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We would like to thank the following colleagues for their help, advice and input into this report: David Bawden Care Quality Commission Kate Hall Policy Advisor, Monitor Dr. Gary Orr Consultant Psychiatrist, Hutt Valley Health Board Christine Boswell Chief Dr. Alasdair Honeyman Associate Director, Executive,Rotherham, Doncaster and Good Governance Institute Elaine Protheroe Board Secretary, Scunthorpe Mental Health Services NHS NHS Kensington and Chelsea Fred Hucker Chair, NHS Oxfordshire Janet Seaton Technical Services Manager, Dr. Tim Crossley General Practitioner, Angus Malcolm Healthcare Media Clinical Governance and Risk Management Consultant, Good Governance Institute Unit, NHS Grampian David Dalton Chief Executive, Salford Royal Hilary Merrett Consultant, CHKS Dr. David Somekh Past President, European Cost savings in healthcare organisations: Hospitals NHS Foundation Trust Peter Molyneux Chair, NHS Kensington and Society for Quality in Healthcare Bhavana Desai Non-Executive Director, Chris Spry Non-Executive Director, Dorset Central and North West London NHS Julie Moore Chief Executive, University County Hospital NHS Foundation Trust the contribution of patient safety Hospitals Birmingham NHS Foundation Trust Dan Taylor Director of Marketing, Datix Christa Echtle Chair, Datix Limited Paul Moore Chief Risk Officer, University of Jill Freer Director of Quality and Safety and South Manchester NHS Foundation Trust Darren Thorne Chief Officer: Wanstead, A guide for boards and commissioners Executive Nurse, NHS Warwickshire Jan Norman Director of Safeguarding, Annette Furley Audit Commission NHS Northamptonshiire Dr. Greg Wilcox Clinical Executive Chair, NHS Hastings and Rother and East Sussex Fiona Gale Consultant, CHKS Anne O'Brien Director of Clinical Governance, NHS Professionals Andrew Corbett-Nolan, Jonathan Hazan and Dr. John Bullivant ed our QIPP benefits e being achieved and nt. Our boar e able to articulate the e consistently meeting our eduction, QIPP and ef Our cost impr consistently met. Our boar describe the patient safety contribution to cost savings.
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W studies fr we shar W developed elsewher ar benchmarking ar pr Our commissioners ar to outcomes rather than pr This report is part of a growing series of reports developed by the Good Governance Institute that consider issues contributing to the better governance of healthcare organisations. We would e information and f especially like to thank Datix for making available by an educational grant the resources to enable n of incidents to this report to be developed and distributed as well as the many colleagues working in healthcare fecting the quality who have who have contributed ideas and input and helped review the report. Within the report, ogramme with others, the Maturity Matrix uses the style readers will be familiar with from our work and is used under e benchmarking our harm licence from the Benchmarking Institute who originated this approach. We have made our best e track our patter ogrammes ar e have examples of wher e has led to mor e understand how our QIPP ogramme is ef efforts to ensure the quoted case studies are accurate and reflect genuine better practice, but we W understand whether QIPP pr W car resour W pr safety and experience of our patients and the boar systematically tracking this.
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nance Institute with input fr each in the next 12 months. The Good Governance Institute is committed to develop and promote the Good Governance elationship e and r Body of Knowledge e service changes e have examples of e designed to r eworking, and err e have set out our ambitions to e explain our appr e made. W ojects initiated by clinicians.
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W with our commissioners ar cost savings plans and QIPP oss England, made possible with an educational grant fr Development by the Good Gover cle the level you believe your organisation has r Published by the Good Governance InstituteOld HorsmansSedlescombe, near Battle East Sussex TN33 0RL ow to the right to the level you intend to r om the Benchmarking Institute – ‘Good is only good until you find better' GGI Limited, 2010 ISBN 978-1-907610-04-2 Designed by www.merceronline.co.uk eleasing plans ar Patient safety and cost savings: Maturity Matrix fectiveness patient safety ersion 1.1 – November 2010V To use the matrix: identify with a cir and then draw an arr supported by patient safety strategy/business plan Clinical engagement Developed under license fr Executive summary Introduction – what this report is about and who it is for What we know about the relationship between better, safer care and cost reduction Improvement to care administration Better care solutions Reform of non-care bureaucracy Care setting substitution Not to fund decisions Recommended further reading and contributors Patient safety and cost savings maturity matrix Executive summary "We know from the evidence that better, safer care is also more cost effective care."1 This report concerns the important topics of improving patient safety and reducing costs. It hasbeen researched by authors who have been intimately involved in the development of the patientsafety movement in the United Kingdom. They bring a fresh approach to this topic because of theirprofessional roles in working with NHS boards and developing the principal patient safety ITsystem used by the NHS. The report is aimed at those responsible for the management of healthcareorganisations, including board members, accountable officers and commissioners.
Most of the writing on this issue looks at patient safety practice and then identifies how this mightbe linked to unnecessary expense. Instead, this report approaches the topic from the oppositedirection by looking at the principal cost saving measures implemented by healthcare organisationsand then identifying the contribution that patient safety can make to these.
This report examines the following cost reduction methods: Improvement to care administration Better care solutions Reform of non-care bureaucracy Care setting substitution Not to fund decisions For each method, case studies are given by way of example and details of contact points. These showthe contribution we believe that patient safety and quality can make, in varying degrees, to reducingcosts and freeing up resources.
The report also provides, using the familiar maturity matrix approach, a means by whichorganisations can reflect on their own readiness to manage disinvestment in parallel with improvingpatient safety.
Sir David Nicholson, The Spending Review Settlement, Department of Health, 20 October, 2010 "Our patient safety journey is ongoing and we are saving money as we go."2 In February 2010 we published our first report into the good governance of patient safety.3 Thisreport provided key information for all board members of healthcare organisations aboutiatrogenic harm, a significant public health issue in all healthcare systems. It included a maturitymatrix ‘ready reckoner' to help organisations understand where they are in relation to agreed betterpractice in terms of governing patient safety, and also a model template for board reports to ensurethat the board is properly accountable for patient safety.
We take it as read that patient safety is the right thing to do. Any patient harmed by an error is a tragedyworth the effort to avoid. Without any other cue, boards should be making patient safety their toppriority and working hard to minimise lives wrecked through unsafe care. Commissioners/purchasersof services should likewise be concerned when one of their patients experiences an issue.
This second report intends to help board members and accountable officers understand therelationship between patient safety and resources. With the imperative to drive waste out of thesystem, this report looks at the potential contributions that patient safety can make to achieving costreductions. It is aimed at all those on healthcare boards or commissioning healthcare services and,with the significant proposed changes to the structure of the NHS in England, we have prepared thisreport with an eye to the new commissioning organisations that will need to quickly develop theirown thoughts about this issue.
The crucial issue for those on boards of healthcare organisations is whether patient safety willrelease cash. The argument that safer care reduces costs is certainly seductive, with fundingmechanisms in the NHS being shaped on this expectation. The evidence points to real effort beingneeded to translate better care into cheaper care. It is much more straightforward to shift costs thanto improve quality and safety, while at the same time removing costs4,5. However, this is exactly thechallenge of the NHS Quality, Innovation, Productivity and Prevention (QIPP) programme. TheMinister for QIPP states: "We need to fashion a vibrant, creative NHS that really fizzes with ideas of how to improve quality andhow to reduce costs… So, instead of relying on ever more funds flowing from the Treasury, we must lookto ourselves to make savings. This practical imperative is what QIPP is all about… We have theresources, we have the knowledge and we have the ability to give the people of this country a truly firstclass NHS and to deliver it within our means."6 In our contribution to this debate, we emphasise that this is indeed an aspiration worth dedicatedeffort and full attention. We do, however, counsel against a trite or trivial approach to this issue.
Taking realisable costs from the healthcare system using the medium of quality or patient safety isnot a quick fix. We appreciate there is a pressing need for continued exploration of this issue andresearch to reliably link quality improvement to cash savings.
Patient Safety First campaign website, George Eliot Trust case study, George Eliot Hospital NHS Trust, 2010 A Corbett-Nolan and J Hazan, What every healthcare board needs to understand about patient safety, Good Governance Institute, February 2010 J Appleby et al, Improving NHS productivity: more with the same not more of the same, King's Fund, July 2010 P Smith, Measuring Value for Money in Healthcare: concepts and tools, Health Foundation, September 2009 Earl Howe, Minister for QIPP, Department of Health, 2 July, 2010 What makes our report different to others that tackle the same subject is that we have created asimple approach to understanding the different kinds of costs that healthcare systems can aim toreduce. We have refined this at various workshops and seminars over a period of six months.
In the course of developing this report we were highly impressed by the significant and systematicwork being undertaken in many organisations interested in patient safety. What these organisationshold in common is an approach that sees patient safety as the right thing to do, rather than justbeing a convenient means to a financial end. Good patient safety efforts are their own rewards, andany cash released for investment in other care services is a bonus.
Our aim is that board members become more discerning when presented with proposals thatpromise much by way of releasing cash, while at the same time improving safety or service quality.
Board members need to ask informed questions when presented with such proposals, and toconstructively challenge in a thoughtful and discerning manner. As clinicians are increasingly askedto ensure an evidence base to their practice, we likewise ask that healthcare boards use the samerigour to guide their own decisions.
