This document summarizes Scotland's national efforts to reduce patient harm and mortality rates in acute care hospitals between 2008-2015. Key points: 1. Scotland set ambitious aims in 2008 to reduce mortality by 15% and adverse events by 30% by 2012 through a system-wide strategy focused on reliability and implementation of safety bundles/checklists. 2. By 2015, Scotland achieved a 20% reduction in mortality, a 30% reduction in adverse events, and reliability of over 95% for safety processes through developing leadership, measurement systems, and testing improvements at local hospitals before spreading changes nationally. 3. Improvements included a 90% reduction in C. difficile infections, a 25% reduction in ICU

1. Reducing Harm at a
National Level:
The Scottish Story
1st Symposium IHI-Einstein: Implementation and
Scale Up of Patient Safety Programs
November 4, 2013
São Paulo, Brazil
Derek Feeley
Carol Haraden

2. “By what method?...
only the method counts”
W Edwards Deming
Emphasis on Method

3. Our Change Theory
A clear and stretch goal
A method
Predictive, iterative testing
3

4. Where We Started:
SPSP Outcome Aim Set (2008)
Mortality: 15% Reduction
Adverse Events: 30% Reduction
– Ventilator Associated Pneumonia: 0 or 300 days between
– Central Line Bloodstream Infection: 0 or 300 days between
– Blood Sugars within Range (ITU/HDU): 80% or > w/in range
– MRSA Bloodstream Infection: 30% reduction
– Crash Calls: 30% reduction
4
To be achieved across the nation by 2012
Mortality aim amended to 20% by 2015

5. Developments in Acute Care Hospitals
5
Aims: To Further Improve the Safety of People
in Acute Adult Healthcare
1. Reduce Harm
95% of people in acute adult health care free from harms in the Scottish
Patient Safety Index by 2015:
Cardiac Arrest
Catheter Acquired Urinary Tract Infections
Pressure Ulcers
Falls
2. Reduce Hospital Associated Morality
Reduce HSMR by 20% by 2015

6. Further improve
the safety of
people in Acute
Adult Healthcare
Reduce Harm:
95% of people in acute
adult health care free
from harms in SPSI:
• Cardiac Arrest
• CAUTI
• Pressure Ulcers
• Falls
Reduce HSMR by
20%
By December 2015
Strategic
Priority
Point
of Care
Infrastructure
• Ensure safety and quality are
organisational priorities
• Provide leadership & oversight to
ensure delivery of programme
• Actively develop your safety culture
• Essentials of Safety are
comprehensively implemented
• Reliable person centered response to
deteriorating patients
• Reliable recognition & care delivery for
patients with Sepsis
• Reliable care delivery for patients with
Heart Failure
• Prevent avoidable Pressure Ulcers
• Reduce SSI
• Reliable risk assessment to prevent VTE
• Prevent CAUTI
• Reduce Falls
• Safer Use of Medicines
• Develop & utilise local capacity &
capability in QI
• Effective measurement systems
• Programme Management
• Effective Communications
• Manage transitions of care

7. Back to the start: What We Set Out to
Improve
Acute Program: 5 workstreams
Critical Care
Peri-operative Care
General Ward Care
Medicines Management
Leadership for Safety
7

8. How do we improve?

9. The Improvement Trilogy
Will
Ideas
Execution

10. What We Know Works
Leadership is critical
Clear Aim and Purpose
Strong Team
The Use of Data and Measure
Testing on a Small Scale
Deliberate Spread of Innovation

11. Three Separate and Critical
Competencies
1. Building successful prototypes
2. Implementation of the successful prototype
3. Spreading the change

12. Skills to Support Improvement
Using Data
Developing a Change
Testing a Change
Implementing a Change
Working With People

13. Critical Care
13

14. Care Bundles to Support
Peripheral Vascular Catheter (PVC) Bundle (HPS)
Check to ensure the PVC in situ are still required
Remove PVCs where there is extravasation or
inflammation
Check PVC dressings are intact
Consider removal of PVS in situ longer than 72 hours
Perform hand hygiene before and after all PVS
procedures
14

15. Peri-operative
15

16. General Ward
16

17. Medicines Management
17

18. Leadership
18

19. 0,8
0,9
1,0
1,1
Oct-Dec
2006
Apr-Jun
2007
Oct-Dec
2007
Apr-Jun
2008
Oct-Dec
2008
Apr-Jun
2009
Oct-Dec
2009
Apr-Jun
2010
Oct-Dec
2010
Apr-Jun
2011
Oct-Dec
2011
Apr-Jun
2012
StandardisedMortalityRatio
HSMR Scotland: January 2008 -September 2012
8497 less than expected deaths
12.4% reduction

20. HSMR – Annual Rolling Averages
20
0,8
0,9
0,9
1,0
1,0
1,1
1,1
1,2
1,2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
SMR
Quarters
HSMR - Annual Rolling Averages
Year Ending Oct-Dec 2002 to Jul-Sep 2012
1.4%
(Annualised Reduction)
Oct-Dec 2002 to Jan-Mar 2010
4.0%
(Annualised Reduction)
Apr-Jun 2010 to Jul-Sep
Dec 2009:

21. General ward C.Difficile rate (per thousand patient days)
21
0
0.5
1
1.5
2
2.5
Jan-08
Apr-08
Jul-08
O
ct-08
Jan-09
Apr-09
Jul-09
O
ct-09
Jan-10
Apr-10
Jul-10
O
ct-10
Jan-11
Apr-11
Jul-11
O
ct-11
1.15
0.12
90% reduction

