1. Transforming Care at the Bedside
Using reliable techniques to improve
patient safety and patient’s experience of care
Annette Bartley RGN BA(hon) MSc MPH
Head of Modernisation
NHS North Wales (Central)

2. Facts Increased Technology Better treatment options Outcomes improving
So WHY are patients consistently complaining about the NHS
Everyone of us can tell a story
What is going wrong?

3. The Context
In the last 20 years the average length of stay in hospitals has declined significantly
Nurses are spending an average of between 24%-35% or even less of their time in direct patient care
13-28% of their time in patient care documentation Korst 2003, Pabst 1996, Smeltzer 1996, Upeniecks 1998
Total time ALL health care workers spent in direct patient care and assessments on a med-surg unit is a median of 1.7 hours in a 12 hour period IOM, Keeping Patients Safe, 2004

4. (IOM Committee on Quality).
Background to TCAB
Issues with recruitment and retention of nurses in US
Patient satisfaction deceasing
Patient Safety
As many as 90,000 people die annually from mistakes – an error rate unacceptable in any other industry. There are more deaths due to medical errors than deaths from accidents, breast cancer, or AIDS
(IOM Committee on Quality).
Relevant healthcare clinical research can take as long as 17 years to find its way into common practice, Isaacson said. Many national agencies such as AHRQ is seeking ways to accelerate the adoption and spread of innovations in healthcare through a "user-driven" strategy. It takes more than publication of research, synthesis of evidence, and changes in guidelines and performance measures, she said. Real change happens when a compelling message meets users’ needs and is supported by a sustained infrastructure.

5. TCAB USA Three Phases Local data collection
Phase 1-three hospitals
Phase 2 10 hospitals
Phase 3 spread AONE & IHI
Local data collection
Run Chart-Time series analysis
Data compared ‘within’ hospitals rather than ‘between’
Research evaluation (UCSF)

6. TCAB core themes Transformational Leadership Teamwork &Vitality
Patient and Family centred care
Value-added Care (Lean element)
Safety &Reliability

7. TCAB-aims
Increase the amount of time nurses spend in value-added/direct care to 70 %
Reduce hospital acquired pressure ulcers by 50%
Reduce the number of in patient falls by 50%
Increase the patients satisfaction with their experience of care to >95%(ie pt –reporting excellent care)
Increase staff satisfaction to >95%

8. Transform Care at the Bedside in the two development sites by
Content Area
Drivers
Interventions
Transformational Leadership
Establish, oversee and communicate system levels aims for improvement
Align measures, strategy & projects and leadership learning system
Channel leadership attention to quality improvement and safety
Build the right team
Align Quality projects to Finance.
Engage Physicians in improving care at all levels
Build improvement capability
Value-Added Care
Increase the percentage of time spent in direct/value-added care to 70% by:
Eliminating waste & Improve work flow processes for admissions, hand-offs an discharge
Improving work environment through physical space re-design
Enhancing efficiency with technology
Reducing duplication & time spent in documentation
Transform Care at the Bedside in the two development sites by
2010
Safety & Reliability
Reduce the adverse events rate in pilot wards
Prevent Falls by implementing falls bundle
Prevent Pressure Ulcers by implementing Skin bundle
Support and involve patients and families
Ensure patients physical comfort
Optimise care transitions to home or elsewhere
Create Patient- Centred Healing Environments
Provide Emotional & Spiritual Support
Ensure Patients rights to privacy & dignity is maintained
Patient
Centred Care
Empower ward managers to create care teams with the authority to act and transform care
Build capability of front line staff and mid level managers in Innovation and Improvement
Utilise clinical micro system model & tools
Enhance physical environment for staff &prevent staff injuries
Optimise communication across the care team
Develop staff and match roles to responsibility
Teamwork
& vitality

9. Improvement Methodology
Innovation/ Prototype testing
Ideas Generation
‘The Deep Dive’ / ‘Snorkel’/ Paddle
The IHI Model for Improvement
PDSA
Lean methodology
Learning from Industry

10. Collaborative Care Patient Progression
Tollgate 1
Tollgate 2
Tollgate 3
Tollgate 4
Tollgate 5
Are we
progressing
care?
Are we
progressing
care?
Are we
progressing
care?
Are we
progressing
care?
Are we
progressing
care? PT
Care PT
Care PT
Care PT
Care PT
Care
Patient Admission
Patient Discharge PT
Care NO NO NO NO NO
Problem
Solve
Problem
Solve
Problem
Solve
Problem
Solve
Problem
Solve
Collaborative Care Value Stream Metrics
Copyright 2006 © All Rights Reserved. Patent Pending.

