Sustaining Quality

“Expectations will always exceed capacity. The service must always be changing, growing and improving…”. Aneurin Bevan, 1948

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials Gordon C S Smith, Jill P Pell. BMJ 2003;327; Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design: Systematic review of randomised controlled trials Results: Our search strategy did not find any randomised controlled trials of the parachute.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials Gordon C S Smith, Jill P Pell. BMJ 2003;327; Conclusion: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

“Society’s huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves.” “Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.”

Fidelity vs Efficacy $29 Billion $32 Billion $100 Million 0.002%

The aspirin example In patients who have had a stroke or TIA aspirin reduces risk by 23% 100,000 patients – 23,000 fewer strokes 58% of eligible patients receive aspirin = 13,340 fewer strokes

Two options Fidelity – increase to 100% of eligible patients = 9,660 strokes Efficacy – requires a proportional improvement over aspirin of 74% Clopidogrel = 10% more efficacy than aspirin

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

Example Interventions Critical Care –Ventilator acquired pneumonia bundle, central line Ward –Early rescue –Communication Medicines –Medicines reconciliation Theatres –Surgical pause –Infection prevention/control Leadership –Safety walkrounds –Executive leadership board patient safety profile

But Does It Work Outside SPSP? Acute pain management in orthopaedics

Start data collection AIMS Meet Julie – ward manager – set AIMS Test drug recognition with recovery room nurses Meet anaesthetists SH, CR, TMcL, JD – describe tests with recovery nurses Test script of questions for recovery nurses to use 2 days per week Spread to 5 days per week

Only 45% patients with no or only mild pain in 1 st 24 hours postoperatively 75% patients with no or only mild pain in 1 st 24 hours postoperatively 526 patients337 patients

Winter review Patient safety walk rounds continued during the winter period Daily monitoring and reporting of 8 hour trolley waits in the Emergency Departments An action tracker has been established to ensure that the key lessons for improvement are being progressed Data: –Breach Analysis of A&E waiting times –Boarder numbers –Delayed Discharges –Elective cancellations –Re-admission rates

The Healthcare Quality Strategy for NHSScotland Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

“We look to Scotland for all our ideas of civilisation.” Voltaire (Francois Marie Arouet, 1694–1778)