bruce Keogh, National Medical Director,
NHS England
Patient Safety Collaboratives - Dr Liz Mear, Chief Executive,
North West Coast AHSN and Dr Chris Streather, Managing
Director, South London AHSN
AHSN local meetings
Coffee break
Supporting and developing Patient Safety Collaboratives -
Phil Duncan and Fiona Thow, Patient Safety Collaborative
Delivery Leads, NHS Improving Quality
The national picture - The Rt Hon. Jeremy Hunt MP,
Secretary of State for Health
Sign up to Safety - Sir David Dalton, Chief Executive, Salford
Royal NHS Foundation Trust & Dr Suzette Woodward, Campaign
Director, Sign up to Safety
Summary and next steps - Steve Fairman, Interim Managing
Director, NHS Improving Quality
Chair: Final remarks and close – Dr Mike Durkin, Director for
Patient Safety, NHS England and Professor Norman Williams,
Chair, National Patient Safety Collaborative Programme Board
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Anna Burhouse
Director of Quality, West of England Academic Health Science Network
Anna Burhouse leads on the Quality Improvement programmes, Evidence into
Practice and Evidence into Commissioning and is supported by the Quality
Improvement Team.
Anna is a Health Foundation Improvement Fellow, and a Consultant Child and
Adolescent Psychotherapist. Throughout her career Anna has specialised in
roles which combine clinical and leadership skills to improve the quality and
safety of services.
Priscilla Chandro
Patient Leader
Priscilla Chandro suffered a heart attack at the age of 37 and has since gone on
to become what she terms as a “professional” patient and public
representative. Her heart attack went undetected for three days, as she was
misdiagnosed as having flu. Through her “work”, she is conscious of
highlighting misdiagnosis and “stereotyping” when necessary, as she feels that
these are not issues solely related to cardiac cases.
Coming from a corporate background, she is now self employed and
passionate about helping others to achieve the “better health outcomes for all”
and “no decision about me, without me” straplines.
She is an Ambassador for the British Heart Foundation and has been involved in
many activities, including media work to raise awareness of Women and Heart
Disease, member of grant committees, the Cardiovascular Disease Outcomes
Strategy and the Keogh Mortality Rapid Response Reviews, amongst others.
She is currently involved as a lay member for the new style CQC hospital
reviews. Her “fixed” positions are as Public Governor for the South East Coast
Ambulance service, Secretary for Cardiovascular Care Partnership UK, co-opted
member of council, being the first female patient, for the British Association of
Cardiovascular Prevention and Rehabilitation and as a lay member for the South
East Coast Cardiovascular Strategic Clinical Network and Clinical Senate. She is
also part of the national Women’s Health Patient Safety Committee.
“Whether you want to help shift change locally or nationally, there are a
number of ways you can get involved on different levels. I am very fortunate to
have been involved in some amazing opportunities and seen real change as a
result and I would urge anyone to consider helping to shift change where
change is needed..”
She feels that partnership working between healthcare professionals and the
public/patients is paramount on many levels. More importantly, when both
sides are “working as one” towards a common goal, this serves as a great
benefit to the end user.
Shaun Clee
Chief Executive, 2gether NHS Foundation Trust
Shaun Clee is an experienced NHS Chief Executive with a clinical background
and track record of getting things done and successful partnership working.
Shaun has presented at numerous national and international conferences, is an
active member of the International Initiative for Mental Health Leadership, an
alumni of the Leadership Trust and places a great deal of emphasis on
leadership skills development. He chairs the NHS South of England Improving
Safety in Mental Health Clinical Faculty, has represented the National Mental
Health Network on the Care Quality Commission's Provider Advisory Group and
is currently Chair of the NHS Confederations National Mental Health Network,
(MHN), a Trustee of the NHS Confederation, a Non-Executive Director of the
NHS Confederation, the Health representative on the National Criminal Justice
Council, and Chair of Kids Like Us, a Midlands based charity for children, young
people and their families who experience Juvenile Arthritis. In his role as Chair
of the MHN he has grown the membership to include Social Housing providers
and championed a joint statement between the MHN and the National Housing
Federation on Mental Health and Housing
Speaker Biographies
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His organisation, 2gether NHS Foundation Trust, was one of the first 10 Mental
Health Trusts to achieve Foundation Trust status. 2gether NHS FT has sustained
high performance since its inception built upon greater engagement and
involvement internally and externally with partners. His organisation was one of
only 37 from over 370, to be awarded Excellent for both quality of services and
quality of financial management by the CQC in 2009 and has retained a
Governance rating of Green, a Mandatory Services rating of Green and a
Financial Risk Rating of 4 every quarter since authorisation in July 2007.
With over 36 years’ experience in Mental Health services and exposure to some
of the best performing teams in America, New Zealand, Canada and Europe,
Shaun is always looking to reduce the time from idea to positive impact.
He is married, has 3 children in their mid 20's and when asked about his
proudest achievement said "that my kids will call us when we are out to see if
we fancy a pint with them - even if it is me getting the round in"!
Ian Chappell
Improvement Manager – Patient Safety, NHS Improving Quality
Ian Chappell BA (Hons), has worked in quality improvement within the NHS for
the past five years. A qualified Improvement Advisor (IA IHI Professional
Development Programme), Ian has worked locally, regionally and nationally on
large scale change programmes and held improvement roles in a number of
leading North West organisations e.g. AquA, Haelo. Ian has been involved in
numerous Breakthrough Series (BTS) collaboratives in an IA capacity and has a
background in measurement for improvement.
Ian is currently an Improvement Manager within the Patient Safety Team at NHS
IQ where he leads on Measurement, supporting the National Patient Safety
Collaborative programme and other NHS IQ initiatives.
Sir David Dalton
Chief Executive, Salford Royal NHS Foundation Trust
Sir David Dalton has been a Chief Executive for 19 years – 12 of these at
Salford Royal. He has a strong profile, both locally within Greater Manchester,
and also nationally in the areas of quality improvement and patient safety.
Under Sir David's leadership, the Trust set out its clear ambition to be the safest
organisation in the NHS and has adopted a disciplined approach of applied
'improvement science' coupled with deep staff involvement.
Sir David's other interest is in sustaining an organisational culture which delivers
high reliability of clinical standards, this has included supporting clinical leaders
and creating a new framework for aligning an individual's contribution to the
goals and values of the organisation.
Sir David chairs a network organisation of Foundation Trusts - NHS QUEST -
which aims to achieve unprecedented levels of quality improvement and he is
Vice Chair of the Greater Manchester Academic Health Science Network, which
aims to improve health through better adoption of evidence of best practice.
Sir David received his knighthood in the New Year's Honours List 2014 for his
services to the NHS.
Sir David has been chosen by the Secretary of State for Health, the Rt Hon
Jeremy Hunt MP, to lead the Dalton Review into how leading NHS hospitals can
expand their reach to benefit more patients.
Phil Duncan
National Patient Safety Collaborative Lead, NHS Improving Quality
Phil Duncan BSc (Hons), has worked in the NHS for nearly 25 years, first
qualifying as a Registered General Nurse in 1992. Following experience in a
range of clinical settings, Phil moved into acute trust business and general
management and then to the Modernisation Agency in 2002. Formerly Director
of the Lung Improvement Programme with NHS Improvement, Phil has also
worked on other national improvement programmes including those for Heart
and Stroke Improvement.
His work interests lie mainly with designing clinical processes that sustain
improvements as well as mainstreaming best practice within organisations. He
is on a personal mission to seek new ways of working and empower staff to
‘have a go at change’, but also to think differently about current systems using
the variety of tools and techniques available.
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Dr Mike Durkin
Director for Patient Safety, NHS England
Dr Mike Durkin is the National Director of Patient Safety at NHS England. Prior
to joining NHS England Mike was the Medical Director of the South of England
Strategic Health Authority since 2006.
He qualified at The Middlesex Hospital and has held research and teaching
appointments in London and Bristol. He was appointed to the faculty at Yale
University School of Medicine where he was also an Attending
Anaesthesiologist. He was Medical Director of Gloucestershire Royal NHS Trust
from 1993 to 2002 where he has a consultant post in Anaesthesia. He was
appointed as Medical Director and Director of Clinical Quality for Avon,
Gloucestershire and Wiltshire Strategic Health Authority in 2002. He has led
clinical performance and governance reviews for Royal Colleges and in NHS and
Independent hospitals in the United Kingdom, for other Strategic Health
Authorities in England and in 2003/04 for a Ministerial Review in Gibraltar. He
was on the core team for the Patient Safety Campaign for England as an
advisor on leadership interventions. He sits on Advisory Boards for The Health
Foundation and British Medical Journal Group. He chairs the Management
Board of the NICE National Clinical Guidelines Centre.
Elizabeth Dymond
Deputy Director of Enterprise & Translation
West of England Academic Health Science Network (WEAHSN)
Elizabeth Dymond has over 10 years of experience within innovation, most
recently holding the post of Innovation Manager at North Bristol NHS Trust and
University Hospitals Bristol NHS Trust. She is part of the innovation working
group of Bristol Health Partners. She is a medical engineer by background, and
has worked in the NHS in the areas of Ambulatory ECG and Assistive
Technology for people with complex disabilities.
Judith Dyson
Lecturer in Mental Health, University of Hull
A qualified General and Mental Health Nurse with a Masters degree in Public
Health and a PhD investigating the use of psychological theory in influencing
the adoption of best practice by health care practitioners Judith is currently a
Lecturer in Mental Health. Judith’s research interests include behavioural
psychology, the implementation of evidence based practice and using
psychological theory to change behaviour. She is actively engaged in
implementation of evidence based practice in her work as an Academic
Improvement Fellow for the Improvement Academy of the Yorkshire and
Humber Academic Health Science Network.
Recent publications:
Dyson, J., Cowdell, F., (2014). Development and psychometric testing of the
‘Motivation and Self-Efficacy in Early Detection of Skin Lesions’ Index Journal of
Advanced Nursing (impact factor 1.527).
Büscher, T.P., Dyson, J., Cowdell, F., (2013). The effects of hoarding disorder on
families: an integrative review. Journal of Psychiatric and Mental Health Nursing
(impact factor 0.795) Jul 21. Doi: 10.1111/jpm.12098.
Dyson, J., Lawton, R., Jackson, C., & Cheater, F. (2013). Development of a
theory-based instrument to identify barriers and levers to best hand hygiene
practice among healthcare practitioners. Implementation Science, (impact
factor 2.31) 8, 111
Dyson, J., Lawton, R., Jackson, C., Cheater, F., Does the use of a theoretical
approach tell us more about hand hygiene Behaviour? The barriers and levers
to hand Hygiene. Journal of Infection Prevention, 12(1), 2011
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Steve Fairman
Interim Managing Director, NHS Improving Quality
Steve Fairman is the Managing Director of NHS Improving Quality, the national
body which supports the NHS to improve the efficiency and effectiveness of its
services for patients.
Steve joined the NHS following significant spells in Local Authorities and a
social research unit. Trained initially as a demographer and more recently as a
health economist, he has led a number of complex multi-organisational
improvement programmes to successful conclusion. His work is based around
building successful, and influential, partnerships for change – particularly with
clinicians.
Steve has previously held Board level positions to Regional level in the NHS and
specialises in improving the quality and cost-effectiveness of public services for
end users. Most recently, as Director of Business Improvement & Research for
NHS England, he led nationally on the establishment and licencing of Academic
Health Science Networks (AHSNs), and was a key leader in the NHS England
approach to advancing Telecare and Telehealth initiatives.
Dr Kate Granger
Specialist Registrar in Geriatric Medicine
Hello my name is Dr Kate Granger and I am a final year Elderly Medicine
Specialist Registrar working in Leeds. I graduated from Edinburgh University in
2005. My main clinical passion is improving how we look after older people
who are dying in the acute hospital setting. I live in Wakefield with my husband
Chris. What makes me unusual is that I am also a terminally ill cancer patient,
diagnosed with a very rare and incurable form of sarcoma in summer 2011. I
have shared my illness on the other side through books, my popular blog and
frequent tweeting. I am also the founder of the global #hellomynameis
campaign which aims to encourage and inspire all healthcare workers to
introduce themselves to every patient they meet.
Although I face my impending mortality in the coming months I am also very
busy living a full and happy life as we complete my Bucket List.
Abigail Harrison
Senior Programme Manager – Measurement and Innovation, Haelo
Haelo is an Innovation and Improvement science centre focussed on improving
health and healthcare. Abigail Harrison has expertise in improvement science
and delivery of measurement and change at scale. She leads Haelo’s
Measurement and Innovation teams and leads a number of programmes of
work including the NHS Safety Thermometer national programme, the Making
Safety Visible programme which builds on the ‘Measurement and Monitoring
of Safety’ framework and a programme of work to improve Medications Safety.
Abigail previously managed the NHS Safety Thermometer pilot for the QIPP
Safe Care programme and worked with NHS QUEST on building measurement
capabilities, specifically around measuring harm. Before that she worked in a
number of NHS organisations including the Greater Manchester Cancer
Network, Salford Royal NHS Foundation Trust, and Lancashire Teaching
Hospitals NHS Foundation Trust.
Abigail studied at the University of Manchester for a Masters in English
Literature and before that studied drama, drawing on this learning when
thinking about how we best communicate and share knowledge to improve
health and healthcare.
The Rt Hon Jeremy Hunt MP
Secretary of State for Health
Jeremy Hunt was appointed Secretary of State for Health in September 2012.
He was elected as MP for South West Surrey in May 2005.
Professor Sir Bruce Keogh
National Medical Director, NHS England
Professor, Sir Bruce Keogh became the National Medical Director for NHS
England in April 2013. He is responsible for the clinical and professional
