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Clarifying National Aims for Improvement

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Clarifying National Aims for Improvement Powered By Docstoc
					   Pat.O’Connor
      National
   Patient Safety
Development Advisor
Operation Life
  Denmark
    2008
McGlynn, et al: The quality of health care delivered
 to adults in the United States. NEJM 2003; 348:
 2635-2645 (June 26, 2003)

 Conclusion: The “Defect Rate” in the technical
        quality of American health care is

              approximately    45%
The first law of improvement


Every system is perfectly
designed to achieve exactly
    the results it gets.

         Peter Senge The Fifth Dimension
        Scotland’s Profile
• Population 5 million

• 2005 Life expectancy UK
    • women lowest in the European Union
    • men, the second lowest after Portugal
    • Urban and rural populations
    • 12 health Integrated primary community and
      hospital care care areas
    • Less than 5 % private healthcare
    • NHS free at the point of delivery across the UK
    • Devolved health Budget to Scottish Government
Characteristics of NHS Tayside


  •   Static Population 400,000
  •   Rural and Inner city
  •   3 Acute Hospitals
  •   2400 beds Primary and Acute
  •   1200 Acute
  •   Unique patient identifier
  •   14,500 staff
                              Stracathro Hospital




Perth Royal Infirmary
                        Ninewells Hospital
UK Patient Safety Journey
• The Health Foundation 2004 £4M
• Competitive process throughout the
  UK
• 52 organisations applied
• 4 selected
• Coincidence 1 in each country
• 1 Scotland, 1 Wales, 1 England,
  1 Northern Ireland,
 Learning System (Phase I):
  Collaborative Learning
  Organisational Model      P                  P               P
    Self Assessment     A                                 A
                                 D      A          D               D

                            S                  S              S

Site          4 day              2 day              2 day          1 day LS
Selection     Kickoff            LS                 LS             + Congress

                                                   Supports
            Key Changes                     Expert clinical faculty

            Improvement              Listserv               2 Site Visits

            Measures                 Phone conf             Assessments
                                        Monthly Reports via web



             Jan 2005           May 2005           Late 2005       June 2006
             The Goal


Using a patient safety portfolio evidence
 based change

          Reduce adverse events
           by 50% by Oct 2006
    The Key Elements of
 Breakthrough Improvement


Will to do what it takes to change to a
 new system
Ideas on which to base the design of the
 new system
Execution of the ideas
The Improvement Guide, API
Rapid Cycle Change with PDSA

 • What does this mean?
 • Plan, Do, Study, Act
 • Rapid cycle starts with e.g. One
   doctor, one nurse, one patient
 • Moving to 1…..3…..5…..All
 • These changes happen in hours
   and days not weeks and months
Adopter Categories
                           Source: E.M. Rogers, Diffusion of Innovations (1995)




      Early      Early                   Late
     Adopters   Majority                Majority                Laggards

2.5% 13.5%       34%                     34%                     16%
        Work Streams
•   Leadership
•   Medicines management
•   Peri-operative care
•   Intensive care
•   General ward

Throughout the organisation
   The Results in 20 months

• 63.5% reduction in adverse events(case note
  review)
• 91% reduction in medication errors rates on
  admission
• 66% reduction of line infections in renal and
  ICU
• 60 % reduction of MRSA bacteremias in
  surgery
• SSI bundle 95% compliance
• 50% reduction in VAP
Surgery
ICU
          Teams and Leaders: Roles
• Set Aims
• Build Will
• Assure Resources
• Remove Obstacles         Senior Leaders
• Review and Reflect
• Assure Spread
    • Make Improvements
    • Test and Learn
    • Report Lessons           Teams
    • Make Requests
• Human Resources
• Technical Expertise
• Information Technology
• Budget and Capital       Infrastructure
• System for Spread
       Cultural Elements
• Robust Governance and Risk
  management arrangements
• A preoccupancy with failure
• A culture of openness
• Abandoning blame as a major mode of
  action
• Trust in the workforce
• Involvement of patients and families
      The Unique Role of
     Organisation Leaders

• Set the tone and values system in their
  organisations,
• Establish strategic goals for activities to be
  undertaken,
• Align efforts within the organisation to achieve
  those goals,
• Provide resources for the creation of effective
  systems remove obstacles for staff, and
• Require adherence to revised practices
                                        Framework:
                            Leadership for Improvement
                        1. Set Direction: Mission, Vision and Strategy
                                                                          Make the future attractive PULL

