Celebrating Haelo – The Safety Thermometer

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On day 1 of our Haelo celebration, we are looking back at the Safety Thermometer.

Developed for the NHS by the NHS as a point of care survey instrument.

The NHS Safety Thermometer was a ground-breaking project that gave trusts across England an easily applicable tool to aid in local improvement efforts.  It was a very different approach than the traditional accountability measures used in the NHS, moving from simply counting the number of harms that occurred to a more patient centred ‘Harm free care’ approach.

This measurement for improvement tool was developed by Haelo, and an expert panel, to help understand how the most common harms affected patients under care in both acute and community settings and how this changed over time;  giving trusts another way to look at their data.

The original Safety Thermometer gave birth to a set of ‘Next Generation’ thermometers for more specific areas and settings, which continued to give a thorough understanding of change over time in ‘Harm Free care’.

Commissioned by NHS England, the Safety Thermometer programme used iterative PDSA cycles to develop a number of measurement tools that measure harm in different care settings. It allows teams to measure harm and the proportion of patients that are ‘harm free’ during their working day, for example at shift handover or during ward rounds. This isn’t limited to hospitals; patients can experience harm at any point in a care pathway and the NHS Safety Thermometer helps teams in a wide range of settings, from acute wards to a patient’s own home, to measure, assess, learn and improve the safety of the care they provide.

Haelo developed a suite of 5 Safety Thermometers for use in a number of care settings aiming to support the NHS to provide a healthcare environment free of harm for our patients.

Origins of the Safety Thermometer

Studies have shown that the NHS is inundated with a myriad of local and national datasets to try to understand harm. Many of these measures are slow to provide feedback and only relate to the most severe of harms, for example incident reports and mortality data respectively. Our ambition was to build a measurement system which would provide a ‘temperature check’ on the prevalence of harm and empower front-line staff to lead improvement efforts.

Haelo led the development and design of NHS Safety Thermometers since their inception in 2010, working within and alongside NHS bodies (such as NHS Digital and NHS Improvement) and data hosting experts (South West Quality Observatory). Haelo’s experience and knowledge of developing measurement strategies was complemented with input from clinical experts and front-line users, who provided feedback and ideas throughout the development of the NHS Safety Thermometers.

Journey

In 2010 the Harm free care programme was launched to support teams in reducing common harms across the health economy. We faced a common challenge – in order to improve safety we needed to be able to access regular data that could be used over time to measure improvement. At the time there was no data source which could be used at a local and national level to provide a snapshot of harm and so we set about developing the NHS Safety Thermometer with clinical expert groups to measure:

  • Pressure ulcers
  • Falls
  • Urinary tract infections (in patients with a catheter)
  • Venous thromboembolism

These harms were not chosen at random. They each had a high prevalence and huge impact on patients lives and were relevant across the health economy but importantly they are interlinked. Most improvement efforts on these harms were happening in silos but actually the same patients are at risk of each of these harms, many key interventions (for example intentional rounding) are similar and working to reduce one of these harms has the potential to increase another (for example you might cause a pressure ulcer using ted stockings to prevent a VTE). At the time we also had no data on how many people were experiencing more than one of these harms. The NHS Safety Thermometer ‘classic’ enables us to understand the burden of each individual harm, tracking improvement over time and the ‘harm free’ care measure provides a totally unique composite that is focused on the patient’s experience of harm wherever they are being cared for.

Implementation

Developing a new measurement system requires a precarious balancing act between the cost of collection vs the value added of the data, however the Safety Thermometer is not only about data; the act of data collection at the point of care raises awareness and brings the opportunity for immediate improvements to patient care, empowering frontline teams with data and calling them to action. This guiding principle led the creation of a point-of-care survey methodology that is carried out on 100% of patients on one day each month. Data are collected by frontline teams at the point of care as part of the daily work flow, ensuring quick and easy collection. Definitions are clinically valid and data are sourced through conversation with the patient, patient assessment and paper or electronic notes.

