African Partnerships for Patient Safety (APPS):

Lessons and Learning for Patient Safety

Webinar 4 of 6

APPS Webinar Series

Julie Storr

January 9, 2014

Review of Webinar 3

1. Outlined the linkage between "spread" and

national patient safety policy.;

2. Examined a WHO pilot tool for developing

national patient safety policy in the African

Region;

3. Described policy context in different

countries in Africa through case studies;

4. Articulated key lessons on patient safety

policy change.

http://www.who.int/patientsafety/implementation/apps/webinars/en/index1.html

Webinar 4 - Objectives

1. Outline the current and future mechanisms for sharing

patient safety improvement experience within and

between the APPS network

2. Articulate 10 key lessons from APPS partners over the

last four years

3. Through sharing of the 10 key lessons, describe how the

collective wisdom and experience can benefit those

starting the patient safety partnership journey

4. Introduce the APPS Evaluation Framework

Mechanisms for sharing

APPS network

Europe

Africa Rest of

the world

The knowledge sharing network of patient safety partnerships

The APPS Web Community Platform

An Online Forum

Access to an online

community

Chance to join

thematic discussions

Share experience

and learning

Receive quarterly

newsletter

An expanding online community

• 54 Community Members

• 1 Implementer

• 21 Countries

Thematic discussions

Ask questions – access a network of

experienced improvers

Share ideas

Follow the conversation

Learn

Experience and lessons shared

APPS News

Join us now

•Following registration to the

APPS Network you will

receive an email inviting you

to join the APPS Web

Platform;

•Join and be an active part of

this learning and sharing

network.

And - consider all media for learning &

sharing

The HIFA 2015 “Family” of discussion fora

http://www.hifa2015.org

HIFA CHILD 2015 email forum

http://www.hifa2015.org/child2015-forum/

HIFA - Portuguese

http://www.hifa2015.org/hifa-pt/

HIFA - Zambia

http://www.hifa2015.org/hifa-zambia/

HIFA - EVIPNet-Francais

http://www.hifa2015.org/hifa-evipnet-francais/

Other Partnership Focused Organizations

http://www.esther.eu

http://www.thet.org

http://www.esther.fr/en/

Turning the World Upside Down

http://www.ttwud.org

And….Social Media

Learning together

Patient Safety

Partnerships

Patient Safety

Improvement

Patient Safety Spread

APPS Compendium of Experiences & Momentum Report

http://www.who.int/patientsafety/implementation/apps/resources/en/index.html

10 lessons for patient safety partnerships

SUMMARY

Lesson #1: Identify the patient safety problem

• Patient Safety Situational

Analysis

• Set small achievable goals (2-5

Action Areas seems optimal)

• Choose inter-related Action

Areas

Gondar University Hospital, APPS Site Visit Report 18 | P a g e

“Practice  i

s

 n ot  difficult  fo r  h and  hygiene. Most of us know what to do. It is a problem with attitude where some workers do not make it a priority to wash hands” Surgical ward nurse

Structural Challenge:

Lack of sustainable

approaches to ABHR

production Alcohol Based Handrub has been

produced by the Gondar pharmacy staff

and utilized on various wards at Gondar

Hospital. However, sustainable methods

to produce the ABHR has been a

challenge. Due to limited space and

poorly constructed buildings, the

pharmacy staff has struggled to delineate

a sterile space for ABHR production.

The supply for the WHO recipe ABHR

ingredients were utilized for the first

ABHR launch, however, the pharmacy

staff has a keen interest in using a

sustained approach towards ABHR

production. The area that was used for

ABHR production is located in the same

area where boxed supplies are currently

located. Aware of the need for a more

streamlined and sterile approach to

ABHR production, Gondar lead

pharmacist, Endalkachew Admassie will

be traveling to Central Kamuzu Hospital

in Malawi in January 2013 to directly

observe their sterile area and learn how

to produce the ABHR in a sterile

manner.

