Pat.O’ConnorNational
Patient Safety Development AdvisorOperation 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
Ninewells HospitalPerth Royal Infirmary
Stracathro 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
Model
Site Selection
SupportsExpert clinical faculty
Listserv 2 Site Visits
Phone conf Assessments
Monthly Reports via web
2 dayLS
A
P
D
S
A D
P
S
4 day Kickoff
D
S
P
A
2 dayLS
Key Changes
Improvement
Measures
May 2005 June 2006Late 2005Jan 2005
OrganisationalSelf Assessment
1 day LS+ Congress
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
Late Majority
Early Majority
Early Adopters Laggards
Innovators
Adopter Categories
2.5% 13.5% 34% 34% 16%
Source: E.M. Rogers, Diffusion of Innovations (1995)
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
Senior Leaders
Teams
Infrastructure
• Make Improvements• Test and Learn• Report Lessons• Make Requests
• Set Aims• Build Will• Assure Resources• Remove Obstacles• Review and Reflect• Assure Spread
• Human Resources• Technical Expertise• Information Technology• Budget and Capital• 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
PULL
PUSH
1. Set Direction: Mission, Vision and Strategy
Make the status quo uncomfortable
Make the future attractive
3. Build Will• Plan for Improvement• Set Aims/Allocate Resources• Measure System Performance• Provide Encouragement• Make Financial Linkages• Learn Subject Matter
5. Execute Change• Use Model for Improvement for Design and Redesign• Review and Guide Key Initiatives• Spread Ideas• Communicate results• Sustain improved levels of performance
4. Generate Ideas• Understand Organization as a
System• Read and Scan Widely, Learning
from other Industries & Disciplines• Benchmark to Find Ideas• Listen to Patients• Invest in Research & Development• Manage Knowledge
Framework: Leadership for Improvement
2. Establish the Foundation• Prepare Personally• Choose and Align the Senior Team
• Build Relationships• Develop Future Leaders
• Reframe Operating Values• Build Improvement Capability
Why are we measuring?
The answer to this question will guide your The answer to this question will guide your entire quality measurement journey!entire quality measurement journey!
Improvement
Improvement
??
Judgment?
Judgment?
Research?
Research?
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
Aspect Improvement Accountability ResearchAim Improvement of care Comparison, choice,
reassurance, spur for change
New knowledge
Methods:• Test Observability
Test is observable No test, evaluate current performance
Test blinded or controlled
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential
samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of Hypothesis
Hypothesis flexible, changes as learning
takes place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test
• Determining if a Change is an Improvement
Run charts or Shewhart control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi
square), p-values
• Confidentiality of the Data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
““The Three Faces of Performance Measurement: Improvement, Accountability and Research”The Three Faces of Performance Measurement: Improvement, Accountability and Research”Lief Solberg, Gordon Mosser and Sharon McDonald JoLief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement urnal on Quality Improvement vol. 23, no. 3, (March 1997), vol. 23, no. 3, (March 1997), 135-147. 135-147.
0
50100
150200
250
300350
400
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Inpatients/Day Cases
>15 weeks
12-15 weeks
Outpatients
>15 weeks
12-15 weeks
0
200
400
600
800
1000
1200
>15 weeks
12-15 weeks
>18 weeks
0
20
40
60
80
100
120
140
>6 weeks = 8
Short Stay = 7
Total October 2008 = 81
Target from Apr 08 = 0
Measures for Improvement• RRT
• Communication
• Hand Hygiene
• SSI bundle
•Early warning scoring Time to call, interventions•Use of SBAR•Cardiac arrest rate
•Safety briefings•Use of SBAR in all areas
•Observations & opportunities
•Floor and OR activities•DVT prophlyaxis•Antibiotics on time •No shaving•Normothermia•Infection rates
Measures for Improvement• Med Mgt
• Global trigger tool
• ICU
•Pharmacy FMEA•Med reconciliation all units•ADE’s anticoag•ADE trigger tool
•Monthly measure •Spreading to units…. real time
•VAP rates •Bundle compliance CLI bundle Hand Hygiene •Safety briefings
Percent of Unreconciled Medicines on Admission (Standard Project Measure) NHS Tayside Team
0%
10%
20%
30%
40%
50%
60%
70%
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
Perc
ent U
nrec
onci
led
on A
dmis
sion
Testing in medical
admissions only
New form being tested
Test of direct access to
electronic GP records in 1
patient- access slow
Intake of new junior doctors
Testing in 3 wards in different
specialities
Reconciliation form included in
admissions ward documentation
Pilot population altered - 10
medical admissions, 10
general admissions
Ongoing testing in wider range of
clinical specialities - 6
wards
Test of direct access to
electronic GP records in 50 patients on one day -
25% success rate
Testing / Implemented in 21/43 wards on Ninewells site
Reconciliation training for medical students
Pilot population - 20 patients from
across organisation
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