leadership of doctors, dentists, pharmacists, scientists and allied health
professionals; improving clinical outcomes and promoting innovation.
Between 2007-2013 he was the NHS Medical Director at the Department of
Health. Before taking up his national leadership role he was an associate
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medical director at University Hospital Birmingham prior to becoming Director
of Surgery at The Heart Hospital and Professor of Cardiac Surgery at University
College London.
In a distinguished career in surgery, he has been President of the Society for
Cardiothoracic Surgery in Great Britain and Ireland, Secretary General of the
European Association for Cardiothoracic Surgery and a Director of the US
Society of Thoracic Surgeons. He has served as a Commissioner on the
Commission for Health Improvement and the Healthcare Commission and was
knighted for his services to medicine in 2003.
Ed Kingdon
Clinical Lead EQ-AKI Pathway,
Kent, Surrey and Sussex Academic Health Science Network
Consultant nephrologist at Brighton and Sussex University Hospitals NHS Trust
and clinical lead for the AKI pathway for the 11 acute trusts in KSS. Trained in
North Thames in medicine and nephrology. Lead consultant for the Sussex
Kidney Unit and chair of the Sussex collaborative renal clinical reference group.
Kay Mackay
Director of Improvement
Kent, Surrey and Sussex Academic Health Science Network
A nursing background; clinical experience in a range of acute and community
specialities and then at Board level as Director of Nursing and Operations.
Continued at Board level in commissioning and service redesign before moving
to regional level in 2009 to establish the enhancing quality and recovery
Programme (EQR) across Kent Surrey and Sussex which has been an incredible
privilege to lead. (www.enhancingqualitycollaborative.nhs.uk) Next exciting
challenge is to establish the Kent, Surrey and Sussex patient safety
collaborative.
Lesley Massey
Director of the Advancing Quality Alliance (AQuA)
Lesley Massey is a founder member and Director of the Advancing Quality
Alliance (AQuA) an NHS North West of England based membership
organisation with a focus on quality and safety improvement.
Before joining AquA, Lesley had undertaken a NW regional review of quality
improvement capability and capacity within NHS care systems. Lesley has
worked in the NHS since qualifying as an Occupational Therapist in 1985; she
has an MA in Health Care Management and has undertaken a number of
senior leadership positions. Lesley has a passion and commitment to making
improvements in care quality and patient safety and has designed and led
several large scale regional and national improvement programmes particularly
in the areas of reducing avoidable hospital mortality, patient safety campaigns
and patient experience programmes, including shared decision making/self-management
support. Lesley leads the AquA Academy, overseeing the strategy
for and delivery of training and development for QI, providing the tools and
methodologies for building capability and capacity from boards to the front line
of care delivery. Lesley has particular interest and experience in working with
senior clinical leadership and executive teams as they build their systems for
improvement within integrated quality and safety strategic plans.
Joanne Matthews
Head of Safety
Healthcare Improvement Scotland
Joanne Matthews joined Healthcare Improvement Scotland in April 2013 as
Head of Safety for the Scottish Patient Safety Programme following a career
spanning a number of years in the South of England. A nurse by background,
Joanne trained and worked in Scotland before moving to England carrying out
a number of clinical roles across acute care and NHS Direct.
Following this Joanne moved to the Primary Care Trust (PCT) in Brighton to lead
service improvement across community and acute services before taking on a
Strategic Commissioner and Joint Commissioner (Adult Social Care) role across,
acute and community care for adults and children. During this time Joanne also
participated within the Department of Health, Long Term Conditions Quality
Innovation, Productivity and Prevention (QIPP) leading the Sussex Programme.
Prior to returning to Scotland Joanne successfully led the CCG authorisation
process for Brighton and Hove PCT and the close down of the PCT in line with
the recent changes to the NHS in England.
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Dr Liz Mear
Chief Executive, North West Coast Academic Health Science Network
Dr Liz Mear the Chief Executive of The North West Coast Academic Health
Science Network and a Board member of the Health Services Research
Network.
Prior to joining the AHSN Liz was Chief Executive of the Walton Centre NHS
Foundation Trust, an acute neurosciences trust in Merseyside, which operates a
hub and spoke model of service across a foot print of 3.5 million residents. Liz
was also Chair of the Cheshire and Merseyside Comprehensive Local Research
Network.
Before working at the Walton Centre Liz held a number of Director roles in a
variety of NHS organisations including the acute sector, mental health and
ambulance service.
Liz worked in local government for 17 years, holding a variety of senior
customer service roles. Liz has also worked as a Senior Management
Consultant, specialising in public sector business performance improvement
and change management.
Jane Murkin
Head of Patient Safety and Improvement, NHS Lanarkshire
Jane Murkin is an experienced change leader with extensive experience in both
national and local senior leadership roles where she has led on the design and
implementation of improvement programmes to transform health and care.
These have included:
• Patient safety and reducing harm
• Person centred health and care
• NHS Scotland’s Quality Improvement Hub
• Whole system patient flow
• Planned Care
Jane led on the initiation and early implementation of the Scottish Patient
Safety Programme from 2007 till 2010 and the design and initiation of NHS
Scotland’s Quality Improvement HUB. Having spent several years working in the
Scottish Government, where she also lead on the design and establishment of
improvement programmes for both patient flow and the Person Centered
Health & Care Programme for NHS Scotland. Jane worked as a Professional
Advisor for the Chief Nursing Officer on Quality Improvement.
Jane has many years experience teaching, coaching and facilitating
improvement and supporting organisations and teams to drive a culture of safe,
effective and person centred health and care and embedding a culture of
continuous quality improvement.
Jane is a nurse and midwife by background.
Anne Pullyblank
Clinical Director, West of England Patient Safety Collaborative
West of England Academic Health Science Network (WEAHSN)
Anne Pullyblank is the Clinical Director of the West of England Patient Safety
Collaborative.
Anne is also Clinical Director for Surgery at North Bristol NHS Trust, responsible
for urology, plastic and burns surgery, dermatology, breast, transplant and
general surgery. She has a number of years’ experience leading on projects for
the trust and is passionate about improving patient safety.
Dr Helen Smith
Co-Medical Director and Clinical Lead
South of England Improving Safety in Mental Health Collaborative
Dr Helen Smith is the Co-Medical Director and Consultant Forensic Psychiatrist
at the Devon Partnership NHS Trust. She is the clinical lead for the Quality
Improvement Academy in the Trust and the South of England Improving Safety
in Mental Health Collaborative.
Helen’s first consultant post was within the Forensic Services in the West
Midlands, before moving to Devon in 2004. She has a Master’s degree in
Criminology from the University of Cambridge (1996). Helen completed the
Patient Safety Officer training at the Institute for Health Improvement (IHI) in
Boston USA (2008) and has a Post Graduate Certificate in Patient Safety and
Clinical Risk Management for the University of Leeds (2010).
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Jan Sobieraj
Managing Director, NHS Leadership Academy
Jan Sobieraj was appointed Managing Director of the NHS Leadership Academy
shortly after its launch in April 2012.
The Academy’s vision is to be a centre of excellence and beacon of good
practice on leadership development. It is a strategic intervention for the NHS,
designed to make sure the health system develops the leadership it needs to
meet the challenges it will face in the coming years.
Jan was appointed after having served in the post of Managing Director for
NHS and Social Care Workforce at the Department of Health from July 2011.
In 2011 he was seconded from NHS Sheffield where he was Chief Executive
from 2006 to the Department of Health as Director of Leadership.
He has been a Chief Executive in different NHS organisations for 13 years,
including taking Barnsley Hospital to a first wave NHS Foundation Trust.
Jan is a Honorary Professor of De Montfort University and a visiting Senior
Fellow at Sheffield Hallam University and has held a number of senior roles on
national bodies and in local organisations including Trustee of the Health
Foundation and Local Government Association Leadership Centre.
Over the last 30 years of his management career, Jan has been passionate
about working in partnership with leaders, staff, patients and trade unions to
improve healthcare.
Suzie Shepherd
Lay chair and RCP Patient and Carer Network
Suzie Shepherd is the current lay chair of the RCP Patient and Carer Network
(PCN) and lead for patient involvement in the Future Hospital Programme. The
PCN consists of patients, carers and members of the public from a wide range
of backgrounds, who have opted to help the RCP develop and enhance its
relationship with patients in the interest of improving healthcare. Suzie was a
key contributor to the Future Hospital Commission through her role.
Suzie sits on several medical boards including the medical accreditation, health
informatics patient records and revalidation boards, as well as chairing
committees relating to patient involvement in health and social care including
the public health agenda. Suzie also speaks regularly at external conferences
and events on behalf of the RCP.
Prior to ill health retirement Suzie worked within the NHS as a hospital trained
dental nurse on an oral surgery unit and latterly as a strategic Organisational
Development and Improving Working Lives Lead in an SHA.
More importantly Suzie manages two complex long term conditions and has
both health and social care service needs in an ever changing, complicated
environment.
Dr Chris Streather
Managing Director, Health Innovation Network/
South London Academic Health Science Network
Dr Chris Streather is a renal physician by training. He worked at Brighton,
Kings, as a National Kidney Research Foundation Fellow, and Cambridge,
before being appointed to St Georges as a Consultant in 1997. He became
Medical Director in 2004, later Director of Strategy and worked on the National
Physicians Assistant pilot, the RCP Acute Medicine Task Force and Lord Ara
Darzi’s Framework for Action. In 2008 he was the London Clinical Director as
London’s Stroke services were comprehensively redesigned and worked on the
Primary and Community Care Advisory Board of the NHS Next Stage Review. He
is Deputy Chair of the London Leading for Health Partnership, a member of
Lord Ara Darzi’s Health Commission and Mayor Boris Johnson’s London Health
Board. From 2009-2012 he was the first CEO of South London Healthcare, and
is now the Managing Director of the Health Innovation Network, leading for
the Networks Nationally on Patient Safety. He relaxes with his family, cycling or
following the fortunes of Reading FC.
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Corinne Thomas
Programme Director, South West Quality and Patient Safety Improvement
Programme, South of England Improving Safety in Mental Health Collaborative
Corinne Thomas, RN, BA (Hon), MA, is Programme Director for the South of
England Improving Safety in Mental Health Collaborative, the South West
Strategic Clinical Network Zero Suicide Collaborative and formally for the South
West Quality and Patient Safety Improvement Programme. Corinne has 13
years experience as a Director of Nursing in organisations providing community,
mental health and learning disability services as well as acute care. She has
been executive lead for the successful implementation of the Safer Patient
Initiative 2, and has practical experience of leading change across a large,
complex organisation.
Following her passion for patient safety, in March 2009 she completed the
Patient Safety Officer Course at the Institute for Healthcare Improvement in
Boston, and in 2010 she qualified as a Team Resource Management Instructor
with Global Air Training. In January 2015, Corinne graduates as an
Improvement Advisor with the Institute for Healthcare Improvement.
Fiona Thow
National Patient Safety Collaborative Lead, NHS Improving Quality
Fiona Thow joined the Patient Safety Programme for NHS Improving Quality on
the 1st April 2014 where she will be working with colleagues to support the
delivery and co-production of the national Patient Safety Collaborative across
England, in partnership with NHS England and the AHSNs. Other work will
involve supporting capacity and capability building to support staff to make
improvements in safety, based on the needs and choices of patients, their
families and carers. In previous roles she has supported a range of improvement
programmes across diagnostic services including radiology, audiology,
endoscopy and physiology diagnostic services over the last 5 years. A recent
initiative included supporting the early work on 7 day service delivery models.
Following a clinical career as a radiographer and clinical manager, Fiona moved
into service improvement in 2001.She has held a range of service improvement
posts across a range of specialties working at Trust, SHA and National level and
has undertaken several initiatives with the Department of Health. She gained
an MBA from Durham in 2000.
Fiona is very much looking forwards to working with staff, patients, their
families and carers to support the design and delivery of a national safety
programme that will build on areas of excellence and create the conditions to
spread and sustain best practice nationally. Creating a culture of openness,
where staff and patients feel supported to raise concerns and shape their own
improvement efforts locally, she believes will be key to success.
Charles Vincent M Phil PhD
Professor of Psychology, University of Oxford
Charles Vincent trained as a Clinical Psychologist and worked in the British NHS
for several years. Since 1985 he has carried out research on the causes of harm
to patients, the consequences for patients and staff and methods of improving
the safety of healthcare. He established the Clinical Risk Unit at University
College in 1995 where he was Professor of Psychology before moving to the
Department of Surgery and Cancer at Imperial College in 2002. He is the editor
of Clinical Risk Management (BMJ Publications, 2nd edition, 2001), author of
Patient Safety (2ned edition 2010) and author of many papers on medical error,
risk and patient safety. From 1999 to 2003 he was a Commissioner on the UK
Commission for Health Improvement and has advised on patient safety in many
inquiries and committees including the recent Berwick Review. In 2007 he was
appointed Director of the National Institute of Health Research Centre for
Patient Safety & Service Quality at Imperial College Healthcare Trust. He is a
Fellow of the Academy of Social Sciences and was recently reappointed as a
National Institute of Health Research Senior Investigator. In 2014 he has taken
up a new most as Health Foundation professorial fellow in the Department of
Psychology, University of Oxford where he will continue his work on safety in
healthcare.
13

