Implementing the Safety Thermometer tool in one NHS trust Catherine Buckley, Katrina Cooney, Eileen Sills and Eamonn Sullivan
Key words: Patient safety ■ Organisational culture ■ Prevalence ■ Leadership ■ Harm-free care
P
atient safety is a discipline in the healthcare sector that applies safety science methods to the goal of achieving a trustworthy system of healthcare delivery (Emanuel et al, 2008). Reviews of case records in the UK have shown that over 10% of patients experience an adverse event while in hospital (Vincent et al, 2001), which is reflected in similar studies around the world (Jha et al, 2008; Landrigan et al, 2010). Although patient safety has been high on healthcare agendas nationally and internationally for more than a decade, a lack of reliable information on safety and quality of care has hindered improvement in safety across the world (Vincent et al, 2008). The goal of the field of patient safety is to minimise these events and eliminate preventable harm in health care. This article will discuss a national initiative, the NHS Safety Thermometer (Department of Health (DH), 2012a) that has been developed to address measurement of patient safety and will describe the implementation process of this in a large NHS foundation trust. The culture of patient safety and the initiatives that are
Catherine Buckley is Safety Thermometer Lead, Katrina Cooney is Deputy Chief Nurse, Eileen Sills is Chief Nurse and Director of Patient Experience, Guys and St Thomas’ NHS Foundation Trust, London; Eamonn Sullivan was previously Deputy Chief Nurse, Guy’s and St Thomas’ NHS Foundation Trust and is now Deputy Chief Nurse, University College London Hospitals NHS Foundation Trust, London Accepted for publication: February 2014
268
Background In 2011, around 1000 frontline clinicians from strategic health authorities took part in a Safety Express (DH, 2011a) pilot to design and test innovative ways to achieve a reduction in patient harm. One of the programme’s successes was a simple audit tool, the ‘Safety Thermometer,’ which helped organisations gauge the likelihood of common harms and enabled them to track improvement progress and how rapidly it was happening. Voluntary reporting of patient safety incidents, including adverse events and serious untoward incidents are a vital component of a learning healthcare system (National Audit Office, 2005); however, they do not comprehensively measure harm. A shift in policy direction to enable a move in emphasis and resources away from unsystematic voluntary reporting, towards systematic measurement, as recommended by Vincent et al (2008), is logical and inevitable (Power et al, 2012). The NHS Safety Thermometer assists in addressing this recommendation. As a result of the success of the pilot, the NHS in England launched the Safety Thermometer nationwide under the Commissioning for Quality and Innovation (CQUIN) scheme in 2012 (DH, 2011b).The scheme provided a financial reward as an incentive to providers of NHS care to measure four common harms (pressure ulcers, falls, urinary infection in patients with a catheter and venous thromboembolism) on all patients being treated on one date each month using the Safety Thermometer tool. The initial government response to the Francis (2010) report has called for more openness, transparency and candour in order to create and underpin a culture of caring throughout the NHS (DH, 2013). This scheme provides an opportunity to establish a national data collection that can contribute to national initiatives and assist with these objectives.
Patient safety: our commitments to patients The trust, which is situated in inner London, is one of the largest NHS trusts in the UK and has integrated community services with more than 1.6 million patient contacts each year. It provides services from two major hospital sites that serve local populations and is a national referral centre for specialist services. Safety is the main focus for the authors’ trust’s leadership and creating a strong organisational safety culture is a fundamental responsibility of the trust’s leaders. Organisational culture can determine the success and sustainability of patient safety initiatives (Dixon-Woods et al,
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Abstract
To address measurement of patient safety, the NHS in England has introduced the NHS Safety Thermometer using the Commissioning for Quality and Innovation (CQUIN) scheme. The scheme offers a financial reward to all providers of NHS care measuring four common harms using the NHS Safety Thermometer on one day each month, with further incentives to achieve improvement goals in subsequent years of the scheme. This article discusses the background to the scheme and a rationale for the focus on pressure ulcers, falls in care, catheter use and urinary tract infection, and venous thromboembolism. The implementation process for this scheme in a large NHS foundation trust is detailed together with its effect within the authors’ organisation on harm-free care for their patients.
relevant to the scheme at this trust which were developed are also discussed in this article.
