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Getting to Zero-Safer Care Improvement Programme. Annette Bartley RGN BA MSc MPH Health Foundation/IHI Quality Improvement Fellow. Learning Session 1 Overview. 09.00-09.15 Welcome & Introductions 09.15- 10.00 Background and Context Programme aims & objectives

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    1. Getting to Zero-Safer Care Improvement Programme Annette Bartley RGN BA MSc MPH Health Foundation/IHI Quality Improvement Fellow

    2. Learning Session 1 Overview • 09.00-09.15 Welcome & Introductions • 09.15- 10.00 Background and Context • Programme aims & objectives • Links to other work • 10.00-11.00 Overview of Quality Improvement • Tools & techniques • Measurement for improvement • The role of local coaches • 11.00-11.30 Refreshment break • 11.30- 13.00 Team Presentations / Storyboard rounding • 13.00-13.45 Lunch • 13.45-15.00 The Snorkel – Generating Ideas from frontline staff • 15.00-15.15 Refreshment break • 15.15-16.15 Action planning and report out • 16.15-16.30 Summary next steps and close

    3. Understanding the context of frontline care What’s good about it? What’s not so good? What could be improved?

    4. It’s a Fact that … “Without good and careful nursing many must suffer greatly, and probably perish, that might have been restored to health and comfort, and become useful to themselves, their families, and the public, for many years after.” Benjamin Franklin (1751)

    5. The Reality in Practice

    6. How do we make sense of all the expectations & bring the work into a coherent whole Health Foundation Safer Communities National Patient Safety Agency (NPSA) Safety Alerts Matching Michigan CNO High Impact Changes QUIPP & Safety Express NHS III LIPs Productive Series Safer Patients Network (SPN) The Health Foundation (with IHI) WHO World Alliance for Patient Safety NICE Quality Standards Department of Health (DoH) High Quality Care for All IP&C CQUIN targets

    7. Getting to Goal Will Ideas Execution

    8. The politics of hope • “We got used to the politics of disappointment -- figuring out how soon we were going to be let down. ... There’s a different dynamic in the ... politics of hope. It’s much more challenging. It means you’ve got to get up and do something. There’s opportunity. If you don’t take advantage of that opportunity, you really have to bear responsibility for not doing so. That’s how I see the time we’re in. ” • Marshall Ganz

    9. Transforming Patient Experience • Metanoia: • Reorientation of one’s way of life • (The New Economics. Deming, p. 95, 1993) • Begins with individual • More than a change • Develop new habits of mind

    10. Where to begin • Will • Ideas • Execution

    11. Programme Aims • Alignment with Safety Express • To reduce the incidence of Avoidable Hospital /Community Acquired Pressure Ulcer • Reduce of Falls (falls with harm) • Reduce Catheter Associated Urinary Tract Infections (CAUTI) • Prevention of Venous Thromboembolism ( VTE)

    12. Programme overview

    13. Underpinning principles Transformational Leadership Safety & Reliability Patient and Family Centred Care Value-added care Teamwork and Vitality

    14. Patients as partners “ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”

    15. Alignment -Harm Free Care

    16. Prevention of Pressure Ulcers

    17. Transforming Care at the Bedside framework ! Spread the Learning and celebrate the successes

    18. Pressure Ulcers The “Case for Change” • National Focus on Patient Safety • I in 10 patients harmed by what we do • Poor Public Perception of Care • Impact of financial cutbacks • Pressure Ulcer Incidence 1 in 5 • As high as 1 in 3

    19. Prevention of Falls (Harm from falls) • Falls prevention is a complex issue crossing the boundaries of healthcare, social care, public heath and accident prevention. • Across England and Wales, approximately 152,000 falls are reported in acute hospitals every year, with over 26,000 reported from mental health units and 28,000 from community hospitals. • A significant number of falls result in death or severe or moderate injury, at an estimated cost of £15 million per annum for immediate healthcare treatment alone (NPSA, 2007).