Dr Suzette Woodward
National Campaign Director, ‘Sign up for Safety’ Campaign
Suzette Woodward is the national Campaign Director for Sign up to Safety, a
campaign to support the NHS in England to save 6000 lives and reduce harm
by 50%. Suzette has worked at a national and international level in patient
safety for over 20 years. She is seconded from her executive director role in
safety and learning at the NHS Litigation Authority. Previous to this Suzette
was Director of Patient Safety at the National Patient Safety Agency. Suzette
specialises in implementation of patient safety initiatives using campaigning
and movement expertise and led the Patient Safety First Campaign. She has a
doctorate in patient safety implementation and masters in clinical risk from
UCL. Suzette was named as one of the top 50 Inspirational women in the NHS
in 2013 and named one of the top Nurse Leaders in the NHS in 2014.
14

Breakout Session One 11.05am – 12.00 pm (Delegates choose one of the following)
Leadership for quality improvement & safety
Chair – Lisa Butland, Director of Innovation, North West Coast AHSN
The Leadership difference
Jan Sobieraj, Managing Director, NHS Leadership Academy
The Patient Safety Collaborative has set out two key enablers - measurement
and leadership. Good leaders make a significant difference to the quality of
patient care and the NHS Leadership Academy is an England wide agency
designed to improve the leadership skills of leaders at all levels of the wider
healthcare system. The 15 minute presentation will outline: Why leadership is
an important factor to safety improvement, How the NHS Leadership Academy
is supporting the development of leaders, The opportunities that exist to
develop leaders through the Patient Safety Collaborative.
The Board’s role in leading for quality and safety- A regional approach
and programme
Lesley Massey, Director of the Advancing Quality Alliance (AQuA)
AQuA has been working with Boards and senior leadership teams for several
years and has established a development programme aimed at building the
capability of those teams in the improvement, oversight and governance of
quality and patient safety. Our ambition is to support every organisation to
build a system for improvement within a quality and safety strategy. A view into
that work is given and an insight into next stage developments for both acute
providers and for CCG governing bodies.
Leadership for safety – learning from Scotland
Joanne Matthews, Head of Safety, Healthcare Improvement
Scotland and Jane Murkin Head of Patient Safety and Improvement,
NHS Lanarkshire
Scotland’s Patient Safety Journey
This session will describe the safety work within NHS Scotland and share the
key leadership interventions and explore the leadership and cultural impact this
has had at both a national and local perspective.
Through Collective Leadership
Scotland’s policy focus and commitment to a quality improvement approach to
deliver safe, effective and person centred care within healthcare
National and local Infrastructure to support implementation
Translated to care at the bed side.
15