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PATIENT SAFETY 2012). The aim of the initiative in the authors’ organisation was to further the concept of harm-free care through leadership, safety culture, clinical care and support of the infrastructure necessary to deliver this care. As part of the implementation process, ward sisters and charge nurses were visited by the Safety Thermometer lead to discuss the implementation in their area. Leadership and safety culture is a primary driver of the NHS Safety Thermometer and the engagement from the frontline leaders within the authors’ organisation with this initiative has helped to develop the culture of safety within the organisation. Intentional rounding was an integral part of the process of implementing the Safety Thermometer as this ensured patients were placed at the centre of the ward routine and assisted ward leaders in educating staff about safety concepts and the importance of professional skill. Ensuring reliable data collection was a key issue and therefore it was important that all staff undertaking the audit understood the application of definitions. The importance of having robust data-collection systems to deliver accurate data and investing time in checking this information was emphasised to all staff involved in the audits. Feedback received was that the instrument was intuitive and able to be completed in approximately 10 minutes per patient. The tool contains clinically valid and practical definitions of harm, which enable it to be used across different settings (Table 1). The expert advisory groups had difficulty in reaching consensus on an outcome for catheter-associated urinary tract infection or venous thromboembolism (VTE) that could be used across healthcare settings. Therefore, process measures of VTE risk assessment and prophylaxis, and presence of a urinary catheter, are used. As healthcare issues are very complex, this leads to the concept of proxy measures where process measures are used instead of an outcome. Treatment of a urinary infection and VTE treatment are proxies for the outcomes. Despite controversy around the definitions of harm used in the tool and the statistical robustness of the tool, the Safety Thermometer is very important in raising awareness of avoidable harm and helping embed a culture of harm-free care. A review of available literature has shown a promising comparison with small-scale epidemiological studies and national audits, particularly with respect to pressure ulcers and catheter use (Power et al, 2012). One of the key measures in the NHS Safety Thermometer is the harm-free care composite measure, which is derived from the data collected in the audit. This harm-free measure is defined as the proportion of patients without the following: ■■ Any pressure ulcer regardless of origin ■■ A fall in care over the previous 72 hours ■■ A urinary tract infection in patients with a urinary catheter ■■ Treatment for a new VTE. Previous approaches to measuring harm have focused on the harm rather than the patient, for example the number of patients with a pressure ulcer. The design of the Safety Thermometer has attached importance to examining the four harms chosen collectively as patients who suffer one harm have a high probability of suffering further harm (Landrigan et al, 2010). There is clinical consensus that these four common harms are largely preventable through appropriate patient care; therefore, these were chosen as the
British Journal of Nursing, 2014, Vol 23, No 5
Table 1. Definition of harms measured by the Safety Thermometer Harm
Measurement
Pressure ulcer grade, based on European Pressure Ulcer Scale*
■■ Record
Falls in previous 72 hours in a care setting
■■ Record
Urinary catheter status (include if catheter removed in previous 72 hours)
Record number of days urinary catheter in situ: 1–28 days, greater than 28 days, or unknown duration (Supra pubic catheters not included)
Urinary tract infection
■■ Record
category of worst pressure ulcer (II, III, or IV) on admission (or within 72 hours of admission) or before referral to community case load = OLD ■■ If ulcer developed 72 hours post admission or after referral to community case load = NEW ■■ Present
severity of fall: No harm, low harm, moderate harm, severe harm or death ■■ Include home if patient on a district nurse caseload
if patient being treated for a urinary tract infection present on admission or before referral to community caseload = OLD ■■ If developed after admission or referral to community caseload = NEW ■■ If
Venous thromboembolism
■■ Record
if patient being treated for a VTE (deep vein thrombosis, pulmonary embolism, or other VTE) ■■ If present on admission = OLD, if after admission = NEW
*Source: European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009
Box 1. Review of background literature on harms in the Safety Thermometer Pressure ulcers Pressure ulcers present a major health challenge as they affect large numbers of people, are a major cause of morbidity, mortality and result in considerable health system expenditure (Whittington et al, 2004). Measuring the volume of pressure ulcers is complex and variations in the collection of data make valid study comparisons difficult. The occurrence of pressure ulcers is increasingly being used to assess the quality of care delivered by clinical facilities as many pressure ulcers are considered preventable (Baharestani et al, 2009). Falls Accidental falls are the most commonly reported safety incident and in 2005/6 accounted for more than 200 000 reports to the National Patient Safety Agency (Healey et al, 2007). An average ward will have approximately 10 falls each month, and of these 30% will result in harm (Healey et al, 2008). Falls are associated with various factors including age, confusion, medications and acute illness in older patients (Oliver et al, 2007). Catheter-associated urinary tract infection There is very little national data on the rates of catheter use in the UK; however, most surveys demonstrate that between 15% and 20% of inpatients in general hospitals are catheterised. Among all methods investigated, the most important intervention to preventing catheter associated urinary tract infection is limiting catheter use as the risk of developing an infection is between 3% and 7% a day when patients are catheterised (Hooton et al, 2010). Venous thromboembolism Each year VTE causes 25 000 deaths in the UK (National Clinical Guidelines Centre, 2010). It is unclear how many of these deaths are avoidable; however, 50% of patients who develop a VTE have been hospitalised in the previous 2 months (Cohen et al, 2007). Providers of care are contractually required to risk assess all patients and provide prophylaxis where appropriate.
focus of the Safety Thermometer audit by the DH. Box 1 summarises the background literature on harms in the Safety Thermometer. The NHS Safety Thermometer includes a function to merge patient safety data across all teams and wards in an
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organisation, and a built-in mechanism to submit data to the Health and Social Care Information Centre for inclusion and publication in the national database. Data validation at local and organisational level to ensure the robustness of the information is vital and errors need to be corrected before this information is submitted by a designated cut-off date each month. The accuracy of the data obtained depends on the skill set of the person auditing; therefore, for consistency and quality, all staff undertaking the audit should understand application of definitions. It is essential to invest time in checking the data as one wrong entry can underestimate or overestimate harm-free care significantly. The data from the Safety Thermometer around these four harms can be measured equitably across care settings from all organisations who submit data, giving an indication of safety in organisations around these harms. The aggregated assessment results generate a ‘percentage of harm-free care’ for the organisation. Over time, the data from the NHS Safety Thermometer can be used to establish a baseline against which improvement can be tracked. This scheme has enabled the NHS to publish the relative likelihood of a harmfree patient experience through the Health and Social Care Information Centre across every hospital participating and is the first healthcare system in the world to do so (Hunt, 2013).
Use of the NHS Safety Thermometer tool Clinicians undertaking the audit are required to use the operational definitions in the tool and obtain detail from medical records, patient examination and information from the patient where appropriate (Figure 1). All patients receiving NHS-funded care should be included in this audit, undertaken in all areas in an organisation on the same day. These include patients in hospital or care homes and patients in their own homes being visited by district nurses, specialist nurses or other members of the multidisciplinary team. Outpatient clinics, health visitors and school nurses are not required to include their clients in the audit.
