Development of Patient Safety from practical point of view

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1 Development of Patient Safety from practical point of view Berit Axelsson, improvement leader/ project leader. Jönköping County Council

2 During this hour. The Swedish Health Care System The National Work of Patient Safety Lex-Maria The law The agreement Patient safety package - initiative The work in Jönköping County Council Safer Health care- every time, all the time Safety culture

3 The Agency for Health Care (IVO) The County councils have considerable degree of autonomy and have independent powers of taxation

4 Open comparisons of Health Care Quality and Efficiency. Comparison between counties 2012

5 The National Patient Safety Work

6 Lex Maria The name lex Maria comes from the incident in 1936 when four patients at the Maria Hospital in Stockholm, died as a result of malpractice when they were injected with disinfectant instead of anesthetic.

7 Lex Maria The caregiver must report incidents that have led or could have led to a serious health damage to the Agency for Health Care (IVO). This rule is called Lex Maria. The Agency for Health Care (IVO) has been a part of National Board of Health and Welfare but on June 1st 2013 it became a new authority. They are taking care of complains from patients and Lex Maria cases.

8 National Swedish The Swedish Association of Local Authorities and Regions (SALAR). Initiative in Patient Safety

9 The Patient Safety Law The Caregivers responsibility Implement systematic Patient Safety Works and work preventative. They have an obligation to analyse adverse events They must inform patients and relatives as soon as possible in case of harm. They shall also inform what they have done to prevent the same thing to happen again. Patient and relatives should be a part of the Patient Safety work

Patientskador per tusen vårddagar Patientupplevelse Procent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% dec- 10 Följsamhet Basala Hygienrutiner och Rätt klädd jan feb mar apr maj jun jul aug sep okt

10 Patientskador per tusen vårddagar Patientupplevelse Procent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% dec- 10 Följsamhet Basala Hygienrutiner och Rätt klädd jan feb mar apr maj jun jul aug sep okt nov dec Tidsperiod Basala hygienrutiner Rätt klädd Målvärde Agreement between SALAR and the Demands 2013 Indicators 2013 Ministry of Health and Social Affairs. A.Patient Safety story 1. Hand hygiene and clothes > 70% Landstingets hälso- och sjukvård Nationell patientenkät, Primärvården 2010, (läk+ssk) B. National survey for patients (Primary Care Centres) 2. Use of antibiotics C20 C21 C22 Genomsnitt C. Update action plan Survey on patient safety culture 3. Use of medication 75 % of departments have routines for medication story 4. PPM- Pressurer ulcer 0,2 0,18 0,16 0,14 0,12 0,1 0,08 0,06 0,04 PPM-Trycksår, v 12 och 40, Landstinget i Jönköpings län. PPM-Trycksår v 12 PPM- Trycksår v 40 0, Patientskador per tusen vårddagar D. GTT records/ month/ hospital 5. Measure overcrowding Höglandets Jönköpings Värnamos sjukvårdsområde sjukvårdsområde sjukvårdsområde (Eksjö/Nässjö) (Ryhov) Sjukhus Landstinget i Jönköpings län Tertial 1 Tertial 2 Tertial Tertial 1 Tertial 2 Tertial Tertial 1 Tertial 2 Tertial 3 Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde Landstinget E. NPÖ (Give access to records) 25 % 6. Infection tool

11 The Work in Jönköping County Council

12 Jönköping County Council is responsible for the public health care services 3 hospitals 52 primary care centers 9,500 employees 350,000 inhabitants visits per day visit a specialist/day visit to GP/day (300 visits to private doctors/day) Jönköping Värnamo Höglandet 160 new patients staying over night at the hospitals/day 9 newborns/day

13 Leadership Structure Measurements Berit Axelsson Success factors Microsystemthinking patient and staff Culture Qulturum Everything at the same time

14 Strategic Improvement Areas

15 Klicka här för att ändra format på bakgrundsrubriken Klicka här för att ändra format på bakgrundstexten Nivå två Nivå tre Nivå fyra» Nivå fem Vision Patient Safety Create conditions to make it right from the beginning 15

16 Structure for the Patient Safety work The County Council leaders The Health Care leaders The Big Group of Health Care Berit Axelsson

17 The Big Group of Health Care Berit Axelsson 17

18 Structure for the Patient Safety work The Health Care leaders The Big Group of Health Care Risk and safety/security council Reference Group for Patient Safety Qulturums support in Patient Safety The departements strategy for Patient Safety Berit Axelsson