Measurement for improvement
Chair – Tony Roberts, Deputy Director, Quality Assurance Team, South
Tees Hospitals NHS Foundation Trust
Is healthcare getting safer’?
Professor Charles Vincent, Patient Safety Lead, Oxford AHSN
Patient safety has been high on the national and international agenda in health
care for over a decade. Studies around the world have shown that over 10% of
patients experience an adverse event while in hospital. Considerable efforts
have been made to improve safety, and it is natural to ask whether these efforts
have been well directed. Are patients any safer? The answer to this simple
question is curiously elusive. Although some aspects of safety are difficult to
measure for technical reasons (defining preventability for instance), the main
problem is that measurement and evaluation have not been high on the
agenda. There is evidence of major safety improvements from specific
programmes but it has been hard to demonstrate large scale improvements in
safety. The presentation will reflect on the challenges for the new patient safety
collaboratives.
A system based on continual learning: a guide to using
measurement for improvement
Phil Duncan, Patient Safety Collaborative Lead, NHS Improving Quality
and Ian Chappell, Improvement Manager, NHS Improving Quality
The purpose of this presentation is to explore what systems that learn look like
and how they ensure a learning cycle as opposed to one off encounters. This
session aims to:
• Provide an overview of what continual learning looks like within healthcare,
from national to local levels and offer insight into the opportunities for safety
that continuous learning provides
• Outline the Safety Framework and explore how continuous learning underlies
all aspects of safety improvement, from measuring improvement, providing
evidence of where to focus improvement efforts and as one indicator of a
safe working culture
• Review how we currently use data nationally to monitor patient safety and
the challenges of national and local measurement of safety improvement
• Outline 5 key principles of measurement for improvement
• Priority Setting and Baseline development
• A small number of operationally defined measures
• Understanding variation through regular measurement over time
• Smart analysis: how to cut the data to provide learning
• Qualitative Review: using regular reporting to provide theories of change.
The Safety Thermometer and measurement for improvement
Abigail Harrison, Senior Programme Manager,
Measurement and Innovation, Haelo
An overview of the NHS Safety Thermometer in the context of the AHSN
Patient Safety Collaboratives including:
• Context and challenges with measuring improvement
• What Safety Thermometers are available
• What baseline data you and your members already have access to
• How you can use the data for your Patient Safety Collaboratives
16

Collaboratives great and small – learning from
experience
Chair – Julie Neethling, AHSN Business Support Lead for NHS England
Integrating patient safety into the AHSN’s
Anna Burhouse, Director of Quality, West of England AHSN,
Elizabeth Dymond, Deputy Director, Enterprise & Translation, West of England
AHSN, Anne Pullyblank, Clinical Director, West of England AHSN
In the South West of England we have run a patient safety collaborative for 5
years involving 18 trusts with workstreams on peri-operative care, medicines
management, general ward, critical care and leadership. We have experience in
training for quality improvement, running themed workshops, developing
faculty and producing a system for measurement. We reduced HSMR so
delivered a real patient safety benefit. This was expanded from secondary care
to include mental health. We will present how we plan to use this existing
structure to build the AHSN collaborative and how we will integrate the work
with primary care and other sectors.
Learning from working regionally with collaboratives
Corinne Thomas, Programme Director South West Quality and Patient Safety
Improvement Programme, South of England Improving Safety in Mental Health
Collaborative
"Working collaboratively to achieve a common aim – my experience”
In this session your will hear about one methodology you may consider when
developing and running a collaborative. You will appreciate the factors critical
to success as well as understand some of the challenges you may face during
the life of your collaborative.
‘Sign up to Safety’ campaign – national considerations
Dr Suzette Woodward, Campaign Director, ‘Sign up to Safety’ campaign
A brief overview of the ‘Sign up for safety’ campaign.
17

Breakout Session Two 12.05pm – 12.35 pm (Delegates choose one of the following)
Chair, Philip Dylak, Director of Transition, North West Coast AHSN
Achieving Behaviour Change for Patient Safety
Judith Dyson, Lecturer Mental Health, University of Hull
Achieving Behaviour Change for Patient Safety
The problems with implementing best practice are widely acknowledged.
Interventions to change practice have had limited success. Two reasons have
been identified for this:
• Implementation strategies are not based on prospective assessment of
barriers and levers to practice and
• There is generally no theoretical basis informing the assessment of barriers
and levers and the subsequent implementation strategies employed.
The Improvement Academy, embedded in the Yorkshire and Humber AHSN is
working with internationally recognised behaviour change experts to apply a
theoretical approach to implementation through: i) regular, regional workshops
offering instruction on this approach, ii) a publically available behaviour change
toolkit offering resources and examples for the adoption of this approach and
iii) support for healthcare practitioners in clinical practice with applying these
techniques to patient safety issues.
This presentation will offer a brief outline of the behaviour change techniques
employed by the Academy and will demonstrate the feasibility and
effectiveness of this approach by giving examples of its application in practice.
Chair – Nigel Acheson, Regional Medical Director, NHS England South
Enhancing Quality and Recovery – Acute Kidney Injury
Kay Mackay, Director of Improvement, Kent, Surrey & Sussex (KSS) AHSN
and Ed Kingdon, KSS AKI Clinical Lead, Enhancing Quality
The Kent Surrey and Sussex Enhancing Quality and Recovery Programme is a
large scale clinical change programme aimed at embedding best practice and
reducing variation in care and outcomes for patients. The vision was that the
care a patient received would comply with known best practice and should not
depend on what hospital they attended, which clinical team they saw, what day
of the week or what time of day they received their treatment. The Acute
Kidney Injury (AKI) pathway began in 2011 with the aim of enhanced
recognition of AKI, implementation of simple responses to AKI in all clinical
disciplines and to spread learning rapidly across all acute hospitals in KSS. The
programme relies heavily on systematic, rigorous measurement to produce
credible, clinically-relevant benchmarking. Clinical leadership with local support
and ownership by each organisation is critical in achieving the goals.
18