    20. Facts • Pressure sores are an increasing problem that affect thousands of people unnecessarily every year.. • They are painful, debilitating and can be life threatening • The cost of treating a pressure ulcer varies from £1,064-£10,551 with the estimated total costin the UK of between £1.4–£2.1 billion annually- 4%of total NHS expenditure (Bennett et al 2004)

    21. What matters most to inpatients. Consistency and coordination of care Treatment with respect and dignity Involvement Doctors Nurses Cleanliness Pain control

    22. Methods and Tools

    23. Change vs. Improvement Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress. W. Edwards Deming • We must become masters of improvement • We must learn how to improve rapidly • We must learn to discern the difference between improvement and illusions of progress

    24. The Lens of Profound knowledge • Deming Appreciation of a system Theory of Knowledge Psychology C Q I Aims or values Understanding Variation

    25. Quality Improvement Methods /Tools The Model for Improvement The Science of Reliability Driver Diagram Change Package Lean/5S Safety Cross/ Safety Thermometer SSKIN Bundle/ Intentional Rounding

    26. The Model for Improvement will underpin the programme, enabling teams to connecting an aim to action and measurement which will enable you to demonstrate their progress.

    27. Improvement requires a clear aim Measurement & Action

    28. AIM • Aims infuse meaning and hope in our lives, they create a target to achieve and inspire and motivate us to achieve it. • How good do you want to be and by when? • Make your aims SMART • Specific • Measurable • Achievable • Realistic • Timely

    29. Developing a systems-based approach to the prevention of hospital acquired pressure ulcers What will success look like? Risk Identification Risk Assessment Communication of Risk status Appropriate preventative strategy implemented Evaluation of outcome

    30. The “Case for Change” • National Focus on Patient Safety • I in 10 patients harmed by what we do • Public Perception of Care • Impact of financial cutbacks • Strong link between Patient Satisfaction & Employee Satisfaction

    31. Purpose of Using Data & Measuring The purpose of measuring is to answer critical questions and to guide intelligent action. Cliff Norman- Associates in Process Improvement

    32. “In God we trust. All others bring data.” W. E. Deming

    33. S+P=0 S=Structure The environment in which health care is provided P=Process The method by which health care is provided O=Outcome The consequence of the health care provided Avedis Donabedian Physician

    34. Research vsMeasurement for Improvement

    35. Three Types of Measures Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)

    36. Measurement Guidelines • A few key measures that clarify a team’s aim and make it tangible should be reported, and studied by the team, each month • Be careful about over-doing process measures for monthly reports • Make use of available data bases to develop the measures • Integrate data collection for measures into the daily routine • Plot data on the key measures each month during the life of the project

    37. Measurement Guidelines • The question - How will we know that a change is animprovement? - usually requires more than one measure • A balanced set of five to eight measures will ensure that the system is improved • Balancing measures are needed to assess whether the system as a whole is being improved

    38. Measurement- It is YOUR data!! (data MUST be locally owned) • Outcome measures • Incidence ( count on safety cross) • Days between events • Process measures • Percent Compliance with risk assessment • Percent Compliance with process ( bundle) • Percent compliance with Intentional Rounding tool • Balancing measures • Patient Experience • Staff satisfaction • Length of Stay • Complaints • Staff turnover /Sickness rates • Budget implication

    39. Visual Measurement

    40. Real Time Data for improvement – Process

    41. It’s time… A little less conversation a little more action

    42. Getting it rightCo-ordinating Care

    43. Health Care Processes Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Desired - variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom - variation Terry Borman, MD Mayo Health System

    44. Intentional Rounding The Evidence • The Studer Group • Alliance for Health Care Research • 38% Reduction in Call Lights • 12 point mean increase in Pt Satisfaction • 50% reduction in patient falls • 14% reduction in pressure ulcers Flaws in the study but…

    45. On Finding What Works… “We need to standardize, simplify, and steal shamelessly from everyone who can contribute, because we’ve reached a point where no excuses are allowable.” Roger Resar, MD Senior Fellow, IHI

    46. Intentional Rounding – What is it? • Structured process where frontline staff regularly round on patients and reliably perform scheduled/required tasks • Rounding with purpose- linked to an aim • 8 key behaviors • Opening key words – managing up • Perform scheduled tasks • Address the 3 p’s of pain, potty? position (SKIN Bundle)(toileting), and • Assess comfort needs • Environmental assessment • Closing key words • Explain when you or others will return • Document the round on the log

    47. OMHS Intentional Rounding - wins • 59% reduction in Pressure ulcers • 54% reduction in call lights • (2878 fewer calls after rounding) • Patient feedback – ‘I know someone will be back to check on me, when they come…’ • Improved employee satisfaction – 5.67 on a 7 point scale compared to national norm of 4.66 (Baird and Borling) • Reduction in cost • $3.02/pt 6 month avg. prior • $2.39/pt 8 months avg. following