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					                SAB HEAT target Support Initiative
                Learn, Sustain, Embed! - Tuesday 30 November 2010
09.40               Log in to National Video Conference
                    Important: Equipment switch on at least 15min before start
10.00-10.05         Welcome                                                      CHAIR
10.05–10.30         Overview and Future Vision                                   Ros Moore, CNO

10.30-11.00         Making it Happen                                             Jason Leitch, National Clinical Lead,
                                                                                 Patient Safety, SG

11.00- 11.30        Q&A                                                          All Health Boards
11.30 -11.45        Disconnect National Video Conferencing
                    Log into Regional Conferencing         Facilitated regional discussions                             Regional
                                                                                 West: Evonne Curran, HPS
                                                                                 East: Peter Christie, NHS QIS
                                                                                 North: Jackie Ley, NHS QIS

13.00               Disconnect Regional Video Conferencing
13.30 – 15.00       Learning in Action:                                          Local facilitators
                    Local Health Board discussion and development of
                    action plans

15.00- 15.15        Log in to National Video/Tele conference
                    Important: Equipment switch on at least 15min before start
15.15 – 15.45       National Discussion                                          Ros Moore
                                                                                 All Health Boards
            To prepare for the day
•   Your identified local facilitator
•   Flip charts (2) 1 marked ‘barriers’ 1 marked ‘solutions’
•   Post its
•   Refreshments (there will be no official tea / coffee breaks)
•   Lunch 13:00 – 13:30 (local arrangements)
•   In addition to the information identified in both tables below.
    Please bring the QIS SAB Driver Diagram/Change Package and
    Force Field Analysis Template previously provided.

    9 Boards who received SAB          All other NHS Boards BRING:
      diagnostic visit BRING:
                                  •Your local and last quarter HPS SAB
•SBARs (big and small)            data
•Latest monthly data from HPS     •Your SAB action plan
•Progress to date                 •Progress to date
•Achievements thus far            •Achievements thus far
•Barriers thus far                •Barriers thus far
                      Timings for VC Connections

Grampian Bridge will call you on the number detailed
  on your registration form and link you to the
  national and regional connections as per the
Please inform Jane Somerville 0131 623 4744 of any changes to these details.
9.30am Open your connection for national VC
11.30 – 11.45 Disconnect national link up but do not
  switch off. Await connection to regional link up as
  per registration details
13.00       Disconnect connection
15.00 Open your connection for national VC or TC as
  per registration details
             Please open connection for national VC 09:30

       National Video Conference 10:00 – 11:30

                              Forth Valley       Tayside
                 Borders                                       GJNH

       Lothian                  Ros Moore
                               Jason Leitch                      A&A

WIs              D&G                                Grampian

                                                               NHS QIS
                                Shetland                        NES
      Fife         Highland                   Lanarkshire

10:00-10:05   Welcome from Ros Moore, CNO

10:05-10:30   Overview and future vision
              Ros Moore

10:30-11:00   Making it happen
              Jason Leitch

11:00-11.30   Q&A
                   Borders          Regional Video Conference
                                            11.45 – 1.00
              PC                    facilitated regional discussions
                             Fife      • Jackie Ley (JL)
                                       • Peter Christie (PC)
                                       • Evonne Curran (ETC)

   Grampian                                                 GG&C
                    Highland                GJNH

                                      D&G           ETC
                             WIs                                 A&A
             Shetland                              Lanarkshire
    Facilitated regional sessions
       This is an opportunity

• Opportunity for dedicated reflective time
  – Consider your own issues
  – Consider your own progress
• Self-assessment
                            At this point consider - what
  – Your picture                    activity in SAB
                            reduction/prevention is your
  – Your purpose                board really good at?
  – Your process / plan     What area of activity in SAB
                            reduction/prevention do find
  – Your part                   most challenging?
           Picture – what is yours?
    Direction: VADs, UCs SST, SSIs BC conts
            Endpoint: March 2011 (No 1)

