Improving Care turning the world blue
Euan M Wallace
CEO, Safer Care Victoria
Carl Wood Professor of Obstetrics and Gynaecology, Monash University
better healthcare
High quality healthcare is ……
Safe: Avoids harm to patients.
Effective: Provides evidence-based care based to all who could benefit, and not
to those not likely to benefit.
Patient-centred: Provides care that is respectful of and responsive to individual patient
preferences, needs, and values; ensuring the patient guides decisions.
Timely: Reduces waits and sometimes harmful delays.
Efficient: Avoids waste, including of equipment, supplies.
Equitable: Provides care that does not vary in quality because of personal
characteristics.
US National Academy of Medicine
Safe: Avoids harm to patients.
Effective: Provides evidence-based care based to all who could benefit, and not
to those not likely to benefit.
Patient-centred: Provides care that is respectful of and responsive to individual patient
preferences, needs, and values; ensuring the patient guides decisions.
Timely: Reduces waits and sometimes harmful delays.
Efficient: Avoids waste, including of equipment, supplies.
Equitable: Provides care that does not vary in quality because of personal
characteristics.
High quality healthcare is ……
US National Academy of Medicine
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1.5
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4.5
Digital safetysolutions
EMR Nationalinterventions
Monitoring andreporting of patient
safety
Building a positivesafety culture
Expert
rating
What are the leading interventions to reduce patient harm?
OECD 2017
patient harm is 14th leading cause of global disease burden
(similar to TB or malaria)
medical error is 3rd most common cause of death in US
about 15% of total hospital activity and expenditure is on (avoidable) patient harm
in Canada this equates to 500,000 bed days or four large hospitals
Medical error and avoidable patient harm
Makary and Daniel, BMJ May 2016
Author Country Share of public hospital
spending
Brown (2002) New Zealand 32%
Rafter et al (2016) Ireland 4%
Etchells et al (2012) Canada 4.2%
Jackson (2009) Canada 14%
Health Policy Analysis (2013) Australia 16.5%
Ehsani et al (2006) Australia (Vic) 15.7%
Zsifkovits et al (2016) Europe 6%
Hoonhourt et al (2009) Netherlands 1.8%
most adverse events are preventable
patient harm is 14th leading cause of global disease burden
(similar to TB or malaria)
medical error is 3rd most common cause of death in US
about 15% of total hospital activity and expenditure is on (avoidable) patient harm
in Canada this equates to 500,000 bed days or four large hospitals
Medical error and avoidable patient harm
Makary and Daniel, BMJ May 2016
Author Country Share of public hospital
spending
Brown (2002) New Zealand 32%
Rafter et al (2016) Ireland 4%
Etchells et al (2012) Canada 4.2%
Jackson (2009) Canada 14%
Health Policy Analysis (2013) Australia 16.5%
Ehsani et al (2006) Australia (Vic) 15.7%
Zsifkovits et al (2016) Europe 6%
Hoonhourt et al (2009) Netherlands 1.8%
most adverse events are preventable
Issue 2017 2016 2015
Financial challenges 2.0 2.7 3.2
Governmental mandates 4.2 4.2 4.5
Personnel shortages 4.5 4.8 5.1
Patient safety and quality 4.9 4.6 4.2
Patient satisfaction 5.5 5.5 5.3
Physician-hospital relations 5.9 5.9 5.7
Access to care 5.9 5.8 6.2
Technology 7.0 7.2 7.1
Population health management 7.3 6.6 6.3
Reorganization 7.5 7.8 7.4
(ACHE Survey 2017)
Health service CEO priorities
Issue 2017 2016 2015
Financial challenges 2.0 2.7 3.2
Governmental mandates 4.2 4.2 4.5
Personnel shortages 4.5 4.8 5.1
Patient safety and quality 4.9 4.6 4.2
Patient satisfaction 5.5 5.5 5.3
Physician-hospital relations 5.9 5.9 5.7
Access to care 5.9 5.8 6.2
Technology 7.0 7.2 7.1
Population health management 7.3 6.6 6.3
Reorganization 7.5 7.8 7.4
(ACHE Survey 2017)
Health service CEO priorities
Scheduled flight Barcelona to Dusseldorf, 24th March 2015
Dep 09.01 GMT, GMT 09.41
Within hours of crash BEA team (7 people) were on site
3 days after the crash the co-pilot’s home was visited
Within 1 week the flight recorder had been recovered
2 wks after the crash the pilot’s medical history was known
Within 2 months (May) all airlines had changed policy