19 Reference Group for Patient Safety Head doctors (ylilääkäri) Lex Maria Head nurses Synergi manager Manager of patients right s committee Managers from infectios disease control and infection control The manager from medication committee The manager from Metodikum Patient Safety Qulturum Patient

20 Driver Diagram Patient Safety Aim: Safe Health Care All The Time Primary drivers Reliability Competence and Skills Learning Organisation Leadership Patient involvement Secondary drivers Standardize work routines Use Checklist Decrease variation Access Adaptability Improvement work Skill training Awareness of the current situation Incident reporting system Measurements Patient Safety Culture Motivation, action, follow up and feedback Challenge The process of patient Microsystem

Patientskador per vårdtillfälle 0,05 0,04 0,03 0,02 0,01 0,00 Tests performed with unequal sample sizes Månad 2007 UCL=0,03795 _ U=0,01789 LCL=0 ADE per dos 1 1 1 Micro Akuten Cor lab IVA/HIA Rehab

22 Patientskador per vårdtillfälle 0,05 0,04 0,03 0,02 0,01 0,00 Tests performed with unequal sample sizes Månad 2007 UCL=0,03795 _ U=0,01789 LCL=0 ADE per dos Micro Akuten Cor lab IVA/HIA Rehab The distribution of colours in Jönköping County Council Andel kliniker som skattat implementering av "Säker vård - alla gånger" % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Höglandet Jönköping Värnamo 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Område Patientskador per vårdtillfälle (AE) - Landstinget i Jönköpings län januari februari mars april maj juni juli augusti september oktober november december Läkemedelsrelaterade patientskador (ADE) Landstinget i Jönköpings län ,006 0,005 0,004 UCL=0, ,003 _ U=0, ,002 0,001 LCL=0, ,000 Tests performed with unequal sample sizes jun au g ok t dec feb apr jun au g ok t dec feb apr jun au g ok t dec feb apr jun au g ok t dec feb apr jun au g ok t dec feb apr jun au sep g Månad System measures 2005, Trustees of Dartmouth College, Nelson, January

24 Driver Diagram Patient Safety Aim: Safe Health Care All The Time Primary drivers Reliability Competence and Skills Learning Organisation Leadership Patient involvement Secondary drivers Standardize work routines Use Checklist Decrease variation Access Adaptability Improvement work Skill training Awareness of the current situation Incident reporting system Measurements Patient Safety Culture Motivation, action, follow up and feedback Challenge The process of patient Microsystem

25 If you want to have a successful event reporting system You have to work with: Structure for reports in the system and how to manage events Culture

improvement, exposure value) The event is recorded in Synergy Case

26 Structure - How to report An event occurs (workrelated injury, accident, incident, observation, patient comments, suggestions for improvement, exposure value) The event is recorded in Synergy Case Coordinator at responsible unit receives the information: where, when, who and what?

27 Structure how to work with the events Case Coordinator initiate investigation Feedback to the reporter Discuss the matter in working group and it must lead to something

28 Results from Synergi Jun The most important thing is not the number but rather what it is that have been reported and what has been done Events in the area of Patient Safety registered Jan-may Antal registreringar Patient- /kundsynpunkter Avvikelse - Olycka/Negativ händelse Avvikelse - Tillbud (ej personalrelaterad) Avvikelse - Iakttagelse/Risk Förbättringsförslag Patients feedback Adverse events Incidents Observati ons/ risks Ideas of improvem ent

29 Culture What we say and what we do. (ange enhet via Infoga sidfot)

30 What do we know about our patient safety culture? When there is much to do, we can not bring ourselves to report. Then we forget it. I do not understand why we must report things that were not of a serious matter. Quotes from patient safety culture measurement (ange enhet via Infoga sidfot)

31 A Safety Culture has many linked parts Reporting culture Just culture Flexible culture Learning culture

32 Säkerhetskultur All these elements must be linked correctly.

33 Forma en säker kultur To build a safe culture Methods and structures Attitudes and values Using and doing Thinking and believing

34 And.. Put patients behind the numbers The taste of water

35 Advice from a patient ( Orlando) Anne - Maj Thorsson

36 090922

37 Thank you.

AT&T Global Network Client for Windows Product Support Matrix January 29, 2015

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