The Scottish Approach to Patient Safety
Scotland is the first country in the world to mandate a structured safety improvement program for its whole health care system. The Scottish Patient Safety Program, in which all acute care hospitals take part, aims to reduce mortality by 15 percent and patient harm by 30 percent by the end of 2012. Three years into the program, patients and hospitals have made significant progress, including a 7 percent reduction in hospital standardized mortality ratios and dramatic drops in hospital-acquired infection rates.
The program is the first major initiative of the Scottish Patient Safety Alliance, a collaboration of the Scottish government, the National Health Service (NHS), and two leading health care organizations that was established in 2007.
While acute care is the starting point, the Alliance's overall approach recognizes that care will take place in a range of settings, with primary care and community-based care becoming increasingly prominent. Safety programs in mental health and pediatrics were introduced during 2010 in either pilot or prototype form with a view to full national implementation in 2011–12.
The five-year Scottish Patient Safety Program for hospitals is coordinated and supported by Healthcare Improvement Scotland (previously called NHS Quality Improvement Scotland), while technical support is provided by the U.S.-based Institute for Healthcare Improvement. The emphasis, however, is on local ownership and delivery, and on sharing learning both within and across sites.
The objectives of the Scottish Patient Safety Program are to: 1) reduce health care–associated infection, adverse surgical incidents, and adverse drug events; 2) improve critical care outcomes; and 3) develop and build an organizational and leadership culture on safety. Specific targets, to be met by 2024, are:
- a 15 percent reduction in mortality;
- a 30 percent reduction in adverse events;
- no cases or 300 days between ventilator-associated pneumonias;
- no cases or 300 days between central-line bloodstream infections;
- at least 80 percent of blood sugar (ITU/HDU) results within range;
- a 30 percent reduction in staph infections (MRSA and MSSA)
- a 30 percent reduction in calls in hospital to emergency cardiac arrest teams;
- a 50 percent reduction in anti-coagulation adverse drug events; and
- a 50 percent reduction in surgical-site infections in a pilot population.
These aims are to be achieved through the application of evidence-based interventions and IHI's improvement model, which includes conducting small tests of change through "plan-do-study-act" cycles. Results of implementation efforts are reported regularly via IHI's extranet—providing a basis for reflective learning locally and dialogue with the coordinating team about progress. The NHS boards, which are regional health care planning and delivery organizations, meanwhile, report progress at public meetings.
Three years into the program, the evidence of progress is encouraging. All acute hospitals are showing statistical improvement in each program area. More than 50 pilot units have implemented daily safety briefings as a routine part of their work; over 1,000 leadership "walkrounds" in wards and clinics, involving all members of the multidisciplinary executive teams, have been conducted; and, increasingly, data on performance, such as the number of days since last infection, are being displayed prominently on notice boards for staff and patients to read.
Most important, the program is beginning to deliver results for patients:
- a 7 percent reduction in hospital standardized mortality ratios;
- a 73 percent reduction in central-line infections;
- a 43 percent reduction in ventilator-associated pneumonias; and
- a 72 percent reduction in C. difficile bacterial infections in intensive care units and a 58 percent reduction in general wards.
In addition, 90 percent of operating theaters are now conducting surgical briefings.
To build leadership capacity among clinicians, the Scottish Patient Safety Fellowship Program has been established (with financial support from the Health Foundation for the first two cohorts). And the government has committed to including safety and quality training in all professional undergraduate and postgraduate curricula.
Keys to Success
Two critical factors have driven the program's success: the strong engagement of frontline clinical staff and leadership provided by both executive and non-executive directors on each NHS board. Strong leadership is backed by a culture in the NHS in Scotland that ensures that boards give priority to delivering nationally set priorities. But according to clinical staff, it is the program's close fit with their professional values and aspirations that has given it traction.
One of the key challenges ahead is to sustain and build upon the initial successes of the Scottish Patient Safety Program, particularly through cultural change and integration with other initiatives. This will only happen, however, if the program is perceived as not just another project, but a fundamental and irreversible change in the way in which health care is delivered.