Figure 1: Lead Gondar pharmacist, Endalkachew

Admassie holds a bottle of ABHR produced at

Gondar University Hospital. The area behind him

shows the non-sterile area where it was produced.

Despite ABHR production, the

distribution of ABHR equally on

medical and surgical wards has been

inconsistent. Observational survey data

showed how only one bottle of ABHR

was available on the orthopedic ward.

The ABHR was located in the corridor,

however, far from many patient bed

areas. Healthcare workers stressed how

lack of time due to nursing duties

prevented them from utilizing ABHR on

a consistent basis. Distance from patient

areas was also a common answer when

healthcare workers were asked about

barriers to ABHR use. Partners in UHL

had introduced personal-sized containers

for each health worker, however

malfunctioning flip tops on the

containers led to the ABHR spilling into

workers pockets. Currently, there are

bags full of empty plastic personal sized

containers in the supply area next to the

ABHR production area. Focus group

interviews revealed a strong interest in

having personal sized containers for

ABHR.

Lesson # 2: Convince others of the need to act

• Early institutional

engagement

• Use Situational Analysis

• National: Ministry of Health;

WHO; NGOs; Media;

Community

• International: Private

Organizations for Patient

Safety and alcohol based

handrub example

• “Healthcare is expensive. A

ny efforts to protect the health

of the patient and improve

patient safety in the hospital

will make our care more cost-

effective,” APPS Team member, Pharmacist

Lesson # 3: Patient safety improvement is not just another project

• Integrate with existing

frameworks

• Emphasize mutual

benefits, global learning

and local benefits for

patients

• Measurement is hard-

wired into the approach

Lesson # 4: Building a patient safety culture takes time (don’t be over-ambitious)

Small achievements can help build a

culture of safety:

■ Patient bill of rights, Healthcare worker bill of

rights displayed in clinic areas

■ ABHR for each healthcare worker – empowerment

“Even something as small as

personal towels for nurses, empower

us and make us feel important”

11 | P a g e

Central Kamuzu Hospital, APPS Site Visit Report

“People  need  t

o

 constantly  b

e

 reminded about hand hygiene, especially our healthcare workers. To empower the patients themselves to remind us to wash our hands is essential and for this to happen, patients need to know their rights”   APPS Lead, Dr. Jessie Mlotha

Key Achievement: Empowering Patients to

Demand Safe Care

Despite the challenges faced at Central

Kamuzu, the APPS team has made

several achievements in patient safety.

Change is often slow and cultural shifts

can be critical components in the

promotion of sustainable approaches.

Sharing these reverse innovations with

other APPS partners could provide a

mechanism to promote meaningful

change and promote patient safety

spread.

Understanding the importance of

empowering the patient and community,

APPS has promoted the use of poster

reminders in-patient waiting areas to

educate patients and empower them to

demand safe care. The APPS team

understands that simultaneous

approaches in patient safety include not

only procuring basic infection

prevention supplies, but also promoting

cultural shifts within the hospital

community.

Figure 4: Patient Bill of Rights and Responsibilities

in local language posted outside clinic patient

waiting areas.

APPS team members highlighted how

community engagement and engaging

the patient directly in the dialogue on

hand hygiene is critical for progress in

patient safety. One dental surgeon told a

story about how a patient asked him

prior  t

o

 st arting  hi s  ex amination,  “Did  

you  wash  your  hands  w

i

t h  so a p?”  Th e  

recognition of patient rights in

healthcare delivery through visual

reminders in clinic areas can empower

patients directly and hold all healthcare

staff accountable for infection

prevention. These cultural shifts are

often slow, but critical tipping point

moments such as these that can influence

cultural ideologies about quality health

care services. If patients can advocate

for themselves, this can be a more

sustainable way to influence compliance

in hand hygiene.

