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Examples of large systems transformations:
NSW as world leader
Jeffrey Braithwaite, PhD
Founding Director and Professor
Australian Institute of Health Innovation, UNSW Medicine
Monday 28th October 2013
Australian Institute of Health Innovation
Australian Institute
of Health Innovation’s mission
… to enhance local, institutional and
international health system decision-
making through evidence; and use
systems sciences and translational
approaches to provide innovative,
evidence-based solutions to specified
health care delivery problems.
http://www.med.unsw.edu.au/medweb.nsf/page/ihi
Australian Institute of Health Innovation
• Professor Jeffrey Braithwaite Professor of Health Systems Research, Director, AIHI; Director, Centre for Clinical Governance Research
• Professor Enrico Coiera Professor of Health Informatics, Centre for Health Informatics, AIHI, UNSW
• Professor Ken Hillman Professor of Intensive Care, Simpson Centre for Health Services Research, AIHI, UNSW
• Professor Johanna Westbrook Professor of Health Informatics, Centre for Health Systems and Safety Research, AIHI, UNSW
Background - the Centre
The Centre for Clinical Governance
Research undertakes strategic research,
evaluations and research-based
projects of national and international
standing with a core interest to
investigate health sector issues of
policy, culture, systems, governance
and leadership.
http://www.med.unsw.edu.au/medweb.nsf/page/ClinGov_About
Part 1: Introduction
“After decades of improving the
health care system, patients still
receive care that is highly variable,
frequently inappropriate, and too
often, unsafe”
We have done studies at scale
MERIT study
• Medical Emergency Teams in NSW [Hillman et al Lancet 2005]
IPL study
• Large scale inter-professional learning [Braithwaite et al IJQHC 2012]
Weekend mortality
• Weekend hospital treatment [Coiera et al BMJ Quality & Safety 2013]
We have done studies at scale
Electronic medication systems
• Reductions in medication errors by 50% [Westbrook et al PLoS Medicine 2012]
Accreditation study
• How accreditation is associated with leadership and culture [Braithwaite et al IJQHC 2010]
On line evidence to clinicians
• Use of CIAP by 55,000 clinicians [Westbrook et al JAMIA 2004]
We have done studies at scale
CareTrack Study
• Proportion of appropriate care delivered to adults in Australia: 57% [95% CI 54-60%] [Runciman et al MJA 2012]
CareTrack Kids Study
• Proportion of appropriate care delivered to children in Australia: ?% [Braithwaite et al NHMRC Partnership Grant application approved for $2.5M, 2013-2016]
A key facet of the problem
• Current understanding of how to effect
large scale system change is poor
• Challenges:
• Translation [Implementation]
• Take up [Evidence]
• Diffusion [Spread]
The initial solution
• To do this we need partnerships:
• Researchers
• Policymakers
• Managers
• Clinicians
• Patients
Part 2: Celebrated
international successes
Celebrated successes
• Pronovost US; Matching Michigan UK
• Aim: reduce catheter-related bloodstream
infections in 103 ICUs across Michigan
• Results: mean rate of 7.7 infections per
1000 catheter days reduced to 1.4 at 18
months
• Conclusion: Evidence-based intervention
worked; and again in the UK [Pronovost et al 2006; see also Brion, et al, 2013]
Celebrated successes
• Haynes et al “Safe Surgery Saves Lives”
• Aim: 19-item surgical safety checklist
implemented in 8 hospitals in 8 cities
• Results: Rate of death was 1.5% and
complications, 11% before the checklist; and
0.8% and 7% afterward
• Conclusion: Reduced death, complications
[Haynes et al, 2009; see also de Vries et al, 2010]
Part 3:
What about other systems
improvement at scale?
