what is improving patient safety in the...
TRANSCRIPT
![Page 1: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/1.jpg)
What is Improving Patient Safety in the England?
20th Annual International
Forum on Quality & Safety
in Healthcare
Carol Haraden &
Mike Durkin
24 April 2015
![Page 2: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/2.jpg)
www.england.nhs.uk
The VTE Journey
2005 2006
APPTG
2007
HSC
Inquiry
CMO announces
national approach
NICE
CG46
2008
Exemplar
Centre
website
2009
Leadership
Summit
Risk
Assessment
template
NICE CG92
CQUIN
NICE QS3
Focal Point
for Change
2010
RA data
collectionCQUIN goal
reached
2011………….Present
Risk Assessment
figs now at 96%
New e-learning
modules
NHS Choices
Self-assessment
tool
National
Patient
Information
Leaflets
Commissioning
Toolkit
VTE in NHS
standard
contract
Information
Standard
2
![Page 3: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/3.jpg)
www.england.nhs.uk
Comprehensive, systematic approach to VTE prevention
VTE Prevention Programme was the first national initiative of its kind
Key patient safety initiative:
Delivering high quality care
Reducing avoidable harm from VTE
Making hospitals safer
Leadership from patients and their families, the NHS, parliamentarians, charities….
Striving for excellence – VTE Exemplar Centres Network
Delivered change, enabled by levers provided by NHS
Risk Assessment rates have risen from <50% in 2010
Now stand at 96%
The NHS VTE prevention programme
3
![Page 4: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/4.jpg)
www.england.nhs.uk
The impact of CQUIN
4
![Page 5: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/5.jpg)
www.england.nhs.uk
Improving Outcomes
5
• QI data at trust level: increased risk
assessment, decrease in rates of HAT,
increased rates of appropriate TP,
reduction of inadequate prophylaxis,
• QuORU: 15% reduction in mortality
nationally when 90% risk assessment
goal reached
• Catterick & Hunt: in 2011 & 2012,
around 940 deaths owing to VTE have
been avoided in England. Impact of the national venous thromboembolism risk
assessment tool in secondary care in England:
retrospective population-based database studyDavid Cattericka,b and Beverly J. Huntc
Blood Coagulation and Fibrinolysis 2014, 25:00–00
ONS data shows 9% reduction in VTE deaths since 2010
Improvement corroborated by 3 studies:
![Page 6: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/6.jpg)
www.england.nhs.uk
Case Study:
King’s College Hospital
• Thrombosis committee established 1999 – an instrument for clinical governance and driving change
• Leader of VTE Exemplar Centres Network established 2007
• Director King’s Thrombosis Centre is clinical lead for the National VTE Prevention Programme and chair of VTE Board
• Continuous monitoring of outcomes:
VTE risk assessment is key performance indicator
Regular audit vs NICE VTE prevention Quality Standard
Registry for RCA of cases of hospital-associated thrombosis
6
![Page 7: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/7.jpg)
www.england.nhs.uk
Link Nurse/
MidwivesPatient
information
Thrombosis
team
Staff
education
RCA of
HAT cases
Electronic
VTEp
systems
Audit
programme
VTE
Prevention
Supportive
managers
Preventing VTE
![Page 8: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/8.jpg)
www.england.nhs.uk Roberts et al – Chest 2013;144:1276 8
![Page 9: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/9.jpg)
www.england.nhs.uk
• QI project at King’s College Hospital 2010-12
• Mandatory, documented VTE risk assessment, thromboprophylaxis guidance, mandatory VTE education, identification of hospital-acquired VTE with root cause analysis
VTE Prevention Programme Reduces
Hospital-Associated VTE
2010-11 2011-12 p
VTE risk assessment 63% (38-88) 93% (90-97)
HA-VTE 236
19.7/mo
189
15.8/mo
0.014
Inadequate prophylaxis
among HA-VTE
37% 21% 0.005
Anticoag prophylaxis in
high VTE/low bleeding
group
70% 89% 0.001
Roberts et al - Chest 2013;144:1276; Geerts 2014 9
![Page 10: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/10.jpg)
www.england.nhs.uk
Acute Kidney Injury Programme
10
![Page 11: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/11.jpg)
www.england.nhs.uk 11
![Page 12: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/12.jpg)
www.england.nhs.uk
Southern Derbyshire CCG saw
Think Kidneys as a way to drive
quality & improvement locally
• NCEPOD ‘Adding Insult to Injury’ framed
AKI as driver for patient safety innovation
at scale
• Strong commitment from CCG