Early phases of collection relied upon the completion of a simple template which was then submitted by email for data processing and analysis, undertaken on a monthly basis, but by 2013 this was available via an online platform to enable data entry via portable devices, although paper forms are also available. In 2015 all Safety Thermometers were supported by dedicated Apps downloadable from the website. Instant charts are available for all Safety Thermometers once data has been entered. Run charts, funnel plots and Pareto charts can be viewed at a ward / team, organisational, regional or national level.

Haelo developed a series of bespoke tools to interpret data for improvement and provide recommendations, using core principles of statistical process control charts to identify.

Incentivised Improvement

We were commissioned by NHS England to lead the national roll out the CQUIN, acting as the primary point of contact and providing all supporting information and data analysis and running a series of regional and national events. CQUIN stands for commissioning for quality and innovation. The system was introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of patient care.

Following it’s launch in 2012, an incredible 180,000 patients being surveyed across acute and community based care each month. The launch of the CQUIN was supported by the “Harm-Free Care” campaign, which was designed and led by Haelo and demonstrated our expertise in delivering impactful and effective communications. The campaign was supported by a website with learning resources and case studies, social media presence (#harmfreecareselfie) and presentations to national audiences.

By the end of 2013, over a thousand organisations (including NHS trusts, care homes and private hospitals) were regularly collecting and submitting data via the NHS ‘Classic’ Safety Thermometer portal, therefore the next phase of the national CQUIN was to incentivise improvement in the data collected. You can find out more about the CQUIN monitoring tool on the website.

Next Generation

The widespread use of the NHS ‘Classic’ Safety Thermometer was a huge success story, however feedback suggested that the definition of harm-free care was not appropriate in all clinical settings. In response to this demand, Haelo led the development of a number of bespoke ‘Next Generation’ Safety Thermometers, using the harm-free care principle and survey methodology in the following settings:

In addition, the Medicines Safety Thermometer was developed to shed light on an area where harm is prevalent but poorly reflected in existing datasets.

Results

Since 2012, data on over 11 million patients have been submitted to the NHS Safety Thermometers from across the healthcare economy, making it one of the largest patient safety data collections of its kind in the world. This is an incredibly valuable data resource and presents an opportunity to capture knowledge and learning about the impact of safety improvement initiatives.

Haelo undertook analysis of the available data to better inform our understanding of healthcare-associated harm occurring throughout the NHS. The national picture the NHS Safety Thermometer data provides can challenge current practice, identify problem areas in the system and influence national programmes of work.

One completed analysis looked at the rate of urinary catheter use over time. Catheters increase the risk of urinary tract infections. There is evidence that catheters are inserted inappropriately in up to 50% of cases, unnecessarily exposing patients to infection risk. We found no clinically significant reduction in urinary catheter prevalence over the 46 months of study, likely due to guidelines focusing on care of catheter in situ as opposed to indication for insertion. We therefore called for further guidance on indication for catheter insertion.

Building Capacity

Throughout the harm-free care campaign and development of NHS Safety Thermometers, Haelo sought to use innovative techniques to build system capability to understand and interpret data for improvement. Initially this took the shape of online teaching sessions, creation of interactive guidance documents and films (included above). As our understanding of the needs of users grew, we provided more responsive products to meet specific demands.

Future

For seven years, working with a range of partners and sub-contractors, Haelo led the innovation and development of the NHS Safety Thermometer portfolio providing measurement and capability building expertise for the NHS. With the NHS Safety Thermometers largely well-established, the day-to-day administration of the programme is now managed by South Central West Commissioning Support Unit, on behalf of NHS Improvement.

The success of the NHS Safety Thermometers is reliant upon the hundreds / thousands of NHS staff who collect and review data on a monthly basis as part of their commitment to providing safe care to every patient, every day.

Day 2 of our Haelo celebration will be looking back at NHS Health Checks. Keep up with the conversation on twitter, using @_Haelo #celebratinghaelo

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