Embedding the Safety Thermometer in practice For the authors’ trust, the NHS Safety Thermometer was an excellent opportunity to engage student nurses in promoting a safety culture. At the launch of the Safety Thermometer at
the authors’ trust in 2012, they trained 160 student nurses in NHS Safety Thermometer data collection. Education was given around the four key ‘harms’ described in the tool and also in human factors, detecting, minimising and learning from mistakes. In working with the ward leaders to assist in collecting and analysing the NHS Safety Thermometer data, the authors’ objectives were to educate their students in the concept of harm-free care, and how to recognise and act on near misses and actual errors in hospital. Empowering the students to act when they came across a potential safety incident in the clinical area immersed them in a safety culture. Student nurses were employed on the trust bank with CQUIN funds to assist in clinical areas with the NHS Safety Thermometer.The trust worked closely with higher education colleagues, ensuring students’ coursework or placements were not compromised by the initiative. Students have informed the authors how much they enjoyed participating in this audit and how it has helped them gain a deeper understanding of the concept of harm-free care. In December 2012, the trust’s implementation of the Safety Thermometer was recognised as one of three national ‘best practice examples’ by the DH. The National Reporting and Learning Service encourages healthcare organisations to foster a culture of patient safety. This culture is implemented in many ways at the trust. One approach is a weekly Friday quality briefings, chaired in turn by matrons from all areas, where the weekly key safety and operational performance indicators are presented for discussion. This forum attracts on average more than 100 nurses, students, general managers, therapists, doctors and estates staff from across acute and community sites. Although the briefings have been in place for a number of years, the trust has completely re-orientated the process using a ‘harmfree’ care methodology to align with the concepts in the Safety Thermometer. Re-orientating an established meeting where trust and openness had built up over time toward harm-free care has been highly successful. As part of the safety culture at the trust, results from NHS Safety Thermometer are presented each month at this forum. The forum is open and non-judgmental and data are presented in a manner that encourages the audience to participate, which has made it an excellent forum to discuss the monthly results. All areas participating in the audit receive feedback on their Safety Thermometer audit results through a scorecard detailing results of harm-free care. Ward managers and matrons display these results and these are also available in the organisation’s electronic scorecard system and accessible to all staff. All wards have access to their data to enable clinical staff to monitor progress and measure the impact of their actions on reducing patient harm. If clinical teams are to ensure or improve safety and quality, it is vital that they have data on their performance and an opportunity to reflect on the trends and features of those data over time (O’Neil et al, 2008).
Figure 1. Safety thermometer audit tool
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The NHS Safety Thermometer measures prevalence, not incidence, therefore it is of benefit to understand the difference between these and how these harms are measured in the tool. Prevalence is defined as the total number of cases of a particular harm in the surveyed population at one
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Understanding prevalence and incidence
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PATIENT SAFETY point in time. For example, all patients with a pressure ulcer on the day of the audit will be included regardless of when or where the pressure ulcer occurred. The tool will provide information on the prevalence of harm in the organisation around these key measurements on Safety Thermometer audit day. Incidence is measured through occurrence of harm over a period of time; for example, within an organisation, how many pressure ulcers or falls occurred over one week or month.
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Initiatives around harm-free care In 2013/14, there is a national CQUIN incentive relating to the Safety Thermometer and the reduction in pressure ulcers (DH, 2012b). Evidence from the Safety Thermometer pilot data suggests that it is possible to achieve a 50% reduction in pressure ulcer prevalence using strong leadership, highquality evidence (as in National Institute for Health and Care Excellence guidelines) and through integration of the goal into local change plans (DH, 2012c). The trust is part of the Shelford Group, which comprises 10 leading NHS multispecialty healthcare organisations and aspires to demonstrate system-wide leadership for the benefit of patients. As part of this plan to benefit patients and demonstrate leadership nationally in the goal of reducing the burden of pressure ulcers, the trust has agreed, together with commissioners, an ambitious scheme to establish a preventative outreach tissue viability team. The aim of this team is to promote improved prevention of pressure ulcers throughout the community reaching out beyond the hospital and community services into primary care, care homes and other organisations. Before the introduction of NHS Safety Thermometer at the trust, there were established work streams with innovative work around falls, pressure ulcers and VTE. However, the Safety Thermometer data highlighted the need to focus on urinary catheter use at the trust. The tool provided a monthly audit of urinary catheter use and demonstrated that usage was roughly in line with the national average. Strategies to reduce the use of catheterisation have been shown to be effective and are likely to have more impact on the incidence of catheter-associated urinary tract infections than any other strategies addressed in guidelines (Hooton et al, 2010). A working group has been set up to examine urinary catheter use and, within the trust, the authors intend to elevate urinary catheter use to the same level of introspection as intravenous catheter use. Multiple studies of interventions to decrease inappropriate catheter placement have demonstrated a decrease in the use of urinary catheters (Meddings et al, 2010). The authors’ trust has introduced one such initiative around electronic recording of catheter use—which includes indication for use and catheter days for patients who are catheterised— and is planning to extend this initiative to more clinical areas. Ongoing surveillance and feedback is an important intervention to reduce catheter-associated infection and sustain prevention efforts (Fakih et al, 2012). Other initiatives have included highlighting catheter awareness through a screensaver displayed on all trust computer screens, to encourage staff to ensure catheter clinically indicated before
British Journal of Nursing, 2014, Vol 23, No 5
Figure 2. Screensaver displayed on trust personal computers
