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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,
Organisational Self Assessment P P P A A D D D A S S S Site Selection 4 day Kickoff 2 day LS 1 day LS + Congress 2 day LS Supports Expert clinical faculty Listserv 2 Site Visits Phone conf Assessments Monthly Reports via web Key Changes Improvement Measures May 2005 Late 2005 June 2006 Jan 2005 Learning System (Phase I): Collaborative Learning Model
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 dowhat it takes to change to a new system Ideason which to base the design of the new system Executionof the ideas
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 Majority LateMajority Early Adopters Innovators 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
Teams and Leaders: Roles • Set Aims • Build Will • Assure Resources • Remove Obstacles • Review and Reflect • Assure Spread Senior Leaders • Make Improvements • Test and Learn • Report Lessons • Make Requests Teams • Human Resources • Technical Expertise • Information Technology • Budget and Capital • System for Spread Infrastructure
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 PULL Make the future attractive Make the status quo uncomfortable PUSH • 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 • 3. Build Will • Plan for Improvement • Set Aims/Allocate Resources • Measure System Performance • Provide Encouragement • Make Financial Linkages • Learn Subject Matter • 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 2. Establishthe Foundation • Reframe Operating Values • Build Improvement Capability • Build Relationships • Develop Future Leaders • Prepare Personally • Choose and Align the Senior Team
Why are we measuring? Judgment? Improvement? Research? 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.
Measures for Judgement WAITING TIMES Inpatients/Day Cases 12-15 weeks >15 weeks
Measures for Judgement WAITING TIMES Outpatients 12-15 weeks 12-15 weeks >18 weeks >15 weeks >15 weeks
Measures for Judgement DELAYED DISCHARGES Total October 2008 = 81 >6 weeks = 8 Short Stay = 7 Target from Apr 08 = 0
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 Measures for Improvement
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