Chief/Deputy Nurse and Royal Derby
Hospital renal team
• CCG Board signed up inspired by patient
story & Board briefings
12
![Page 13: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/13.jpg)
www.england.nhs.uk
Progress at Southern Derbyshire CCG
• CQUIN developed during January 2014
Secondary care assessment on admission & discharge information
£1 million funding attached gave high priority
Year 2 CQUIN agreed
• Primary care planning:
Locally Commissioned Service Framework signed up to by 56 practices
Baseline survey in general practice 467 + clinical respondents
Programme of education & awareness raising sessions in SC &PC
Strategic Clinical Network funded education & awareness raising sessions
Primary Care Quality Forum focus on AKI, RDH Academic Detailing & Peer Review supported by Renal Consultants, resource dissemination to GPs
Evaluation framework working in collaboration with Salford
AKI Policies, Procedures & Guidelines support care planning Shared Care Pathology website AKI guidance through RDG
Sick day rules – CCG Meds Management team
Read codes approved and being implemented
13
![Page 14: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/14.jpg)
www.england.nhs.uk
Impact on
standards of
basic care
• Cases note audit of 306 pts.
• 132 cases baseline
• 156 cases post intervention• 77 in 2012 audit, 79 in 2013 audit
• Equal numbers in each AKI stage
Baseline 2012 2013 p value
Fluid balance assessed 36.4% 66.2% 79.7% p<0.001
Medication review 71.1% - 88.4% p<0.001
Renal imaging (AKI 2 & 3) 45.3% 54.2% 71.0% p<0.001
Nephrology referral (AKI 3) 37.8% 56.5% 78.9% p<0.001
Urinalysis performed 40.3% 57.1% 35.5% p=0.177
* **
*p<0.001
![Page 15: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/15.jpg)
www.england.nhs.uk
Saving £millions through better
treatment of sepsis
• The UK Sepsis Trust estimates 35,000 deaths per
year in UK from sepsis (1,2,3)
• Treatment of sepsis costs the NHS an estimated £2.5
billion a year
15
1.Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European intensive care units: results of the SOAP study. Critical Care
Medicine 2006; 34: 344–53
2.Hall MJ, Williams SN, DeFrances CJ, et al.: Inpatient care for septicemia or sepsis: A challenge for patients and
hospitals. NCHS data brief Hyattsville, MD: National Center for Health Statistics 2011; 62
3. The Intensive Care National Audit and Research Centre (2006)
The reliable delivery of basic elements of sepsis
care could save an estimated 11,000 lives a year
across the country and £150 million annually
In a typical district general hospital could save an
extra 100 lives a year (approx £1.25 million)
![Page 16: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/16.jpg)
The Sepsis Six
1. Give high-flow oxygen via non-rebreathe bag
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation Hartmann’s or equivalent
5. Check lactate
6. Monitor urine output consider catheterisation
within one hour
..plus Critical Care support to complete EGDT
![Page 17: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/17.jpg)
www.england.nhs.uk
What Doncaster and Bassetlaw NHS
Foundation Trust did to improve?1. Establish project lead and a multidisciplinary
sepsis team
2. Develop and implement a sepsis pathway
document (IPOC)
3. Educate staff about sepsis and the IPOC
(Quiz)
4. Sepsis screening as part of triage
5. Analyse and learn from failure to deliver
sepsis 6 within 1Hr
6. Treat all patients with sepsis in resuscitation
area
7. Give regular feedback on progress
8. Ongoing MDT education on sepsis and
improvement17
![Page 18: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/18.jpg)
18
![Page 19: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/19.jpg)
Sepsis 6
Sept-Oct 2013 March 2014
IPOC (n=71 58%)
Non-IPOC (n=50 42%)
IPOC (n=33 70%)
Non-IPOC (n=14 30 %)
Oxygen <1 hour
99% 94% 100% 95%
Antibiotics <1 hour
90% 67% 91% 72%
IV Fluids <1 hour
94% 37% 97% 81%
Blood cultures <1 hour
97% 47% 94% 72%
Lactate <1 hour 93% 39% 94% 72%
Urine measured <1 hour
84% 25% 97% 72%
Survival 87.3% 79.1% 93.9% 78.6%
![Page 20: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/20.jpg)
![Page 21: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/21.jpg)
21www.england.nhs.uk
![Page 22: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/22.jpg)
Spread and Scale Up: Coverage and Completeness
These presenters have nothing to disclose
P22
![Page 23: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/23.jpg)
“Up to 70% of improvement projects never spread.”
Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012;
53(4): 43-50.
![Page 24: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/24.jpg)
Core elements included in the design: 1. Phased Approach
P24
PDSA “ramp” testing under different conditions (Langley, 2006)
![Page 25: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/25.jpg)
Degree of Belief in Change Ideasd
eg
ree
of b
elie
f
Innovation Phase(set design targets, develop
Ideas and predictions, and draft
an initial conceptual model and
change package)
Pilot Phase(test and
revise/amend conceptual
model and
change package)
Adapt and Spread(implement and disseminate
a successful
change package)
High
Moderate
Low
![Page 26: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/26.jpg)
Prototype development of a “slice” of the system (Massoud, 2004)
26
![Page 27: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/27.jpg)
Core elements included in the design: 2. Adoption mechanisms
P27
IHI’s framework for spread (Nolan, Schall et al. 2005)
![Page 28: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/28.jpg)
Core elements included in the design: 3. Existing concepts of “spread” and “scale up”
• “scale-up” - overcoming the system/infrastructure issues that arise during efforts to scale-up implementation (5x thinking)
• “spread” – the leadership, social, and environmental factors that promote adoption and replication, with little modification, of an intervention within a health system
P28
Unpublished document: Kurapati, Laderman, et al., 2011.
![Page 29: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/29.jpg)
Adoption MechanismsP29
• Well-tested set of interventions are deployed at large scale, adopted with minimal further adaptation by frontline staff
• Focus on replication and sustainability • Strong reference to leadership, social networks,
communication and attributes of the intervention (IHI’s Spread Framework)
• Culture of urgency and persistence• Planned diffusion models (e.g. Mayo “managed
diffusion”, Kaiser Permanente “spread toolkit”)
![Page 30: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/30.jpg)
Support SystemsP30
• Build human capability for scale-up . • Leadership team to guide the process • Reference to 5x thinking – phased training from volunteers to trained,
dedicated improvement specialists• QI-based programs for those who need additional training (start
before scale-up begins).• QI teams
• Build infrastructure for scale-up: • Balance targeted resource addition vs system redesign • reconfiguration of existing resources (e.g., on-site lab for lactate,
nephrology referral, thrombosis team) • Additional tools (e.g., checklists, data capture systems), • Communication tools, and • Key personnel (data capturers, quality improvement mentors)
![Page 31: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/31.jpg)
Support SystemsP31
• Build reliable data collection and reporting systems• Track and provide feedback on the performance of
key processes
• Data systems for improvement vs monitoring
• Develop learning systems:• Mechanisms for collecting, vetting, and rapidly
sharing change ideas or interventions
![Page 32: What is Improving Patient Safety in the England?aws-cdn.internationalforum.bmj.com/pdfs/G10_CarolHaraden...What is Improving Patient Safety in the England? 20th Annual International](https://reader036.vdocuments.us/reader036/viewer/2022071118/600fd2d4b542d63a6f6885a1/html5/thumbnails/32.jpg)
Sustainability
• Key design feature in all phases (i.e., build into change package)
• Ensure high-reliability of the new processes (e.g., use failures to continually improve processes)
• Create monitoring systems to ensure desired results are being achieved
• Build support for structural elements (i.e., training, policies and procedures, standardize processes, etc.)
• Develop and use ongoing learning systems (i.e., opportunities for shared learning and support, refined change package and materials, etc.)
P32