insertion and to document rationale daily for continued use (Figure 2). Safety Thermometer data will allow for assessment of the effect of initiatives on catheter use within the trust. The trust continues to focus on falls and VTE, the two other harms in the Safety Thermometer audit. The trust’s falls group continues to analyse trends and incidences of falls and recommend remedial actions where appropriate. Falls incidents that are more complex are reviewed and the information is disseminated across the trust to inform learning. In addition, all patients that suffer a hospitalassociated thrombosis will have a root cause analysis as part of a drive to further learning and reduce harm from VTE. Nationally, it is too early to judge the reliability of NHS Safety Thermometer data as the number of patients and organisations reported has doubled during the reporting period thus far and the proportion of patients reported from different care settings has also changed. Data from the Safety Thermometer will be used to monitor the 20132015 CQUIN target (NHS England, 2013), which requires organisations to demonstrate a 50% reduction in pressure ulcer prevalence. There has been no change in the national prevalence of pressure ulcers to date; therefore, the authors would argue a concerted effort will be required through policy and regulation to provide the necessary impetus. Further lessons from large-scale implementation of the Safety Thermometer and the global learning from this initiative
KEY POINTS n Reviews
of case records have shown that 10% of patients experience an adverse event while in hospital
n The
NHS Safety Thermometer has been developed to address measurement of patient safety
n Organisational
culture can determine the success and sustainability of patient safety initiatives
n It
is vital that clinical teams have data on their performance to improve safety and quality
n The
NHS Safety Thermometer has provided insights to assist in reducing unintentional harm to patients within the trust
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on harm and measurement will be published in the future (Power et al, 2012). This first year of the CQUIN scheme has been concerned with data collection, staff training and establishing an accurate baseline. It has provided important insights within the authors’ organisation regarding harm-free care and has helped refocus the authors’ efforts to reduce harm to their patients. It has raised their awareness around urinary catheter use and will assist in their mission to become world leaders in patient BJN safety and to achieve the best patient outcomes. Conflict of interest: none Baharestani M, Black J, Carville K et al (2009) International Guidelines. Pressure Ulcer Prevention: Prevalence and Incidence in Context. A Consensus Document. http://www.woundsinternational.com/pdf/content_24.pdf (accessed 26 February 2014) Cohen AT, Agnelli G, Anderson FA et al (2007) Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 98: 756-64 Department of Health (2011a) Quality, Innovation, Productivity and Prevention. http://tinyurl.com/k547r94 (accessed 26 February 2014) Department of Health (2011b) The Operating Framework for the NHS in England 2012/13. http://tinyurl.com/nzn92ds (accessed 26 February 2014) Department of Health (2012a) Delivering the NHS Safety Thermometer CQUIN. A Preliminary Guide to Measuring ‘Harm Free’ Care 2012/2013. http://tinyurl.com/k8eeauc (accessed 26 February 2014) Department of Health (2012b) Delivering the NHS Safety Thermometer CQUIN 20112/13. http://tinyurl.com/b7kptql (accessed 26 February 2014) Department of Health (2012c) Using the Commissioning for Quality and Innovation payment framework: Guidance on new national goals for 2012-13. http://tinyurl.com/lmzys5d (accessed 26 February 2014) Department of Health (2013) Patients First and Foremmost. The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry http://tinyurl.com/cfceb3k (accessed 26 February 2014) Dixon-Woods M, McNicol S, Martin G (2012) Ten Challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf 21: 876-84 Emanuel L, Berwick D, Conway, J et al (2008) What exactly is patient safety? In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds, Advances in Patient Safety: New Directions and Alternative Approaches. Volume One: Asessment. Agency for Healthcare Research and Quality, Rockville MD http:// tinyurl.com/mle2dfl (accessed 26 February 2014) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Treatment of Pressure Ulcers: Quick Reference Guide. http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf (accessed 26 February 2014)
ction charting the geneaology of y and in the UK from the late 1980s
ss the patient’s role in safety nt Safety Agency, the role of ents safe, safe staffing levels, ol, how patients evaluate safety, based practice for safety, and the ns from safety failures.
Understanding Patient Safety
views on the emergence of patient considered an area of high priority
Understanding Patient Safety
Fakih MG, Watson SR, Greene MT et al (2012) Reducing inappropriate urinary catheter use. A statewide effort. Arch Intern Med 172(3): 255-60 Francis R (2010) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/ne2cx9s (accessed 4 March 2014) Healey E, Scobie S, Oliver D, Pryce A, Thomson R, Glampson B (2008) Falls in English and Welsh Hospitals’. Results of national observational study based on retrospective analysis of 12 months’ incident reporting. Qual Saf Health Care: 17(6): 424-30 Healey F, Scobie S, Glampson B et al for National Patient Safety Agency (2007) Slips, Trips and Falls in Hospital. The Third Report from the Patient Safety Observatory http://tinyurl.com/p729hmq (accessed 26 February 2014) Hooton TM1, Bradley SF, Cardenas DD et al (2010) Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 50(5): 625-63 Hunt J (2013) If we are to improve the silent scandal of patient safety across the NHS we need a new culture of openness, transparency and accountability. Speech given at University College London Hospitals 21 June 2013. http://tinyurl.com/lve3jkx (accessed 26 February 2014) Jha A, Prasopa-Plaizier N, Larizgoitia I, Bates D (2008) Patients safety research: an overview of the global evidence. Qual Saf Health Care 19: 42-7 Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. (2010) Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 363: 2124-34 Meddings J, Rogers MA, Macy M, Saint S (2010) Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 51: 550-60 National Audit Office (2005) A Safer Place for Patients: Learning to improve patient safety. http://tinyurl.com/p6lbwb2 (accessed 26 February 2014) National Clinical Guideline Centre – Acute and Chronic Conditions (2010) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. (Full version of NICE CG92). http://tinyurl.com/nu7u7fs (accessed 26 February 2014) NHS England (2013) Putting Patients First: The NHS Business Plan for 2013/14-2015/16. http://tinyurl.com/clssgfn (accessed 26 February 2014) Oliver D, Connelly J, Victor CR et al (2007) Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 334: 82-7 O’Neil O, Cornwell J, Thompson A et al for The King’s Fund (2008) Safe Births: Everybody’s business. Independent inquiry into the safety of maternity services in England. http://tinyurl.com/pma4eyw (accessed 26 February 2014) Power M, Stewart L, Brotherton A (2012) What is the NHS Safety Thermometer? Clin Risk 18(5): 163-9 Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322: 517-9 Vincent C, Aylin P, Franklin BD, et al (2008) Is health care getting safer? BMJ 337: a2426 Whittington K, Briones R (2004) National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care 17(9): 490-94
