Two years to make a difference in Welsh Healthcare 2008-2010 1000 Lives Campaign reaches aim of saving 1,000 lives The Campaign is estimating that 1,199 additional lives have been saved by NHS staff in Wales between April 2008 and April 2010. Every health board and trust was involved in the Campaign, working on up to seven key content areas. These include reducing healthcare associated infections and surgical complications, and improving critical care and medicines management. The Campaign has used a new measurement tool which has enabled organisations to identify where harm occurs. This represents the first time harm has been measured on a national level and is to be the subject of a major four year research study. The final figures indicate that 50,000 episodes of harm have been prevented, but it is recognised that the solutions and ensure concerns are replacement of razors with surgical methodology needs further work quickly acted upon directly with senior clippers and better monitoring of in order to provide a greater degree managers. More than 600 WalkRounds patients’ temperatures before, of confidence. have already taken place across Wales. during and after surgery; “It’s important that we are able to Working with health boards and trusts • Worked with GPs to improve measure when, and where, harm takes over the last two years, the 1000 Lives the reliability of drug dosage place,” says Campaign Director Dr Campaign has: instructions given to patients, Alan Willson. “The work undertaken particularly in relation to Warfarin; Made sure that patients with by organisations through the Campaign • Improved treatment for patients deteriorating conditions are now • provides the basis for ongoing work to with chronic heart failure through being identified earlier, so that reduce harm in Welsh healthcare.” enhanced services, including nursing staff can intervene more improvements in diagnosis, Best initiative quickly and request medical medication and lifestyle advice; The Campaign has been effective in intervention; rolling out best practice across Wales, Developed a number of ‘trigger Implemented a procedure to prevent • as seen in the implementation of the • tools’, which are now being used by pressure ulcers, which has led to World Health Organization’s Surgical GPs, the Welsh Ambulance Service some wards having gone more than a Safety Checklist, which is now being and staff at Velindre Cancer Centre year without a case; used by operating theatre teams to identify and track potential harm. Changed attitudes towards throughout Wales. • Maintain the momentum infections caused by central lines – The checklist ensures that there is they are now regarded as avoidable “Patient safety is now on the agenda effective communication by those and often investigated as a critical of every health board and trust in involved in the surgery. It focuses on incident when they occur; Wales and the Campaign’s new ways of working are clearly making an impact,” basic good practice: checking the Made sure catheter related blood • says Dr Alan Willson. patient’s identity and the correct part stream infections (CRBSI) are now of the body for operation, ensuring all rare, rather than common events “However, it’s essential we maintain necessary equipment is available and in Wales; the momentum and don’t lose focus. providing an opportunity for discussing The ultimate goal will be to have this any complications that may arise. • Engaged patients in the safety agenda by using more of their good practice embedded in every WalkRounds stories to complement traditional organisation, so that it can be reliably Patient safety WalkRounds have been reports and data-based information and consistently delivered.” introduced in nursing homes, GP in board meetings; For further details on how the mortality practices and hospitals. These help • Reduced the number of infections and harm figures were attained, visit staff to raise safety concerns, suggest related to surgery – thanks to the www.tinyurl.com/3yvkcqw 2 Safer Patient Care The 1000 Lives Campaign aimed Introduction to save an additional 1,000 NHS staff save lives every day lives and prevent 50,000 episodes – the 1000 Lives Campaign has of harm in Welsh helped them save more. healthcare over a Two years to make a difference We know that modern healthcare can cause in Welsh Healthcare two year period. 