12 | P a g e

Central Kamuzu Hospital, APPS Site Visit Report

Key Achievement:

Innovations to Reduce Waste

Innovations to reduce waste in an

already overburdened system reveal how

the APPS team has developed

sustainable approaches to measure

utilization of ABHR. Despite lack of the

ABHR solution, it was rare to see a

healthcare worker without a personal-

sized ABHR container clipped to their

white coat. During focus group

interviews, health care workers

expressed how empowered they felt

having their own personal ABHR

container and it was evident from the

APPS data that utilization of ABHR on

specific wards was better in some than

others. The next steps would be to

continue using the pharmacy as a data

collection station as staff come to

restock their ABHR supply. Subsequent

projects could involve analyzing why

certain wards are not utilizing the ABHR

as often and exploring means to promote

hand hygiene compliance in a targeted

manner.

Figure 5: Personal ABHR clipped to white

coat of healthcare worker.

When the pharmacy staff at Central

Kamuzu was successful in developing

the WHO recipe ABHR, there was a real

enthusiasm among the healthcare staff to

use the ABHR. Dr. Jessie Mlotha, APPS

Lead, in coordination with the South

Tees NHS Trust hospital partnership was

able to procure 500 personal-sized

plastic containers with a surgical clip.

Despite the lack of ABHR supply

currently at Central Kamuzu, it was not

uncommon to see many healthcare staff

clipped with an empty plastic ABHR

container to their coats. The added

benefit of such an innovation was with a

goal to reduce plastic waste since waste

management is a serious challenge on

the hospital grounds. During focus group

interviews, many staff members were

frustrated that there was a good supply

of ABHR for months, followed by

challenges in basic supplies leading to

cessation of ABHR production.

“The  i

d

ea  was  th at  each  he althcare  worker could have their own alcohol hand rub attached to their coats. When they would run out of the hand rub, they would go to the central pharmacy and refill their bottle. This would also be a way to track data on which wards are using how much hand rub” APPS Lead, Dr. Jessie Mlotha

Lesson # 5: Awareness of context and the need for adaptation are critical

• Agree roles at the start

• Contextual challenges must be taken into account

• Infrastructure

• Human resources

• Data collection and surveillance

• Community engagement

• Culture

• Consider unintended consequences

Lesson # 6: Keep it simple

• Simplify interventions

• Policies and guidelines – a

good start (co-development

across partnerships)

• Front-line realities taken into

account

• Adapt the 6-Step cycle

• SMART plans

• Choose simple starting points

Lesson # 7: Improving safety and quality is a team sport

• Build a strong core team

• Then build smaller teams

• Use all available data

• Measurement is important – small results have big impact

• Visits help build momentum

• Individual passion motivates teams

• Celebrate success

Lesson # 8: Knowledge is the enemy of unsafe care

“Patient safety tools are simple, but

behavior change is difficult. These

are new concepts for us and

through persistent education we

can

promote shifts in our hospital cul

ture”

Nursing Patron

• Sensitize healthcare workers

through training and education

• Start with basic principles of

patient safety

• Develop contextual training

materials

Lesson # 9: Communication

• Highlighted as the single most important success factor

• Schedule regular communications and protect time

• Agree the preferred mechanism

• Post-visit follow-up communication is key

• Joint visit reports

• Communicate across the partnership

Lesson # 10: Clinical leadership and engagement is important (local and national)

• Early engagement with executive decision makers

• Sell the benefits across the hospital

• Senior hospital leaders as part of the patient safety team

• Engage national decision makers

• Use national events to launch/communicate about patient

safety

AND…..The APPS Evaluation Framework

Evaluation focused on the three programme

objectives:

■ Patient safety improvement

■ Partnership strength

■ Patient safety spread

A wealth of additional learning

Join APPS Webinar 6 to hear a synthesis of the

evaluation results so far.

SUMMARY POINTS

1. APPS provides a mechanism for sharing patient safety

improvement experience

2. Systematic analysis of existing partnerships has resulted

in 10 broad lessons for improvers that can aid

partnership work

3. The collective wisdom and experience is growing every

week – you can be part of this

4. The APPS Evaluation Framework webinar 6 builds on the

lessons presented here

THANK YOU

Please visit our website to find out more about

the programme and access our resources

www.who.int/patientsafety/implementation/apps