This work was made possible by an educational grant from Datix, the leading supplier to the NHSof incident reporting systems. Datix also has a unique insight into areas where the patient safety andrisk management system itself can be improved to release cash savings. This insight builds on theGood Governance Institute's previous work on reducing the costs of governance, such as theintegrated governance work aimed at streamlining and improving governance processes. The Datixhistory itself provides a key lesson in terms of how mechanisation can help reduce costs while at thesame time improving reliability, and for this reason we unapologetically reproduce the story here.
Finally, this is new territory. We predict that over the coming years, many of the more substantialand sustained efforts to improve care services and patient safety will increasingly provide evidencethat attention to doing the right thing, right, right away both improves safety and reduces waste. Weexpect that good healthcare providers will increasingly use patient safety as a means of engaging allin improvement efforts that will save both lives and money.
Dr. John Bullivant
Good Governance Institute Good Governance Institute 1 What we know about the relationship between better, safer care and cost reduction "I stand no wiser than before."7 Iatrogenic harm affects a significant proportion of all those who come into contact with healthcareservices. For this reason, healthcare systems invest heavily in reducing the numbers of patientsaffected by iatrogenic harm and minimising the effects of harm when an incident takes place.
This report is limited to looking at the patient safety costs within the healthcare system. The cost ofpoor safety can also be picked up by other care providers, such as social care, as well as by patients andtheir families. This is another important area that needs research, but is not the focus of this report.
The common sense proposition is that good care costs less, and improving healthcare quality is theultimate win-win for both patients and the system. Figures for the costs of poor quality care rangefrom 25% of total healthcare system costs for failures in healthcare processes, through to the costsof successful litigation against the NHS amounting to around £787,000,000. Healthcare associatedinfections alone are estimated to cost in excess of £1 billion8.
The drive to connect patient safety and the better use of resources comes from the top too. TheLuxembourg declaration of 2005 stated: "Focus on patient safety leads to savings in treating patients exposed to adverse events and theconsequential improved use of financial resources. In addition, savings are achieved in administrationcosts associated with complaints and applications for compensation."9 The Health Foundation commissioned a major review of the evidence relating poor quality andcosts. In this review of the evidence10, Dr. John Øvretveit found that: Poor care is both common and costly. He identified evidence of overuse, misuse and underuse
of treatments, as well as costs directly associated with poor care. Examples are delirium acquired
in hospital through poor nursing care, sloppy prescribing practice and a disorientating
environment.11
Some interventions to improve quality do work, but may cost more money than they save.
Examples include using GPs to triage cases arriving at accident and emergency departments. GPs
can, in this role, significantly reduce those requiring hospital-based care and work at Salford
showed that around 15% of attendances could be routed to more appropriate care. However,
whether realisable costs were achieved is much more complex to identify
Some interventions to improve quality do work and save money. However, the implementation
of such initiatives is not trivial, requires skill and takes time. Often, not much cash is actually
released. Efforts to reduce hospital-associated infections can certainly mean that some patients will
spend less time in hospital. So can work to eradicate pressure sores. However, translating that to
being able to shut a pod of four beds in a predictable pattern and thus release resources for use
elsewhere is uncertain. The opportunistic use of beds freed up on a happenstance basis by safer care
is useful in a system where providers are able to increase revenue through increasing activity. In the
NHS, however, the aim has been to make savings, rather than allow providers to increase revenue
Johann Wolfgang von Goethe, Faust, 1806 National Audit Office, Reducing healthcare associated infections in hospitals in England, National Audit Office, June 2009 Presidence Luxembourgoise du Conseil de l'Union Europeenne, Luxembourg Declaration, DG Health and Human Protection, European Commission,5 April, 2005 10 J Øvretveit, Does improving quality save money? The Health Foundation, 2009 11 L Young and J George, Guidelines for the prevention, diagnosis and management of delirium in older people in hospital, Royal College of Physicians, 2005 Costs and benefits are spread over time and between different organisations differentially.
There is no ‘one size fits all' solution, and often the organisation making the investment will not
be that which benefits from the savings. For example, investment in preventative measures may
not deliver savings until many years later. An example is the use of particular diabetic therapies
which cost more, but reduce the propensity of patients to develop vascular compromise. The
costs of poor care often fall to non-healthcare organisations, and indeed to patients themselves.
Investing in such interventions is without doubt the right thing to do, but does not release
immediate cash for the NHS to invest in itself. The NHS needs to be encouraged to think in
terms of lifetime care costs for patients.
Context factors influence whether a provider saves money by improving quality. To
incentivise providers to improve quality, changes are needed in routine financing and
performance management systems. Currently, most providers would not be able to identify the
revenue at risk if there were a financial penalty attached to episodes of care associated with an
incident.
The simpler the change, the more likely implementation will succeed. Some simple clinical
changes can lead to considerable quality improvements. Examples include the early use of
thrombolytic therapies with appropriate stroke patients
Complex processes and organisational changes offer the greatest potential for savings. These
would include the rationalisation of hospital care, hospital location and service configuration.
However, there is even less evidence as to their effectiveness, and greater risk of failure. An NHS
Confederation report12 points to a mixed record of evidence of benefits from large scale
organisational change in healthcare, as reorganisations have rarely been seen through to the
extent of being able to realise benefits.
Øvretveit concluded that while it is possible for providers to realise savings from improving quality,this is difficult. It also depends on a number of factors, including: The cost of the problem, which is often not known.
Whether a solution already exists or can be developed and implemented locally. Local innovationis generally better rewarded, even if the results are unproven or mixed. Conversely, methods thatare proven to have succeeded elsewhere do not attract the same incentives.
The overall costs of the solution, and how much the provider will pay for it. For example anumber of hospitals are putting significant investment into information technology, trainingand systems development in order to identify where safety improvements can release resourcesin later years.
How conducive the environment is to the implementation of the solution. At University HospitalBirmingham, a significant cultural change, together with hard work at developing systems, hasdelivered best-in-class improvements in reducing medications errors.
12 N Edwards, The triumph of hope over experience, NHS Confederation, 2010 Cost reduction programmes and the contribution of patient safety Cost reduction programmes have traditionally achieved their aims through the more effective useof existing resources, combined with efforts to improve safety, quality and patient experience.
They have taken five distinct routes: 1. Improvements to care administration. The improvement of the administration of care services
through the reduction of waste, duplication, unnecessary steps in the care process and thepotential for process failure.
2. Better care solutions. By this we mean clinical interventions that create an earlier resolution of
a healthcare problem and thus stem the need for further chronic, acute or palliative treatment.
3. Reform of non-care bureaucracy. This involves the simplification of bureaucracy and focussing
of resources on direct service provision itself. It manifests itself in Gershon-type savings, themechanisation of administrative systems, removing bureaucratic functions altogether or shiftingbureaucratic costs away from the NHS.
4. Care setting substitution. This has a good track record of helping the NHS achieve savings. It
includes transfer of services from an acute setting to the community, replacing inpatient carewith day services or outpatient care and telemedicine solutions.
5. Not to fund decisions. The decision not fund a service at all and remove the entitlement from
NHS coverage or agree that some kinds of care are inappropriate at various stages in the patient'scare pathway.
The focus of this report is the nexus between patient safety and cost savings. We will now examinehow patient safety contributes to the different kinds of savings described above and can alsocontribute to making the proposed NHS reforms a success.
2 Improvement to care administration "Can more be had than is had?"13 Example approaches:– Lean systems approaches to care pathways – Information technology solutions to sharing information – Mechanisation – Use of agreed protocols and guidelines – Reforms to unscheduled care Quality management approaches have promised much to the reform of the NHS. Leading up to the1997 election in the UK, all the main political parties saw considerable benefits to bringinghealthcare quality to a more central place in the reform agenda. Early attempts to develop qualityas a means of reform included the Patient's Charter, some of the initial time-based systems targetsand waiting list initiatives. At that time, process engineers were starting to look at the carecontinuum. This involved introducing work that had been undertaken in the United States onrationalising and structuring the patient journey through the use of integrated care pathways. As weknow, the 1997 election went to Labour and the new Secretary of State published ‘A First ClassService' in 1998 that developed a new vision for healthcare with quality at the forefront.14 The quality and patient safety movements in the UK developed congruently. In qualitymanagement terms, the reduction of error and waste were both seen as means by which more couldbe had. This new thinking, gradually initiated over the first decade of the 21st century, led to theuptake of many central initiatives that sought to reform care administration along qualitymanagement lines. These were implemented using a carrot and stick management approach. Theapproach introduced new regulators, with penalties for late or poor quality care. It also providedhelp from various improvement agencies and financial incentives under the tariff system.
A growing body of evidence identifies the contribution of poorly organised healthcare systems topoor patient safety15,16. Simple quality failures, such as poor handover and communication betweenclinicians, have been shown to impact on patient safety17,18.
An example of a whole organisation approach to quality is Royal Bolton Hospital NHS FoundationTrust, where David Fillingham, the chief executive, and his team have applied a lean thinkingapproach to the delivery of reform and improvement.
Case study – an organisation-wide approach to instituting care Lean thinking is a management approach that identifies for any given process the essential andvalue added elements of that process based on the customer's view of service. It then isolates andreduces waste within the process to provide an improvement in quality. It is generally driven byan organisation-wide impetus for improvement, but works on a project-by-project basis.