2008-2010 harm – and yet we know that no-one working in healthcare goes into work each day to do less than Professor Sir Mansel Aylward CB a good job. The size of the system, the complexity Contents of the tasks and the diversity of treatments often conspires to work against the best endeavours of Introduction 3 individuals, ultimately causing patients harm. Empowering Frontline Staff to It was against this backdrop that the 1000 Lives Improve Patient Care 4 Campaign was launched in April 2008 – with the aim of saving an additional 1,000 lives and Improving Leadership for Quality 6 preventing 50,000 episodes of harm in Welsh healthcare. Reducing Healthcare Associated As you turn the pages of this report, which reflects Infections 8 Dr Chris Jones some of the Campaign’s major highlights, you will Improving Critical Care 10 read of the commitment and determination of NHS Wales staff – in both clinical and non-clinical settings – to introduce Improving Medicines Management 12 changes to improve the care they deliver. The 1000 Lives Campaign illustrates what can be achieved when we work Reducing Surgical Complications 14 together – and the final figures are evidence of the real difference that has been made. The changes that have been introduced in health boards Improving General Medical and and trusts throughout Wales will benefit generations of patients to come. Surgical Care 16 We want to say a sincere ‘Thank you’ to staff across Wales for the care Transforming Care at the Bedside 18 they provide to patients every day – and for taking up the challenge of the 1000 Lives Campaign and making it such a success. Measurement for Improvement 20 The Campaign’s achievements have provided a solid foundation for the 1000 Lives Plus national programme which has succeeded it. With a Putting the PR into Patient Safety 21 commitment to providing patients the care they need, by reducing harm, Patient Experiences Improving waste and variation, the programme will ensure that the Campaign’s aim Healthcare 22 to ensure consistent care across Wales will continue. This work is truly transformational. It enables staff to heal, not harm; to 1000 Lives Plus - The Next Step help, not hurt; and to bring life, hope and comfort to those who suffer for Healthcare Improvement 23 and are in pain. Thank you for your commitment, which has already achieved so much. It is a humbling and inspiring task to chair this programme as we move This report will shortly be available in forward. We welcome the opportunity to work alongside you as we Welsh, via the 1000 Lives Plus website. continue to build a better health service for the people of Wales. 1000 Lives Plus Office: 14 Cathedral Road, Cardiff CF11 9LJ Professor Sir Mansel Aylward, CB, Chair, Public Health Wales Tel: (029) 2022 7744 Dr Chris Jones, Medical Director, NHS Wales Email: [email protected] Chairs, 1000 Lives Plus Web: [email protected] Twitter: www.twitter.com/1000livesplus The 1000 Lives Campaign was run as a collaborative, which involved the National Leadership and Innovation Agency for Healthcare, National Patient Safety Agency, Public Health Wales and the Clinical Govenance Support and Development Unit. Support has also been provided by the Institute for Healthcare Improvement and the Health Foundation. Introduction 3 Hospital staff walked a mile around Ysbyty Glan Clwyd in a local launch of the Campaign. Empowering frontline staff to improve patient care The creation of a culture where sustainable patient safety and quality care is at the top of the NHS agenda is one of the legacies of the 1000 Lives Campaign, according to its directors. Reflecting on the two year Dr Willson said, “We knew that the infections and ventilator associated Campaign, Drs Jonathon Gray and Campaign was ambitious, but we also pneumonias in critical care wards, Alan Willson explain why it has been knew that it was the right course of improved hand hygiene leading to a the small changes that have made action to improve patient safety in reduction in infections and action to the biggest difference to patient hospitals and community settings reduce pressure ulcers, with some care across Wales. across Wales.” wards going more than a year without a case. When the 1000 Lives Campaign Sustainable launched in April 2008, its leaders “Sustainable changes for the future The key, according to Dr Gray, has knew that the biggest challenge had to be made in many areas. Patient been to empower staff to deliver would be engendering a culture safety and quality has to be the main and accelerate change. change that would ensure improving focus for everyone and patients need He said, “We were aware when we patient safety became the norm for to be central to all that is delivered. began the Campaign that success everyone in NHS Wales. “We had to engender a culture change would only come if frontline staff And the key to this was to empower where situations were not accepted as were driving forward change and frontline staff to make small changes unavoidable, but solutions were sought were engaged in monitoring and that would improve patient care. that would deliver better care. delivering results. “Frontline staff have been “Organisations needed to own their able to implement small improvement work and this has been changes such as improved achieved by improved leadership and hand washing, listening better engagement with mortality to patients needs and data.