22. VAP Prevention Bundle Reliability
(average Scottish ICUs)
22
VAP Prevention Bundle Reliability
and VAP rate/1000 ventilated days
(average across Scottish ICUs)
50%
75%
100%
Feb-08M
ay-08A
ug-08N
ov-08Feb-09M
ay-09A
ug-09N
ov-09Feb-10M
ay-10A
ug-10N
ov-10Feb-11M
ay-11A
ug-11N
ov-11Feb-12M
ay-12A
ug-12N
ov-12
0
6
12
18
Better
Better

23. Ventilator Acquired Pneumonia Rate
23

24. Surgical Safety Briefings
24

25. Scottish Amalgamated Hospital
Post-Op Surgical Mortality
25
0,00
0,20
0,40
0,60
0,80
1,00
1,20
1,40
1,60
1,80
Apr-Jun1981
Apr-Jun1982
Apr-Jun1983
Apr-Jun1984
Apr-Jun1985
Apr-Jun1986
Apr-Jun1987
Apr-Jun1988
Apr-Jun1989
Apr-Jun1990
Apr-Jun1991
Apr-Jun1992
Apr-Jun1993
Apr-Jun1994
Apr-Jun1995
Apr-Jun1996
Apr-Jun1997
Apr-Jun1998
Apr-Jun1999
Apr-Jun2000
Apr-Jun2001
Apr-Jun2002
Apr-Jun2003
Apr-Jun2004
Apr-Jun2005
Apr-Jun2006
Apr-Jun2007
Apr-Jun2008*
Apr-Jun2009*
Apr-Jun2010*
Apr-Jun2011*,p
%MortalityonDischarge
Quarter of Discharge
P' Chart for Surgical Mortality

26. Scotland ICU Mortality Percentage
26
0
5
10
15
20
25
30
jan/…
mar…
mai…
jul/…
set/…
nov…
jan/…
mar…
mai…
jul/…
set/…
nov…
jan/…
mar…
mai…
jul/…
set/…
nov…
jan/…
mar…
mai…
jul/…
set/…
nov…
jan/…
mar…
mai…
jul/…
Intensive Care Unit Mortality %
Units reporting via Extranet Average n = 16
National Average Annual…
14.6%
19.0% 18.3%
16.7%
14.3%
Overall reduction 25%

27. Scotland Average Length of Stay
27
0
1
2
3
4
5
6
7
jan/08
mar/08
mai/08
jul/08
set/08
nov/08
jan/09
mar/09
mai/09
jul/09
set/09
nov/09
jan/10
mar/10
mai/10
jul/10
set/10
nov/10
jan/11
mar/11
mai/11
jul/11
set/11
nov/11
jan/12
mar/12
mai/12
jul/12
Days
ICU average length of stay
15% reduction in median length of stay
average ICU los
median los
4.08 days
4.8 days

28. ICU ALOS
28
6.2 days
5.1 days
18% reduction
(1.1 days)
Cost saving of £990,000

29. How’d We Do? NHS Highland
Mortality: 15% reduction
Adverse Events: 30% reduction
Ventilator Associated Pneumonia: 0 or 300 days between
Central Line Bloodstream Infection: 0 or 300 days between
Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range
Harm from Anti-coagulation: Reduction in INRs > 6
All process measures will be > 95% reliable
AHO3
Adverse Events
Rate per 1000 patient days
.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
AHO3
Adverse Events
Rate per 1000 patient days
.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
7
11
9
11
11
11
1
12
3
12
5
12
7
12
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
7
11
9
11
11
11
1
12
3
12
5
12
7
12
CCO1
VAP Rate
Rate per 1000 ventilated days
.0
2.0
4.0
6.0
8.0
10.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
CCO1
VAP Rate
Rate per 1000 ventilated days
.0
2.0
4.0
6.0
8.0
10.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
CCO2
Central Line Infection
Rate per 1000 patient days
.0
2.0
4.0
6.0
8.0
10.0
6
11
8 10 12 2 4 6
12
CCO2
Central Line Infection
Rate per 1000 patient days
.0
2.0
4.0
6.0
8.0
10.0
6
11
8 10 12 2 4 6
12
CCO6
Optimal Glucose Control
Percent
70.0
75.0
80.0
85.0
90.0
95.0
100.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
CCO6
Optimal Glucose Control
Percent
70.0
75.0
80.0
85.0
90.0
95.0
100.0
6
11
8
11
10
11
12
11
2
12
4
12
6
12
MMP3C Filtered
INR>6
Percent
0.0
0.1
0.2
0.3
0.4
0.5
0.6
7
11
9
11
11
11
1
12
3
12
5
12
7
12
MMP3C Filtered
INR>6
Percent
0.0
0.1
0.2
0.3
0.4
0.5
0.6
7
11
9
11
11
11
1
12
3
12
5
12
7
12
Process reliability achieves improved outcomes!
697 days! 596 days!

30. 10 Interventions Now Embedded
10 Patient
Safety
Essentials
Hand Washing
PVC Bundle
Surgical Brief
& Pause
VAP Bundle
CVC
Insertion
CVC
Maintenance
General Ward
Safety Brief
Early Warning
Score
ICU Daily
Goals
Leadership
Walk rounds

31. Missing Ingredients
31
We needed a partner to help
us with design and
execution.
We needed to overcome
clinical (mainly medical)
resistance.
We needed to convince
leaders and managers that
this was not just “another
initiative.”
We needed to start
somewhere.

32. Solutions
32
Improving
the safety
of patients
Quality of
care &
patient safety
above all else
Engage &
empower
patients and
carers
Foster staff
development
and growth
Embrace
transparency
unequivocally

33. Remember…..
33
“Health statistics represent
people with the tears wiped off.”
Sir Austin Bradford Hill (1897-1991)