13th May 2016 final BEA Report issued
Germanwings flight 9525
Aviation security changes
Flight / event Response
Palestinian hijackers (1970) introduction of metal detectors at checking
Pan-Am 103 (1988) improved baggage security (5% to 100% screening)
airport security staff independent of carrier
9/11 (2001) categorisation of airports (capability framework)
reinforced, locked cockpit doors
increased armed air marshalls
no sharp objects (tweezers, scissors, knives, box-cutters), plastic cutlery
enhanced ID checks (multiple photo ID, pre-screening, risk profiling)
Richard Reid AA63 (2001) no shoes, belts, jackets off, pat down, scanning
2006 thwarted attack (UK) 100mL liquid limit
Germanwings 9525 (2015) minimum 2 persons in cockpit at all times
Thwarted attack (2017) no carry-on laptops from some origin ports
Umar Farouk Abdulmutallab ???????????
selection of health service inquiries ……..
hospital /
service report year $
patient
needs
registration &
credentialling culture leadership governance complaints
outcome
monitoring incidents
Bristol Kennedy 2001 ✗ ✗ ✗ ✗ ✗ ✗ ✗
King Edward Douglas 2001 ✗ ✗ ✗ ✗ ✗ ✗ ✗
Campbelltown Walker 2004 ✗ ✗ ✗ ✗ ✗ ✗
Bundaberg Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Rockhampton Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗
Hervey Bay Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗
14 NHS (Eng) Keogh 2013 ✗ ✗ ✗ ✗ ✗ ✗
Mid Staffs Francis 2013 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Furness, UK Kirkup 2015 ✗ ✗ ✗ ✗ ✗ ✗ ✗
Bacchus Marsh Wallace 2015 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Victoria Duckett 2016 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
To err is human, to forgive divine Alexander Pope
Errare humanum est,
sed in errare perseverare diabolicum. Lucius Annaeus Seneca
Manuel Domínguez Sánchez
To err is human, to cover-up is unforgivable,
to fail to learn is inexcusable. Sir Liam Donaldson
high performing hospitals…..
have specific and quantified goals for improving care
use systematic, transparent measurement and reporting of progress
use an established method of quality improvement (in a sustained manner)
have clinical leadership, teamwork and engagement at all levels
have a culture in which patient care quality and safety are valued
continually reduce fear in the workforce
use the workforce to design and re-design work and processes
have a commitment to listening and learning from patients and carers
Improving quality in the English NHS. King’s Fund 2016
high performing hospitals…..
have specific and quantified goals for improving care
use systematic, transparent measurement and reporting of progress
use an established method of quality improvement (in a sustained manner)
have clinical leadership, teamwork and engagement at all levels
have a culture in which patient care quality and safety are valued
continually reduce fear in the workforce
use the workforce to design and re-design work and processes
have a commitment to listening and learning from patients and carers
Improving quality in the English NHS. King’s Fund 2016
Patient outcomes mortality rates
readmission rates
hospital acquired complications (falls, HAIs, PE, pressure injury)
medication errors
Wellbeing outcomes patient satisfaction
quality of life
patient mood
depressive symptoms
symptom burden at end of life
positive workplace and organisational culture
Mapping a safety culture in Victorian public healthcare
(VMIA 2012)
1 in 4 Victorian hospital staff would not attend their own hospital for care
Oppositional
cautious
controlling
flexible
hierachical
reasoned
resistant
Generative
curious
encouraging
experimental
forceful
inquiring
nurturing
Defensive
cautious
conforming
controlling
directive
hierarchical
resistant
Uniform
appreciative
considered
controlling
competitive
flexible
hierarchical
✔ ✗
✗ ✗
psychological safety
low
high
cognitiv
e d
ivers
ity
high
low
40% vs 15%
33% vs 10%
24% vs 5%
(Alison Reynolds and David Lewis, HBR 2018)
organizational attributes
setting culture
deciding not only how to act but …
how NOT to act
disrupt
unhelpful behaviours
strengthen and sustain
psychological safety commit to new routines
focus on the team, performance will follow
Failing to create a generative team leads to ….
