Pat.O’Connor National Patient Safety Development Advisor Operation Life Denmark 2008

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: (June 26, 2003) Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%

The first law of improvement Every system is perfectly designed to achieve exactly the results it gets. Peter Senge The Fifth Dimension

Scotland’s Profile Population 5 million 2005 Life expectancy UK women lowest in the European Union men, the second lowest after Portugal Urban and rural populations 12 health Integrated primary community and hospital care care areas Less than 5 % private healthcare NHS free at the point of delivery across the UK Devolved health Budget to Scottish Government

Characteristics of NHS Tayside Static Population 400,000 Rural and Inner city 3 Acute Hospitals 2400 beds Primary and Acute 1200 Acute Unique patient identifier 14,500 staff

Ninewells Hospital Perth Royal Infirmary Stracathro Hospital

UK Patient Safety Journey The Health Foundation 2004 £4M Competitive process throughout the UK 52 organisations applied 4 selected Coincidence 1 in each country 1 Scotland, 1 Wales, 1 England, 1 Northern Ireland,

Learning System (Phase I): Collaborative Learning Model Site Selection Supports Expert clinical faculty Listserv2 Site Visits Phone conf Assessments Monthly Reports via web 2 day LS A P D S A D P S 4 day Kickoff D S P A 2 day LS Key Changes Improvement Measures May 2005June 2006Late 2005 Jan 2005 Organisational Self Assessment 1 day LS + Congress

The Goal Using a patient safety portfolio evidence based change Reduce adverse events by 50% by Oct 2006

The Key Elements of Breakthrough Improvement Will to do what it takes to change to a new system Ideas on which to base the design of the new system Execution of the ideas

The Improvement Guide, API

Rapid Cycle Change with PDSA What does this mean? Plan, Do, Study, Act Rapid cycle starts with e.g. One doctor, one nurse, one patient Moving to 1…..3…..5…..All These changes happen in hours and days not weeks and months

Late Majority Early Majority Early Adopters Laggards Innovators Adopter Categories 2.5%13.5%34% 16% Source: E.M. Rogers, Diffusion of Innovations (1995)

Work Streams Leadership Medicines management Peri-operative care Intensive care General ward Throughout the organisation

The Results in 20 months 63.5% reduction in adverse events(case note review) 91% reduction in medication errors rates on admission 66% reduction of line infections in renal and ICU 60 % reduction of MRSA bacteremias in surgery SSI bundle 95% compliance 50% reduction in VAP

Surgery

ICU

Teams and Leaders: Roles Senior Leaders Teams Infrastructure Make Improvements Test and Learn Report Lessons Make Requests Set Aims Build Will Assure Resources Remove Obstacles Review and Reflect Assure Spread Human Resources Technical Expertise Information Technology Budget and Capital System for Spread

Cultural Elements Robust Governance and Risk management arrangements A preoccupancy with failure A culture of openness Abandoning blame as a major mode of action Trust in the workforce Involvement of patients and families

The Unique Role of Organisation Leaders Set the tone and values system in their organisations, Establish strategic goals for activities to be undertaken, Align efforts within the organisation to achieve those goals, Provide resources for the creation of effective systems remove obstacles for staff, and Require adherence to revised practices

PULL PUSH 1. Set Direction: Mission, Vision and Strategy Make the status quo uncomfortable Make the future attractive 3. Build Will Plan for Improvement Set Aims/Allocate Resources Measure System Performance Provide Encouragement Make Financial Linkages Learn Subject Matter 5. Execute Change Use Model for Improvement for Design and Redesign Review and Guide Key Initiatives Spread Ideas Communicate results Sustain improved levels of performance 4. Generate Ideas Understand Organization as a System Read and Scan Widely, Learning from other Industries & Disciplines Benchmark to Find Ideas Listen to Patients Invest in Research & Development Manage Knowledge Framework: Leadership for Improvement 2. Establish the Foundation Prepare Personally Choose and Align the Senior Team Build Relationships Develop Future Leaders Reframe Operating Values Build Improvement Capability

Why are we measuring? The answer to this question will guide your entire quality measurement journey! Improvement ? Judgment? Research?

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

The Three Faces of Performance Measurement AspectImprovementAccountabilityResearch Aim Improvement of careComparison, choice, reassurance, spur for change New knowledge Methods: Test Observability Test is observableNo test, evaluate current performance Test blinded or controlled Bias Accept consistent biasMeasure and adjust to reduce bias Design to eliminate bias Sample Size “Just enough” data, small sequential samples Obtain 100% of available, relevant data “Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes as learning takes place No hypothesisFixed hypothesis Testing Strategy Sequential testsNo testsOne large test Determining if a Change is an Improvement Run charts or Shewhart control charts No change focusHypothesis, statistical tests (t-test, F-test, chi square), p-values Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected “The Three Faces of Performance Measurement: Improvement, Accountability and Research” Lief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement vol. 23, no. 3, (March 1997),

Inpatients/Day Cases >15 weeks weeks

Outpatients >15 weeks weeks >15 weeks weeks >18 weeks

>6 weeks = 8 Short Stay = 7 Total October 2008 = 81 Target from Apr 08 = 0

Measures for Improvement RRT Communication Hand Hygiene SSI bundle Early warning scoring Time to call, interventions Use of SBAR Cardiac arrest rate Safety briefings Use of SBAR in all areas Observations & opportunities Floor and OR activities DVT prophlyaxis Antibiotics on time No shaving Normothermia Infection rates

Measures for Improvement Med Mgt Global trigger tool ICU Pharmacy FMEA Med reconciliation all units ADE’s anticoag ADE trigger tool Monthly measure Spreading to units…. real time VAP rates Bundle compliance CLI bundle Hand Hygiene Safety briefings

Scottish Patient Safety Alliance Royal Colleges Surgery, Medicine, Nursing, Midwifery Specialist societies Government National Education Scotland National Services Scotland- National procurement, National data centre, e-health Director for Scotland Scottish Patients Societies National Safety Research network Quality Improvement Scotland

Scottish Patient Safety Alliance The Aims: Transform the safety of health care in Scotland -start with acute care and move to community hospitals, primary care and mental health Build the infrastructure, capacity and capability to create best in class for any strategic improvement priority

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 Harm from Anti-coagulation: 50% reduction in ADEs Surgical Site Infections: 50% reduction

How will we do this? 12 evidence based interventions 5 work streams: Critical care General Ward Medicines Management Peri-operative leadership Major change programme based on integrated arrangements at national, regional and local levels Science of improvement – Model for Improvement Measurement tools to determine results and outcomes

12 Interventions Deploy rapid response teams Deliver reliable, evidence based care for acute myocardial infarction Prevent adverse drug events Prevent central line infections Prevent surgical site infections Prevent ventilator associated pneumonia Prevent pressure ulcers Reduce staphylococcus aureus (MRSA+MSSA) infection Prevent harm from high alert medications Reduce surgical complications Deliver reliable, evidence based care for congestive heart failure Get NHS Boards on board

How will we know if the changes have made a difference? Some is Not a Number, Soon is Not a Time! The Numbers: 30% Reduction in adverse events, 15% reduction in Mortality The Time: January 1, 2011