'First Do No Harm' is a clinically-led patient safety campaign involving the four Northern Region DHBs (Auckland DHB, Counties Manukau DHB, Waitemata DHB and Northland DHB). The campaign is one of three strategic priorities of the four DHBs’ Northern Region Health Plan [view the Northern Region Health Plan]
The four DHBs share information about patient safety initiatives and use quality improvement strategies consistently across the region. The campaign strategies include raising awareness of patient safety; helping build quality improvement capacity and capability; using a formal improvement methodology to guide quality improvement activities; and developing strong partnerships and alignment with other regional and national programmes.
The clinically-led areas of 'First Do No Harm' work are:
- reducing harm from falls (working with the region’s aged residential care facilities)
- reducing harm from pressure injuries
- reducing harm from health-care associated infections
- improving medication safety
- improving transfer of clinical information
Key aims for 'First Do No Harm' are to:
- reduce falls by 20% across the region
- reduce pressure injuries by 20% across the region
- reduce central line associated bacteraemia (CLAB) by 40%
Recently, two consumer representatives joined the 'First Do No Harm' Steering Group to give a stronger consumer voice to the 'First Do No Harm' work. One of the representatives is a Health Link consumer representative.
In March / April 2012, the region’s four DHBs began submitting data to the 'First Do No Harm' team, and baseline data for the campaign’s area of work was established in November / December 2012. A series of collaborative learning sessions focusing on falls and pressure injuries began at this time. A 'First Do No Harm' steering group meets each month to review the data. The following charts show some of the results.
1a. Total Falls per 1,000 occupied bed days (OBD) [U-chart]
- The graph shows an increase in the rate of falls since February 2013. This is due to an intense monthly review of our falls data by the quality team and improvements we have made to our reporting system. As a result we are now able to more accurately identify falls occurring in our hospitals.
1b. Falls with Major Harm per 1,000 OBD (SAC 1&2 events) [U-chart]
- A fall is defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects”. Falls with Major Harm is a subset of falls and occurs when the fall results in major harm as defined regionally (it includes any fracture and a cut requiring stitches) and is recorded as a Severity Assessment Code (SAC) 1 or 2.
- The graph shows an increase in the rate of falls with major harm since February 2013. This is due to an intense monthly review of our falls data by the quality team and improvements we have made to our reporting system. As a result we are now able to more accurately identify falls occurring in our hospitals.
2a. Total Pressure Injuries per 100 patients [P-chart]
- A pressure injury is “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction”. This is the number of unique patients with pressure injuries, regardless of how any pressure injuries they may have.
- Pressure injury data are collected as prevalence, i.e. a randomised sample size is collected consistently on the same day of the month.
- 'First Do No Harm' regional DNH data collection for pressure injury commenced March 2012. There are insufficient data points to report any significant statistical change.
2b. Patients with Grades 3, 4 and ungradeable pressure injuries (never events) per 100 patients [P-chart]
- This is a subset of Pressure Injuries and occurs when the Pressure Injury is recorded as grade 3, 4 or ungradeable.
- There have been zero Grade 3 or 4 pressure injuries acquired during admission at Waitemata DHB since December 2012 (as at 13 September 2013).
3. CLAB - number of infections per 1,000 line days [U-chart]
- A CLAB (central line associated bacteria) is a bacteraemia infection that has spread to the bloodstream via an intravascular access device or catheter that is inserted in a large vein that terminates at or close to the heart in one of the great vessels, and which is used for infusion, withdrawal of blood, or haemodynamic monitoring.
- As of 31 August 2013, Waitemata DHB’s ICU is 605 days CLAB free, with a rate of 0 infections per 1,000 line days (target is <1 infection per 1,000 line days).
- The region’s mean is 0.62 infections per 1,000 line days.
Interpretation of quality time series data - Control Charts
The control charts represent variation in the data analysed. The control limits are derived from this variation and do not, therefore, indicate the desired performance limits. The processes or outcomes analysed may thus indicate stability (within control limits), trends and shifts only. The goal of quality of improvement is to reduce such process variation and improve process performance (e.g. a shift in the mean).
Types of control chart used:
- X-bar chart: In this chart the sample means are plotted in order to control the mean value of a variable (e.g. mean value of blood glucose standard)
- U-chart: A type of control chart used to monitor ‘count-type’ data where the sample size is greater than one, typically the average number of nonconformities per unit. In this chart the rate of defectives is plotted, that is, the number of defectives divided by the number of units inspected where this varies with samples, for example occupied bed days each month
- P-chart: The p-chart is a type of control chart used to monitor the proportion of nonconforming units in a sample, where the sample proportion nonconforming is defined as the ratio of the number of nonconforming units to the sample size. In this chart, we plot the per cent of defectives (per batch, per day, per machine, etc.) as in the u chart, where this varies with samples, for example patient volumes each month
The Institute of Healthcare Improvement (IHI) recommends that 15 to 20 data points are needed for a control chart before any results can be derived. Data presented in this report is the current view at the time of reporting. Data can be changed retrospectively to reflect incident reporting.
Transition of care - yellow envelopes project
In November / December 2012, a working group was established to look at how the transfer of health information using a ‘yellow envelope’ developed by Northland DHB could be introduced to the three Auckland DHBs. The envelope was launched in the three DHBs in March / April 2013 [view more about the transition of care (yellow envelopes) project].