The Scottish Patient Safety Programme

1. The Scottish Patient Safety Programme The Science of Improvement:Model for Improvement Jason Leitch, DDS, MPH Lindsay Martin, MPH

2. Quality Improvement “Health Care Quality Improvement is a broad range of activities of varying degrees of complexity and methodological and statistical rigor through which health care providers develop, implement and assess small-scale interventions and identify those that work well and implement them more broadly in order to improve clinical practice.” Mary Ann Bailey, The Hastings Center

3. HealthCare

4. Leading Quality Models • Baldrige • ISO/QMS • Six Sigma • Lean Enterprise (TPS) • IHI Model For Improvement

5. Deming’s Profound Knowledge Understanding Systems Thinking Understanding Variation CQI Understanding Theory Understanding Human Behaviour

6. Quality Planning Juran’s QualityTrilogy Quality Improvement Quality Control Juran’s Quality Trilogy

7. Model for Improvement The Improvement Guide, API

9. A Vision and Bold Aims Coupled with Relentless Execution of Small, Repeated Tests of Large Changes Organisational Transformation Requires….

10. Aim

11. The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets. Peter Senge, The Fifth Dimension

12. Aims Create Systems • “Set the Table”

13. Set the dinner table for 6 people by 6pm

14. Constructing an Aim Statement • Boundaries: the system to be improved (scope, patient population, processes to address, providers, beginning & end, etc.) • Specific numerical goalsforoutcomes • Ambitious but achievable • Includes timeframe (How good by when?) • Provides guidanceon sponsor, resources, strategies, barriers, interim & process goals

15. Aim • Aligned • Timed • Numeric • Unachievable (by hard work alone) • Non-negotiable (once set)

16. Aim StatementsOutcomes, Process, Relative or Absolute? Achieve 100% compliance with appropriate selection and timing of prophylactic antibiotic administration in 3 months Reduce Central Line Infections in the ICU by 75 percent within 11 months Medications reconciled at 10-3 within 6 months

17. Measurement

18. “When you have two data points, it is very likely that one will be different from the other.” W. Edwards Deming

20. Unit 1 Unit 2 Unit 3 R Lloyd, Institute for Healthcare Improvement

21. Measurement is Central to the Team’s Ability to Improve • The purpose of measurement in QI work is for • All measures have limitations, but the limitations do not negate their value for learning • You need a balanced set of measures reported daily, weekly or monthly to determine if the process has improved, stayed the same or become worse • These measures should be linked to the team’s Aim • Measures should be used to guide improvement and test changes • Measures should be integrated into the team’s daily routine • Data should be plotted over time on annotate graphs • Focus on the Vital Few!

22. The Quality Measurement Journey AIM(Why are you measuring?) Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis ACTION

23. 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)?

24. Topic: Improve Waiting Time and Patient Satisfaction in A & E Measure Perspective (O, P, B) • % patient receiving discharge materials • Patient volume • Total Length of Stay (LOS=wait time) • Time to registration • Staff satisfaction • Patient Satisfaction Scores • Availability of antibiotics • “Left without being seen” (LWBS) • Costs P B O P B O P B B

25. Stages of Facing Reality: • “The data are wrong” • “The data are right, but it’s not a problem” • “The data are right; it is a problem; but it is not my problem.” • “I accept the burden of improvement”

26. Improvement vs. ResearchContrast of Complementary Methods Improvement Aim: • Improve practice of health care Methods: • Test observable • Stable bias • Just enough data • Adaptation of the changes • Many sequential tests • Assess by statistical significance Clinical Research Aim: • Create New clinical knowledge Methods: • Test blinded • Eliminate bias • Just in case data • Fixed hypotheses • One fixed test • Assess by statistical significance

27. UCL time “What is the variation in one system over time?” Walter A. Shewhart - early 1920’s, Bell Laboratories Dynamic View Static View Static View LCL • Every process displays variation: • Controlled variation • stable, consistent pattern of variation • “chance”, constant causes • Special cause variation • “assignable” • pattern changes over time Static View

28. Elements of a Run Chart The centerline (CL) on a Run Chart is the Median ~ X (CL) Measure Time Four simple run rules are used to determine if special cause variation is present