Understanding Patient Safety n Timely evidence-based text on safety practices n Discusses governmental and the patient’s role in safety
Evaluating and Improvement, e, Oxford
n Includes a review of the history of patient safety
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Key words: Patient safety ■ Organisational culture ■ Prevalence ■ Leadership ■ Harm-free care
P
atient safety is a discipline in the healthcare sector that applies safety science methods to the goal of achieving a trustworthy system of healthcare delivery (Emanuel et al, 2008). Reviews of case records in the UK have shown that over 10% of patients experience an adverse event while in hospital (Vincent et al, 2001), which is reflected in similar studies around the world (Jha et al, 2008; Landrigan et al, 2010). Although patient safety has been high on healthcare agendas nationally and internationally for more than a decade, a lack of reliable information on safety and quality of care has hindered improvement in safety across the world (Vincent et al, 2008). The goal of the field of patient safety is to minimise these events and eliminate preventable harm in health care. This article will discuss a national initiative, the NHS Safety Thermometer (Department of Health (DH), 2012a) that has been developed to address measurement of patient safety and will describe the implementation process of this in a large NHS foundation trust. The culture of patient safety and the initiatives that are
Catherine Buckley is Safety Thermometer Lead, Katrina Cooney is Deputy Chief Nurse, Eileen Sills is Chief Nurse and Director of Patient Experience, Guys and St Thomas’ NHS Foundation Trust, London; Eamonn Sullivan was previously Deputy Chief Nurse, Guy’s and St Thomas’ NHS Foundation Trust and is now Deputy Chief Nurse, University College London Hospitals NHS Foundation Trust, London Accepted for publication: February 2014
268
Background In 2011, around 1000 frontline clinicians from strategic health authorities took part in a Safety Express (DH, 2011a) pilot to design and test innovative ways to achieve a reduction in patient harm. One of the programme’s successes was a simple audit tool, the ‘Safety Thermometer,’ which helped organisations gauge the likelihood of common harms and enabled them to track improvement progress and how rapidly it was happening. Voluntary reporting of patient safety incidents, including adverse events and serious untoward incidents are a vital component of a learning healthcare system (National Audit Office, 2005); however, they do not comprehensively measure harm. A shift in policy direction to enable a move in emphasis and resources away from unsystematic voluntary reporting, towards systematic measurement, as recommended by Vincent et al (2008), is logical and inevitable (Power et al, 2012). The NHS Safety Thermometer assists in addressing this recommendation. As a result of the success of the pilot, the NHS in England launched the Safety Thermometer nationwide under the Commissioning for Quality and Innovation (CQUIN) scheme in 2012 (DH, 2011b).The scheme provided a financial reward as an incentive to providers of NHS care to measure four common harms (pressure ulcers, falls, urinary infection in patients with a catheter and venous thromboembolism) on all patients being treated on one date each month using the Safety Thermometer tool. The initial government response to the Francis (2010) report has called for more openness, transparency and candour in order to create and underpin a culture of caring throughout the NHS (DH, 2013). This scheme provides an opportunity to establish a national data collection that can contribute to national initiatives and assist with these objectives.
Patient safety: our commitments to patients The trust, which is situated in inner London, is one of the largest NHS trusts in the UK and has integrated community services with more than 1.6 million patient contacts each year. It provides services from two major hospital sites that serve local populations and is a national referral centre for specialist services. Safety is the main focus for the authors’ trust’s leadership and creating a strong organisational safety culture is a fundamental responsibility of the trust’s leaders. Organisational culture can determine the success and sustainability of patient safety initiatives (Dixon-Woods et al,
© 2014 MA Healthcare Ltd
Abstract
To address measurement of patient safety, the NHS in England has introduced the NHS Safety Thermometer using the Commissioning for Quality and Innovation (CQUIN) scheme. The scheme offers a financial reward to all providers of NHS care measuring four common harms using the NHS Safety Thermometer on one day each month, with further incentives to achieve improvement goals in subsequent years of the scheme. This article discusses the background to the scheme and a rationale for the focus on pressure ulcers, falls in care, catheter use and urinary tract infection, and venous thromboembolism. The implementation process for this scheme in a large NHS foundation trust is detailed together with its effect within the authors’ organisation on harm-free care for their patients.
relevant to the scheme at this trust which were developed are also discussed in this article.
British Journal of Nursing, 2014, Vol 23, No 5
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© 2014 MA Healthcare Ltd
PATIENT SAFETY 2012). The aim of the initiative in the authors’ organisation was to further the concept of harm-free care through leadership, safety culture, clinical care and support of the infrastructure necessary to deliver this care. As part of the implementation process, ward sisters and charge nurses were visited by the Safety Thermometer lead to discuss the implementation in their area. Leadership and safety culture is a primary driver of the NHS Safety Thermometer and the engagement from the frontline leaders within the authors’ organisation with this initiative has helped to develop the culture of safety within the organisation. Intentional rounding was an integral part of the process of implementing the Safety Thermometer as this ensured patients were placed at the centre of the ward routine and assisted ward leaders in educating staff about safety concepts and the importance of professional skill. Ensuring reliable data collection was a key issue and therefore it was important that all staff undertaking the audit understood the application of definitions. The importance of having robust data-collection systems to deliver accurate data and investing time in checking this information was emphasised to all staff involved in the audits. Feedback received was that the instrument was intuitive and able to be completed in approximately 10 minutes per patient. The tool contains clinically valid and practical definitions of harm, which enable it to be used across different settings (Table 1). The expert advisory groups had difficulty in reaching consensus on an outcome for catheter-associated urinary tract infection or venous thromboembolism (VTE) that could be used across healthcare settings. Therefore, process