  NHS board
achieves SAB
 HEAT target
   ahead of
 March 2011
 by reducing
VAD infections
• Some patients are          • How do you build the
  getting serious life-        case?
  infections that are
  preventable with           • How do you present the
  good basic care!             story to different

                                                 Visible harm
 HEAT Target              Narrative
                ‘Six days post-operatively the
                patient was noted to have pus
                coming from a cannula site.’
                Case study 6
              Process & infrastructure
     • Make sure the processes at every level are
       clear and understood & that people understand
       how the process links clearly to the picture and

  Reduction of device use

                             Reduction in risk           Reduction in SAB

                                          All board to ward processes

Optimisation of device use
• What needs doing?

• Who is going to do it?

• What is your part in this?

• Are all parts allocated?
                Human Barriers
Change is met with enthusiasm   Change is met with confrontation
  when                            when people
• Agree on the change           • Are not involved
• Involved                      • Opinions not considered
• Opinions are heard and        • Don’t see the benefits / harm
  listened to                   • Don’t feel the benefits / harm
• There is clear benefit to     • They like the status quo
  organisation patients etc     • Do not trust / like ….
• Dislike the status quo        • Cannot see the big picture
• Respect and line the change   • No support
                                • To much change at once
• Believe change is important
                                • No proper change
• Believe change is necessary
                                • Time is not right
              Other barriers
• What are the other barriers?

• What impact would it have on the change effort?

• What could the group do about it?

• Who would be most effective?
                                 At this point consider - what
• Who will lead / solve……                activity in SAB
                                 reduction/prevention is your
                                     board really good at?
                                 What area of activity in SAB
                                 reduction/prevention do find
                                     most challenging?
                          Borders                Local Learning in Action
     Lothian         LF
LF                                                      13:30 - 15:00

       LF                      LF                        Local facilitation
 FV                 LF


     Tayside                                                       GG&C
                    LF                            GJNH
         LF                                                       LF
                              Grampian             LF               LF
Orkney                                     WIs
               LF                                                        A&A
          Local facilitation

• Sort and prioritise

• Make decisions using the results

• Check
Who is leading this?
                 Over to you
• Your picture                  15 mins

• Your purpose

• Your process infrastructure

• Your (and others’) parts
Your barriers / solutions
                                        15 mins

• Use the information provided to you
  – Driver diagram
  – Force field analysis
• Use your local information
  – Action plan for improvement
• Identify who can help
                                     15 mins

• What will each element cost and how
  much effort will be required?
• What can you accelerate to gain maximum
• Work out what will work for you?
• Who do you need to engage to achieve
  this (national & local)?
            Impact Analysis
• Define the extent of the change       15 mins

• Determine key differences in the
  changed state (equipment methods people
• Focus on the possible effects of key
  differences? (be clear what will achieve most
  for least effort)
• Picture – is it clear does it have a clear end point?

• Purpose – Has the case been built?

• Process / infrastructure – Will it achieve the picture?
  Using available tools?

• Part – who is doing what / are all parts allocated (local
  and national) who can help?

• Have the barriers been identified and plans for removal
  their agreed?

• Have the best bang per buck priorities been set?
              Please open connection for national VC/TC 15:00

          National Video Conference 15:15- 15:45

   Orkney                       Ros Moore

                     Borders             GG&C

                          Forth Valley
 WIs              D&G
                                    Shetland                 NHS QIS
                     Highland                  Lanarkshire
• Have you identified a priority action?

• Do you have an action plan identified to
  make this change

• What support do you need locally?

• What national support do you need?
         The CNO’s 5 must do’s
1.   Taking blood cultures safely

2.   Development and implementation of a PVC insertion

3.   Root cause analysis to be carried out on all SABs

4.   To identify who is leading the agenda to reduce SABs
     at the various levels of the organisation - i.e. from the
     Board to point of care

5.   What the communication strategy is to share the
     learning's from the event with colleagues - for Board to
     the point of care