MiST (Making it Safer Together) - A New UK Paediatric Patient Safety Collaborative

Author: Dr. Hannah Zhu
Addenbrooke’s Hospital, PIPSQC Ambassador, GTC database Committee

Setting the Scene in the UK
Patient safety has been starring in the BBC News and National Health Service (NHS) spotlight this year. Although NHS fundamental principles are to provide the best possible quality of care, the Francis Report on Mid-Staffordshire and other research into the culture and behaviour in the NHS indicate that there is a huge amount of inconsistency, unclear goals and overlapping priorities. The Chief Medical Officer's annual report 2012: 'Our Children Deserve Better: Prevention Pays,' highlights the importance of focussing on children, since child health sets the foundations for health in later life and has great potential for long-term economic benefits. Recent evidence has shown that paediatrics in the UK is not performing as well as we should compared historically and to other EU countries for mortality, morbidity, wellbeing, social determinants and key indicators of health service provision. However the huge variation within the UK, with some pockets of outstanding care, shows us what is possible: we know we can all do better if we share resources and learn from the best.

Introduction of MiST (Making it Safer Together)
The idea for MiST originated at the PSC & PIPSQC Paediatric Patient Safety Conference (20, May 2013, Birmingham); to learn from each other and continuously improve the care we deliver to children. For the inaugural MiST meeting, we invited representatives from all children’s hospitals with a Paediatric Intensive Care Unit in the UK for the purpose of sharing quality improvement (QI) data to learn and improve safety without being in competition. Measurement and data collection is essential since we need to know where we are currently before knowing what and how to improve. We wish to develop the foundations for safety (policy, organisational structure, safety plan) and the framework for measuring and monitoring safety.

UK Sites – Learning from Each Other
The MiST meeting kicked off with brief summaries of QI initiatives and data collection already happening at each hospital. Recurring themes addressed by almost all participating hospitals were prevention/recognition/escalation of the deteriorating child, prescribing safety, handover/communication and preventing hospital acquired infections. In addition, strategies were already in place for transforming culture; almost all hospitals had a form of regular (daily or weekly) safety briefings and risk meetings. Serious incident reporting was well established and several hospitals had advanced root cause analysis strategies for analysing paediatric respiratory/cardiac arrests and other emergency bleeps. Some of the larger children’s hospitals already have sophisticated programs for collecting and managing the increasing amount of QI data available – for example Great Ormond Street Hospital for Children NHS Foundation Trust  employs four data analysts specifically for this purpose.

The secret to success of these initiatives seemed to be creating a culture for change and gaining support and co-operation from all stakeholders, from executive level to frontline professionals delivering care, with individuals taking clear ownership and responsibility for change. It’s also essential for people to see the effects of QI data use, understand why we collect data and see tangible improvements as a result of their efforts. Engagement with patients and families is also essential – to this purpose, PIPSQC is currently developing surveys for children, families and healthcare professionals, on patient experience, provider experience and adverse events, to find out how we can make care more compassionate and what we can do to improve from their perspective.

In addition, it should be noted that the NHS is moving towards paperless records and transforming to ‘E-hospital,’ with electronic prescribing, integrated patient records and guidelines. We need to embrace technology and use it as a dynamic platform for QI interventions, education and data collection on process and outcome measures.

The UK is already rich in national data sources. For example, the 
Paediatric Intensive Care Audit Network (PICAnet) and Standardised Electronic Neonatal Database (SEND) are well established specialist databases, from which we can learn and build upon.

International Inspiration
There is a thirst for QI collaboration across the world. We drew much inspiration from Dr. Steve Muething at Cincinnati Children’s Hospital and the Ohio Children's Hospitals' Solutions for Patient Safety (OCHSPS) national network. The network started with eight children’s hospitals in the state of Ohio, initially collaborating to eliminate codes outside the ICU and reduce surgical site infections and adverse drug events. The hospitals committed to complete transparency and data sharing to foster an “all teach, all learn” culture. Their initial efforts are estimated to have saved 7,700 children from unnecessary harm and avoided $11.8 million in unnecessary health care costs.

In 2010, the hospitals came to the decision to go after all serious harm at the same time - targeting nine hospital-acquired conditions (HACs) and readmissions across all organizations. In the last two years, the network has blossomed greatly to include 78 hospitals across the USA, capturing 50% of all admissions to children’s hospitals. Through data sharing, they found they were seriously hurting 15 children every day - providing further urgency and drive for change, aiming for zero harm.

The current HACs include: adverse drug events (ADE), catheter associated urinary tract infections (CA-UTI), catheter associated blood stream infections (CLA-BSI), falls, obstetrical adverse events (OB-AE), pressure ulcers (PU), readmissions, surgical site infections (SSI), ventilator associated pneumonia (VAP), venous thromboembolism (VTE). These are selected due to a combination of being the most concerning and the most feasible to measure. Some overlap with top concerns in the UK and we are currently in the process of deciding on what we are going to prioritise measuring.

In the USA, participating hospitals were initially encouraged to decide how best to improve locally and design their own bundles if they wish. The main requirement was for each hospital to submit data, aiming for 90% reliability on whatever intervention they choose to do over a period of 2 years. Progress was sustained with 10-12 webinars per week for local project managers. Each participating hospital received monthly reports on their process and outcome measures, compared to the mean of the network. They also distributed quarterly reports of who the best hospitals were with contact details so that others could learn from them.

Beyond the network's internal SharePoint website, OCHSPS has a public website where they've made key network materials available to all - including:
OCHSPS Operating Definitions
- OCHSPS Recommended Bundles

Our Next Steps
1. Identify the top data collection priorities for paediatric patient safety and QI in the UK and carefully define these.
2. Set up a parallel data entry platform and database, as well as personnel and resources to sustain this.
3. Recruit CEOs and executive teams of relevant hospitals.
4. Show significant improvement progress within 12 months.
5. Aim to present pilot results at the National Study Day in 2015.

Exciting Times Ahead
This is a really exciting time for paediatric patient safety and QI and I am really honoured to be a part of this! Dr. Peter Lachman will be incorporating a focus on paediatric patient safety and QI on a national stage at the 
Royal College of Paediatrics and Child Health (RCPCH) Annual Conference (8-10 April 2014, Birmingham). NHS England is currently forming their response to the Berwick report, which includes the launch of patient safety collaborative programmes to share data and accelerate change. For paediatrics, they will look to PIPSQC and MiST for inspiration and leadership. I have every confidence that we will rise to the challenge.

Useful links
Francis report on the Mid Staffordshire NHS Foundation Trust Public Inquiry
2. Chief Medical Officer's annual report 2012: Our Children Deserve Better: Prevention Pays
3. PSC & PIPSQC Paediatric Patient Safety Conference
4. MiST (Making it Safer Together) Paediatric Safety Forum - Meeting Minutes
5. Great Ormond Street Hospital for Children - 'Quality, Safety and transformation' 
6. Paediatric Intensive Care Audit Network (PICAnet)
7. Ohio Children’s Hospitals’ Solutions for Patient Safety (OCHSPS)
8. NHS England - News: 'NHS England promises new and far reaching drive to improve patient safety 
Berwick Review into Patient Safety
10. Dixon Woods M, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf. published online Sept. 9, 2013