Sustainabilityinqualityimprovement

Dr.FrancesMortimerMedicalDirector,CentreforSustainableHealthcare,Oxford

February2017

SustainabilityinQualityImprovementtrainingmaterials,developedbytheCentreforSustainableHealthcarewithgrantfundingfromNorthBristolNHSTrust.

Aims– youshouldbeableto:

1. Recognise sustainabilityasadomainofqualityinhealthcareanddiscussitsrelationshiptootherdomains.

2. Reviewtheenvironmental,socialandeconomicinputstoagivenhealthsystem,andidentifyrelevantcarbonhotspots.

3. ApplytheprinciplesofsustainableclinicalpracticeinthedesignofaQIintervention.

4. Identifyoutcomeandactivitymeasuresinordertoevaluateimpactonsustainability/sustainablevalue.

“Ourvisionofsustainablehealthandcare:Asustainablehealthandcaresystemworkswithintheavailableenvironmentalandsocialresourcesprotectingandimprovinghealthnowandforfuturegenerations.”

Sustainabilityasadomainofquality

SustainablePatient CentredEquitable

Efficient

Effective

Timely

Safe

Dr Donal O’DonoghueNational Clinical Director for

Kidney Care 2007-13

Seealso:Atkinson,S.etal.Defining QualityandQualityImprovement.Clin Medvol.10,no.6537-539(2010)

SettingQIgoalsIncludingsustainabilitywithinyourprojectaims(howwillthisaffectengagementwithcolleaguesandwiderstakeholders?)

Sustainable value in healthcare:

Academy of Medical Royal Colleges, 2016 (with CSH)

(goods – harms)

Informedbypatientvalues

outcomesValue =

environmental + social + financial costs(the “triple bottom line”)

SustainableQI

StudyingthesystemUnderstandingenvironmental andsocialresourceuseandimpacts

Carbonhotspots

Socialimpacts– onwhom?

👤 Patient👥 Staff👥 Carers👥 Dependants👥 Localcommunity👥 Distantcommunities(e.g.supplychainworkers)

Socialimpactsondistantcommunities

“Labourers insurgicalinstrumentmanufactureareoftenpaidlessthanUS$1perday,havepoorjobsecurity,havewoefullyinadequateprotectionofhealthandsafety,andmanyemployeesarechildren,someasyoungassevenyearsold.”BMAMedicalFair&EthicalTradeGroup

Socialsustainability• Basicneeds,includinghousingandenvironmentalhealth• Educationandskills• Employment• Equity• Humanrightsandgender• Poverty• Socialjustice• Demographicchange(ageing,migrationandmobility)• Socialmixingandcohesion• Identity,senseofplaceandculture• Empowerment,participationandaccess• HealthandSafety• Socialcapital*• Wellbeing,HappinessandQualityofLife

*definedas“networkstogetherwithsharednorms,valuesandunderstandingsthatfacilitateco-operationwithinoramonggroups”(OECD)

Source:Colantonio,A.&Dixon,T.(2009)MeasuringSociallySustainableUrbanRegenerationinEurope.OxfordInstituteforSustainableDevelopment(OISD)

DesigningyourQIinterventionApplyingtheprinciplesofsustainableclinicalpractice

Howwill80%carbonreductionbeachieved?

Sustainableclinicalpractice:principles

Reducecarbonwithoutreducing

health

Reduceactivity

Prevention

Selfcare

Leanpathways

Reducecarbonintensity

Lowcarbonalternatives

Sustainableestates

Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11

Outcomeneeded

Secondarydrivers

Primarydriver

Primarydriver

CENTRE forSUSTAINABLEHEALTHCARE

Sustainableclinicalpractice:principles

Reducecarbonwithoutreducing

health

Reduceactivity

Prevention

Selfcare

Leanpathways

Reducecarbonintensity

Lowcarbonalternatives

Sustainableestates

Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11

Outcomeneeded

Secondarydrivers

Primarydriver

Primarydriver

CENTRE forSUSTAINABLEHEALTHCARE

Sustainableclinicalpractice:principles

Reducecarbonwithoutreducing

health

Reduceactivity

Prevention

Selfcare

Leanpathways

Reducecarbonintensity

Lowcarbonalternatives

Sustainableestates

Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11

Sustainableclinicalpractice

Outcomeneeded

Secondarydrivers

Primarydriver

Primarydriver

Infrastructure&processCENTRE for

SUSTAINABLEHEALTHCARE

e.g.drypowderinhalers(1/20xcarbonofMDI)

