HSCP Research ConferenceFriday 28th February 2014

Dr. Philip Crowley, National Director QPS

Safer Higher Quality Care for our Patients

Media coverage

€320k payout as hospital says sorry over death from dehydration

Healthcare System Failures

Where does improvement Happen?

Quality Improvement of Patient care

National

Group

Ward

Where Improvement Happens

Quality Improvement of Patient care

National

Group

Ward

ConditionsLeadershipPatient involvementClinical GovernanceEducation & Learning:- Measurement- QI Methods

ConditionsLeadershipPatient involvementClinical GovernanceEducation & Learning:- Measurement- QI Methods

A culture change – safety first

1. Individual relationship between HSCP and patient

2. Multidisciplinary Team / Ward

3. Hospital / organisation

Patient and H+SCP

Take ownership – accountable for the safety of care

Pivotal role in respecting and defending the dignity of every stage of life

Pivotal role in advocating for and on behalf of patients

What are the 3 biggest challenges that prevent me in delivering care – communicate out and up

MDT and Ward

Leadership role in drawing others into supporting change

Engaging Patients and staff you manage Safety Pause

MDT and Ward

Understanding what safety and quality means for your ward

Safer Better Healthcare Standards

Multidisciplinary team prompts

MDT and Ward

How well are you delivering Safe Quality Care QA+I tool, clinical audit

Clinical audit guidelines

Hospital / Organisation

Strong culture of Governance for Quality and Safety – be a champion for quality/question everything

Generate a culture of listening to your staff and patients Quality and Safety Walkrounds

Transparency Patients – open disclosure Measurement – Quality Profile

Checklists

Safe survey national policy and checklist Ward rounds principles for best practice and

checklist

Open disclosure

National Guidelines National Policy Guide for health and

social care staff Patient information

leaflet Staff support ‘assist me’

model

Quality Profile

Patient Experience

Staff Experience

Quality Improvement

Dashboard of Quality Indicators and Outcome Measures

0 0 0

1

0 0 0 0 0 0 0 0012

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Occ

ura

nce

s

Foreign Body left in Post Operatively

10

32

1

4

0 0

2 2

01

0246

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

In hospital fracture

25

20

20

6

03

0

7

00

5

10

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

In hospitals falls

3 4 210

26

1 1 3 2 4

01020

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Accidental Puncture or Laceration

23

1 12

0

2

4

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Transfusion Reaction

1

00.5

11.5

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Iatrogenic Pneumothorax

23

0

2

4

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Post Operative DVT / PE

1

0

0.5

1

1.5

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Wound Dehiscence

1

32

1 1

0

2

4

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Cardiac Arrest

21

0

2

4

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Post Operative Hip #

00.5

11.5

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Time to Hip # surgery

42 3

1

5

1 1 13

52 10

5

10

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Pressure Ulcers

0

1

2

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Mortality Indicators

00.5

11.5

Jan

Feb

Ma

rch

Ap

ril

Ma

yJu

ne

July

Au

gSe

pt

Oct

No

vD

ec

Medication Management

2

6 63 4

1 1

5

0

5

10

Jan

Feb

Mar

ch

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

Dec

Post Operative Sepsis

+

Employees & Patients: Likelihood to Recommend

16Press Ganey Associates

Em

plo

yee L

ikelih

ood

to

Reco

mm

en

d

Patient Likelihood to Recommend

How can we support you?

Quality and Patient Safety Division

Patients and StaffEngagement

Improvement Supporting and Assuring Quality

Improve the Safety of Patients

Listen to and empower patients

Listen to staff Foster development

and growth

Embrace Transparency through

Measurement(Indicators/Clinical Audit)

QI skills and knowledge

Areas for focus by QPS

Patient central

Patient Forums National Healthcare Charter Patient Safety Champions Measuring experience

Surveys Patient stories – from ward to board

Listening to Staff

Staff experience – seek and value feedback/ideas for improvement

Patient Safety Culture Survey/ Walk-rounds

Prioritise staff welfare

‘Walk in my shoes’

Elements of the National QI Programme

Each parallel element targets a different level of healthcare professional, maximising penetration of QI capability across the hospital system

Measurement

ASK FOR THE DATA

Data driven quality improvement Number of incidents plus trends

Ensuring preventable don’t keep reoccurringQuality Profile New quality indicators Patient experience and Staff experience Complaints…

Clinical audit Use data to generate light not heat

Berwick’s Challenge Abandon blame as a tool and trust the good will and

good intentions of staff Reassert the primacy of working with patients and

carers to achieve healthcare goals Use quantitative targets with caution – they should

never displace the primary goal of better care Recognise that transparency is essential and expect

and insist on it Give staff career-long help to learn, master and

apply modern methods for quality improvement Make sure pride and joy in work, not fear, infuse the

service

Oh! The places you’ll go..... And will you succeed?

Yes! You will, indeed! (98 and ¾ percent guaranteed.)

Kid, you’ll move mountains!Today is your day!Your mountain is waiting.So…get on your way!

Dr. Seuss

Thank You