13 The final question of the Doomsday Book inquests, detailed in the Inquisitio Eliensis, 1086 14 Department of Health, ‘A First Class Service', Department of Health 1 July 1998 15 S Burnett et al, How safe are clinical systems?, Health Foundation, May 2010 16 R Francis, The Mid Staffordshire NHS Foundation Trust Inquiry, Department of Health, 24 February, 2010 17 P Turner, MC Wong and KC Yee, Clinical Handover Literature Review, eHealth Services Research Group, Launceston: University of Tasmania, 18 WHO Collaborating Centre for Patient Safety Solutions, Communication during patient hand-overs, Patient Safety Solutions, vol 1. Geneva: World Health Organization, 2007 Waste, delay, redundant processes, handover points and unstructured care are all associatedwith poor patient safety and provide a seed-bed for iatrogenic harm.
The key elements to lean systems thinking are: Specifying value from the customer's point of view Seeing all work as a process and understanding the end to end value stream Making processes flow with no delays Pull patients through the system Be relentless in the quest for continuous improvement The Trust set up the Bolton Improving Care System (BICS) as a small team to facilitate thisimprovement. The BICS Academy is an in-house service that offers competency training inlean and has to date included about one third of the workforce. BICS also facilitates monthlyprogress meetings with the various projects, where each project is able to present progressupdates on the scheme in hand to an open meeting of staff and guests.
The special local circumstance that led to the initiation of BICS was the arrival of DavidFillingham as chief executive in 2008. Mr Fillingham had been the chief executive of the NHSModernisation Agency and had prior industry experience of quality systems. The trust atBolton was in turnaround and needed a new approach to managing targets, financial balanceand clinical quality. Mr Fillingham promoted lean management as a way in which to create anorganisation-wide culture of improvement that would deliver on these business goals.
Mr Fillingham said "For more than four years, teams from across the trust have been learningto use BICS – or lean thinking – to tackle problems and improve the way we do things, so thatwe can deliver a better service for patients, better working lives for staff and better value formoney. Since we started there have been 1,255 members of staff involved in 270 (April 2010)BICS rapid improvement events. We are steadily learning that lean thinking can offer a goodway of really understanding our processes, and it gives teams of front-line staff some ways tostart fixing them when they don't work. We have a vision that the Royal Bolton Hospital NHSFoundation Trust will be an organisation where the whole workforce is involved, every day, inmaking our processes better. At the heart of this approach is getting rid of waste – the kind ofthing that we all see too often in our everyday work – wasted journeys because things are in thewrong place; wasted supplies; wasted time doing things twice, or doing unnecessary things orjust hanging around waiting; wasted effort, sometimes having to put right things that weren'tright the first time; wasted talent of people who are distracted from what they really come towork to do – delivering a good service." David Fillingham, Chief Executive, Royal Bolton Hospital NHS Foundation Trust Other organisations have used the lens of patient safety to achieve the same ends. Patient safety hasthe advantage of being able to engage clinicians, which can be more difficult to achieve with qualitymanagement approaches borrowed from industry. The technical mechanisms are, however, thesame in both cases.
The Institute for Healthcare Improvement (IHI), under the leadership of Professor Don Berwick,spotted this early on. As an organisation heavily committed to the use of industry quality systemsin healthcare, the IHI ran parallel programmes such as their 100,000 Lives campaign (now 5Million Lives) which sought to use patient safety as the measurable means of understanding thesuccess of improvement efforts.
The better use of resources, improved customer satisfaction and good governance were all useful by-products of a measurable patient safety journey. In the UK, the Health Foundation acted as theconduit for IHI efforts and introduced the ‘Patient Safety First' campaign. Healthcare organisationswere encouraged to adopt a holistic approach, building engagement at all levels to achieve marketchanges in safety and thereby quality. An example of an organisation that has used patient safety asa means for improvement is Salford Royal NHS Foundation Trust.
Case study – using patient safety as the lens for system reform Following a visit to the Institute of Healthcare Improvement in Boston, David Dalton, the chief executive of the hospital trust in Salford, has led a programme to reduce harm to patientsby half and to use this as a means to deliver better, more sustainable and cost effectivehealthcare services.
Mr Dalton said Hope Hospital/Salford Royal has progressively developed its services and itsreputation over a generation.
"This has culminated in being recognised as having the highest consistent rating for servicequality coupled with one of the highest sets of patient and staff satisfaction scores. This is dueto two key factors: firstly, the experience, talent and motivation of our staff and secondly, therelationship that exists between management, clinicians and staff working together to deliverthe highest standards of service." Mr Dalton said.
"The NHS has just passed through a phenomenal and unprecedented period of growth and thescale of the financial challenge to the NHS and wider public sector is now becoming clearer. Inorder to help us to meet this challenge we believe we need to reduce our operating costs byabout 15% over three years and we want to reassure everyone that we will manage any changesproperly.
"We have clear plans to ensure our standards continue to remain high and we have fourprincipal priorities that will help us to achieve this. They are: We must safely reduce our costs by 15% over three years We must continue with our ambition to be the safest hospital in the NHS We must create the right culture with agreed shared aims and shared values We must create improved pathways of care for patients (integration with primary care andcommunity services) "I want our staff and our patients to see that we are prepared and will look for improvementsthat matter, together. We have always taken this approach to ensure that we deliver the higheststandards and safeguard our services to patients.
"There is no denying that public services face challenging times, but across our region thehealth service will work together and with other partners to meet growing demand, maintainthe quality and safety of care and deliver best value." David Dalton, Chief Executive, Salford Royal NHS Foundation Trust Salford Royal began with the chief executive setting tough ambitions for the organisation. Key to theprogramme at Salford has been to evidence improvement. This includes a measurable reduction inharm and better resource utilisation. These two factors are closely linked. If iatrogenic harm isreduced, it frees up resources that would otherwise be taken up in caring for patients who have beeninvolved in incidents. In a hospital setting, this enables the organisation to reduce the number ofbeds and staff servicing those beds.
Initial challenges at Salford have included reliable, real time information systems that alert cliniciansand management to probable cases of iatrogenic harm – patients who acquire sepsis in hospital, forexample. Current work includes focusing on particular wards to enhance care services and tobetter understand the relationship between improved safety and realisable resource savings.
A focus on known areas of poor care has been key to many efforts at taking costs out of the system,while at the same time improving the opportunities and experience of patients. A high level ‘hit list'of such care failings includes: Medication errors Healthcare associated infections Falls in care settings Failure to identify deteriorating patients Handover failures Non-availability of key equipment Availability of information at times of clinical decision making We have selected two examples of approaches to addressing some of these issues. The first of theseis the Learning Clinic system for the safer care of patients at risk of deterioration: Safer care for patients at risk of deterioration The Learning Clinic is a pioneer in developing systems to provide real-time clinically relevantdata within hospitals to drive safer care, better use of resources and a step change in outcomes.
VitalPAC, a system which captures patient information in real time at the bedside, underpinsthe approach, enabling clinically essential information to be shared between all members of thecare team in real time. Various rules and algorithms are built into the system to create alerts,trigger interventions and ensure that clinicians focus their attention on patients at the greatestrisk of deterioration or other complications.
VitalPAC enables nurses to record each patient's vital signs (respiration rate, blood pressure,oxygen saturation, pulse, level of consciousness, temperature, etc.) on hand held wirelessdevices. These are programmed to ensure that (often junior) staff take a complete set ofmeasurements as frequently as needed, based on the patient's condition. The system thencalculates an Early Warning Score, based on these measurements, which calculates how sick thepatient is and advises staff on what actions they need to take, for example to: Prompt further readings Summon a more senior clinician, such as a doctor Other predetermined response, as agreed by the clinical team The recently published VitalPAC Early Warning Score (ViEWS) identifies high risk patientsmuch more accurately than existing scoring systems, because it has been validated using thehuge database captured over the past five years from hospitals that use the system.
The VitalPAC approach means that observations are tailored to the patient, rather than theusual ‘one size fits all' approach to taking observations. The rote process of taking observations,usually undertaken by junior staff, is raised in profile. Repetitive tasks are completed reliablyand an audit trail created immediately. Staff numbers and skill mix can be better matched topatient acuity, with more senior clinicians able to focus on patients with the greatest needs. Thecalculation of the Early Warning Score is simplified and made less prone to errors throughmechanisation. Finally, should an error or untoward incident occur, it is a simple matter toreconstruct what happened, when and who was involved.
With the VitalPAC platform in place, it is possible to add in a wide variety of additionalmodules such as routine checking of intravenous cannulas (the most common cause ofbloodstream infections), screening for MRSA and Clostridium and risk assessment for bloodclots. The system can be linked to pathology data to improve the identification of high riskpatients and personal devices for doctors and others can be added to enable them to viewpatient details and respond to escalations of care immediately.
VitalPAC has proven very popular with clinicians because it is intuitive to use and enables themto capture important, clinically relevant data at the bedside. The intelligence generated helps them provide better care and decision support provided makes their job easier. The fact thatsuch data underpins the efficient and safe running of a hospital is a valuable spin-off, butVitalPAC is only able to provide such important operational information because it is designedaround a hospital's core business – patient care, delivered by clinical staff.
Dr Peter Greengross, Medical Director, The Learning Clinic University Hospitals Birmingham NHS Foundation Trust is an organisation with a good record forleading improvement. Patient safety has been a key method that has helped to build animprovement culture and develop individual strategies for modernisation. One initiative hasinvolved various approaches to driving down prescribing errors. Nationally, medicinesmanagement19 issues and prescribing errors are well-understood patient safety issues, with a medianin-hospital prescribing error rate of 7% being reported in a recent systematic review of prescribingfor inpatients20.