measures of VTE risk assessment and prophylaxis, and presence of a urinary catheter, are used. As healthcare issues are very complex, this leads to the concept of proxy measures where process measures are used instead of an outcome. Treatment of a urinary infection and VTE treatment are proxies for the outcomes. Despite controversy around the definitions of harm used in the tool and the statistical robustness of the tool, the Safety Thermometer is very important in raising awareness of avoidable harm and helping embed a culture of harm-free care. A review of available literature has shown a promising comparison with small-scale epidemiological studies and national audits, particularly with respect to pressure ulcers and catheter use (Power et al, 2012). One of the key measures in the NHS Safety Thermometer is the harm-free care composite measure, which is derived from the data collected in the audit. This harm-free measure is defined as the proportion of patients without the following: ■■ Any pressure ulcer regardless of origin ■■ A fall in care over the previous 72 hours ■■ A urinary tract infection in patients with a urinary catheter ■■ Treatment for a new VTE. Previous approaches to measuring harm have focused on the harm rather than the patient, for example the number of patients with a pressure ulcer. The design of the Safety Thermometer has attached importance to examining the four harms chosen collectively as patients who suffer one harm have a high probability of suffering further harm (Landrigan et al, 2010). There is clinical consensus that these four common harms are largely preventable through appropriate patient care; therefore, these were chosen as the
British Journal of Nursing, 2014, Vol 23, No 5
Table 1. Definition of harms measured by the Safety Thermometer Harm
Measurement
Pressure ulcer grade, based on European Pressure Ulcer Scale*
■■ Record
Falls in previous 72 hours in a care setting
■■ Record
Urinary catheter status (include if catheter removed in previous 72 hours)
Record number of days urinary catheter in situ: 1–28 days, greater than 28 days, or unknown duration (Supra pubic catheters not included)
Urinary tract infection
■■ Record
category of worst pressure ulcer (II, III, or IV) on admission (or within 72 hours of admission) or before referral to community case load = OLD ■■ If ulcer developed 72 hours post admission or after referral to community case load = NEW ■■ Present
severity of fall: No harm, low harm, moderate harm, severe harm or death ■■ Include home if patient on a district nurse caseload
if patient being treated for a urinary tract infection present on admission or before referral to community caseload = OLD ■■ If developed after admission or referral to community caseload = NEW ■■ If
Venous thromboembolism
■■ Record
if patient being treated for a VTE (deep vein thrombosis, pulmonary embolism, or other VTE) ■■ If present on admission = OLD, if after admission = NEW
*Source: European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009
Box 1. Review of background literature on harms in the Safety Thermometer Pressure ulcers Pressure ulcers present a major health challenge as they affect large numbers of people, are a major cause of morbidity, mortality and result in considerable health system expenditure (Whittington et al, 2004). Measuring the volume of pressure ulcers is complex and variations in the collection of data make valid study comparisons difficult. The occurrence of pressure ulcers is increasingly being used to assess the quality of care delivered by clinical facilities as many pressure ulcers are considered preventable (Baharestani et al, 2009). Falls Accidental falls are the most commonly reported safety incident and in 2005/6 accounted for more than 200 000 reports to the National Patient Safety Agency (Healey et al, 2007). An average ward will have approximately 10 falls each month, and of these 30% will result in harm (Healey et al, 2008). Falls are associated with various factors including age, confusion, medications and acute illness in older patients (Oliver et al, 2007). Catheter-associated urinary tract infection There is very little national data on the rates of catheter use in the UK; however, most surveys demonstrate that between 15% and 20% of inpatients in general hospitals are catheterised. Among all methods investigated, the most important intervention to preventing catheter associated urinary tract infection is limiting catheter use as the risk of developing an infection is between 3% and 7% a day when patients are catheterised (Hooton et al, 2010). Venous thromboembolism Each year VTE causes 25 000 deaths in the UK (National Clinical Guidelines Centre, 2010). It is unclear how many of these deaths are avoidable; however, 50% of patients who develop a VTE have been hospitalised in the previous 2 months (Cohen et al, 2007). Providers of care are contractually required to risk assess all patients and provide prophylaxis where appropriate.
focus of the Safety Thermometer audit by the DH. Box 1 summarises the background literature on harms in the Safety Thermometer. The NHS Safety Thermometer includes a function to merge patient safety data across all teams and wards in an
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organisation, and a built-in mechanism to submit data to the Health and Social Care Information Centre for inclusion and publication in the national database. Data validation at local and organisational level to ensure the robustness of the information is vital and errors need to be corrected before this information is submitted by a designated cut-off date each month. The accuracy of the data obtained depends on the skill set of the person auditing; therefore, for consistency and quality, all staff undertaking the audit should understand application of definitions. It is essential to invest time in checking the data as one wrong entry can underestimate or overestimate harm-free care significantly. The data from the Safety Thermometer around these four harms can be measured equitably across care settings from all organisations who submit data, giving an indication of safety in organisations around these harms. The aggregated assessment results generate a ‘percentage of harm-free care’ for the organisation. Over time, the data from the NHS Safety Thermometer can be used to establish a baseline against which improvement can be tracked. This scheme has enabled the NHS to publish the relative likelihood of a harmfree patient experience through the Health and Social Care Information Centre across every hospital participating and is the first healthcare system in the world to do so (Hunt, 2013).
Use of the NHS Safety Thermometer tool Clinicians undertaking the audit are required to use the operational definitions in the tool and obtain detail from medical records, patient examination and information from the patient where appropriate (Figure 1). All patients receiving NHS-funded care should be included in this audit, undertaken in all areas in an organisation on the same day. These include patients in hospital or care homes and patients in their own homes being visited by district nurses, specialist nurses or other members of the multidisciplinary team. Outpatient clinics, health visitors and school nurses are not required to include their clients in the audit.