We identified six interventions at
scale - criteria
• Took measures before and after
• Or had a control group, or both
• Evaluated the interventions
• Demonstrated large scale
systems improvement
• Peer-reviewed
Systems improvement at scale
Study Type Design Target Findings
Larson et al,
2000
Hand
hygiene
Organisation
al climate
intervention
Non-RCT
intervention and
follow up in two US
hospitals one as
intervention the
other control
Reduced
nosocomial
infections
baseline vs
follow-up
• Frequency of
hand washing
doubled
• Culture
worsened then
improved
Nowinski et
al, 2007
Conversion
to EHR
Organisation
al electronic
health record
intervention
Intervention in three
US hospitals;
observational study
Quality
improvement
indicators
Mixed changes in
culture and
clinical outcomes
Systems improvement at scale Study Type Design Target Findings
Grayson et
al, 2011
Hand
hygiene
National
hand hygiene
initiative
Intervention in 512
Australian hospitals;
observational study
SAB infections;
introduction of
a tool;
measurement
two years
before and after
the study
• HH compliance
increased
[nursing staff
74%; medical
staff 52%]
• SAB infections
declined post
implementation
Muething et
al, 2012
Serious
safety
events and
patient
safety
culture
Collaborative
quality
improvement
intervention
Intervention in a
large US paediatric
academic medical
centre;
observational study
Reduced
serious safety
events and
improved
patient safety
culture
• SSEs per
10,000
adjusted
patient days
decreased
from 0.9 to 0.3
• Patient safety
culture initially
worsened, then
improved over
time
Systems improvement at scale
Study Type Design Target Findings
Benning et
al, 2011
Safer
Patients
Initiative
mixed
methods
evaluation
of phase 1
Multi-faceted
improvement
intervention
applying
training,
champions,
tools,
leadership
Controlled mixed
method evaluation
and follow up in four
UK hospitals
Reduced
adverse events
• Modest
penetration of
SPI knowledge
and initiatives
• Modest
improvements
in some clinical
processes eg
vital signs
monitoring; no
additional
gains
Systems improvement at scale
Study Type Design Target Findings
Benning et
al, 2011
Safer
Patients
Initiative
controlled
evaluation
of phase 2
Assessment
of staff
attitudes;
review of
case notes of
high risk
ward
patients;
surgical
patients;
evaluation of
hand hygiene
compliance;
measurement
of outcomes
Controlled before
and after design
with five sub-
studies in 20 UK
hospitals [10
interventional and
10 matched control
hospitals]
Improvements
in SPI 1 with a
longer
intervention
period and less
budget
• Improvements
across the
board on both
interventional
and control
hospitals
occurred over
an eight year
period in the
UK
• No net
detectable
additional
effect in SPI
hospitals
Part 4: What’s to be done in
NSW?
How can NSW be world leader?
• It’s done great things, e.g.,
•ACI
•BtF
•EoC
•Hand hygiene
•Decentralisation
• But …
To what extent has NSW …
• Demonstrated large scale change?
• Measured at baseline and after?
• Evaluated interventions?
• Done comparisons between
intervention groups?
• Uncovered why things work in one
setting and not so well in another?
To what extent has NSW …
• Demonstrated:
• Translation [Implementation]?
• Take up [Evidence]?
• Diffusion [Spread]?
• Answer: not as well as we
want
What would this look like?
M
e
a
s
u
r
e
M
e
a
s
u
r
e
T1 T2
What would it look like?
[Braithwaite, 2011]
Above the waterline lie the observable workplace behaviours, practices and discourse: this is ‘the way we do things round here’.
Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: ‘How we think’ and ‘why we do the things we do round here’.
The iceberg
model of culture
What would it look like?
• The Promoting Action on Research
Implementation in Health Services
framework
SI = f (e,c,f) [SI = Successful implementation; e = evidence; c = context; f = facilitation]
[Stetler et
al., 2011]
Part 5: AIHI is doing things to
help
NHMRC Program grant 2014-2018
• New proposal funded by NHMRC for
$10.85 million
• Creating safe, effective
systems of care: the
translational challenge
[Investigators: Braithwaite, Westbrook, Coiera, Day,
Runciman, Hillman]
NHMRC CRE grant 2012-2016
• Proposal funded by NHMRC for $2.5
million
• NHMRC Centre for Research
Excellence (CRE) in e-health
[Investigators: Coiera, Sintchenko, Liaw, Luxan, Magrabi, Lau, Arguel,
Lui , Glasziou]
NHMRC Partnership grant 2013-
2016
• Proposal funded by NHMRC for $2.5
million
• The appropriateness of
healthcare delivered to Australian
children: CareTrack Kids
[Investigators: Braithwaite, Jaffe, White, Cowell,
Harris]
Part 6: Conclusion
Conclusion
• NSW is already doing things at
scale
• We have to strengthen, evaluate,
demonstrate this within the State
and to the world
• Comments or questions, please?