    PUSH Make the status quo uncomfortable

         3. Build Will                           4. Generate Ideas                     5. Execute Change
•   Plan for Improvement                    • Understand Organization as a           • Use Model for Improvement for
•   Set Aims/Allocate Resources               System                                   Design and Redesign
•   Measure System Performance              • Read and Scan Widely, Learning         • Review and Guide Key Initiatives
•   Provide Encouragement                     from other Industries & Disciplines    • Spread Ideas
•   Make Financial Linkages                 • Benchmark to Find Ideas                • Communicate results
•   Learn Subject Matter                    • Listen to Patients                     • Sustain improved levels of
                                            • Invest in Research & Development         performance
                                            • Manage Knowledge




         • Reframe Operating Values
                                          2. Establish the Foundation               • Build Relationships
                                              • Prepare Personally
         • Build Improvement Capability                                             • Develop Future Leaders
                                              • Choose and Align the Senior Team
Why are we measuring?




   The answer to this question will guide your
     entire quality measurement journey!
 17 years to apply 14% of research
     knowledge to patient care!


Balas EA, Boren SA. Managing clinical knowledge for health care
   improvement. Yrbk of Med Informatics 2000; 65-70
                  The Three Faces of Performance
                                      Measurement
   “The Three Faces of Performance Measurement: Improvement, Accountability and Research”
   Lief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement vol. 23, no. 3, (March 1997),
   135-147.



         Aspect                          Improvement                         Accountability                          Research
Aim                                   Improvement of care                 Comparison, choice,                      New knowledge
                                                                          reassurance, spur for
                                                                                change
Methods:                                Test is observable              No test, evaluate current                  Test blinded or
                                                                             performance                             controlled
• Test Observability

• Bias                               Accept consistent bias              Measure and adjust to               Design to eliminate bias
                                                                             reduce bias
• Sample Size                          “Just enough” data,                  Obtain 100% of                        “Just in case” data
                                         small sequential               available, relevant data
                                             samples
• Flexibility of                      Hypothesis flexible,                     No hypothesis                      Fixed hypothesis
                                      changes as learning
  Hypothesis                              takes place
• Testing Strategy                       Sequential tests                          No tests                         One large test

• Determining if a                  Run charts or Shewhart                   No change focus                  Hypothesis, statistical
  Change is an                          control charts                                                        tests (t-test, F-test, chi
  Improvement                                                                                                         square),
                                                                                                                      p-values
                           Inpatients/Day Cases
400

350

300

250                                                               12-15 weeks
200

150

100                                                               >15 weeks
 50

  0
      Nov-   Dec-   Jan-    Feb-   Mar-   Apr-   May-   Jun-   Jul-   Aug-   Sep-
       07     07     08      08     08     08     08     08     08     08     08
M




              0
                  200
                          400
                                                 600
                                                             800
                                                                                   1000
                                                                                          1200
   ar
      -0
          7
 Ap
     r-0
M 7
  ay
      -0
         7
 Ju
    n-
        07
  Ju
     l -0
Au 7
    g-
        0
Se 7
    p-
        0
Oc 7
    t-0
         7

                                     >18 weeks
No
    v-0
De 7
    c-
        07
 Ja
    n-
                                                                                                 Outpatients




        08
Fe
    b-
        0
M 8
   ar
      -0
          8
 Ap
     r-0
M 8
  ay
      -0
         8
 Ju
    n-
        08
  Ju
     l -0
                                                                     12-15 weeks




Au 8
    g-
                        >15 weeks




        0
                         >15 weeks




Se 8
                                                       12-15 weeks




    p-
        08
                                                 20
                                                                     40
                                                                          60
                                                                               80
                                                                                    100
                                                                                          120
                                                                                                          140




            0
Ap
    r-
       0
M 7
 ay
     -0
        7
Ju
   n-
      07
Ju
   l-0
       7
Au
   g-
      0
Se 7
  p-
      07
Oc
    t-0
        7
No
   v-
      0
De 7
   c-0
       7
Ja
   n-
      08
Fe
   b-
      0
M 8
  ar




            Target from Apr 08 = 0
     -0
        8
Ap
    r-
       0
M 8
 ay
     -0
        8
Ju
   n-
      08
Ju
   l-0
       8
Au
   g-
      0
Se 8
  p-
      08
Oc
    t-0
        8
No
   v-
      0
De 8
   c-0
       8
Ja
   n-
      09
Fe
   b-
      0
M 9
  ar
     -0
        9
Ap
    r-
                                                                                              2008 = 81
                                                                                          Total October