In Birmingham, these efforts have contributed to improved care pathway control, identification ofpossible cases of harm and increased accountability to those referring patients to their hospitals.
Improvements in safety and efficiency have been achieved in parallel with cost reductions.
Case study – better safety through information systems and mechanisation at Birmingham University Hospitals NHS Foundation Trust Better information technology has unlocked both service benefits and improved use ofresources at University Hospitals Birmingham NHS Foundation Trust. This work grew froman initial project to improve medicines management and has developed into a holistic clinicalinformation system. It has enabled management to make a stepped change in providing safer,higher quality care and containing costs.
Chief executive Julie Moore said the Prescribing Information Communication System (PICS)has helped the hospital to avoid between 400 and 450 potential medication errors each week.
"The trust expects to save approximately 10% of the drug budget due to more accurateprescribing and medication administration." Ms Moore said.
"PICS uses automated approaches to prescribing such as the Motion C5, the industry's firstmobile clinical assistant. Developed in collaboration with Intel and the NHS, it is designedspecifically for healthcare environments. It has a rugged design and includes an integratedbarcode scanner, RFID reader, digital camera and smartcard reader to ease clinician workloads,improve productivity and enhance patient care.
19 S Woodward, We need to improve drug use to minimize risks to patients, Nursing Times, 3 September, 2009 20 T Dornan, PJ Lewis, D Taylor et al, Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review, Drug Safety, vol 32, pp 379–389, 2009 "We can also now analyse in great detail any potential areas that can lead to errors and continuously improve the system to even further reduce medication errors. We havegained credit for this in our last quality account, which included achievement of the followingspecific aims: To improve medication safety through the development of an electronic data collection andreporting system for beta blockers, aspirin, warfarin, and clopidogrel and delivery of aperformance improvement target for patients on each of the prescribing pathways To improve patient safety by delivering a reduction in the number of missed drug doses To increase patient safety by reducing delays between prescription and administration ofantibiotic drugs "However, the using the PICS system to help improve the quality and safety of prescribing isonly the beginning. We have built the information system outwards to include details of thewhole pathway of care for our patients, and by using nationally available comparative data arenow able to identify very specifically where particular care pathways for our patients fall belowwhat we would expect. We have also developed an international care comparison relationshipwith the Cleveland Clinic, and have begun the process of ensuring that the safety of ourpatients, our quality of care and our use of resources exemplifies international best practice.
And when we make such claims that we can back these up with evidence and data.
"As the NHS moves forward and we increasingly need to help the national effort to pick up the effects of the recent recession, it is important that we know, and can prove, that better safety practice is contributing to our use of resources. We are actively sharing this informationwith local GPs to build better partnerships with those who refer patients to our care in thecoming years." Julie Moore, Chief Executive, University Hospitals Birmingham NHS Foundation Trust An example where a one-service improvement holds the promise of whole organisation benefits isat Gloucestershire Hospitals, where changes have been made to the arrangements for emergencyadmission of patients and service planning across the healthcare system has been developed alongpatient-centred lines in order to minimise risk for emergency patients.
This builds on learning derived from many studies, such as the various National ConfidentialEnquiry into Patient Outcome and Death (NCEPOD) reports21. These identified that the mostcritically ill patients were often seen by the most junior medical staff at a time when there was theminimum of clinical or diagnostic support available. Additionally, patients defaulting to theunscheduled care system but with primary care needs were being admitted to hospital, with all thequality, safety and cost issues that this entails.
21 H Cooper et al, Caring to the end?, National Confidential Enquiry into Patient Outcome and Death, 2009 UTOPIA: improving emergency care in Gloucestershire At Gloucestershire Hospitals NHS Foundation Trust, 73% of admissions arrive via theemergency route. Elderly patients are increasingly admitted with complicated, multiplemedical needs, which has a major impact on hospital resources.
Consultation with staff revealed that providing unscheduled care is problematic for thosewho are the first point of contact for potentially critically ill patients. In addition, patients andstaff stated that the system for reviewing and managing inpatients who unexpectedlydeteriorate whilst in care could also be improved.
Under the UTOPIA programme, a group of clinicians with a range of specialist expertise isbased in the emergency departments and acute care units of both the trust's hospitals to createan Unscheduled Care Team (UCT). This team is responsible for managing emergencyadmissions (excluding Obstetrics and direct admissions to a small number of specialist servicesincluding Oncology and Renal). The aim is to provide a seven day emergency service thataligns clinical decision making and capacity to activity profiles, improving the quality of careand patient safety, creating better conditions for staff and providing an improved, targeted,more efficient use of resources.
Central to the UTOPIA programme is an extended hours, on-site consultant assessmentservice responsible for assessing and stabilising all emergency patients and directing morejunior members of the team. This ensures that the best course of action is determined muchearlier in the patient pathway and provides the opportunity to enhance supervision and guidedlearning for junior doctors, giving them a level of autonomy and responsibility relating to theircompetence and experience.
The UCT has access to seven-day diagnostics and clinical support services (radiology,pathology and pharmacy), therapies, mental health and discharge planning services. Anoutreach service is another integral part of the new team to help the specialty wards withpatients who develop complications whilst in our care.
Some patients being admitted through the UCT require the skills of the other specialty teamsand plans to establish discharging arrangements on the speciality wards and to enable theirspecialist input to patients in the UCT are being developed.
A single point of clinical contact for all unscheduled referrals to the hospitals has provided animproved service for GPs, with stronger links established with community and primary careservices. This ensures that patients are directed to the service that is best able to meet theirneeds, whether this is within the hospital or from community services, and provides clinicianswith all the immediate information they require to manage the patient when they arrive. It willalso save GPs the frustration of making multiple calls to arrange a hospital admission.
The anticipated major benefits of UTOPIA are improved quality and a more efficient approachto managing emergency care. The aim is that patients will be seen by the right people, in theright place, at the right time.
Jenny Lewis, Project Leader, Gloucestershire Hospitals NHS Foundation Trust For local healthcare organisations, improvement to care administration lies very much within themanagement orbit. Understanding this provides practical actions that can be taken. For example,failures in reliability pose a real risk to patient safety. 15% of outpatient appointments in a recentstudy sites were affected by missing clinical information22.
The potential realisable resources are high, and patient safety has been demonstrated as a keymeans by which a local organisation can make a difference. Additionally, using patient safety as aprincipal means by which such changes are made is useful to engaging clinical staff in the reformprocess. This approach is only successful as part of a holistic and sustained effort over the mediumperiod. It is not a quick fix, and requires leadership from the top23,24,25.
Accordingly, we recommend that: All boards should consider how they are using patient safety as a means to improve careadministration. The annual review of patient safety undertaken by all boards should alsoconsider how patient safety activity dovetails into better care administration for patients.
The goals set by the board for the chief executive and the executive team should include specificrequirements to develop the care administration system so that safer care is holistically institutedacross the organisation.
Boards should adopt a safety and quality programme that links to the better use of resources.
Boards should set meaningful targets to reduce the waste of resources, coupled with thereduction of harm to patients.
Boards should identify their own ‘hit list' of top areas to focus care reform attention, built fromthe local pattern of reported incidents, augmented by problem areas identified in the literature.
Patient safety should be reported and discussed at all business meetings of the board, withreports that pick up the key messages from our February 2010 template board report. The mainthemes which should be picked up in these regular reports to the board are: Incident management – when incidents occur we properly record, follow-up and managethese so as to minimise harm to patients and reduce risk to our organisation.
Incident patterns and quality problems – we understand what our pattern of incidents are telling us, and can be certain that there is no special cause quality problem that we needto rectify.
22 S Burnett et al, ibid 23 J Storey, Why good governance in the NHS matters, Open University Business School, March 2010 24 S Burnett et al, Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes, Qual Saf Health Care 2010;19:313-317 25 Nursing Times, Leading the way to the safest possible care, Nursing Times, 2009 Mar 31-Apr 6;105(12):27 Harm reduction and resources saved – we know our progress towards our target to reduceharm and understand the financial risk and resources lost as a result of patient safetyincidents.
Instituting improvement – we are tracking the systematic institution of known to be effectivesafety and improvement efforts against an agreed plan.
Boards should set aside regular time for seminars or workshops to help develop a corporateapproach to safer and more effective care administration.
Boards should understand the potential to upscale smaller improvement programmes to thewhole organisation.
3 Better care solutions "You better cut the pizza in four pieces because I'm not hungry enough to eat six."26 Example approaches:– Use of thrombolytic therapy with streptokinase in acute ischemic stroke – Anti-retroviral therapy for patients with HIV – Treatment of major trauma within the Golden Hour – Early diagnosis and treatment of meningococcal meningitis – Vaccination and immunisation programme Payback time
Ease to achieve
Possibly high, but Medium term – three little evidence based years onwards Many examples of improvements to care services that claim to also reduce resource expenditureactually shift costs rather than save costs, either from one organisation to another, or over time.
However, there are examples where safer services and interventions actually reduce the subsequentneed for care and therefore costs. Most examples are innovations or new approaches to care.
Accordingly, the issue for individual healthcare organisations is that where such new modalities ofcare have been identified is assurance that they are being instituted locally.
