3. Standing on the shoulders of giants: Early improvement works in Scotland
Improvement efforts in Scotland are most known for the Scottish Patient Safety Programme – the first national and systematic approach to patient safety improvement in the world. Yet, at this point Scotland already had a long history of various improvement and innovation projects, particularly within the health care sector. And while improvement was not understood in the same way as it is now, all these efforts aimed at improving care for the patients.
Dating back 5 decades, the earliest works revolved around audit, clinical guidelines, and evidence-based best practice. A prominent example of the clinical audits using clinical data is Sir Graham Teasdale and Bryan Jennett’s (1974) development of the Glasgow Coma Scale that allows for an assessment of the level of consciousness of patients with acute brain injury. Regarding guidelines, the Scottish Intercollegiate Guidelines Network ( SIGN) was formed in 1993 with the objective of improving the quality of health care for patients through the development and dissemination of evidence-based clinical guidelines. Since 2005, SIGN forms part of NHS Quality and Improvement Scotland, now Healthcare Improvement Scotland, and has approximately 150 guidelines available ( SIGN, 2016). In 1994, the Scottish Audit of Surgical Mortality was introduced to reduce deaths under the care of surgeons and reached over 1100 voluntary participants and 3000 yearly death reviews ( SASM, no date). Since 2001, the Scottish Medicines Consortium ( SMC) has been in charge of appraising all new medicines incoming into the country based on clinical and cost effectiveness. Complementing the evidence and advice provided by SIGN and SMC, the Scottish Health Technologies Group focuses on new healthcare technologies since 2008. In the same decade, Scotland developed its own unique patient identifier – the CHI number. The Community Health Index ( CHI) is a population register to ensure that patients can be correctly identified, and that all information pertaining to a patient's health is available to providers of care. The CHI number uniquely identifies a person on that index.
The period of about 1998-2003 took the form of two streams of activity: 1) the Strategic Change Unit within the Scottish Government Health Directorate which focused on leadership and organisational development, and 2) a liaison with key improvers within the Designed Healthcare Initiative run by the NHS Modernisation Agency in England, one of the first initiatives attempting to understand and improve healthcare processes. The latter allowed Scotland to learn and introduce the concepts of process mapping and taking out wasteful steps that didn’t benefit either patients or clinicians. In 2002-2003, these two activities were brought together to form the Scottish Government Centre for Change and Innovation ( CCI). Starting to tap into the emerging improvement knowledge coming from IHI and through connections with the English Modernisation Agency, the CCI realised the potential of improvement science for making Scottish healthcare better. At this time, the CCI ran various national programmes, with voluntary participation, including the Outpatients Improvement Programme (2003 – 2006), the Scottish Primary Care Collaborative (2003 – 2009), the Cancer Service Improvement Programme (2003 – 2006), and the Mental Health Improvement Programme. It was a time of creating a toolkit of methodologies which varied from lean methodologies, through process mapping and mapping patient pathways, to the first applications of the Model for Improvement and the IHI Collaborative method used in the Primary Care Collaborative with the help from the Modernisation Agency.
These early improvement programmes were met by many challenges. The early knowledge of improvement science that was available was pieced together from various sources and therefore potentially missing the necessary methodological rigor. There was a shortage of improvement capacity and capability within Scotland creating an operating model entirely based on seconded members of staff, something that became no longer sustainable once healthcare started facing financial cuts. The alignment to performance and delivery was confusing for the services expecting judgement and performance management. It was possibly a way of thinking most senior management in the health boards, or the service staff, were not ready to understand and learn about. Moreover, there was an emerging stream of adopting lean approaches across the health boards leading to further confusion over competing ideologies.
Taking the learning from the first wave of improvement programmes, a second wave was introduced: The Unscheduled Care Collaborative (2004 – 2007/8), the Diagnostics Collaborative (2005 – 2007), the Planned Care Improvement Programme (2006 – 2008) focusing on patient flow, and more recently the Mental Health Collaborative (2008 - 2011), and the Long-term Conditions Collaborative (2008 - 2011). These programmes were run nationally, expected participation from all NHS Health Boards and were beginning to introduce whole system thinking (Scottish Executive, 2006). In 2005, CCI was rebranded into the Scottish Government Improvement & Support Team ( IST) and brought under the new Health Delivery Directorate. This meant more focus on performance targets and delivery, particularly within the context of waiting times and access. As the Patient Safety Programme started developing, IST rebranded again into Quality & Efficiency Support Team ( QuEST) continuing its programme activity and developing new ones.
Scotland also participated in UK-wide efforts, such as the Safer Patients Initiative ( SPI) launched by the Health Foundation (2004-2008) and supported by the Institute for Healthcare Improvement ( IHI). Together with one hospital in England, one in Wales, and one in Northern Ireland, the NHS Tayside territorial board and its Ninewells hospital in Dundee took part in Phase I of this major improvement programme targeting patient safety in the UK. Then, Phase II spread to further 20 hospitals including in NHS Dumfries and Galloway and NHS Ayrshire and Arran (Health Foundation, 2011). SPI focused on improving reliability of specific processes of care within four designated clinical areas where there were known strategies for improving safety and testing these on an organisation-wide basis within NHS hospitals. Once tested in the first 4 sites with each reporting more than 50% reduction in adverse events (only a portion of identified interventions included), the aims for SPI Phase II were announced: over a 20-month period, to reduce adverse events by 30% and to reduce mortality by 15% in each NHS trust or health board. All of the sites reported improvement within at least a half of the targeted 43 process and outcome measures (Health Foundation, 2011).
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