Embedding the Safety Thermometer in practice For the authors’ trust, the NHS Safety Thermometer was an excellent opportunity to engage student nurses in promoting a safety culture. At the launch of the Safety Thermometer at
the authors’ trust in 2012, they trained 160 student nurses in NHS Safety Thermometer data collection. Education was given around the four key ‘harms’ described in the tool and also in human factors, detecting, minimising and learning from mistakes. In working with the ward leaders to assist in collecting and analysing the NHS Safety Thermometer data, the authors’ objectives were to educate their students in the concept of harm-free care, and how to recognise and act on near misses and actual errors in hospital. Empowering the students to act when they came across a potential safety incident in the clinical area immersed them in a safety culture. Student nurses were employed on the trust bank with CQUIN funds to assist in clinical areas with the NHS Safety Thermometer.The trust worked closely with higher education colleagues, ensuring students’ coursework or placements were not compromised by the initiative. Students have informed the authors how much they enjoyed participating in this audit and how it has helped them gain a deeper understanding of the concept of harm-free care. In December 2012, the trust’s implementation of the Safety Thermometer was recognised as one of three national ‘best practice examples’ by the DH. The National Reporting and Learning Service encourages healthcare organisations to foster a culture of patient safety. This culture is implemented in many ways at the trust. One approach is a weekly Friday quality briefings, chaired in turn by matrons from all areas, where the weekly key safety and operational performance indicators are presented for discussion. This forum attracts on average more than 100 nurses, students, general managers, therapists, doctors and estates staff from across acute and community sites. Although the briefings have been in place for a number of years, the trust has completely re-orientated the process using a ‘harmfree’ care methodology to align with the concepts in the Safety Thermometer. Re-orientating an established meeting where trust and openness had built up over time toward harm-free care has been highly successful. As part of the safety culture at the trust, results from NHS Safety Thermometer are presented each month at this forum. The forum is open and non-judgmental and data are presented in a manner that encourages the audience to participate, which has made it an excellent forum to discuss the monthly results. All areas participating in the audit receive feedback on their Safety Thermometer audit results through a scorecard detailing results of harm-free care. Ward managers and matrons display these results and these are also available in the organisation’s electronic scorecard system and accessible to all staff. All wards have access to their data to enable clinical staff to monitor progress and measure the impact of their actions on reducing patient harm. If clinical teams are to ensure or improve safety and quality, it is vital that they have data on their performance and an opportunity to reflect on the trends and features of those data over time (O’Neil et al, 2008).
Figure 1. Safety thermometer audit tool
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The NHS Safety Thermometer measures prevalence, not incidence, therefore it is of benefit to understand the difference between these and how these harms are measured in the tool. Prevalence is defined as the total number of cases of a particular harm in the surveyed population at one
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Understanding prevalence and incidence
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PATIENT SAFETY point in time. For example, all patients with a pressure ulcer on the day of the audit will be included regardless of when or where the pressure ulcer occurred. The tool will provide information on the prevalence of harm in the organisation around these key measurements on Safety Thermometer audit day. Incidence is measured through occurrence of harm over a period of time; for example, within an organisation, how many pressure ulcers or falls occurred over one week or month.
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Initiatives around harm-free care In 2013/14, there is a national CQUIN incentive relating to the Safety Thermometer and the reduction in pressure ulcers (DH, 2012b). Evidence from the Safety Thermometer pilot data suggests that it is possible to achieve a 50% reduction in pressure ulcer prevalence using strong leadership, highquality evidence (as in National Institute for Health and Care Excellence guidelines) and through integration of the goal into local change plans (DH, 2012c). The trust is part of the Shelford Group, which comprises 10 leading NHS multispecialty healthcare organisations and aspires to demonstrate system-wide leadership for the benefit of patients. As part of this plan to benefit patients and demonstrate leadership nationally in the goal of reducing the burden of pressure ulcers, the trust has agreed, together with commissioners, an ambitious scheme to establish a preventative outreach tissue viability team. The aim of this team is to promote improved prevention of pressure ulcers throughout the community reaching out beyond the hospital and community services into primary care, care homes and other organisations. Before the introduction of NHS Safety Thermometer at the trust, there were established work streams with innovative work around falls, pressure ulcers and VTE. However, the Safety Thermometer data highlighted the need to focus on urinary catheter use at the trust. The tool provided a monthly audit of urinary catheter use and demonstrated that usage was roughly in line with the national average. Strategies to reduce the use of catheterisation have been shown to be effective and are likely to have more impact on the incidence of catheter-associated urinary tract infections than any other strategies addressed in guidelines (Hooton et al, 2010). A working group has been set up to examine urinary catheter use and, within the trust, the authors intend to elevate urinary catheter use to the same level of introspection as intravenous catheter use. Multiple studies of interventions to decrease inappropriate catheter placement have demonstrated a decrease in the use of urinary catheters (Meddings et al, 2010). The authors’ trust has introduced one such initiative around electronic recording of catheter use—which includes indication for use and catheter days for patients who are catheterised— and is planning to extend this initiative to more clinical areas. Ongoing surveillance and feedback is an important intervention to reduce catheter-associated infection and sustain prevention efforts (Fakih et al, 2012). Other initiatives have included highlighting catheter awareness through a screensaver displayed on all trust computer screens, to encourage staff to ensure catheter clinically indicated before
British Journal of Nursing, 2014, Vol 23, No 5
Figure 2. Screensaver displayed on trust personal computers