Many such innovations can be understood as a variation of the compression of morbidity27, whichis a public health concept whose aim is to reduce the period from the onset of a chronic illness todeath by delaying the onset of illness. In some cases, harm to the patient from the illness can beentirely removed or made more remote. In others, the onset of illness itself may not be delayed, butthe costly disabling factors may be reduced by safer care mediations. In other words, the attempt isto flatten and keep the cost curve for already ill patients as low as possible for as long as possible, andto reduce the period of high expenditure and profound ill-health to the shortest possible timebefore death.
We are not necessarily looking for individual healthcare organisations to invent new approaches tocare. However, boards should be sure that their organisation is adopting better care practice. Wherenew approaches to care can either remove harm to patients or compress the onset of morbidity,these should be implemented locally.
26 Attributed to sportsman Yogi Berra 27 Klijs B, Nusselder WJ, Mackenbach JP Compression of morbidity: a promising approach to alleviate the societal consequences of population ageing? Tijdschr Gerontol Geriatr. 2009 Dec;40(6):228-36 An example of this approach is the early diagnosis and correct treatment of meningococcalmeningitis, where in excess of fifty years of care may be avoided by the timely and safe treatment ofillness in a child. Another is the avoidance of disability by the use of thrombolytic therapy withstreptokinase in acute ischemic stroke. A third would be the use of therapeutic approaches to earlydiabetes care that promote the prolonged retention of vascular and kidney health28.
The evidence about effective uptake of better practice is mixed. It is known, for example, that theearly detection of asymptomatic HIV disease and the initiation of drug therapies to arrest damageto the immune system are beneficial to patients. Patients diagnosed late with HIV stand a 10%chance of dying in the year of diagnosis29. It is estimated that around one third of people living withHIV in the United Kingdom are unaware of the fact, with late diagnosis remaining high, at arounda third of all cases. This is despite around 20% of all patients diagnosed with HIV having soughtmedical treatment for symptoms in the twelve months before diagnosis. In a cohort of 168 suchpatients, 35 had experienced an avoidable hospital admission.30 The financial cost of each HIVtransmission is estimated at around £1m.31 83,000 people in the United Kingdom are estimated tohave HIV infection. Late detection figures have not significantly improved in a decade.
In other care areas, it can be demonstrated that services have adopted higher care standards toprevent ill-health and subsequent morbidity32. An example is the early treatment of acute ischemicstroke, which has a highly beneficial effect on reducing disability and mortality. This in turn reduceshealth and social care costs and improves the outcome for the patient.
Stroke 90:10 – improving stroke services in the North West Stroke is the third biggest killer in the UK. Optimising the delivery of acute stroke care is oneof the few interventions where improving the delivery of care can realise savings as well asimprovements in population wellbeing. There are few interventions where the impact ofsavings at whole system level is so great. Of the £8 billion spent on stroke per year on stroke inEngland, one quarter of the costs are on social care, one fifth on health care and the rest are onpersonal costs such as loss of earnings. Any investment we make in service improvementneeds to evidence this saving truthfully as well as the improvement in health and wellbeing.
The Health Foundation funded research that found that the United Kingdom lags behind otherEuropean and Western countries in dealing with strokes. A critical need for concerted effortand action in England and improving stroke services has been a national priority for the pastten years.
Stroke 90:10 aimed to improve compliance with best practice from the national average of 65%to 90% by the 2010 Sentinel Stroke Audit. One pioneering intention was to ensure that anyonewith a suspected stroke receives a brain imaging CT scan within 24 hours. The 2009 ratestood at around 43% of people with stroke in the UK.
Stroke 90:10 sought to ensure that teams were supported to improve systems of care so thatpatients were able to access better practice care in the first week after a stroke had occurred.
28 Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, Ritz E, Atkins RC, Rohde R, Raz I; Collaborative Study Group, Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes, N Engl J Med 345 (12): 851–60, 2001
29 Burns FM et al, Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK, AIDS 2008;22(1):107-13 30 A Sullivan et al, Newly diagnosed HIV infections: review in UK and Ireland, British Medical Journal, June 2005 31 M Adler et al, National Strategy for HIV and Sexual Health, Department of Health, June 2001 32 JA Muir Gray, Evidence-based health care, Edinburgh: Churchill Livingstone, 1997 This included brain imaging, swallowing assessments, aspirin as appropriate and assessmentsby physiotherapists and occupational therapists. During this process, hospitals wereencouraged to develop improvement teams, attend learning sessions and received supportfrom a faculty team. Teams contributed data and reports to an e-learning network. Progresswith the programme was evaluated using are a stratified randomised controlled trial. Resultscomparing phase 1 and phase 2 sites will be available in early 2011.
29 hospitals within 21 trusts took part in Stroke 90:10. Divided into two groups, half thehospitals joined at the start in January 2009 and half in January 2010. Maxine Power, a formerHealth Foundation Quality Improvement Fellow directed the quality improvementintervention, a Breakthrough Series Collaborative. Stroke 90:10 is supported by the HealthFoundation, NHS North West, the Stroke Association, the Royal College of Physicians and theInstitute for Healthcare Improvement.
Maxine Power, National Improvement Advisor, QIPP programme Standards for the organisation of better stroke care were set by the Royal College of Physicians33 andthese are audited annually, attracting a 100% uptake in the audit in 2010. However, the latestsentinel audit34 found marked differences between different localities in terms of the developmentof services towards better practice, building on earlier evidence to this effect35.
Slowness in adopting better practice is an issue that has been well documented. The GoodGovernance Institute, as part of a Health Foundation quality programme, developed a boardassurance prompt for community acquired pneumonia36 with Tayside Health Board which askedwhy boards fail to ensure that local clinical services implement known better practice. Later boardassurance prompts in this series have considered diabetes services37, patient safety38 and the use offlexible clinical workers39 and have provided boards with sample assurance questions to help themknow whether their services are importing evidence-based better practice from elsewhere.
Boards and top teams should be regularly and systematically informed in regard to larger scalecare improvements. This should be done at a strategic distance (for example, blue-sky typethinking), as well as receiving regular reports on care innovations as they become available.
Boards should ensure that regular time is given to receiving assurance that known better practicefrom elsewhere is locally adopted.
Organisations should value the adoption of better practice developed elsewhere, as well as localinnovation. Currently, the system gives greater incentives to the development of new ideas thanthe adoption of existing initiatives from elsewhere that are known to work.
Boards should understand how their organisation is contributing to reducing variation in thecompression of morbidity and how they measure up to efforts from other similar organisations.
33 National Collaborating Centre for Chronic Conditions, Stroke – National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), Royal College of Physicians, July 2008 34 Intercollegiate Stroke Working Party, National Sentinel Stroke Audit 2010, Royal College of Physicians, August 2010 35 S Leatherman et al, Bridging the quality gap, Health Foundation, May 2008 36 J Bullivant, Board assurance prompt for community acquired pneumonia, Good Governance Institute, 2009 37 A Corbett-Nolan, J Bullivant, A Heald and S Thomas, Pathway assurance guide for diabetes services, Good Governance Institute and Institute of Healthcare Management, 2010 38 A Corbett-Nolan and J Hazan, Board assurance prompt for the governance of patient safety, Good Governance Institute, 2010 39 J Bullivant, A Corbett-Nolan, A O'Brien and G Dalley, Board assurance prompt for the governance of flexible workers, Good Governance Institute, 2010 4 Reform of non-care bureaucracy "Bureaucracy is a giant mechanism operated by pygmies."40 Example approaches:– Reduction and reform of healthcare, regulatory and administrative organisations – Reduction and redeployment of management and administrative staff – Streamlined governance and reporting processes Payback time
Ease to achieve
Low, but meaningful Almost immediate Good management is critical to healthcare, as is high-quality administrative support for the careprocess. We are not advocating a blanket reduction in either management or administration, ratherthat these resources properly match demand and have had the same cost-effectiveness rigourattached to them as others areas of healthcare spend. Where possible, mechanisation and using a‘lean thinking' approach should enable non-care processes to improve quality and reduce costs.
Our research suggests this is an area where immediate, sustainable and realisable savings can bemade. Some savings will benefit providers only, whilst others are whole systems savings and willallow resources to be freed up to devote to patient care.
In England, the government's response to reducing bureaucracy is outlined in the White Paper andthe arms-length bodies review41. This has included closing the Strategic Health Authorities, theHealth Protection Agency and the National Patient Safety Agency (NPSA). This area is outside thescope of this report, as our interest lies in the costs associated with the administration of systems ofpatient safety within individual healthcare organisations.
Alongside many other areas of management costs in the governance field, there has been littleattention to the cost of patient safety systems to an organisation and what savings they can deliver.
The work of the Good Governance Institute has helped to understand the thinking of boards asthey develop governance systems and processes. Datix's work provides particular insight into thethinking behind investment decisions in this area that we believe merits sharing with thoseresponsible for governing healthcare providers and commissioning care.
Initially, incident reporting systems were paper based. The completed paper incident report formwas transcribed into an application such as Datix by teams of data entry personnel. Analysis of thedata and the production of reports were performed centrally, with the information sent out onpaper to the wards and departments and management. These were still labour intensive activities,although they were a considerable improvement on wholly manual systems.
40 Honore de Balzac, Comedie Humane, 1841 41 Department of Health, Liberating the NHS: Report of the arms-length bodies review, Department of Health, July 2010 In time, web-based technology allowed clinicians to report incidents directly into the system. Theimproved access also enabled managers to analyse their own data and produce reports withoutburdening the hospital's central patient safety or governance function. This has freed up resourcesthat could be better directed to improving safety.