lack of deep understanding
fewer creative options
diminished commitment to act
increased anxiety and resistance
reduced morale and wellbeing
Successful teams
blend of different problem-solving behaviours
enjoy collaboration
look for problems to solve
maintain discipline
break rules
invent
meet mistakes with curiosity
share responsibility for outcomes
(Alison Reynolds and David Lewis, HBR 2018)
open
lack of fear
The three eras of healthcare: from heroism to
professionalism Don Berwick
Era 1: the age of heroism
Era 2: the age of accountability
- using measurement to drive compliance
- doesn’t work
- creates professional anger and community distrust
- leads to loss of information and “gaming”
- remains the dominant era
Era 3: the age of professionalism
culture
(intrinsic motivation)
compliance
(external measurement)
oppositional generative
defensive uniform
oppositional generative
defensive uniform
oppositional generative
defensive uniform
reaching era 3: the age of professionalism
release the workforce from eras 1 and 2 (backdown from metrics a little)
stop excessive measurement
know your own outcomes (strengths and weaknesses)
share data openly
set ambitious outcome (quality) targets
focus on improvement science
increase patient authority and engagement
culture
(intrinsic motivation)
compliance
(external measurement)
oppositional generative
defensive uniform
high performing hospitals…..
have specific and quantified goals for improving care
use systematic, transparent measurement and reporting of progress
use an established method of quality improvement (in a sustained manner)
have clinical leadership, teamwork and engagement at all levels
have a culture in which patient care quality and safety are valued
continually reduce fear in the workforce
use the workforce to design and re-design work and processes
have a commitment to listening and learning from patients and carers
Improving quality in the English NHS. King’s Fund 2016
high performing hospitals…..
have specific and quantified goals for improving care
use systematic, transparent measurement and reporting of progress
use an established method of quality improvement (in a sustained manner)
have clinical leadership, teamwork and engagement at all levels
have a culture in which patient care quality and safety are valued
continually reduce fear in the workforce
use the workforce to design and re-design work and processes
have a commitment to listening and learning from patients and carers
Improving quality in the English NHS. King’s Fund 2016
better healthcare
better healthcare how good am I today (relative to others)?
how good do I want to be?
how will I know?
2nd Atlas of Variation, ACSQHC
educational tool for individual surgeons
high level overview of mortality
provides insights into care deficiences
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2000
2500
2012-13 2013-14 2014-15 2015-16 2016-17
No.
death
s (
VA
ED
)
year (VASM 2016-17 Report)
15% potentially avoidable
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
Goethe
Using data to improve
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2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17
CLA
BS
I (p
er
1000 c
entr
al lin
e d
ays)
aggregate hospitals
Year
Using data to improve
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2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17
CLA
BS
I (p
er
1000 c
entr
al lin
e d
ays)
aggregate hospitals
Year
Benchmarking Perinatal Care
2013-14
2014-15 2015-16
Casey Hospital
2016-17
Safer Care Victoria work ahead
Safety minimum measure set – shades of blue
improved incident reporting
better learning from error (sentinel events, complaints, litigation)
Culture structured leadership programs
speaking up for safety learning
enhanced clinician engagement
Improvement programs Perineal tears (with WHA)
Maternity bundle
Sepsis
ED partnership
Specialist clinic partnership
Tonsillectomy
Delirium
Five building blocks for patient safety
Committed leadership to lay the right culture.
Clear policies. Every practitioner must know and understand best practices, including on
reporting and learning from medical error.
Data driven improvements, allowing continuous adjustments to care.
Competent and compassionate workforce, in sufficient numbers.
Consumers and families involved and respected.
Dr Tedros Adhanom Ghebreyesus
Director-General, World Health Organization, London 2018