Mid Staffordshire report

1. Mid Staffordshire report

3. www.ihi.org

4. 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

5. Managing change.....In a nutshell? • Have a compelling vision and aim high! • Be sure of your evidence base • Measure, measure, measure! • The measures are backed by guidance that makes it easier to think through the on the ground requirement to deliver • Grow knowledge in improvement and reliability science for you and your teams • Develop a supportive learning community that are trying the same things in different ways and sharing their developments.

6. The “Quality Curve” Shift and narrow the curve: What is the norm? 2 3 1 Cut the tail: What is unacceptable? Extend the ambition: What is great? (What is possible?)

7. 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

8. “Society’s huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves.” “Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.”

9. Total reported events Number of reported events: high and medium risk High/medium risk events Total events 140 9000 8000 120 7000 100 6000 80 5000 4000 60 3000 40 2000 20 1000 0 0 1994 1995 1996 1997 1998 1999 British Airways air safety reports, 1994-99 Source: British Airways (NPSA adapted)

10. 53 Jan Jan Jan Oct Oct Apr Apr Apr Jul Jul Jul System VAP rate per 1,000 vent days 2006 2007 2008 Month Sound impossible? – Here are some examples of success Ascension Healthcare Who they are: Largest Catholic and largest non-profit health system in the US, with 73 hospitals across 20 states and over 100,000 employees 2005 Goal: No preventable injuries or death by July of 2008 Board actions What they achieved • Focused on 8 ‘Priorities for action’, all with clear measures • Began with bottom up clinical engagement, by communicating harm and having staff identify goals and opportunities • Adopted care bundle scoring approach (all or nothing) • Launched 5 initiatives on ‘how we work together’ (organisational learning and cultural change) • Provided additional support to poorer performing hospitals from highest performers • Emphasised the business case for quality • 1500 fewer deaths in 2007/2008 (unadjusted preventable harm) vs. expected • > 20% reduction in mortality 2006-2008 • 60% reduction in VAP • 60% reduction in birth trauma • 50% reduction in pressure ulcers Source: David B. Pryor MD – CMO, IHI Learning Lab, 12/08/2008

11. Primary Outcomes Develop and build a quality improvement and patient safety culture in our hospitals Build in long term sustainability and capability to drive this approach at all levels

12. Interventions • Critical Care • Ventilator acquired pneumonia bundle, central line • Ward • Early rescue , peripheral catheters, • Communication • Medicines • Medicines reconciliation • Theatres • Surgical pause • Infection prevention/control • Leadership • Safety walkrounds • Executive leadership board patient safety profile

13. What is a Bundle? • It is a set of evidence based steps that experts believe are critical  • Having the steps joined provides a “forcing function.” • Evidence based medicine  Evidence based care delivery

14. Bundle Implementation • The steps must all be completed to succeed • The “all or none” feature is the source of the bundle’s power • Pass/fail

15. Peripheral Vascular Catheter Bundle Is the PVC required / still in use No inflammation or extravasation Dressing intact, dated, timed and signed Reviewed/ Removed <72hrs Hand hygiene before and after

16. Systems and Processes Making it easy to do the right thing “Every system is designed to get the result it gets”

23. Perioperative Care at Forth Valley:Better Processes Percent Patients with Perioperative Normothermia Percent On-Time Antibiotics A shift upwards with a new median of 99.5% of the patients within the appropriate range A shift upwards with a new median of 97.7% of the antibiotics administered on-time Percent Patients with Perioperative Briefings Percent Eligible Patients with Perioperative Glucose Control A shift upwards with a new median of 82.6% of patients within range A shift upwards with a new median of 99.6% of the patients receiving briefings

24. The Story of NHS Forth Valley Fewer Deaths Percent Unadjusted Raw Mortality: A Shift Down A Shift Down

26. NHS Fife – 24 wards, peripheral vascular catheter bundle compliance

27. Can we apply the principles to other areas? • Blood Culture Contamination? • Sepsis? • Comprehensive Geriatric Assessment?

28. Future Developments • Paediatric • Primary care • Mental health • Heart failure • VTE • Pressure ulcers

30. The Healthcare Quality Strategy for Scotland Person-Centred- Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Clinically Effective- The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

31. Key messages • Focus on results • Build capability quickly • Rationalise measurement • All improvement is local • Build a guiding coalition in your context • Patient voice • Enjoy the work