Interestingly, however, just 60% of those organisations using Datix have implemented web-basedreporting. Of course, web-based systems can provide real-time information, while paper-basedsystems inevitably have a lag time associated with the transcription and processing of data.
Incident reporting can be viewed as a form of quality assurance mechanism sitting alongside otherforms of feedback and review. Complaints and comments would be another such form of feedback.
In practice, these functionalities are often not linked in organisations using Datix. The full range oflabour saving features provided by the software may not be used, for reasons that include lack ofknowledge resulting from staff turnover. We recommend that organisations spend time tofamiliarise themselves with the labour saving features in the latest versions of their patient safetysoftware. They should also pay attention to features which allow the linking of information indifferent departments, e.g. incidents and complaints.
Case study: implementing web based incident reporting to free up NHS Grampian provides healthcare services to the 500,000 people who live in Scotland'sGrampian region, covering nearly a quarter of the area of Scotland.
NHS Grampian started to implement a web-based patient and staff safety reporting system in2005, replacing a cumbersome and fragmented paper system. The new system, based on theDatix application, was rolled out across the organisation's nine regions over a period of two years.
Janet Seaton, Technical Services Manager based in the Clinical Governance and RiskManagement Unit at NHS Grampian, said that the initial focus was on encouraging staff toreport more incidents using the new web forms.
"The old paper forms were time consuming for staff to fill in," Ms Seaton said. "We workedhard to design a web form that was quick to complete and therefore allowed staff to spendmore time caring for patients." Since the rollout was completed, NHS Grampian has seen thenumber of incidents reported increase almost twofold to 1,600 per month. The database nowholds more than 75,000 incidents.
"With such a major success in increasing the awareness of reporting safety issues, we have beenable to shift our focus from reporting to improvement," Janet Seaton said.
"We taught staff how to access their own data and run reports. We also deployed a dashboardthat illustrated graphically the level of harm in each area. This generated real engagementamongst clinicians as they realised they could start using the data to make improvements in safety." To maintain this level of engagement, the patient safety leadership walkrounds nowincorporate questions on whether clinicians are looking at the data from the system and whatimprovements they are making as a result. Data is now also analysed and reported at a raft ofdifferent levels including management and governance forums and senior staff across theorganisation are notified immediately when a significant incident is reported.
"We have become an organisation where there is visibility of patient safety incident data at thehighest levels," Janet Seaton said.
"With this has come a move from simple data recording to understanding the data and usingit to make a real impact on safety for patients and staff alike.
"We have only been able to do this by automating our manual, paper based systems. Previously,all our risk management resources were devoted to capturing incidents. With the web-basedsystem, we have been able to do more without increasing resources. The same resources arenow able to help with the learning from the system, assisting with the transformation of datainto information that can be used to make real improvements." Janet Seaton, Technical Services Manager, Clinical Governance and Risk Management Unit atNHS Grampian Patient safety is a critical issue for all healthcare organisations, and incident reporting is the bedrockfor management action to reduce harm. However, like all management activities, resources devotedto the data gathering, collation and analysis may not be considered as front-line services.
When purchasing a patient safety reporting application, the cost of the software itself is often thepurchaser's overriding consideration. Little attention is paid to the resources that can be freed upby the automation of manual processes. It is an interesting observation that we could not identifyany healthcare organisation that had available a whole system costing figure for incident reporting.
We also believe that an important direction of travel for incident reporting is the sharing ofinformation about incidents and subsequent quality improvement activity between provider andcommissioner. In our February 2010 report we recommended that details of any adverse incidentsshould be automatically provided to the referring clinician concerned. In a system where the referringclinician is also the commissioner, this becomes all the more important. We recommend that thisshould not be confined to serious untoward incidents, but should be extended to all incidents. The GPis also ideally positioned to detect incidents that have occurred to the patient elsewhere in thehealthcare system. The earlier the sharing of this information commences, the easier it will be to buildconstructive relationships that work to solve problems rather than penalise mistakes.
In the USA, there is an increasing trend towards not paying for episodes of care where the patient hasbeen involved in an adverse event. This principle is now becoming established in the NHS in England.
It will have a direct impact on the provider, who will have to bear the entire cost associated with thepatient's original treatment, as well as the costs of any additional treatment resulting from the incident.
Alongside all other important aspects of governance activity, patient safety will need to pay its way.
It will increasingly be unacceptable to require economies from care areas and management alikewithout systematically appraising the costs and benefits of governance activity.
Case study: understanding governance and risk management processes As the PCT has developed, being sure that we had governance systems and structures in placethat were appropriate, effective and efficient has always been very important. To this end wehave ensured that we ourselves take a view at least each year of the fitness for purpose for ourstructures, systems, reporting arrangements and working practices.
We have used various approaches to doing this. In 2009 we used the tried and tested approach ofgetting an external review which was conducted by interviewing all members of the board andagainst a commonly agreed template of good governance, risk management and patient safetypractice producing assurance for where our systems were appropriate, and recommendations forwhere developmental work was needed. In particular, we were keen to explore options forstepping up the level of clinical input into strategy, commissioning and decision-making but todo so in a way that would not create compromises under competition law.
Previously, as an internal project, we had undertaken a six sigma approach to reviewing of ourgovernance and risk management structures. In a similar way to improvements in themanufacturing sector, we had analysed the work of our governance committees using a SIPOCanalysis, which committee by committee required us to consider the: of that committee.
Putting our governance and risk management structures to this discipline helped create acommon understanding our where improvements and clarifications were needed. More thanthis though, the review helped create an understanding that governance was a process thatshould be run in a business-like way, and where resources and processes should be matched tointent about what we were achieving. Thinking through, for example, who the customers ofour governance and risk management processes were also helped focus the way committeesworked, records were kept and decisions were taken. It helped those on various committeesbetter understand their role, as well as contributed to the overall business-like culture the PCThas been keen to inculcate.
Jill Long, Head of Corporate Affairs, NHS West Sussex We recommend that al healthcare organisations: Produce a board report identifying the costs and benefits of all the administrative governancefunctions, and in particular identify the current key patient safety related management functionsand their total costs. This should include non-managerial time devoted to the administration ofpatient safety systems. The report should include recommendations for reducing the overall costof the administration of patient safety, while at the same time improving access for front-lineclinicians and service improvement managers to patient safety information. Classic qualityimprovement techniques can be applied to governance processes.
Use standard mechanisation techniques wherever possible to reduce the costs associated with theadministration of incident reporting. This will in almost all cases mean adopting web-basedsystems.
Immediately start providing information to all referring clinicians where an incident occurs toone of their patients.
GPs should record where a patient has been involved in an incident elsewhere in the healthcaresystem, as the GP may be the first person to have detected the incident.
5 Care setting substitution "A hospital bed is a parked taxi with the meter running."42 Example approaches:– Telemedicine care for chronic patients – Increasing repertoire of day surgery – Early discharge schemes Payback time
Ease to achieve
Long term – five years Many cost saving schemes have been aimed at care substitution, ensuring that patients are treatedin the appropriate care setting and thus reducing the need for hospital care. Acute in-hospitalservices are resource hungry and pose risks to patients, including healthcare associated infections,risks of becoming institutionalised, acquiring other forms of dependency related to the ward careregime and disorientation.43 Care setting substitution has been given much attention in cost saving literature and is usuallyimplemented by treating patients in primary care or community services. There is, however, also agrowing potential for other means of supporting patients out of hospital, such as telehealth systemswhich enable chronically ill patients to be safely supported in their own homes.
Supporting chronically ill patients at home – telehealth in two Yorkshire settings Chronic obstructive pulmonary disease (COPD) is one of the most common respiratorydiseases in the UK. The annual cost of treating it is £818m annually and is rising. Sheffield'slocal population has a high prevalence of COPD and in some parts of the city up to 8% ofpatients have the condition. This is due to the area's history of occupational exposure from thesteel industry. Likewise Doncaster has a high incidence of smoking and, as an ex-miningcommunity, has a high incidence of respiratory related patients with chronic illness. In bothareas, commissioners and clinicians were keen to help patients maintain a healthy life at homeand reduce the risks and costs associated with unnecessary care interventions and admissionsto hospitals. Tunstall telehealth systems were used.
43 L Young and J George, Guidelines for the prevention, diagnosis and management of delirium in older people in hospital, Royal College of Physicians, The Sheffield story Sheffield hospitals receive some 2,000 COPD related admissions annually. The PCT decidedthat a proactive approach was necessary to minimise avoidable admissions.
An assessment of COPD services revealed that health outcomes could be improved and usageof secondary reduced by using telehealth to monitor patients in their own homes within anearly discharge scheme. This required greater collaboration between primary and secondarycare teams, with improved access to secondary care clinicians skilled in advanced COPD care.
The secondary care clinicians were also used for their specialist knowledge of governance and risk.
The objectives of the pilot scheme were: To support early discharge of the patient To reduce the risks and costs of both elective and non elective admissions To hit key performance indicator targets – reduce A&E figures and discharge early To support community care with virtual wards To reduce possibility of infection by keeping patients out of hospital.
Telehealth monitors were given to 30 high-risk patients for a period of five months, duringwhich time they measured their own vital signs including heart rate, weight, blood pressureand oxygen saturation levels. The monitor was also capable of asking a series of clinicalquestions to further determine their current condition. Once measured, the data is transmittedto the public health development respiratory nurses and/or the COPD nurses' office withinsecondary care. The COPD nurse triages the patients against agreed criteria and applies anorder of priority to the visitation schedule, whilst those patients in need of urgent treatmentare referred to the appropriate care facility.
