Pat.O’ConnorNational

Patient Safety Development AdvisorOperation Life

Denmark 2008

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (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 HospitalPerth 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

SupportsExpert clinical faculty

Listserv 2 Site Visits

Phone conf Assessments

Monthly Reports via web

2 dayLS

A

P

D

S

A D

P

S

4 day Kickoff

D

S

P

A

2 dayLS

Key Changes

Improvement

Measures

May 2005 June 2006Late 2005Jan 2005

OrganisationalSelf 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% 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 The answer to this question will guide your entire quality measurement journey!entire quality measurement journey!

Improvement

Improvement

??

Judgment?

Judgment?

Research?

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

Aspect Improvement Accountability ResearchAim Improvement of care Comparison, choice,

reassurance, spur for change

New knowledge

Methods:• Test Observability

Test is observable No test, evaluate current performance

Test blinded or controlled

• Bias Accept consistent bias Measure 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 hypothesis Fixed hypothesis

• Testing Strategy Sequential tests No tests One large test

• Determining if a Change is an Improvement

Run charts or Shewhart control charts

No change focus Hypothesis, 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”The Three Faces of Performance Measurement: Improvement, Accountability and Research”Lief Solberg, Gordon Mosser and Sharon McDonald JoLief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement urnal on Quality Improvement vol. 23, no. 3, (March 1997), vol. 23, no. 3, (March 1997), 135-147. 135-147.

0

50100

150200

250

300350

400

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Inpatients/Day Cases

>15 weeks

12-15 weeks

Outpatients

>15 weeks

12-15 weeks

0

200

400

600

800

1000

1200

>15 weeks

12-15 weeks

>18 weeks

0

20

40

60

80

100

120

140

>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

Percent of Unreconciled Medicines on Admission (Standard Project Measure) NHS Tayside Team

0%

10%

20%

30%

40%

50%

60%

70%

May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06

Month

Perc

ent U

nrec

onci

led

on A

dmis

sion

Testing in medical

admissions only

New form being tested

Test of direct access to

electronic GP records in 1

patient- access slow

Intake of new junior doctors

Testing in 3 wards in different

specialities

Reconciliation form included in

admissions ward documentation

Pilot population altered - 10

medical admissions, 10

general admissions

Ongoing testing in wider range of

clinical specialities - 6

wards

Test of direct access to

electronic GP records in 50 patients on one day -

25% success rate

Testing / Implemented in 21/43 wards on Ninewells site

Reconciliation training for medical students

Pilot population - 20 patients from

across organisation

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