Suggested References 1. Braithwaite J, Coiera E. Beyond patient safety Flatland. J R Soc Med 2010; 103: 219-
225. 2. Braithwaite J, Greenfield D, Westbrook J et al. Health Service accreditation as a
predictor of clinical and organisational performance: a blinded, random, stratified study. Qual Saf Health Care 2010; 19: 14-21.
3. Braithwaite J, Travaglia J. PubMed articles on ‘engaging clinicians’. Sydney: Centre for Clinical Governance Research, University of New South Wales, 2007, 2009
4. Braithwaite J, Westbrook M, Nugus P, Greenfield D, Travaglia J, Runciman W, Foxwell
AR, Boyce RA, Devinney T. and Westbrook J. (2012) A four-year, systems-wide
intervention promoting interprofessional collaboration, BMC Health Services Research ,
12:99. 5. Braithwaite J, Westbrook, MT. Rethinking clinical organisational structures: an attitude
survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005; 10:1; 10-17.
6. Braithwaite J, Westbrook MT, Iedema R, Mallock NA, Forsyth R, Zhang K. A tale of two hospitals: assessing cultural landscapes and compositions. Soc Sci Med, 2005; 60: 1149–1162.
7. Braithwaite J, Westbrook MT, Pirone C, Robinson P, Robinson M, Michael S. Staff survey on patient safety: South Australian Council for Safety and Quality in Health Care and South Australian Department of Health. Sydney: Centre for Clinical Governance Research, University of New South Wales, 2009.
Suggested References
8. Creswick N, Westbrook JI, Braithwaite J. (2009) Understanding communication
networks in the emergency department. BMC Health Services Research; 9:247.
9. Eccles M.P, Armstrong D, Baker R, Cleary K, Davies H, Davies S, Glasziou P, Ilott I,
Kinmonth A, Leng G, Logan S, Marteau T, Michie S, Rogers H, Rycroft-Malone J. and
Sibbald B. (2009) An implementation research agenda. Implementation Science,
4:18.
10. Goldblatt EM, Lee WH. (2010) From bench to bedside: the growing use of
translational research in cancer medicine. Am J Transl Res; 2(1):1-18.
11. Lenz M, Steckelberg A, Richter B, I. M. (2007) Meta-analysis does not allow appraisal
of complex interventions in diabetes and hypertension self-management: a
methodological review. Diabetologia; 50(7):1375-83.
12. Ogilvie D, Craig P, Griffin S, Macintyre S. and Wareham NJ.(2009) A translational
framework for public health research. BMC Public Health, 9:116.
13. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, et al. (2012) Effects of Two
Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-
Patients: A Before and After Study. PLoS Med ,9(1)
Suggested References
14. Braithwaite J, Westbrook MT, Robinson M, Michael S, MacFarlane M. Staff survey on
patient safety: a comparison of results from Whanganui, Waikato and Capital & Coast
District Health Boards. Sydney: Centre for Clinical Governance Research, University
of New South Wales,2009.
15. Braithwaite J, Westbrook MT, Travaglia J. Attitudes toward the large-scale
implementation of an incident reporting system. Int J Qual Health Care 2008; 20: 184-
191.
16. Braithwaite J, Westbrook MT, Travaglia J et al. Cultural and associated enablers of,
and barriers to, adverse incident reporting. Quality and Safety in Health Care 2010;
19: 229-233.
Contact details
Jeffrey Braithwaite, PhD
Foundation Director
Australian Institute of Health Innovation
Director
Centre for Clinical Governance Research
Professor, Faculty of Medicine
University of New South Wales
SYDNEY NSW 2052
AUSTRALIA
Email: [email protected]
Wiki: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite
Web: http://www.aihi.unsw.edu.au