Key benefits to patients were: Earlier discharge Improved confidence as they know their condition is being closely monitored Rapid response to any change in the condition Better clinical risk management for a group of patients known to the service Fewer unplanned admissions The convenience of being monitored at home The innovative approach to managing the condition saw COPD-related hospital admissionsdecrease by 50%, releasing a saving of around £35,000 and £40,000, which enabled thepurchase of 15 more monitors. On the basis that the PCT could potentially avoid 50admissions a month, the total saving could amount to £1,200,000 annually.
Being able to remotely triage patients helped staff to prioritise visits. During the pilot, homevisits were reduced by 80% resulting in more effective use of staff time.
Initially nurses saw telehealth as a direct threat to their role. However, since its implementationthere has been a complete turn-around in staff attitudes and perception.
The Doncaster experience Over the past four years, significant success has been achieved at Doncaster with embeddingtelehealth and telecare (social care) systems. A planned collaborative approach has beendeveloped between NHS Doncaster and Doncaster Council.
The development of telesystems in Doncaster has been led from a multi-agency strategicsteering group, who have delegated implementation management to a delivery group andfull-time clinical manager. This built on a history of collaborative planning developed underthe auspices of a respiratory working group that was initially asthma-focussed, but over timeprioritised the development of better services for patients with COPD.
A cadre of 50 high risk COPD and heart failure patients are currently cared for by thetelesystem, and this is planned to increase to 180. NHS Doncaster has been working to developthe profile of patients who will best benefit form the telesystem support.
In rolling out the system, issues included the need for thorough patient and staff training at alllevels, including both clinical and administrative staff involved. The telehealth system enabledtolerances to be calibrated to individual patients too, so that each patient's care package, goalsand care profile was truly individual. This sometimes means going outside NICE guidelines butin a way that is more meaningful to achieving the right care for individual patients.
The implementation of the system is thoroughly audited to both develop an evidence base forfuture learning, and to help support better patient compliance, ensure that alerts aremeaningful and that the system evolves and improves over time. It has enabled patients tounderstand their condition better, and has helped reduce hospital admissions and has betterfocussed expert clinical attention. Earlier deterioration has also been picked up in individualpatients, fast-tracking some to intervention and reducing risk. In neighbouring NorthYorkshire and York a recent study has shown a 40% reduction in non-elective hospitaladmissions and a 28% drop in A and E attendances amongst patients using the Tunstalltelehealth system.
Dr. Victor Joseph, Associate Director of Public Health, NHS Doncaster Susan Thackray, Deputy Director of Nursing Development, NHS Sheffield Telehealth systems currently cover few patients, but have the potential to ensure that patients livingwith a chronic condition are able to manage their own health and be guardians of their safety.
Other care substitution schemes are exemplified by taking traditional acute hospital concepts andapplying these within a community setting. One such example would be the use of virtual wards.
A virtual ward is a way of providing support in the community to people with the most complexmedical and social needs. It uses the systems and staffing of a hospital ward, but without thephysical building, providing preventative care for people in their own homes. As in a hospitalward, the virtual ward team shares a common set of notes, meets daily, and has its own ward clerkwho can take messages and coordinate the team.
Virtual ward system at Croydon A system of virtual wards has been developed between the hospital and PCT at Croydon. Eachvirtual ward has a capacity to care for 100 patients. Admission to a virtual ward is determinedsolely by predictive modelling. This ensures that the patients admitted to a virtual ward arethose who will benefit the most: those most at risk of unplanned hospital admission. The NHSin England owns two predictive risk models, which were commissioned from a consortium ledby The King's Fund. These predictive tools are known as PARR (Patients At Risk ofReadmission), which was built by New York University and the Combined Model, built byHealth Dialog.
At the time of admission to the virtual ward, the community matron visits the patient athome and conducts an initial assessment. This record and all further entries by ward staff areentered into a shared set of electronic notes. A summary from the GP computer system isadded into these ward notes before the initial assessment so as to provide backgroundinformation and avoid unnecessary duplication of work. The GP practice is informed of allsignificant changes to the patient's management.
The day-to-day clinical work of the ward is lead by a community matron. Other staff include asocial worker, health visitor, pharmacist, community nurses and other allied health professionals.
A key member of staff is the ward administrator (ward clerk). With a dedicated telephonenumber and email address, the ward administrator is able to collect and disseminateinformation between patients, their carers, GP practice staff, virtual ward staff, and hospitalstaff. Medical input comes from daily telephone contact between the community matron andthe duty doctor at each constituent GP practice. The matron is also able to book surgeryappointments to see any patient's usual GP.
The virtual ward develops close working relationships with organisations such as hospices,drug and alcohol services and voluntary sector agencies.
Members of the virtual ward staff hold an office-based ward round each working day. Patientsare discussed at different frequencies depending on their circumstances and stability. Of the100 patients on each ward: five patients are discussed daily 35 are discussed weekly, with the remaining 60 patients being discussed monthly The community matron can move patients between these different intensity beds according tochanges in their clinical condition from day to day.
One of the key strengths of the Combined Model is that it enables predicted need to bemapped across a borough. The catchment population for each virtual ward can therefore beadjusted so that in areas where there is a high level of predicted need, the catchment populationwill be less than 34,000 and vice versa. In this way it is possible to counter the Inverse Care Lawthat states that the healthcare provided in a locality is usually inversely proportional to its levelof need.
Croydon now has plans for a network of ten wards that would care for the 1,000 patients athighest risk in he borough. The population of Croydon is 340,000 so the catchment population foreach ward will be roughly 34,000 i.e. approximately one ward for every 15 GPs.
Caroline Taylor, Chief Executive, NHS Croydon Other schemes are designed to prevent patients from needlessly defaulting to unscheduled carewhen other service options provide better patient satisfaction, are safer and are better value formoney. In particular, known patients with a chronic illness and older patients too frequently findthemselves in a medical assessment unit at the local acute hospital when their needs could have beenmet in a more appropriate care setting, more safely and for less cost.
As with other cost reduction methods, this must be considered as a whole system initiative. Undera tariff based system, an acute hospital trust would receive financial benefit from treating a patientwhich it would not obtain if the patient were treated in another care setting which is safer, moreappropriate and cost effective. This is an area where the commissioners must play an increasing role.
Where a patient could be better cared for in another care setting, consideration should be givento classifying this as an untoward incident.
Organisations should understand the economic risk associated with caring for patients whocould be managed in another care setting.
Commissioners should understand the pattern of care usage by sector for their local populations,and compare this with other similar populations in other parts of the country. All commissionersshould have in place plans for ensuring that they progress towards being in the upper quartile ofensuring that patients receive care in the appropriate setting.
Commissioners, those referring patients and patient advocate groups should have in place plansto better raise the awareness amongst patients of alternatives to acute care, to help create aclimate whereby patients and their carers understand the benefits of ensuring that patients arecared for in the most clinically appropriate setting according to their needs.
Telehealth systems should have in place robust clinical governance and patient safety systems sothat as they increase in uptake patient safety and confidence in the system is maintained.
6 Not to fund decisions "There are always two choices. Two paths to take. One is easy. And its only reward is that it's easy."44 Example approaches:– Tattoo removal, fertility treatment – Reclassification of healthcare mediations as social care – Convalescent care – End of life care Payback time
Ease to achieve
Low – most savings Savings appear actually costs shifted immediately, but maycost more in longer term Turning the funding tap off has been the tried and tested approach to rationing NHS resources informer years. This is no longer an acceptable route for the NHS to take and PCTs have foundthemselves publicly defending their decisions around limiting the funding of treatments45. Indeed,new funding has been made available for some cancer treatments that NICE has not deemed cost effective.
As information systems have developed, PCTs have increasingly been deciding what they will and willnot fund. Usually this has been at the margins, such as fertility treatments and particular drugtherapies that are not yet NICE approved. Another decision is whether certain services should insteadbe provided by social care. There are some interesting examples, including in Barking and Dagenhamwhere the PCT developed a set of principals for deciding when it would fund non-health spend in theinterests of better public health – swimming sessions, for example. Other PCTs have found themselvesdefending their decisions around limiting the funding of treatments to the public46.
An area where there is a careful debate to be had is terminal care, which may prove the exceptionto the rule. On the clear grounds of quality of life, a growing number of healthcare organisationsare looking at when to stop active treatment of dying patients and to provide palliative care only.
This brings with it cost implications, which need to be managed. The simple fact is that the last sixmonths of life consume the greatest proportion of an individual's lifetime health spend47 and closeto three in five die in hospital, against their preference48. Various initiatives, such as the LiverpoolCare Pathway49, have sought to help carers, patients and clinicians bring the quality benefits of 44 Attribution anonymous 45 L Donnelly, Infertile women told they can have IVF but only between the ages of 39 and a half and 40, Daily Telegraph, 27 June, 2009 46 L Donnelly, Infertile women told they can have IVF but only between the ages of 39 and a half and 40, Daily Telegraph, 27 June, 2009 47 Last six months of life biggest cost factor in health care, Community Action, 18 March, 2002 48 Claire Henry, Too many people are dying in hospital against their wishes, The Guardian, 11 August, 2010 49 Marie Curie Cancer Care, Your guide to the Liverpool Care Pathway, The Royal Liverpool University Hospital and Marie Curie Cancer Care, hospice care to these patients. Other schemes have been put in place to help remove the need forhospital care for dying patients altogether.
