”Development of Patient
Safety from practical point
of view”
Berit Axelsson, improvement leader/ project leader.
Jönköping County Council
2013-10-07
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
2013-10-07
The Agency for Health
Care (IVO)
The County councils have considerable
degree of autonomy and have
independent powers of taxation.
2013-10-07
Open comparisons of Health Care
Quality and Efficiency.
Comparison between counties
2012
The National Patient Safety
Work
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.
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.
The Swedish Association of Local
Authorities and Regions (SALAR).
National Swedish
Initiative in Patient Safety
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
Demands 2013
Agreement between SALAR and the
Ministry of Health and Social Affairs.
A.Patient Safety story
Indicators 2013
Procent
1. Hand hygiene and
clothes > 70%
Följsamhet Basala Hygienrutiner och Rätt klädd
Landstingets hälso- och sjukvård 2011
100%
90%
80%
70%
60%
Basala hygienrutiner
50%
Rätt klädd
Målvärde
40%
30%
20%
10%
Tidsperiod
0%
dec10
B. National survey
for patients (Primary
Care Centres)
Nationell patientenkät, Primärvården 2010, (läk+ssk)
100
90
Patientupplevelse
80
70
60
50
40
30
jan
feb
mar
apr
maj
jun
jul
aug
sep
okt
nov
dec
2. Use of antibiotics
20
10
0
C20
C21
C22
3. Use of medication
Genomsnitt
C. Update action plan
Survey on patient
safety culture
75 % of departments have routines for
medication story
PPM-Trycksår, v 12 och 40, 2011. Landstinget i Jönköpings län.
0,2
0,18
0,16
0,14
4. PPM- Pressurer ulcer
0,12
PPM-Trycksår v 12
PPM- Trycksår v 40
0,1
0,08
0,06
0,04
0,02
0
Höglandets
sjukvårdsområde
(Eksjö/Nässjö)
Jönköpings
sjukvårdsområde
(Ryhov)
Värnamos
sjukvårdsområde
Sjukhus
D. GTT 20 – 30
records/ month/
hospital
Patientskador per tusen vårddagar
40
Patientskador per tusen vårddagar
35
30
25
20
15
5. Measure overcrowding
10
5
0
2008 Tertial 1
Tertial 2
Tertial 3
Höglandets Sjukvårdsområde
2009 Tertial 1
Tertial 2
Jönköpings Sjukvårdsområde
Tertial 3
2010 Tertial 1
Värnamo Sjukvårdsområde
Tertial 2
Tertial 3
Landstinget
E. NPÖ (Give
access to
records)
– 25 %
6. Infection tool
Landstinget i
Jönköpings län
The Work in Jönköping County
Council
Jönköping County Council is responsible for
the public health care services
3 hospitals
52 primary care centers
9,500 employees
Jönköping
350,000 inhabitants
Höglandet
6.100 visits per day
1.500 visit a specialist/day
1.300 visit to GP/day
(300 visits to private
doctors/day)
Värnamo
160 new patients staying over night at the hospitals/day
9 newborns/day
Success factors
•
•
•
•
Leadership
Structure
Measurements
Microsystemthinking – patient and
staff
• Culture
• Qulturum
Everything at the same time….
Berit Axelsson
090205
13
Strategic Improvement Areas
Vision
Klicka här för att ändra format på
Patient Safety
bakgrundsrubriken
• Klicka här för att ändra format på bakgrundstexten
– Nivå två
• Nivå tre
– Nivå fyra
» Nivå fem
Create conditions to
make it right from the
beginning
15
Structure for the Patient Safety
work
• The County Council leaders
• The Health Care leaders
• The Big Group of Health Care
Berit Axelsson
090205
16
The Big Group of Health Care
090205
Berit Axelsson
17
Structure for the Patient Safety
work
•
•
•
•
•
•
Berit Axelsson
090205
18
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
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
Primary drivers
Secondary drivers
Standardize work routines
Use Checklist
Driver Diagram
Patient Safety
Reliability
Decrease variation
Access
Adaptability
Improvement work
Aim: Safe Health
Care All The Time
Competence
and Skills
Skill training
Awareness of the current
situation
Incident reporting system
Learning
Organisation
Measurements
Patient Safety Culture
Leadership
Motivation, action, follow up and
feedback
Challenge
Patient
involvement
The process of patient
Microsystem
Micro
Cor lab
Akuten
Rehab
IVA/HIA
The distribution of colours in Jönköping County
Council. 090223
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Andel kliniker som skattat implementering av "Säker
vård - alla gånger" 090402
1
2
3
4
5
6
7
8
9
100%
Område
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Höglandet
Jönköping
Värnamo
Patientskador per vårdtillfälle (AE) - Landstinget i Jönköpings län
Läkemedelsrelaterade patientskador (ADE) Landstinget i Jönköpings län
0,04
UCL=0,03795
0,006
2003
2004
2005
2006
2007
2008
0,03
0,005
_
U=0,01789
0,02
0,01
0,00
LCL=0
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ADE per dos
Patientskador per vårdtillfälle
0,05
1
1
1
UCL=0,004042
0,004
0,003
_
U=0,002309
0,002
0,001
LCL=0,000575
Månad 2007
Tests performed with unequal sample sizes
0,000
n g t
b r n g t
b r n g t
b r n g t
b r n g t
b r n gp
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Månad
Tests performed with unequal sample sizes
System measures
©2005, Trustees of Dartmouth College, Nelson, January
10
11
12
13
14
www.lj.se/sakervard
Primary drivers
Secondary drivers
Standardize work routines
Use Checklist
Driver Diagram
Patient Safety
Reliability
Decrease variation
Access
Adaptability
Improvement work
Aim: Safe Health
Care All The Time
Competence
and Skills
Skill training
Awareness of the current
situation
Incident reporting system
Learning
Organisation
Measurements
Patient Safety Culture
Leadership
Motivation, action, follow up and
feedback
Challenge
Patient
involvement
The process of patient
Microsystem
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
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?
Structure – how to work with the
events
Case Coordinator initiate
investigation
Feedback to the
reporter
…and it must lead to something
Discuss the matter in
working group
Results from Synergi Jun2013
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 2013
1000
900
800
700
600
500
Antal registreringar
400
300
200
100
0
Patient- /kundsynpunkter
Patients
feedback
Avvikelse Olycka/Negativ händelse
Adverse
events
Avvikelse - Tillbud (ej
personalrelaterad)
Incidents
Avvikelse Iakttagelse/Risk
Observati
ons/ risks
Förbättringsförslag
Ideas of
improvem
ent
Culture
What we say and what we do.
(ange enhet via Infoga sidfot)
2013-10-07
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)
2013-10-07
A Safety Culture has many linked parts
Reporting
culture
Just
culture
Flexible
culture
Learning
culture
Säkerhetskultur
All these elements must be linked
correctly.
Forma en säker kultur
To build a safe culture
Methods and
structures
Using and
doing
Attitudes
and values
Thinking and
believing
And…..
• Put patients behind the numbers……
• The taste of water
Advice from a patient
( Orlando)
Anne - Maj Thorsson
http://vimeo.com/55024381
090922
Thank you.
www.lj.se/sakervard