Chair – James Scott, Regional Medical Director, NHS England South
South of England Improving Safety in Mental Health Collaborative
Shaun Clee, Chief Executive, 2gether NHS Foundation Trust and
Dr Helen Smith, Medical Director, Devon Partnership NHS Trust
Taking to the floor and learning to dance: The highs and lows of setting
up and running a Safety Collaborative in Mental Health
Mental Health Trusts in the South West of England and more recently across
the South of England have been working with the Institute for Health
Improvements (IHI) breakthrough collaborative model since 2011.
Our experience over this time has taught us a lot about how to set up and
running a collaborative and the fundamental building blocks that organisations
need to have in place to benefit most from this approach and to develop
sustainable positive change.
Leadership attention and organisational infrastructure are crucial in developing
the fertile ground required to grow and propagate quality improvement across
an organisation.
Our presentation will share with you the challenges and our attempts to
overcome them and our successes.
19

20
Academic Health Science Networks’ Safety Plans

Patient Safety:
A National and Local Priority
Our Patient Safety Collaborative aims:
Across the AHSN system: To develop a QI infrastructure which will support continued service improvement and innovation
At the point of care: To listen to and address the safety concerns of older patients, their carers, and the staff caring for them
Contacts: Dr Robert Winter EAHSN Managing Director - robert.winter@eashsn.org
Susan Went EAHSN PSC lead - susan.went@eahsn.org
Design Principles. We will seek to make our collaborative
practical and helpful by:
Building on the strength of our existing patient safety work;
Working in partnership with staff, carers and users to
design the work programme;
Working in partnership with other organisations and
networks involved in safety;
Avoiding duplication for the service;
Aligning interventions across care settings, reducing the
number of unique or sector specific interventions;
Advocating organisational, managerial and clinical
leadership for safety and quality;
Developing the capacity and capability of the system to use
data and to drive improvements in quality and safety;
Working across the continuum of improvement, testing
innovative ideas, spreading good practice and encouraging
reliable implementation;
Ensuring evaluation is integral to the design and delivery.
Our Partners
EAHSN Patient Safety Clinical Study Group
East of England Citizens Senate
NHSIQ
AQuA /NHS Leadership Academy/CLAHRC
EAHSN Academia
Delivery method
Adapted BTS collaborative model with twice
yearly whole system learning events
HIGH LEVEL PLAN
21

EMAHSN has consulted and engaged with our partners to
develop consensus on key patient safety priorities [see below].
We will: build alliances to optimise and share existing best
practice support and enable organisations to accelerate the
pace and scale of improvement activities.
cheryl.crocker@nottingham.ac.uk
07808647120 www.emahsn.org.uk @EM_AHSN
22

GMAHSNPatientSafetyCollaborative–PlanonaPage
OctǦDec ‘14 JanǦMarch ‘15 AprǦJun ‘15 JulyǦSept ‘15 OctǦDec ‘15 JanǦMar ‘16
PatientǦ
owned care
Identify what makes a
patient feel safe when
taking medicinces
Qualitative
exploration with
patient groups
Utilise output to informwork streams e.g. what does good patient information look like,
supporting mechanisms for onǦgoing
Patient access to their
data
Link to connected healthcare monitoring below

Point of care testing Increase the uptake of point of care testing for anticoagulant
monitoring – 3 CCGs participating
Patient decision aids Work with designer of NICE CG Patient Decision Aid to support evaluation and
understanding of GP educational needs in using this tool
Supported selfǦcare
selfǦmanagement
From identified sites / CCGs support the uptake in selfǦmonitoring and selfǦ
management – 3 CCGs participating
Solving
problems
Understand baseline
data
Utilising existing database sources to
understand patient safety in terms of
medicines utilization, linked to the
harms in PSC safety topics

Governance GM AHSN will coǦordinate programme, source and analyze information andmeasurement from across the local health economy and
provide feedback
Build leadership
workforce capabilities
in safety

AQUA programme inc advanced team training (12 teams of 6), PS champions training (40 people), improvement practitioner modules
240 places) and Sign up to Safety Network launch and 6 month engagement for all AHSN members (up to 160 attendees)
Health Foundation ’Closing the Gap’ programme for Board Level Collaborative on safety (10 localities), commencing in Feb 15
Connected healthcare
monitoring

Utilise capabilities of existing systems that allow patients access to their records eg. Renal Pt View, and adapt,
adopt and spread
RealǦtime monitoring
measurement

Increase uptake of FARSITE inGP
practices across AHSN footprint from
25% to 60% by March ‘15

Increase uptake of FARSITE inGP practices across AHSN footprint from 25% to 60% by
March ‘15
Social networking
media
Working with FT to design and run a
Hackathon for young adults with
Diabetes
New
mechanisms
for care
Evidence the
interventions which
improve adherence

Work with colleagues in Primary Care Patient Safety Translation Research Centre to align current evidence,
further advance research studies and spread of PINCER studies.

Drug safety
monitoring in real
world
Identify and work with 2 sites for utilisation of GP practice level safety dashboards designed
by Primary Care Patient Safety Translation Research Centre, refine prior to spread of tool.
Early adoption of
evidence, research
technology
Launch deploy
Innovation Nexus
(IN)Ǧ review and
support of SME
developments

Ongoing IN delivery with evaluation of impact and return on investment.
In partnership with NICE design an audit tool for the uptake of NICE guidelines for Medicines Management in
Nursing homes
Identify unmet health
care needs and
support development
Technology
Innovation Fund –
Nutrition and
Hydration £80k
Technology
Innovation Fund –
Medicines
Optimisation £80£

Scope Allmembers across GM e.g. Community hospitals, nursing homes, district nursing teams, acute hospitals, mental healthcare, commissioning
24

26
Health Innovation Network Patient Safety Collaborative -
Patient Safety from Board to Bus Stop
The Health Innovation Network (HIN) is embarking on a five-year
programme to support NHS organisations in South London in achieving
their patient safety aims, from Board to Bus Stop. The HIN Patient Safety
Collaborative (PSC) will be built with over time with patients and carers,
frontline staff, Board leaders and other stakeholders, working together across
the whole healthcare system - from hospitals to patients own homes - to co-design
interventions and initiatives to reduce avoidable harm, save lives and
embed a patient safety culture.
Our embedded aims are to support South London health and social care
organisations to:
• Develop strong leadership and to set an early collective tone and approach
for improvement
• Ensure that patients and carers are at the heart of our programmes, actively
involved in both design and delivery of projects
• Identify evidence-based and reliable practice (locally, nationally and
internationally), and to scale up and spread this in a sustainable way
• Embed a safety culture and help spark social movements for safer care
through broad staff involvement
• Develop improvement capability within organisations and leaders
• Help staff analyse, monitor and learn from safety and quality information
• Be a national exemplar of practice, and to create strategic partnerships with
other exemplars
• Develop interventions and initiatives which can be applied or adapted to all
care settings.
We are working with our stakeholders to understand which patient safety
issues should be prioritised, and how a collaborative approach might be able to
add value to what organisations are already doing to meet national
requirements. The programme will also be closely linked with national and local
initiatives, including ‘Sign up to Safety’, Quality Accounts, Safety Thermometer,
NHS Change Day, and King’s Health Partners Safety Connections programme.
Priorities identified for potential early action identified include: pressure ulcers,
falls, catheter-associated urinary tract infection (CAUTI), deteriorating patient,
and medications safety (insulin management). In year one, plans are under way
to scale up the following interventions:
• Right Insulin, Right Time, Right Dose – a breakthrough collaborative focused
on reducing harm to diabetic patients through better insulin management.
• No Catheter, No CAUTI – a collaborative to reduce harm from CAUTIs by
improving appropriate urinary catheter management in patients in hospital
and following discharge.
• A range of interprofessional interventions are being explored, including a
potential interdisciplinary ‘rounding’ offer and development of communities
of practice.
All interventions will be underpinned by a strong measurement function
supporting front line staff, and focused work with local education
commissioners to scope educational needs in priority areas and to ensure that
these needs can be met. A faculty of experts will act as critical friends for the
PSC, advising on proposals, evaluating impact, and acting as coaches,
facilitators and mentors for PSC projects and for HIN member patient safety
initiatives. Over time, we will evaluate impact, and embed programmes,
ensuring sustainability in the long-term. We will also deliver stretch targets
(expanding work to cover additional priority areas), develop commercial
partnerships, and explore innovative technologies that support patient safety.