Salford and Trafford respite palliative homecare teams Respite palliative homecare teams in Salford and Trafford are enabling terminally ill patientsto be cared for and die at home – regardless of diagnosis.
The homecare teams were originally set up after local studies in the two areas showed that asfew as 21% of all cancer patients were dying at home. A year after their introduction, a surveyrevealed that 80% of all patients visited died at home while three quarters of the remaining20% died in another place of their choice.
The teams are now planning to expand their remit to a greater number of non-cancer patients.
Although care is provided to anyone with a life limiting illness only around 17% of all patientsvisited have a non-cancer diagnosis. The professionals working in these clinical areas will betold about the service in the hope that raised awareness will lead to an increase in referrals.
Education and training will also be provided to all team members to ensure they are adequatelyequipped to offer appropriate support.
Two teams, which are funded by their primary care trusts in collaboration with St Ann'sHospice, offer a combination of psychological and practical support, nursing care and advicethat is supplementary and complementary to the existing community services. They facilitatethe discharge of palliative care patients from hospital or hospice, especially those whosepreferred place of care is home, and provide support if either the patient or carer is facing acrisis. Each team consists of a full-time coordinator and team leader together with registerednurses and health care assistants. An extensive bank of nurses with experience in deliveringpalliative care at home underpins both teams.
Evaluation studies also showed the care provided was excellent and that all carers, professionaland lay, benefited from the increased support provided.
Respite palliative care teams in Salford and Trafford have ensured that 80% of those visitedare able to die at home Before the teams were established only 21% of cancer patients were dying at home The teams now provide care for patients – and carers – during the last year of life Increased uptake among non-cancer patients is now a priority.
The main challenge when setting up these services was the poor response from the districtnursing teams. This has been overcome by raising awareness and involving the district nursesin decisions about service delivery and change.
Carole Brown, Respite Teams Coordinator, Salford & Trafford PCTs The reasons for approaching the use of resources for dying patients through the quality route isobvious. In the run-up to the recent reforms of healthcare50 in the United States, politicians such asSarah Palin described clinical teams meeting to discuss this issue as ‘Death Panels' for limitingresources to terminally ill patients. With a focus on reducing costs, any rationalisation of careneeds to be explicable on grounds of quality, safety and patient choice.
This supports the view that basing the more effective use of resources on a clear safety and qualityrationale will make service changes more readily understood and simpler to introduce. It alsosupports engaging clinicians in identifying improvement opportunities.
Care rationing and rationalisation should be made on the basis of patient needs and benefits.
Patient safety and clinical risks should be an integral part of such decisions Patients and carers should receive accurate, dispassionate information and advice about the risksand benefits of all care they are offered. The option of and consequences to decisions ofwithdrawing from active care should be properly discussed with patients and their carers so thatinformed decisions may be taken by all concerned Quality and safety should be at the heart of all decisions about how care funding is spent, andcommissioners and providers should at all times ensure they are well-informed about the localposition. Patients and carers should be able to access high quality information and to supportthem in what will always be difficult and essentially personal decisions.
50 Andrew Clark, Obama may drop NHS-style provision from healthcare reform plan, The Guardian, 17 August, 2009 Healthcare is a high-risk industry. Combating iatrogenic harm is a significant factor for all thoseleading healthcare organisations. At the same time, demands on healthcare will continually grow asthe generation of baby-boomers becomes old, as chronic illness becomes a feature of the lives of agreater part of the population and as new drugs and therapies become available to treat illness andill health. In a very real sense, the healthcare system is a victim of its own success.
Patient safety errors can ruin lives and consume resources. Safer care is a key aim for all healthcareorganisations in its own right. However, through attention to making care services safer there arereal contributions that can be made to focussing resources better on the needs of patients.
Those charged with finding the resources to invest in increasing demand, better services and newdrugs and therapies as they become available need to look to patient safety as a key means ofhelping achieve better value for money, and releasing resources. Also, cost savings programmes needto be tested to ensure that safe care remains.
Boards and those leading healthcare organisations need to understand the relationship between costsavings and safer care, and the various issues that arise when cost savings programmes are put inplace. Leading organisations will want to know that they are genuinely saving realisable resources.
Using patient safety as a lens for cost savings also will help management engage with clinicians, andwill reassure patients and the public that value for money initiatives will at the same time deliverbetter, safer care. Returning to former policies of poorly thought through service cuts will beneither acceptable nor adequate. The authors believe that patient safety will be an important wayin which organisations can truly transform, and use the coming years to dramatically improve theopportunities of patients and service users.
8 Recommended further reading J Appleby et al, Improving NHS productivity: more with the same not more of the same, King'sFund, July 2010 Boston Consulting Group, The role of boards in improving patient safety, Monitor, June 2010 J Bullivant and M Wistow; Managing projects to a successful conclusion: an introductory guide,Kingston upon Hull City Council /OPM, 2000 J Bullivant, Benchmarking for Best Value in the NHS, NHS Confederation/Financial Times, 1999 S Burnett et al, How safe are clinical systems?, Health Foundation, May 2010 A Corbett-Nolan and J Hazan, What every healthcare board needs to understand about patientsafety, Good Governance Institute, February 2010 S Machell et al, Putting quality first in the boardroom: improving the business of caring, King'sFund, April 2010 J Øvretveit, Does improving quality save money? The Health Foundation, 2009 P Smith, Measuring Value for Money in Healthcare: concepts and tools, Health Foundation,September 2009 J Storey, The intended and unintended outcomes of new governance arrangements within the NHS,Open University Business School, March 2010 J Storey, J Bullivant and A Corbett-Nolan, Governing the new NHS- issues and Tensions,Routledge, 2010 ed our QIPP benefits e being achieved and nt. Our boar e able to articulate the e consistently meeting our eduction, QIPP and ef Our cost impr consistently met. Our boar describe the patient safety contribution to cost savings.
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W with our commissioners ar cost savings plans and QIPP oss England, made possible with an educational grant fr Development by the Good Gover cle the level you believe your organisation has r Published by the Good Governance InstituteOld HorsmansSedlescombe, near Battle East Sussex TN33 0RL ow to the right to the level you intend to r om the Benchmarking Institute – ‘Good is only good until you find better' GGI Limited, 2010 ISBN 978-1-907610-04-2 Designed by www.merceronline.co.uk eleasing plans ar Patient safety and cost savings: Maturity Matrix fectiveness patient safety ersion 1.1 – November 2010V To use the matrix: identify with a cir and then draw an arr supported by patient safety strategy/business plan Clinical engagement Developed under license fr We would like to thank the following colleagues for their help, advice and input into this report: David Bawden Care Quality Commission Kate Hall Policy Advisor, Monitor Dr. Gary Orr Consultant Psychiatrist, Hutt Valley Health Board Christine Boswell Chief Dr. Alasdair Honeyman Associate Director, Executive,Rotherham, Doncaster and Good Governance Institute Elaine Protheroe Board Secretary, Scunthorpe Mental Health Services NHS NHS Kensington and Chelsea Fred Hucker Chair, NHS Oxfordshire Janet Seaton Technical Services Manager, Dr. Tim Crossley General Practitioner, Angus Malcolm Healthcare Media Clinical Governance and Risk Management Consultant, Good Governance Institute Unit, NHS Grampian David Dalton Chief Executive, Salford Royal Hilary Merrett Consultant, CHKS Dr. David Somekh Past President, European Cost savings in healthcare organisations: Hospitals NHS Foundation Trust Peter Molyneux Chair, NHS Kensington and Society for Quality in Healthcare Bhavana Desai Non-Executive Director, Chris Spry Non-Executive Director, Dorset Central and North West London NHS Julie Moore Chief Executive, University County Hospital NHS Foundation Trust the contribution of patient safety Hospitals Birmingham NHS Foundation Trust Dan Taylor Director of Marketing, Datix Christa Echtle Chair, Datix Limited Paul Moore Chief Risk Officer, University of Jill Freer Director of Quality and Safety and South Manchester NHS Foundation Trust Darren Thorne Chief Officer: Wanstead, A guide for boards and commissioners Executive Nurse, NHS Warwickshire Jan Norman Director of Safeguarding, Annette Furley Audit Commission NHS Northamptonshiire Dr. Greg Wilcox Clinical Executive Chair, NHS Hastings and Rother and East Sussex Fiona Gale Consultant, CHKS Anne O'Brien Director of Clinical Governance, NHS Professionals Andrew Corbett-Nolan, Jonathan Hazan and Dr. John Bullivant

Source: http://www.datix.co.uk/ddme_cms/userfiles/files/GGI%20No_2.pdf

Guide to vaccine contraindications and precautions

Contraindications and Precautions Guide to Vaccine Contraindications and Precautions This guide summarizes CDC's recommendations regarding common symptoms and conditions that do and do not contraindicate vaccines licensed in the United States: Human Papillomavirus (HPV) Rotavirus Influenza (TIV & LAIV)

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The Science of Ethnobotany A division of HPHLPNew York into any pharmacy in the United States, Canada, or Western Europe and ask to examine any bottle of prescription medicine chosen at random. There is a one in four chance that the medicine you hold in your hand has an active ingredient derived from a plant. Most of these derived drugs were originally discovered through the study of traditional cures