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Is healthcare getting safer?The challenge of measurement
Charles Vincent Department of Psychology &
Oxford Academic Health Science Network
Evangelists & snails
‘Run don’t walk’
‘The correct question is whether there is a rationale for withholding critical care resources from critically ill patients outside the intensive care unit. The answer is obvious. No’
Walk, don’t run
‘In view of the limitations of the evidence and the heterogeneity of study results it seems premature to declare Rapid Response Teams as the standard of care’.
Davidoff, 2011
UK National Reporting & Learning System
Hospital Episode Statistics: 11.8M hospital admissions in England 2004/5
Intensive careOperating theatre
• Major complication rate decreased 36%
• Mortality decreased 47%
• Post-op infection decreased 48%
• Central line infection rates decreased 66%
• Quarterly infection rate in most ICU’s <1%
• Estimated saving of $175 million
• Potentially more than 1500 lives saved
Major successes in focal clinical areas
Team training and surgical mortality
After controlling for baseline differences the 74 trained
facilities experienced significant decrease in
mortality of 18% as compared with 7% in the non trained
facilities
Neilly et al, JAMA 2010
Safer Patients InitiativeTo reduce adverse events by 50% in 24 hospitals
11
SPI programme elements 4SPI programme elements 4
Improvement = shifting the level of the process in the desirable direction (A) or
reducing variation (B)
A
BA
BA
BPoint of initial intervention
Improvement = shifting the level of the process in the desirable direction (A) or
reducing variation (B)
A
BA
BA
BPoint of initial intervention
Annotated Run Charts
80 metrics (34 standard)
Process analysis
10
SPI programme elements 3SPI programme elements 3
Incremental spread
Iterative development of
local innovations
9
SPI programme elements 2SPI programme elements 2
8
SPI programme elements 1SPI programme elements 1
8
Breakthrough Series Model
Programme model
Change elements Process measurement
QI methodology
Safer Patients InitiativeParticipating hospital site
Collaborative learning
Expert support
Commentaries on patient safety in the United States
five years after the publication of to key reports
on patient safety in 2000 were characterised by some despair
at an apparent lack of progress. Our data suggest
that a more encouraging story on patient safety in the NHS
can now be told
Benning et al, 2011
The Achievements of SPI
Inspirational and important legacy Objectives over ambitious Organisations in different states of readiness First major UK safety initiative that took
evaluation seriously Simply getting basic clinical data and measures
was a major challenge
Making Care Safer. Preventable hospital-acquired conditions would decrease by 40% compared to 2010.
This would mean 1.8 million fewer injuries to patients.
Improving Care Transitions. Preventable complications during a transition be decreased so that hospital readmissions would be reduced by 20% compared to 2010.
This would mean 1.6 million patients recovering without suffering a preventable complication requiring re-hospitalization.
Did Hospital Engagement Networks Actually Improve Care?
‘Weak study design and methods, combined with a lack of transparency and rigour in evaluation …’
‘These numbers appear impressive but given the publicly available data and the approach CMS used it’s nearly impossible to tell whether the PPP actually led to better care’
(Pronovost & Jha, NEJM 2014)
Focus on improvement Menu of national priorities Capacity and capability
building Measurement Leadership Evaluation
15 Patient Safety CollaborativesHosted by Academic Health
Science Networks
Measurement & Evaluation in Patient Safety Programmes
Our major challenge will be to demonstrate change (rather than activity)
This has bedevilled all safety programmes in NHS Measurement is therefore our number 1 priority because:
– It focuses minds and priorities– It has been the major headache for all safety programmes– The time taken to get measures in place has been consistently
underestimated– It is essential for the programme teams to function effectively– It is fundamental to evaluation
We owe this to patients and carers
Information should include the perspective of patients and their families; measures of harm;
measures of the reliability of critical safety processes; on practices that encourage the monitoring of safety;
on the capacity to anticipate safety problems; on the capacity to respond and learn from safety information.