IMPERIAL COLLEGE
Patient Safety Programme HEALTH PARTNERS
VISION PROJECTS DESCRIPTION OF ACTIVITY MEASURING IMPACT
Our vision is to support
organisations to
embed safety in every
aspect of their work.
This means:
‹ Patient and carer
views are obtained
and heard at all
levels as a critical
indicator of safety
‹ There is a strong
ethic of team
working and shared
responsibility for
patient safety
‹ Effective safety
measurement and
monitoring systems
are in place in all
clinical settings
‹ Clinical processes,
practices, equipment
and environment are
standardised and
ZPTWSPÄLK
Patient Safety
Champion
Network
Our programme will deliver:
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involvement and participation in patient
safety improvement initiatives across NWL
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issues and protocols amongst senior staff
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practice among partner organisations
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doctors’ induction across NWL
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and reduction in prescribing errors
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to reduce variation
Foundations
of Safety Best
Practice Forum
‹ NWL wide series of expert forums for nominated Board executives, non-executives,
senior leaders, commissioners and patient representatives.
‹ Participants will be able to foster shared best practice and innovation to
deliver organisational and cultural change.
Safety
measurement
and monitoring
‹ Collaboration with NHS trusts to test and further develop – through
application in practice – a holistic framework for measuring and monitoring
safety, developed by the Centre for Patient Safety and Service Quality
*7::8H[0TWLYPHS*VSSLNL3VUKVU
Prioritisation
of research
‹ Research to identify clinician and patient views on the key priorities for
patient safety in primary care, mental health and cancer care.
‹ Provides crucial intelligence to support future initiatives within these domains.
Prescribing
improvement
model
‹ Pilot improving pharmacists’ provision of feedback to doctors on their
prescribing errors, which aims to support better communication between
pharmacists and doctors.
Standardising
junior doctor
inductions
‹ 7YVQLJ[[VJYLH[LHYLSPHISLYL]PL^TLJOHUPZTMVY[OLHZZLZZTLU[VMHSS
deaths associated with hospital care, in order to assess what proportion
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mortality
research
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a single communication channel for key safety messages to be delivered
to this group.
Contact us
For more information contact our Patient Safety
team on:
ea@imperialcollegehealthpartners.com
Website: www.imperialcollegehealthpartners.com
Twitter: @ldn_ichp
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supporting and promoting their involvement in the design and delivery
of the Partnership’s patient safety work programme.
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27

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28

NENCPatientSafetyCollaborativeplanͲonͲaͲpage2014/15
Measuredusingthefollowingsuccesscriteria
x Havingclearmeasurableobjectivesat
programmeandprojectlevels
x Improvementsinpatientsafetyas
measuredbymilestonesandKPIs
x BiͲmonthlyprogressreportsshowing
projectdevelopmentandspreadof
improvement.
x Matchfundingandwealthcreationused
asacriteriaforinvestment.
x AHSNadditionalfundingsoughtthrough
businessdevelopmentopportunities.
Objective1:Leadershipandaccountability
Toensurethatthereisleadershipand
accountabilityforsafetythroughoutthe
system
Objective3:Transparency,reliability,
resilience,learningandimprovement
Tofosterasafetycultureoftransparency,
reliability,resilience,continuallearningand
improvement,basedonsoundsafety
science
Objective4:Workingingenuine
partnership
Todevelopgenuinepartnershipsbetween
thosewhogivecareandthosewhoreceive
caretoimprovetheirsafety
Deliveredthrough:
• Effectivegovernanceatproject,AcademicHealthScienceNetworkandnationallevels
• MembershipofnationalSteeringgroup
• MembershipofMeasurementandcommunicationssubͲgroups
• Delegationtonationallaunchevent.
Deliveredthrough:
• Buildingsystemwidecapabilityforstaffandpatientsinpatientsafetyimprovementscience.
• Creatingenvironmentsandopportunitieswherepeoplecancometogethertolearnfrom
eachother,includingregionalengagementandprojectlearningevents
Deliveredthrough:
• Systematicspreadofqualityimprovementsacrosshealthandsocialcare.
• Tobeinnovative,whilstgroundedinevidenceandusingtriedandtestedmethods
• Tobuilduponexistinginitiativesandstimulatenewideaslinkedtonationalandlocal
priorities
Overseenthroughthefollowinggovernance
arrangements:
x Accountable toNHSImproving
Quality/NHSEnglandatanationallevel.
x ABoardandExecTeamthatare
credible,engagedandactiveinsupport
oftheAHSNobjectives
x ClearleadershipfromSRO,supported
byasmallcoreteam
x AwellrunSteeringGroup,
representativeofandresponsiveto
constituentstakeholdersandprojects
x RobustmanagementofSLAsand
projectͲspecificcontractsforallfunding
x Proactiveandvibrantcommunication
ensuringbroadstakeholderawareness
andengagement
Objective7:SignuptoSafety
Toalignwithandcomplementthe
ambitionsofthe‘SignuptoSafety’
campaign
Deliveredthrough:
• Locallyownedandstructuredqualityimprovementinitiativesleadingtotransformational
change
• Activemanagementofthecirca£465kofPatientSafetyCollaborativefunding(£275from
nationalpotand£190kfromexistingAHSNbudget)
• Ensuringimprovementsaremeasurableandsustainable
Objective6:Tocollaborate
ToenableNHSstaffintheNorthEastand
NorthCumbriatohavetheopportunityto:
worktogetherinacollaborativeway,both
insideandoutsidetheirownorganisations
andwithnationalandinternational
expertise
Deliveredthrough:
• AfocusonpatientͲcentredapproaches,whichengagethepatientinunderstandingand
managingtheirownsafetyinaccordancewiththeirwishes.
• TocoͲproducesolutionsinvolvingstaffandpatients
Deliveredthrough:
• Peoplebeingsupportedtoengagewithalllevelsoftheorganisationswithinwhichthey
work
• Bringingtogetherpatientsandcarers,nationalandinternationalsafetyexpertisewith
practicalexperience,inpartnershipwithNHSEngland,NHSImprovingQuality,andother
national,internationalandlocalbodiesinterestedinimprovingsafety
• Beinginclusiveofallhealthsectors,withparityofmental,physicalandpsychological
health,inparticularfocussingonsafetyacrosscareboundaries
• WorkinginpartnershipwithotherAHSNswherethereareopportunitiestoshareexpertise
Deliveredthrough:
• Encouraginglocalorganisationstosignuptothecampaignandtodevelopcredibleplansto
achievethecampaignobjectives
• Helpparticipantsinthenationalpatientsafetyfellowshipschemetoachievetheir
objectiveslocally,throughnetworkingandothersupport
Objective2:Creatingtheconditionsfor
safety
Tocreatetheconditionsthathelpprevent
patientsafetyincidentsfromoccurringin
thefirstplace,engenderingasenseofpride
Objective5:Improvementprogramme
TodeliverasystemͲwide,locallyowned
andled,programmethatdeliversyearon
yearimprovementsinsafety
29

30
North West Coast Academic Health Science Network
Patient Safety Collaborative
Organisations involved to date
NWC AHSN has involved all of its NHS partners – providers,
commissioners and improvement bodies (AQuA, HAELO and NW
Leadership Academy) in the development of its proposals and plans for
the PSC (please visit www.nwcahsn.nhs.uk for details of colleague
organisations). On 17 September, NWC AHSN held a stakeholder
engagement event to which all of its NHS and academic partners were
invited. The event was designed to gain agreement on a number of
clinical and action priorities proposed by the AHSN. Organisations
unable to send representatives have been consulted on the outcomes of
the day.
Priority areas of work
NWC AHSN will ensure that all of the current NHS England requirements
are met. Based on outputs from its recent enagement event, its clinical
safety priorities will be medicines optimisation; management of sepsis;
transition between paediatric and adult care; and hydration. It has
already agreed a contract with a provider for a significant element of its
medicines optimisation work.
Its priority areas for action will be providing Board level development in
safety; providing safety training and development to staff working at
patient care level; agreeing a regional policy on patient safety; setting up
learning networks around safety improvement themes; developing
safety champions or leads in each organisation; and undertaking
technology reviews to identify solutions to safety issues.
High level workplan/approach
NWC AHSN will continue to use the principle of working with existing
structres and resources, unless they are patently unfit for purpose.
To drive and accelerate the Patient Safety agenda, NWC AHSN has
issued, with a short turnaround, a number of Preferred Supplier
Agreements to regional improvement bodies for support to its
improvement themes (which will be at the heart of how the PSC brings
about improvement); building leadership capacity and capability;
networking; board development; and measurement and data analysis.
NWC AHSN has asked all its suppliers to work within the established
structures for patient, carer and community engagement.
Contact
North West Coast Patient Safety Collaborative
C/O North West Coast Academic Health Science Network, Vanguard
House, Daresbury Sci Tech, Keckwick Lane, Daresbury, Warrington,
Cheshire, WA4 4AB
Philip Dylak, Programme Manager (Patient Safety)
T: 01772 520282
M: 07538 022771
E: philip.dylak@nwcahsn.nhs.uk

