Insert name of presentation on Master Slide Lessons from the 1000 Lives Campaign Tuesday 29 March 2011 Dr Alan Willson.

Insert name of presentation on Master Slide

Lessons from the 1000 Lives Campaign

Tuesday 29 March 2011

Dr Alan Willson

1000 Lives Plus

Making the case…

• More than one in ten people admitted to hospital are harmed unintentionally by its care.

• There is a one in 300 chance of accidental death through errors in care.

1000 Lives Plus

1000 Lives Plus

“Houston, we have a problem …”

• PRINCE Project Management

• Targets

• Performance Management

What can we do?

1000 Lives Plus

• Clarify the outcome

• Build a coalition

• Trawl the evidence

• Empower the people

1000 Lives Plus

The Campaign’s aims

• Reduce avoidable mortality by 1000• Reduce episodes of harm by 50,000

By improving the reliability and reducing the variation in the systems and processes that we use everyday.

The Campaign’s map

• 3 million people• All Hospitals, Primary Care and

Ambulance services• Six content areas

– Leadership– Critical Care/Rapid response– Medicines– Healthcare associated infection– Surgical care– General medical and surgical care

1000 Lives Plus

1000 Lives Plus

Collaboration

• Peers learning from one another

• Support the methods

• Share the practice

1000 Lives Plus

Learning Session Objectives

LS1

Get ideas

Get methods

Get started

LS2

Get more ideas

Get better at methods

Get a ‘Stride’

LS3

Celebrate success

Get ready to sustain

and spread

1000 Lives Plus

1000 Lives Plus Approach

1. Concentrate on the points where these adverse events occur.

2. Create bundles of evidence-based interventions.

3. Measure compliance/reliability with these bundles.

4. Decide what outcome will be affected by reliable implementation of these bundles and measure it.

Case Study: Acute Stroke

1000 Lives Plus

Background

Why Acute Stoke?• 2006 WAG – Welsh Stroke services lagging behind UK• 2007 WAG – Recognition trend needed to be reversed• 2008 All Wales Stroke Services Improvement Collaborative

Who’s involved?• Welsh Assembly Government• National Leadership and Innovation Agency for Healthcare• Front line staff, 14 teams covering 18 acute hospitals- all collecting data

Evidence reviewed and bundles developed

1000 Lives Plus

Evidence reviewed and bundles developed

1000 Lives Plus

Evidence reviewed and bundles developed

1000 Lives Plus

Evidence reviewed and bundles developed

1000 Lives Plus

Evidence reviewed and bundles developed

1000 Lives Plus

Evidence reviewed and bundles developed

1000 Lives Plus

How to change the system?

1000 Lives Plus

The Model for Improvement

1000 Lives Plus

Repeated use of thePDSA Cycle

Hunches, theories,

best practices

Changes that result in

improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very small scale test

Follow-up tests

Wide-scale tests of change

Implementation of change

Sequential building of knowledge under a wide range of conditions

Evaluation

• Lives saved and harm avoided

• Reusable network for change

• Frontline sign up

• A new focus on using data:

• Local stories – patients & staff

• Management buy-in

• PR & Communications

1000 Lives Plus

• 1,199 lives have been saved by NHS staff in Wales

• Over 50,000 episodes of harm averted

Conclusion - Two years that made a difference

1000 Lives Plus

Campaign Achievements

• WHO Safer Surgery Checklist

• Care bundles reduce ventilator associated pneumonia

• Action to reduce pressure ulcers

• Safer dispensing of Warfarin

• Development of local pathways of care for chronic heart

failure services

• WalkRounds

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From experiment to expectation

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NHS WALES

CORE VALUES

1000 Lives Plus

• Views have not changed

• Amplified the cause

• Aligned the actions

The next step...

• All Welsh Healthcare Organisations have pledged to:– Engage with all the mandatory interventions– At least a 5% reduction in mortality and harm over the next

year

• Safer care for every patient – every where in Wales• Reducing harm, waste and variation• Continuing existing areas of work• Adding new interventions• Local measurement

1000 Lives Plus

What can you do?

1000 Lives Plus

• Clarify the outcome

• Build a coalition

• Trawl the evidence

• Empower the people

If we can improve

care for one person,

then we can do it for ten.

If we can do it for ten,

then we can do it for a 100.

If we can do it for a 100,

we can do it for a 1000

And if we can do it for a 1000,

we can do it for everyone in Wales.