PSC & PIPSQC Paediatric Patient Safety Day: Monday 20 May 2013

Author: Dr. Sebastian Yuen
Consultant Paediatrician, Walsall Healthcare NHS Trust

This year I have been fortunate to have attended two @PIPSQC meetings and have been asked to write about the second. For Tweeters, I have included Twitter handles (eg I am @S3bster).

Before I do, I should mention the awesome and inspiring speakers from around the world at the meeting on 15th April 2013. An overview of the event - hosted by Great Ormond Street Hospital, London - is here: In particular, the team from the Ghana Fives Alive programme blew me away! Funded by the Bill and Melinda Gates Foundation and using IHI improvement methodology, they have significantly reduced the under-five mortality. It is low tech and has spread across the country (

At the end of the day, @PeterLachman (the Chair of @PIPSQC) left us with a challenge. How could the @WHO, @TheIHI and @PIPSQC work together to develop a worldwide network for paediatric quality improvement?

PIPSQC is an International Community, focused on Paediatric Safety and Quality

I discovered what @PIPSQC is all about in Birmingham Children’s Hospital (BCH) on 20th May 2013. Their values are respect, integrity and inclusivity. It certainly lives up to its name. If you have the opportunity to attend a meeting, I strongly encourage you to do so. The atmosphere was welcoming and non-hierarchical. The room contained national and international experts, together with the local curious. All shared a desire to connect, share and learn. There was a strong foundation of safety science knowledge (systems design, Deming, Reason, Vincent, High Reliability Organisations, human factors and lean). I left having met great colleagues and with many valuable new ideas. Thank you for sharing Dale Ann Micalizzi’s (@JustinHOPE) blog (

The feeling that has stayed with me is of an inclusive community, passionate about improving safety for children. What struck me is a comment from Steve Muething (a founding member from Cincinnati Children’s Hospital, @CincyChildrens). His team have created sustained transformational change and yet retain a hunger to improve further, because better is not good enough.

The PIPSQC Presentations Will All Be On The Website!

The slides from the day ( are well worth a look and will be available on the "PIPSQC Presentations" page (

The day began with Dr. Phil Debenham (Consultant Paediatrician, BCH) who shared his fabulous work improving handover. He began by saying that handover was implicated in the Piper Alpha Oil Rig disaster (2 x 10 minute videos: and and Chernobyl (90 minute documentary: He showed a remarkable video of the current state of the BCH handover. It starts and is immediately disrupted as one trainee is bleeped and leaves. Even with the consent of participants to be videoed, another trainee arrives late, checks her mobile phone and then fixes her lipstick! Phil claimed 90% of staff think they are good at handover and, in reality, most are not. He used Failure Modes and Effects Analysis (FMEA) to anticipate the problems that might occur with the introduction of the new system. He moved from Push (“this is what the next shift needs to know”) to Pull (“what would you like to know?”). There is now a new Safer Handover Bundle which includes dedicated preparation time, use of a preparation checklist and defined handover responsibilities. The BCH team followed the IHI mantra of stealing shamelessly and implemented the I-PASS communication tool without telling anyone! (Trey blogs on I-PASS here: The handover has a code of conduct and includes the nursing team. This is something I am keen to learn more about and implement in my new department.

Matt Scanlon (Associate Professor of Pediatrics in Wisconsin) discussed systems thinking (Photo: and the hierarchy of hazard reduction. This has Education and Training at the lowest level, then Administrative Controls (“Do not prescribe 10x opiate overdoses”). More sophisticated approaches include providing barriers to harm (lock concentrated potassium chloride away). At the top of the pyramid is elimination of hazards by Designing for Safety. He mentioned the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety ( Matt also referenced High Reliability Organisations (

One of my highlights was learning from Trey about her experience with the Thedacare community health system in Wisconsin (, an early adopter of lean. They recognise that Behaviour Drives Culture. Whilst we worry about how to change culture, Thedacare feel “project” is a bad word! By inspiring their staff to just do the new behaviour again and again, it eventually becomes the new culture.

Trey presented "DailyCIP", the SickKids' adaptation of the Thedacare model. This is founded on three timed 15 minute huddles between frontline staff and senior managers. They discuss a safety briefing and system niggles. Ideas are shared and prioritised. They give permission to implement changes immediately if easy to do, encouraging frontline staff to “Just Do It”. Simple and effective.

Steve Muething told us the Patient Safety journey will never end! He showed how serious safety events in @CincyChildrens have reduced 80% since 2004. These include never events, falls, VAPs, Central Line Infections, Pressure Ulcers, Catheter-Associated UTI and Adverse Drug Events. The strategy in Cincinnati is to focus on the worst and then move to the next level of harm. He recommended Managing the Unexpected: Resilient Performance in an Age of Uncertainty by Weick and Sutcliffe (Amazon: This gives a comprehensive overview of High Reliability Organisations. Cincinnati are leaders in sharing transparent patient safety data. They started a collaboration among hospitals in Ohio and this has now spread to 81 children’s hospitals in the USA (

@PeterLachman challenged us to decrease harm in UK hospitals by sharing data and successes.

There were great workshops on creating a safe paediatric service and on Paediatric Early Warning Systems (PEWS). The day ended with @AndyLongmate describing the fabulous work that NHS Scotland have achieved in partnership with @TheIHI. They are now developing an Early Years Collaborative to make Scotland the best place in the world to grow up. This uses improvement science to change how multiple agencies work together to improve attachment and outcomes for children (

Don’t Miss The Next Meeting!

For the full experience, you really needed to be there! As with many conferences, it is the conversations and connections that add value for me. Plus I was lucky to join an exclusive tour of BCH, led by Heather Duncan (consultant in PICU, The hardcore PIPSQCers ended the day in a very smart, traditional English pub with a pint and a pie (! There was a rumour that a future meeting may be held in Toronto, ON in partnership with Risky Business ( which I can also highly recommend! Look out for @PIPSQC at The 25th IHI National Forum ( and at the 2014 UK Patient Safety Congress (

How Can PIPSQC Help You?

How could the @PIPSQC community help you make a difference by next Tuesday? Are you working on something that you need help with or could share with like-minded colleagues around the world?

Stay Informed!

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