The Challenges of Implementation(Will, Ideas, Execution)

Dr Elizabeth HaxbyRoyal Brompton and Harefield NHS Foundation Trust

Traditional Approach

• Overwhelming number of issues to be addressed

• Large audits ie 100s of patients telling us what we already knew

• Time consuming committees

• Profusion of policies – average 50 pages long

• Assumption that policy = practice

• Lack of Engagement

Design Design Design Design Approve

Implement

Conference Rooms

Real World

Trust wide VTE prophylaxis compliance

VTE Audit across the Trust (2009)

47% 47%

20%

7%

0%

7%

0%0%4%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

April May J un J ul Aug

Perc

enta

ge

Sydney

Fulham

Harefield

Reasons for Failure

Lack of clear goals or timeframes

Failure to frame the policy and provide context

Elements of the policy impractical

Failure to engage with the people who will implement the policy

Feedback intermittent, not directed

New ApproachSurgical Site Infection

New Approach

Set context

Set clear aim and timeframe

Engage with front line staff

Listen to their concerns and ideas

Try small tests of change

Establish measures and feedback

SSI - cost to patients, cost to healthcare

0

20

40

60

80

100

120

Superficial Deep

LO

S__

Infected Control

0

20000

40000

60000

80000

100000

120000

Superficial Deep

Cost (£

)__

Infected Control

• Patients with a superficial infection had an extra LOS of 20 days (P<0.0000) and cost an extra £9,735 (P<0.0098)

• Patients with a deep or organ space infection had an extra LOS of 54.5 days (P<0.0098) and cost an extra £40,726 (P<0.0098)

Difference in Median LOS Difference in Median Cost

Driver diagram SSI prevention

TribalNon-alignment

AN

AE

ST

HE

TI

ST

S

SURGEONS

NURSES

MANE

GE

RS

EX

EC

s

PO

RT

ER

S

OD

As

Alignment

Staff

Structure

Strategy&

Tactics

Aims

Leadership

Language

Multiple small changes

SSI data review at monthly CG day Cross site multi disciplinary WIP

group Care bundle measurement with

feedback to theatre staff Changes to;

Theatre access Hand hygiene / scrub up Surgical prep Dressings Wound management Vein harvest

Re-enforced antibiotic policy Feedback to individual surgeons on

SSI with RCA and bundle compliance for each patient

Board level reporting Local CQUIN indicator

Small test of change

SSI Prevention Care Bundle

Design

Test and Modify

Test and Modify

Test and Modify

Approve(if necessary)

Conference Rooms

Real World

Implement

SS

I rat

e pe

r 10

0 op

erat

ions

Incidences of Surgical Site Infection All Categories (Superficial/Deep/Organ) Sternal and Donor WoundsSSIs in CABG patients, detected primary admission and re-admission

ROYAL BROMPTON HOSPITALAugust 2009 - July 2010

Data from PATS as at 10/09/2010

1

2

Trend lineCQUIN target = 6.3

National CABG SSI rate = 4.3

RBH CABG July SSI rate = 0 per 100 operations

Augus

t 200

9

Septe

mbe

r

Octo

ber

Novem

ber

Decem

ber

Janu

ary 2

010

Februa

ry

Mar

chApr

ilM

ayJu

ne July

0

5

10

15

20

25

The Challenge of Implementation Clear Aim

Start small

Engage all the right people

Expect failure and respond promptly

Measure

Don’t underestimate anyone

Give information / feedback frequently

Seek additional drivers