North West Coast Patient Safety Collaborative

32
Oxford Academic Health Science Network
Patient Safety Collaborative
Achieving safe health care has the potential to bring very great benefits
to patients, families and all involved in the delivery of care. The impact
of even small improvements in patient safety is massive, both in terms of
reducing the disease burden and in the huge economic benefits of safer
healthcare. Many safety initiatives are in progress in the Oxford AHSN
geography in acute NHS hospitals, community and mental health
settings and in the patient’s home. The bodies involved in this work
include NHS acute trusts, NHS community trusts, NHS mental health
trusts, care homes, social care bodies within county councils, care
commissioning groups, universities and pre-existing collaboratives and
federations.
The Oxford Academic Health Science Network Patient Safety
Collaborative (PSC) will initially focus on a small number of clinical
programmes but also act as an umbrella and coordinating centre for the
many important patient safety initiatives, both practice and research,
within the Oxford AHSN geography of Berkshire, Buckinghamshire,
Bedfordshire and Oxfordshire. The PSC will work alongside the clinical
networks within Oxford AHSN’s Best Care programme and ultimately be
accountable to the Oxford AHSN Partnership Board on which all NHS
providers, CCGs and Universities are represented.
The principal aims of the PSC will be to:
• Develop safety from its present narrow focus on hospital medicine to
embrace the entire patient pathway
• Develop and sustain clinical safety improvement programmes within
the Oxford AHSN
• Develop initiatives to build safer clinical systems across the Oxford
AHSN
• Collaborate and support sister safety programmes both nationally and
internationally.
Early priorities are:
• The active engagement of patients and carers
• The development of a safety information system for the PSC
• Establishment and support of programmes on acute kidney injury,
medication safety, pressure ulcers and safety in mental health
• Developing capacity and capability in leadership for safety
improvement.
The PSC has chosen to focus on a small number of core areas in the first
instance. We are conscious that further consultation needs to take place
with a wide range of partners and that the full programme of work will
only emerge gradually. The priorities set out here should be seen as a
starting point and not a definitive account.
In time we hope to develop programmes which will address risks and
systems vulnerabilities across the system and which are oriented towards
building a safer healthcare system. Our longer term aim must be to
design safe systems of care rather than address individual safety and
quality issues.

34
UCLPartners’ Patient Safety Programme: A collaborative
approach to sustained improvement in patient safety
The aim of the UCLPartners programme is to build, develop and support
improvement capabilities for front-line staff and to improve patient
safety outcomes for a population of six million people across our
partnership. Our focus is on progressively reducing avoidable harm and
embedding safety through an ethos of building continuous improvement into
routine practice at scale; establishing safety as normal practice across
UCLPartners. Nine design principles inform our approach. These are:
• To have meaningful patient, carer and family involvement
• To make partnership initiatives relevant to local priorities; embedding safety
into mainstream delivery
• To make safety relevant to the mainstream front line of care
• To build networks across the partnership and promote shared learning
• To ensure educational and trainee involvement and build leadership capacity
in safety
• To ground work in authentic and rigorous time series measurement
• To support partner organisations to build improvement capacity and capability
at scale
• To implement core informatics enablers for safe care
• To ensure robust evaluation.
Our approach to measurement will align teams’ understanding of where they
are currently and where the highest priority areas for attention lie. This is
rooted in four simple questions:
• Do you know how good you are?
• Do you know where you stand relative to the best?
• Do you know how much variation exists, and at what level in your system?
• Do you know your rate of improvement over time?
UCLPartners will ensure the safety and improvement work draws from and
informs/supports work in other regions and AHSNs wherever it usefully can.
We are focusing on informing commissioning priorities and approaches to
better align the whole system in supporting safety and improvement most
effectively.
UCLPartners
Academic Health Science Partnership
Building on existing foundations
UCLPartners’ patient safety programme builds on improvements and learnings
gained from existing UCLPartners collaborations including, the Deteriorating
Patient Initiative, which over the last three years has grown to involve 16 acute
trusts across UCLPartners’ geography.
Our priorities are derived from patient and population need matched to partner
organisations’ current safety priorities and their views on where partnership
working can add most value to local safety efforts. A small team, rooted in the
efforts of clinicians and front line teams across the partnership, will report to the
UCLPartners Executive, via a Programme Board chaired by Clare Panniker, Chief
Executive of Basildon and Thurrock University Hospitals NHS Foundation Trust.
The initial priorities include sepsis and acute kidney injury (AKI). Discussions are
ongoing with partners regarding other partnership-level priority areas, for
example, falls and pressure ulcers. Each of these areas contributes to our overall
aim of reducing mortality across the partnership, and, crucially, each is also
amenable to a whole health system approach – i.e. relevant in all settings from
care homes/usual place of residence to the acute hospital.
Each of UCLPartners’ integrated AHSN programmes is placing further and more
explicit emphasis on patient safety. These programmes include: cardiovascular,
mental health, neuroscience, children and young people, cancer and complex
patients. Their priority areas are currently being determined.
About UCLPartners
UCLPartners is an academic health science partnership with over 40 higher
education and NHS members, including 23 acute, mental health and
community NHS organisations. Through UCLPartners, members collaborate to
improve health outcomes and create wealth for a population of over six million
people in north east and north central London, south and west Hertfordshire,
south Bedfordshire, and south west and mid Essex.
Tel: 020 7679 6633 www.uclpartners.com

WestofEnglandAHSN– PatientSafety‘Planonapage’
2014/15– 15/16(Draftv0.3)
Patientsafetyas
‘everybody’sbusiness’
• Leadershipatalllevels
• STAREmergencyDepartment(supportedbyTHFShine)
• Maternitytbc
• SingleWestofEnglandEarlyWarningScoretoidentifyand
respondtopatientswhosehealthdeteriorates
• Developmentofameasurementstrategytoidentifylocalneeds
andprioritiesusingdatathatisalreadycollectedwhere
possible,andusingmetricsthataremeaningfultolocalpeople
• IdentificationandsetͲupofasuitablemeasurementsystem
• Mapcurrentquality/patientsafetyimprovementcapability
• DevelopmentofpatientsafetyFaculty/Fellowscohort
• WofE AHSNImprovementAcademy
• Humanfactors(comms)trainingforBands1Ͳ4theirmanagers
• FoundationDoctorQItrainingandprojectsupportnetwork
• Measurementevaluationstrategy
Focusonlocalneedsand
priorities
• Measurementcapabilitycapacity • Provisionofmeasurementforimprovementcapabilitytraining
tobuildcapacityintheWoE healthsystem?analysts?MDs?
• Engagementandinvolvementofstaff,people
whouseservicesandmembersofthepublic
• MultiͲmethodengagementandinvolvementprogrammeto
supportprioritydevelopment,conversationsaboutpatient
safety,andcommunicatingwiththeWofE community
• Newwaysofworkingtoenhancepatientsafety
Innovatingdeveloping
newapproaches
• Primarycareandcommunityincidentreportingandadverse
eventresponseandanalysisprocess(basedonworkinCornwall) • Incidentreportingandmultidisciplinaryresponse
Matchingleadingpractice • Programmeofworkshopsonfalls,medicationsoptimisation,
VTE,pressureulcers,CAUTI,criticalcare,periͲoperative
practice(basedonworkofSaferCareSouthWest)
• SouthofEnglandMentalHealthCollaborative
• PINCER/ECLIPSEmedications(basedonworkinotherAHSNs)
• Sepsis(fromnationalpriorities)
• Emergencylaparotomy(spreadingfromtheRUH/RSCHpilot)
• Acutekidneyinjury
• Conditionspecificsafetyprogrammes
• Mapcurrentquality/patientsafetyimprovementsuccesses
• Developingapproachestooptimisespeedofspreadand
adoptionofleadingpracticeacrosstheWestofEngland
• Spreadmethodology
36