insertion and to document rationale daily for continued use (Figure 2). Safety Thermometer data will allow for assessment of the effect of initiatives on catheter use within the trust. The trust continues to focus on falls and VTE, the two other harms in the Safety Thermometer audit. The trust’s falls group continues to analyse trends and incidences of falls and recommend remedial actions where appropriate. Falls incidents that are more complex are reviewed and the information is disseminated across the trust to inform learning. In addition, all patients that suffer a hospitalassociated thrombosis will have a root cause analysis as part of a drive to further learning and reduce harm from VTE. Nationally, it is too early to judge the reliability of NHS Safety Thermometer data as the number of patients and organisations reported has doubled during the reporting period thus far and the proportion of patients reported from different care settings has also changed. Data from the Safety Thermometer will be used to monitor the 20132015 CQUIN target (NHS England, 2013), which requires organisations to demonstrate a 50% reduction in pressure ulcer prevalence. There has been no change in the national prevalence of pressure ulcers to date; therefore, the authors would argue a concerted effort will be required through policy and regulation to provide the necessary impetus. Further lessons from large-scale implementation of the Safety Thermometer and the global learning from this initiative
KEY POINTS n Reviews
of case records have shown that 10% of patients experience an adverse event while in hospital
n The
NHS Safety Thermometer has been developed to address measurement of patient safety
n Organisational
culture can determine the success and sustainability of patient safety initiatives
n It
is vital that clinical teams have data on their performance to improve safety and quality
n The
NHS Safety Thermometer has provided insights to assist in reducing unintentional harm to patients within the trust
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on harm and measurement will be published in the future (Power et al, 2012). This first year of the CQUIN scheme has been concerned with data collection, staff training and establishing an accurate baseline. It has provided important insights within the authors’ organisation regarding harm-free care and has helped refocus the authors’ efforts to reduce harm to their patients. It has raised their awareness around urinary catheter use and will assist in their mission to become world leaders in patient BJN safety and to achieve the best patient outcomes. Conflict of interest: none Baharestani M, Black J, Carville K et al (2009) International Guidelines. Pressure Ulcer Prevention: Prevalence and Incidence in Context. A Consensus Document. http://www.woundsinternational.com/pdf/content_24.pdf (accessed 26 February 2014) Cohen AT, Agnelli G, Anderson FA et al (2007) Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 98: 756-64 Department of Health (2011a) Quality, Innovation, Productivity and Prevention. http://tinyurl.com/k547r94 (accessed 26 February 2014) Department of Health (2011b) The Operating Framework for the NHS in England 2012/13. http://tinyurl.com/nzn92ds (accessed 26 February 2014) Department of Health (2012a) Delivering the NHS Safety Thermometer CQUIN. A Preliminary Guide to Measuring ‘Harm Free’ Care 2012/2013. http://tinyurl.com/k8eeauc (accessed 26 February 2014) Department of Health (2012b) Delivering the NHS Safety Thermometer CQUIN 20112/13. http://tinyurl.com/b7kptql (accessed 26 February 2014) Department of Health (2012c) Using the Commissioning for Quality and Innovation payment framework: Guidance on new national goals for 2012-13. http://tinyurl.com/lmzys5d (accessed 26 February 2014) Department of Health (2013) Patients First and Foremmost. The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry http://tinyurl.com/cfceb3k (accessed 26 February 2014) Dixon-Woods M, McNicol S, Martin G (2012) Ten Challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf 21: 876-84 Emanuel L, Berwick D, Conway, J et al (2008) What exactly is patient safety? In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds, Advances in Patient Safety: New Directions and Alternative Approaches. Volume One: Asessment. Agency for Healthcare Research and Quality, Rockville MD http:// tinyurl.com/mle2dfl (accessed 26 February 2014) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Treatment of Pressure Ulcers: Quick Reference Guide. http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf (accessed 26 February 2014)
ction charting the geneaology of y and in the UK from the late 1980s
ss the patient’s role in safety nt Safety Agency, the role of ents safe, safe staffing levels, ol, how patients evaluate safety, based practice for safety, and the ns from safety failures.
Understanding Patient Safety
views on the emergence of patient considered an area of high priority
Understanding Patient Safety
Fakih MG, Watson SR, Greene MT et al (2012) Reducing inappropriate urinary catheter use. A statewide effort. Arch Intern Med 172(3): 255-60 Francis R (2010) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/ne2cx9s (accessed 4 March 2014) Healey E, Scobie S, Oliver D, Pryce A, Thomson R, Glampson B (2008) Falls in English and Welsh Hospitals’. Results of national observational study based on retrospective analysis of 12 months’ incident reporting. Qual Saf Health Care: 17(6): 424-30 Healey F, Scobie S, Glampson B et al for National Patient Safety Agency (2007) Slips, Trips and Falls in Hospital. The Third Report from the Patient Safety Observatory http://tinyurl.com/p729hmq (accessed 26 February 2014) Hooton TM1, Bradley SF, Cardenas DD et al (2010) Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 50(5): 625-63 Hunt J (2013) If we are to improve the silent scandal of patient safety across the NHS we need a new culture of openness, transparency and accountability. Speech given at University College London Hospitals 21 June 2013. http://tinyurl.com/lve3jkx (accessed 26 February 2014) Jha A, Prasopa-Plaizier N, Larizgoitia I, Bates D (2008) Patients safety research: an overview of the global evidence. Qual Saf Health Care 19: 42-7 Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. (2010) Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 363: 2124-34 Meddings J, Rogers MA, Macy M, Saint S (2010) Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 51: 550-60 National Audit Office (2005) A Safer Place for Patients: Learning to improve patient safety. http://tinyurl.com/p6lbwb2 (accessed 26 February 2014) National Clinical Guideline Centre – Acute and Chronic Conditions (2010) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. (Full version of NICE CG92). http://tinyurl.com/nu7u7fs (accessed 26 February 2014) NHS England (2013) Putting Patients First: The NHS Business Plan for 2013/14-2015/16. http://tinyurl.com/clssgfn (accessed 26 February 2014) Oliver D, Connelly J, Victor CR et al (2007) Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 334: 82-7 O’Neil O, Cornwell J, Thompson A et al for The King’s Fund (2008) Safe Births: Everybody’s business. Independent inquiry into the safety of maternity services in England. http://tinyurl.com/pma4eyw (accessed 26 February 2014) Power M, Stewart L, Brotherton A (2012) What is the NHS Safety Thermometer? Clin Risk 18(5): 163-9 Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322: 517-9 Vincent C, Aylin P, Franklin BD, et al (2008) Is health care getting safer? BMJ 337: a2426 Whittington K, Briones R (2004) National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care 17(9): 490-94
Understanding Patient Safety n Timely evidence-based text on safety practices n Discusses governmental and the patient’s role in safety
Evaluating and Improvement, e, Oxford
n Includes a review of the history of patient safety
9
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