Enhanced Recovery After Surgery Alan Willson 17 November 2010 Show of hands, those with direct experience of engagement in the 1000 Lives Campaign: Content area re reducing surgical comps; Surgical checklist Hair removal Normothermia maintenance. This was the first time in Wales that there has been a coordinated, shared national effort to reduce harm by focusing on defined and specific interventions, to reduce harm. Enhanced Recovery After Surgery Alan Willson 17 November 2010 Setting the scene 17 November 2010

1000 Lives Plus – Reducing harm, waste and variation. “..we have to accelerate the adoption and full implementation of best and evidence-based practice in all settings all of the time – there can no longer be any justification for not doing this. Paul Williams letter to Chief Executives, launching 1000 Lives Plus. March 2010. Following the conclusion of the Campaign there was a commitment to continue to follow a consistent methodological approach to achieve system-wide improvement. This is where the transforming theatres programme fits.. Setting the scene 17 November 2010

Why is this difficult? “Evidence-based therapies that prevent morbidity and death are often not translated into clinical practice. One reason for this is that research often neglects to look at how to deliver therapies to patients. Consequently,errors of omission are prevalent and cause substantial preventable harm” BMJ, Oct 2008, Vol 337 Setting the scene 17 November 2010

The 1000 Lives Plus - Drawing on the evidence of what works Pronovost et al (2008) Translating evidence into Practice – A model for large scale knowledge translation. BMJ Setting the scene 17 November 2010

National Aggregate CVC Bundle Compliance Setting the scene 17 November 2010

Care Bundle Compliance Having been adopted and implemented by all Welsh ICUs the mean national aggregate compliance for the period April 2007 – March 2008 by bundle was: - Ventilator care bundle - 97.82%. Central Venous Catheter Maintenance (CVCM) care bundle - 97.11%. Central Venous Catheter Insertion (CVCI) care bundle - 94.71%. Setting the scene 17 November 2010

Reduction of Harm and Mortality by Improvement in Processes Setting the scene 17 November 2010

W. Edwards Deming ‘’If I had to summarise my message ….. It is to reduce variation’’ Setting the scene 17 November 2010

Prevent failure – 1 in 10 failure rate Intent to follow a uniform process or guideline. Basic standardization of common equipment brands and guidelines Memory aids such as checklists Feedback mechanisms regarding compliance with standards Awareness-raising and training These tools are effective for the first phase of improvement. Taking the system to a higher levelof reliability requires more sophisticated strategies. Setting the scene 17 November 2010

Local Data Collection Setting the scene 17 November 2010 Yes No   Yes No Clinical Exclusion DVT Prophylaxis √ GU Prophylaxis Head Elevation - 30° Sedation Hold Setting the scene 17 November 2010

Identify and Mitigate 1 in 100 failure rate Identifying instances when the standardized approach is not used Reduce the opportunities for humans to make mistakes. “Error-proofing” Reduce the need for “workaround” solutions. Setting the scene 17 November 2010

Achieving better outcomes Patient’s experience and outcomes Safe, reliable care Value and efficiency Team performance and staff wellbeing Transforming theatres aims to improve patient experience and outcomes by pursuing the 3 main goals of: Increasing the safety and reliability of care Improving team performance and wellbeing Adding value and improving efficiency Setting the scene 17 November 2010

Understand what you are measuring and why.. Board level Frontline team level Measurement for Assurance Measurement for Improvement Core assurance measures Mortality rates Harm rates Improvement measure % compliance with daily team briefings % patients risk assessed for DVT % patients with titrated doses Measuring for improvement and measuring for assurance are different. The AOF requirements to demonstrate requirements are a snapshot of the improvement journey – the assurance is around whether people are looking at and measuring the right things. Setting the scene 17 November 2010

Obstacles and barriers When progress is difficult, the reason is likely to relate to one or more of the following: Failure of Will e.g. a few strong “blockers,” lack of investment in training and education, lack of back-up from more senior levels. Failure of Ideas e.g.Not drawing on the evidence base, or not participating in Learning Sets. Failure of Execution e.g. The leader does not have the authority (as well as the responsibility) to deploy the resources s/he needs. Cross- service links have not been clarified. Competing priorities have not been reconciled. The Model for Improvement is not being used. Setting the scene 17 November 2010 14

Setting the scene 17 November 2010 Other resources.. Setting the scene 17 November 2010