                                                      >6 weeks = 8




       09
                                Short Stay = 7
 Measures for Improvement
                  •Early warning scoring Time to call,
                  interventions
• RRT             •Use of SBAR
                  •Cardiac arrest rate

                  •Safety briefings
                  •Use of SBAR in all areas
• Communication
                  •Observations & opportunities

                  •Floor and OR activities
• Hand Hygiene    •DVT prophlyaxis
                  •Antibiotics on time
                  •No shaving
• SSI bundle      •Normothermia
                  •Infection rates
   Measures for Improvement
                        •Pharmacy FMEA
• Med Mgt               •Med reconciliation all units
                        •ADE’s anticoag
                        •ADE trigger tool


                        •Monthly measure
                        •Spreading to units…. real time
• Global trigger tool

                        •VAP rates
                        •Bundle compliance CLI bundle Hand
                        Hygiene
                        •Safety briefings
• ICU
                                              Percent of Unreconciled Medicines on Admission (Standard Project Measure) NHS Tayside Team

                                    70%

                                                                                   Testing in 3             Reconciliation form
                                                      Testing in                    wards in                    included in
                                                       medical                       different               admissions ward
                                    60%
                                                     admissions                    specialities               documentation
                                                        only
                                                                                                                                                                                  Pilot
                                                                                                                               Pilot population                             population - 20
Percent Unreconciled on Admission




                                    50%                      New form                                                            altered - 10        Test of direct          patients from
                                                            being tested                                                           medical             access to                across
                                                                                                                               admissions, 10        electronic GP           organisation
                                                                                                                             general admissions      records in 50
                                    40%
                                                                                                                                                      patients on
                                                                                                                                                       one day -
                                                                                  Intake of new                                                      25% success            Reconciliation
                                    30%                                           junior doctors                                                          rate               training for
                                                                                                                                                                               medical
                                                        Test of direct                                                                                                        students
                                                          access to
                                    20%                electronic GP
                                                        records in 1
                                                           patient                                                           Ongoing testing in
                                                       - access slow                                                          wider range of
                                    10%                                                                                                                         Testing /
                                                                                                                                  clinical                      Implemented in
                                                                                                                              specialities - 6                  21/43 wards on
                                                                                                                                  wards                         Ninewells site
                                    0%
                                          May-05   Jun-05    Jul-05      Aug-05      Sep-05        Oct-05    Nov-05    Dec-05     Jan-06    Feb-06   Mar-06    Apr-06   May-06     Jun-06
                                                                                                                  Month
   Scottish Patient Safety Alliance
• Royal Colleges Surgery, Medicine, Nursing,
  Midwifery
• Specialist societies
• Government
• National Education Scotland
• National Services Scotland- National procurement,
  National data centre,
• e-health Director for Scotland
• Scottish Patients Societies
• National Safety Research network
• Quality Improvement Scotland
    Scottish Patient Safety Alliance

The Aims:
Transform the safety of health care in Scotland
  -start with acute care and move to community
  hospitals, primary care and mental health
Build the infrastructure, capacity and capability
  to create best in class for any strategic
  improvement priority
                    Outcome Aims

• Mortality: 15% reduction
• Adverse Events: 30% reduction
•   Ventilator Associated Pneumonia: 0 or 300 days between
•   Central Line Bloodstream Infection: 0 or 300 days between
•   Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range
•   MRSA Bloodstream Infection: 30% reduction
•   Crash Calls: 30% reduction
•   Harm from Anti-coagulation: 50% reduction in ADEs
•   Surgical Site Infections: 50% reduction
      How will we do this?
• 12 evidence based interventions
• 5 work streams: Critical care
                   General Ward
                   Medicines Management
                   Peri-operative
                   leadership
• Major change programme based on integrated
  arrangements at national, regional and local levels
• Science of improvement – Model for Improvement
• Measurement tools to determine results and outcomes
             12 Interventions
• Deploy rapid response teams
• Deliver reliable, evidence based care for acute
  myocardial infarction
• Prevent adverse drug events
• Prevent central line infections
• Prevent surgical site infections
• Prevent ventilator associated pneumonia
• Prevent pressure ulcers
• Reduce staphylococcus aureus (MRSA+MSSA) infection
• Prevent harm from high alert medications
• Reduce surgical complications
• Deliver reliable, evidence based care for congestive heart
  failure
• Get NHS Boards on board
    How will we know if the changes have made a
                    difference?

Some is Not a Number, Soon is Not a Time!

    The Numbers:
    30% Reduction in adverse
     events,
    15% reduction in Mortality

    The Time: January 1, 2011

				
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