WessexPatientSafetyCollaborative
WorkingtoimprovesafetyforpatientsinHampshire,Dorset,Isleof
WightandSouthWiltshire
WessexPatientSafetyCollaborativeSupportTeam
WessexAHSNChiefExecutive– MartinStephens
DirectorofPatientSafetyCollaborative– KeithLincoln
ClinicalLeadforPatientSafetyCollaborative– ProfessorJaneReid
PatientSafetyCollaborativeManager– GeoffCoper
(emailsto:firstname.lastname@wessexahsn.net)
PrioritySafetyTopics
SubjecttoaLaunchandListeneventon11Nov14wheretheemphasiswillbeoncoͲ
designandcoͲproduction,theWessexPatientSafetyCollaborativewilllookto
addressthefollowingareasinthefirstinstance:
The‘essentials’
LeadershipandMeasurement
Othersourcesofpotentialharm
MedicationErrors
TransfersofCare– toincludereducedreadmissions,improvedpatientandcarer
experience,reducedoutofhoursreferralsandfewerspecificharmse.g.AKI.
CurrentPosition
Priorityareasofwork
• Engagewithmembers,partnersandwiderstakeholderstoachieveawarenessof
thePSCandbuyͲintotheprogramme
• AsuccessfulLaunchandLearneventforWessexPSC(11th Nov)toidentifyareas
ofworkandachieveparticipationfromallstakeholders.Also,tohighlightthe
alignmenttoSignuptoSafetytosupportorganisationsincomplimentaryactivity.
• BaselinepatientsafetytopicsacrossWessex
HighLevelWorkplan
Oct14Ͳ NationalPSClaunchevent.DevelopoverarchingPSCplanincludingaims,
objectives,strategicdeliveryplansthatalignwiththenationalprogramme
measurementstrategy.
Nov14Ͳ WessexPSClaunchevent– identifyareasofpatientsafetytobeaddressed
bythePSC.Consolidateinformationandlearningfromlaunchevent. EstablishPSC
SteeringCommittee. Communicatelauncheventoutcomeswithstakeholders.
Dec15IdentifyinitialareasforPSCtotackleandstarttocoͲordinateinterested
stakeholdersforqualityimprovementevents. Engagesupporttobuildquality
improvementcapabilitywithinWessex.
Organisationsengagedasof30Sep14
ProviderTrusts
IsleofWightNHSTrust
TheRoyalBournemouthChristchurchHospitalsNHSFoundationTrust
PooleHospitalNHSFoundationTrust
SalisburyNHSFoundationTrust
UniversityHospitalSouthamptonNHSFoundationTrust
PortsmouthHospitalsNHSTrust
DorsetCountyHospitalFoundationTrust
HampshireHospitalsNHSFoundationTrust
DorsetHealthcareUniversityNHSFoundationTrust
SolentNHSTrust
SouthernHealthNHSFoundationTrust
SouthCentralAmbulanceServiceNHSFoundationTrust
SouthWesternAmbulanceServiceNHSFoundationTrust
ClinicalCommissioningGroups
LocalAuthorities
NorthEastHampshireandFarnham
DorsetCountyCouncil
IsleofWight
HampshireCountyCouncil
FarehamGosport
IsleofWightCouncil
NorthHampshire
PortsmouthCityCouncil
Dorset
SouthamptonCityCouncil
Portsmouth
WiltshireCountyCouncil
SouthEasternHampshire
SouthamptonCity
OtherStakeholders
WestHampshire
LocalMedicalCommittee
Wiltshire(Sarum locality)
HealthwatchHampshire
HealthwatchDorset
Universities
Bournemouth
SouthamptonSolent
Portsmouth
Southampton
Winchester
WessexAcademicHealthScienceNetwork,InnovationCentre,Southampton
SciencePark,2VentureRoad,Chilworth,SouthamptonSO167NP
Tel: 02382020840
37

Yorksh
Patient Safet
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ire and Humb
ety Collaborative (2014
up, from the top͛

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14-2019)
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ractical su
safety collaborative will build o
eryone from cleaners to consul
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on our successful patient safe
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xperience, and share learning acro
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se areas of safety that are m
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oss Yorkshire and Humber.
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come Organisatio
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networks
Evidence-based
x Effectivenes
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x Assessing patien
x Improvement
x Accessing t
x Safety measure
d resources for safety impro
ovement
search evidence
ams
m level
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eness Matters summaries of re
safety huddles for frontline tea
patient safety culture at team
ent data close to frontline
the patient voice in safety (e.g
x Managing t
x Online safet
Ref:140925
easurement and monitoring fra
tensions between learning and
safety training resources
Roundtable discussions Ÿ
Action Learning SetsŸ Peer r
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framework
performance
Masterclasses
eer review methods
Further information:
provement Academy,
te for Health Research
AHSN Im
Bradford Institute
www.improve
Tel: 01274 383926
ementacademy.org
38

39
Research Project Summary - Information for Trusts
“Supporting patients and healthcare staff to improve patient safety:
Developing an implementation package for ThinkSAFE”
Background
Approximately 10% of hospital patients are harmed by the care they receive,
leading to many approaches to improving safety, including an international
emphasis on patient involvement.
Within a previous programme of research funded by the National Institute for
Health Research the project group developed ThinkSAFE, a user-informed
robust approach supporting patient and family involvement in improving in-patient
safety. There are four components to ThinkSAFE which address the
needs of both service-user and frontline healthcare staff:
• a patient safety video
• a patient-held Healthcare Logbook, containing tools to facilitate patient/staff
interactions and the sharing of information
• ‘Talk Time’, a dedicated time to discuss queries and concerns with staff
• a theory and evidence-based educational session for staff.
The approach has generated international interest and has twice received a
Patient Experience Network National Award. Our recent pilot work has shown
that the approach is acceptable and feasible, that it can improve patient safety
and positively influence both patient and staff interactional behaviours. The
underlying concepts of the approach are generic, making it adaptable to local
context and varying needs of patients. ThinkSAFE has the potential to support a
fundamental shift in the way patients and staff work together, to deliver
improved patient experience and safety across whole organisations.
The current project will run for 12 months, starting in the autumn of 2014,
culminating in the development of an implementation package that includes a
detailed user-guide and implementation toolkit. This, and all ThinkSAFE
materials, will then be made freely accessible to NHS Trusts and patients via a
dedicated website, to encourage broad, effective and rapid dissemination and
implementation of ThinkSAFE.
Aim
To develop a package to support and promote dissemination and
implementation of ThinkSAFE across the North East AHSN region and beyond.
Objectives
1. To develop a package to include a detailed user manual, implementation
toolkit and promotional materials.
2. To make ThinkSAFE materials freely available to NHS Trusts and patients
through a dedicated website
3. To establish dissemination and promotional processes.
Who is leading the project?
The project is funded by the Academic Health Science Network North East
North Cumbria (AHSN NENC) and is also part of the newly established NENC
Patient Safety Collaborative. The project is led by Richard Thomson, Professor
of Epidemiology and Public Health, and Dr Susan Hrisos, Senior Research
Associate, who are both based in the Institute of Health Society at Newcastle
University.
Who can participate?
We are looking to recruit four acute Trusts across the North East region.
• Northumbria Healthcare and City Hospitals Sunderland NHS Foundation
Trusts have already agreed to take part
• We are now inviting participation of a further two acute Trusts
Interested Trusts should contact Susan Hrisos or Richard Thomson for further
information.
Contact details can be found on the following page.

40
What will Trusts be expected to do to deliver this project?
Participation includes:
Identification and support of a dedicated implementation team, including a
project (ThinkSAFE) Champion. This team will drive the project locally through:
• Promotion and engagement activities within the Trust
• The development of an implementation action plan, including small scale
(PDSA) pilot studies
• Regular team and networking meetings, including participation in an online
support forum to share learning across the four participating teams
• Delivery of staff training sessions about ThinkSAFE
• Implementation of ThinkSAFE
• Participation in co-design workshops to develop and refine the study
implementation package, ThinkSAFE resources and dedicated website
• Participation in dissemination and launch events.
What support is available to help Trusts deliver this project?
• A full time project manager will oversee and co-ordinate the project,
providing on-going guidance and support to each of the four participating
Trust teams
• Implementation teams will receive full training in the ThinkSAFE approach
and the implementation project aims and objectives
• A payment of £5000 is available to support Trust participation in the project
as described above
• Continuous support will also be provided by the project leads and an expert
Advisory Group
• All ThinkSAFE materials will be provided by the researchers.
If you are interested in involving your Trust in this project or would like more
information please contact Susan Hrisos, Senior Research Associate, Institute of
Health Society (IHS) on 0191 208 6774/6826 or by email at:
susan.hrisos@ncl.ac.uk
Further information
www.ahsn-nenc.org.uk/project/patient_safety.php
www.ncl.ac.uk/ihs/research/project/5063
www.ncl.ac.uk/ihs/research/project/4945
www.ihi.org/resources/Pages/AudioandVideo/WIHIEngagingPatientsinSafety.aspx

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