11. World-Wide Sites Replicating TCAB
Sweden & the Netherlands
England, Ireland, Scotland & Wales
Singapore
New Zealand

12. Time in Direct Patient Care – 8 South Surgical Pilot

13. A model for improvement...
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will
result in the improvements we seek ?
Aims
The three fundamental questions for improvement
Measurement
Ideas, evidence, hunches, other people etc.
Act
Plan
Study Do
The fourth question: how to make changes
Langley, Nolan et al 1996

14. Health Care Processes 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
Current -
Variable, lots of autonomy
not owned,
poor if any
feedback for improvement, constantly altered by individual changes, performance stable at low levels
Terry Borman, MD Mayo Health System 14

15. “Reliability is failure free operation over time
“Reliability is failure free operation over time.” David Garvin Harvard Business School 15

16. Whose job is it?
This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done

17. What are we trying to accomplish?
Reduce Pressure Ulcer Incidence by 50%
Preventing pressure ulcers isn't difficult!
It just requires attention to the details and re-establishing good habits. 
Use rounding/bundles to implement new habits and ways of thinking can and will ultimately impact outcomes.

18. Process Eyes
Make the process for preventing Pressure Ulcers (&Falls) visible to ALL
Measure it -so we can ‘see’ if it is adhered to and effective
Make it easy for others to do the right thing (simple checklists, reminders)
The right process with high % compliance WILL influence outcomes

19. Care bundles
A “care bundle” is a collection of interventions (usually three to five) that may be applied to the management of a particular condition. It is distinct in several ways from just any checklist about patients’ care.
The elements in a bundle are best practices based on evidence, and all clinicians should know them. In routine clinical practice, these elements may not always all be done in the same way, making patient care vary.
So a bundle aims to tie them together into a cohesive unit that must be adhered to for every patient, every time. All the tasks are necessary and must all occur in a specified period and place.
Successfully completing a bundle is clear cut, and compliance is measured in an “all or none” approach, as its proponents argue that better outcomes are achieved when interventions are executed together rather than individually.

20. Using bundles to improve reliability
Bundles demand “all or none” thinking and measurement.
Bundles facilitate identifying failures.
Failures are actively used to redesign the process.
Teamwork & communication improve

21. ALL OR NONE-COMPOSITE MEASURE
Compliance ( or non-compliant)
Y/N
Risk assessment on admission
2. Communication of risk status-Verbal & Visual Cue
3. Surface- x
4. Keep patients turning- care round
5. Skin Inspection-care round
6. Nutritional assessment- care round
ALL OR NONE-COMPOSITE MEASURE

22. TLC Rounds Created more time-less bell calls Pressure areas checked
Position changed
Pain assessment
Nutrition-check (fluids encouraged where appropriate)
Obstacles & Call bells –Call don’t fall
Personal Hygiene
Emotional support

23. New Jersey Hospital Association
Exemplars of success
New Jersey Hospital Association
Educational programs, information distribution list, monthly conference calls with experts
70% reduction in pressure ulcer incidence and 30% reduction in prevalence
“No ulcers”
Nutrition and fluid status
Observation of skin
Up and walking or turn and position
Lift (don’t drag) skin
Clean skin and continence care
Elevate heels
Risk assessment
Support surfaces for pressure redistribution

24. Exemplars of success Ascension Health SKIN bundle
Nurses throughout the organization created and implemented care methods under the SKIN bundle
Reduced pressure ulcer incidence to about 1.4 per 1,000 patient days system-wide
Six hospitals had no pressure ulcers for 1 year
Almost all that did occur were Stage I or II
SKIN bundle
Surface selection
Keep turning
Incontinence management
Nutrition

25. Design in Implementing the Ventilator Bundle
                                                                           
RT built into 1 hour scheduled vent checks as a)
Integrate daily goals with MDR to identify defects as a
Feedback on compliance
Education
Baseline 25

26. Steps to reliable care Do the acid test? Segment your population
Design an articulated process goal,
Agree a clear outcome goal connected to the process with some good medical evidence.
In addition you have now set up a theoretical design using the prevent, identify, mitigate and with the knowledge of failures how to redesign
design your first test of change
Determine the tempo of change you will “dance to” 26

27. Safety is No 1 Safety Walk-rounds
Safety first agenda item in every meeting
Safety Briefings at shift handover
SBAR (Situation/ Background/ Assessment / Recommendations )
MEWs reporting
Transfer/Discharge
C-DIFF & MRSA
Admission/Discharge nurse
Admission Trio

28. THANK-YOU Questions? Contact details: Annette Bartley