29. Minimum Standard for Monthly Reporting Annotated Time Series Cycle Time in Office Patient moved into Huddles tried rooms ASAP 60 Nurses start early Lab 50 Changes Minutes 40 30 Goal 20 6/12 7/12 8/11 9/10 10/10 11/9

30. Changes The Improvement Guide, API

31. Out of The Box Thinking

32. Out of The Box Thinking

33. Out of The Box Thinking

34. The PDSA Cycle for Learning and Improvement Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarise • what was • learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

35. Why Test Changes? • To increase the belief that the change will result in improvements in your setting • To learn how to adapt the change to conditions in your setting • To evaluate the costs and “side-effects” of changes • To minimise resistance when spreading the change throughout the organisation

36. Key Language for Stating the Objective of the Test Probably Change Test Redesign Eliminate Reduce Deliver Relocate Probably No Change Recruit Distribute Continue Examine Discuss Teach

37. To Be Considered a Real Test Test was planned, including a plan for collecting data Plan was carried out and data was collected Time was set aside to analyse data and study the results Action was based on what was learned

39. PDSA Worksheet

40. StartSmall ~ 1:3:5:All • 1 patient • 1 day • 1 admit • 1 clinician

41. Move Quickly to Testing Changes • Year • Quarter • Month • Week • Day • Hour “What tests can we complete by next Tuesday?”

42. Model for Improvement What are we trying to accomplish? How will we know thata change is an improvement? What change can we make that will result in improvement? A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement Spread DATA Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Sequential building of knowledge under a wide range of conditions Follow-up Tests Very Small Scale Test

43. D S P A A P S D D S P A A P S D A P S D Aim: Improve care of patients with cardiovascular disease by involving patients in their care Multiple Cycles of PDSAs(an example) 10% have SMG Improved care DATA Cycle 5: All staff orientedin use of SM goal sheet. 0% have SMG Cycle 4: All patients work with Nurse rather than Doctor Cycle 3: Nurse introduces goal-setting during rooming, Doctor follows up. Having patients set self-management goals will improve care. Cycle 2: Doctor uses form with all patients for one week Cycle 1: Doctor tries self-management goal form with 3 patients Source: Catahoula Parish CHC, Apr. 2003

44. D S P A A P S D D S P A A P S D A P S D Multiple Cycles of PDSAs(continued) Aim: Improve care of patients with cardiovascular disease by involving patients in their care 70% have SMG Improved care DATA 10% have SMG Cycle 8: Doctor does follow- up of SMG as found in chart Using outreach will increase the patients who have opportunities to set goals. Patients in for lipid tests givenSM goal sheet by Nurse Cycle 7: Cycle 6: Using registry, query patients without lipid test, call in proactively for free lab work. Source: Catahoula Parish CHC, Apr. 2003

45. Critical Care Driver Diagram

46. Aim: Provide appropriate, reliable and timely care to critically ill patients using evidence-based therapies in Hospital X, Pilot Site Y, by August 2008 Change 1 Change 4 Change 4 Change 4 Change 4 Change 4 Change 3 Change 3 Change 3 Change 3 Change 3 Change 2 Change 2 Change 2 Change 2 Change 2 Change 1 Change 1 Change 1 Change 1 Complications from Ventilators Complications from CVCs Optimal Glucose Control Sepsis Recognition and Treatment HAIs

47. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Aim: Reduce Complications from CVCs in Hospital X, Pilot Site by June 2008 Central Line Insertion Bundle Standardize Process: Line Carts and Dressing Kits CVC Maintenance Bundle Partner with Accident and Emergency and Operating Theatres for Standardisation Lead 1 Lead 2 Lead 3 Lead 1

48. P P P P P A A A A A D D D D D S S S S S S S S S S D D D D D A A A A A P P P P P A A A A A P P P P P S S S S S D D D D D P P P P P A A A A A D D D D D S S S S S Aim: Design a Reliable Process for CVC Maintenance Bundle by May 2008 Daily Checking and Need for CVC Dressing in tact and changed w/i 7 days CVC hub decontamination Chlorhexidine gluconate Hand Hygeine priot to access Lead A Lead A Lead B Lead C Lead B

49. Act Plan Study Do The Sequence for Improvement Make part of routine operations Spreading a change to other locations Test under a variety of conditions Implementing a change Testing a change Theory and Prediction Developing a change

50. Think About Size