Improvesustainabilityofrespiratoryinhalerprescribing

1.Preventavoidablerespiratorydisease

Reducesmoking Reviewreferral ratestosmokingcessationservice

Reducecold/mould exposure Investigatehousingimprovementreferral scheme

ReduceairpollutantexposureInputtolocaltransportpolicy

Ensurepatientsreceiveairqualityhealthadvice

2.Empowerpatientstoimprovediseasemanagement

Co-production

Ensureyearlycareplanning

Rescue packsforacuteexacerbations

Socialprescribing Singing/pulmonaryrehabreferral forms

3.Ensureleanprescribinganddispensingsystems

Leancommunications Introducepaperlessprescribing/repeat requests

Highvalueprescribing Introduceannualinhalerreviews

4.Switch tolowercarbonalternatives Preferential useofDPIvsMDI inhalers

Updateprescribingguidelines

Writearticle forlocalGPnewsletter

5.ImproveoperationalresourceuseInhalerrecycling Signpostrecyclingpoints

Waste,energy,travel Relevantactions

Leansystems…spottingwaste

• Outofdatestock• Singleuseitems• Cancellation• Packaging• Standby• Noncompliance• Waitingtime• Commutingtime• …canyouadd2moreeuphemismsforwaste?

Yourservice- sustainableclinicalpractice

Principle Opportunities?

1.Prevention

2.Patientempowermentandselfcare

3.Leansystems

4.Lowcarbonalternatives

Yourservice- sustainableresourceuseResourceuse Opportunities?

Energy

Travel(staff,patients)

Medicalsupplies

Non-medicalsupplies

Water

Waste

Prioritise

Opportunity Impact(1-3) Feasibility(1-3)

Measuringenvironmentalandsocialcosts/impacts

Sustainable value in healthcare:

Academy of Medical Royal Colleges, 2016 (with CSH)

(goods – harms)

Informedbypatientvalues

outcomesValue =

environmental + social + financial costs(the “triple bottom line”)

EnvironmentalCosts

Carbonfootprint- thesumofgreenhousegasemissionsreleasedinrelationtoanorganisation,productorservice,expressedascarbondioxideequivalents(CO2e).

Carbonfootprint:whatisincluded?(operationalboundaries)

Scope3:Indirectemissions

(other)

Scope2:Indirectemissions

(electricity)

Scope1:Direct emissions

• Supplychain• Travel• Wastedisposal

• Electricityuse

• Energygeneration• Vehicleemissions• HFCs,N2O,etc.

Topdowninput-output

Bottomupprocess-based

Emissionsfactorsappliedtocomponentsofaprocessorproduct,e.g.materials,energyuse

Emissionsfactorsappliedtospendindifferenteconomicsectors

Hybrid

Methods

Availablefromhttp://www.ukconversionfactorscarbonsmart.co.uk/

Greenhousegasemissionsfactors– UKGovt

Goodsandservicescarbonhotspots, NHSSustainableDevelopmentUnit(2013)

Care Pathways Guidance on Appraising Sustainability (SDU, 2015)

Carbonbyunitsofhealthcareactivity

Measuringenvironmentalcosts- exampleAprimarycareteamnoticedthatsomepatientswhowerereferredforhipandkneereplacementswerebeing

referredbacktotheGPsurgeryafterpre-operativeassessmentatthelocalhospital.Thiswasbecauseparameters,suchasbloodpressure,wereeitheroutsidethetargetrangeorwerenotcommunicatedproperly

inthereferralinformation.Anauditrevealedthat1in6patientsloopedthroughthesystem– 10/year.

Activity Outcome £’s CO2e Social

ExtraGPconsult [delaytosurgery]

£451 18kg2 Patient&carertime/stress

ExtraHospitalconsult [delaytosurgery]

£1121 23kg2 Patient&carertime/stress(parking…)

Total (for 10loops) £1570 410kg

1. UnitCostsofHealthandCare,PSSRU,December2015.Availableat:http://www.pssru.ac.uk/project-pages/unit-costs/2015/index.php2. CarbonHotspotsupdateforthehealthandcaresectorinEngland2015,SustainableDevelopmentUnit,January2016.

CharlieKenward,SevernGPST3SustainabilityScholar2014-15

Measuringsocialimpacts?

Patients Carers Community Supplychain Staff

Housing

Poverty

Health

Education

Employment

Safety/security

Satisfaction

Participation

Socialgradient

Canyouidentifyoutcomeandactivitymeasurestoevaluatesustainabilityimpactof…?

• Introducingone-stopservice,e.g.• Breastlumpassessment• Peripheralvasculardisease• Backpain

• Integratingpreventativeservices,e.g.• Vascularclinic– smokingcessationetc• Gallstonespathway- dietetics

• Overnight>daycasesurgery,e.g.• Laparoscopiccholecystectomy• Roboticprostatectomy

ThinkingsustainablywithinaQIproject

1. ApplysustainabilityapproachatthedifferentstagesofANYproject

2. Chooseaprojectareathatrelatescloselytosustainability,e.g.a. Prevention,patientempowerment,etc.b. Reducingpharmaceuticalwastec. Reducingover-investigation/over-treatment

http://sustainablehealthcare.org.ukfrances.mortimer@sustainablehealthcare.org.uk