1. Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative Learning Session One 21 st October 2009

2. Supporting NHS Wales to Deliver World Class Healthcare Driver Diagrams and Care Bundles Chris Hancock Critical Care Specialist

3. Slide 3 WCCIP

4. Slide 4 ABC of Critical Care Medicine Arrive Blame Criticise Delegate Exit

5. Slide 5 WCCIP 2006-08 All Welsh ICUs participated Ventilator Care Bundle Central Line Care Bundle

6. Slide 6 National Aggregate CVC Bundle Compliance

7. Slide 7

8. Slide 8 Reliability of Healthcare How often during your episode of healthcare should you receive the agreed optimum care and treatment? Sometimes Most of the time Always

9. Slide 9 A Major Study of “Reliability” in American Health Care… The Defect Rate in technical quality of American health care is approximately: 45% McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

10. Slide 10 In the UK Retrospective case note review of 1006 admissions to a large NHS hospital. Adverse events - 8.7%, of these: Disability > 6 months – 15% Contributed to death – 10% Adverse events are common, serious and potentially preventable (Sari, Sheldon, Cracknell et al, Qual Saf Health Care 2007;16:434–439.)

11. Slide 11 Who Comes to Work to do a Bad Job?

12. Slide 12 Instead of Considering the Entire Patient Pathway why not Concentrate on the Points Where These Adverse Events Occur?

13. Slide 13 What Does the Evidence Tell us Should be Done Reliably at These Points?

14. Slide 14 If We Do These Processes Reliably What is the Expected Outcome for the Patient?

15. Slide 15 Hence the Driver Diagram

16. Slide 16 Driver Diagrams Do: Establish the expected outcome Identify the critical points within the system Set out the relevant evidence based interventions

17. Slide 17 Driver Diagrams Don’t: Describe the whole pathway or all the necessary interventions Limit clinical or professional judgement Prevent or discourage innovation

18. Slide 18 Care Bundles Are: A small collection of evidence based interventions That are essential to the completion of a small part of overall process Carried out within a defined time period On every occasion unless there is a good reason for not doing so. They are all or nothing in nature

19. Slide 19 Welsh Ventilator Care Bundle Daily sedation rest Elevation of the head of the bed. DVT prophylaxis Peptic ulcer prophylaxis

20. Slide 20 Variance Tracking YesNoClinical Exclusion DVT Prophylaxis√ GU Prophylaxis √ Head Elevation - 30°√Signed Sedation Hold√

21. Slide 21 We already do that!

22. Slide 22 As it represents a reduction in errors of omission, compliance with the care bundle is a good proxy for reliability of that process.

23. Slide 23 A simple idea but it has many repercussions – as long as ownership is shared and is of both the intervention and the data analysis

24. Slide 24

25. Slide 25 Thank You. Happy Bundling!