Post on 18-Dec-2015
Welcome to the Inaugural Event
3 February 2011
1630 hours
Sandy Watson, OBE, DLChairman
NHS Tayside
John ConnellDean
University of Dundee
Gerry MarrChief Executive
NHS Tayside
Welcome and Opening Remarks
Responding to the Quality Challenge
Derek FeeleyActing DG Health and Social Care
Chief Executive NHSScotland
I’ll cover
• Nature of the challenge• Lessons from patient safety• Implications (and a reason for you to celebrate)
Building from a strong base
Really good people too
4 Improvement Aims• Health (prevention and anticipation)• Healthcare Quality• Value (i.e. quality/cost)• Integration
Six Dimensions of Quality
In this for the long haul…Patients want speedy treatment and quick access to care, but they want more than that. They also want a health service that is compassionate and treats them with dignity; they want to see real partnership between clinicians, patients and others; they want services to be provided in a clean and safe environment; they want hospital food to be good; they want continuity right though their journey of care; and, of course, they want to have confidence in the quality and effectiveness of any treatment.Achieving all that for every patient, every time that they use the NHS, is what the quality strategy is all about. At its heart is a simple but very ambitious aim: to make the NHS in Scotland a world leader in the quality of health care services that it delivers.That aim is not just good for patients, it is also right for staff. There is real enthusiasm across the NHS for the quality strategy—something that I would be the first to accept cannot always be said about Government initiatives.
Nicola Sturgeon, Scottish Parliament 13/5/10
Potential for political consensus?I welcome the opportunity to discuss the NHS quality strategy and I congratulate the Scottish Government on introducing it. I find little to disagree with in the document and I am sure that that view will be shared among members across the chamber. We all want safe, clinically effective and person-centred treatment, which is at the heart of the quality strategy. We all want Scotland to become a world leader in the delivery of health care. It is right that we should continually strive to improve our delivery of services and the outcomes that we achieve for people throughout the country.The ambition is right, and I am sure that the cabinet secretary will acknowledge that achieving that ambition will be dependent on leadership at all levels of the NHS, shared ownership of the objectives and, of course, partnership with staff, patients and carers. All that will be critical if we are to achieve change on the scale that is required and to begin to meet the objectives and take the direction of travel that the strategy sets out.
Jackie Baillie MSP, Scottish Parliament 13/5/10
What patients see as high quality healthcare?
• caring and compassionate health services;
• collaborating effectively with clinicians, patients and others;
• confidence and trust in health services;• providing a clean and safe care
environment;• improving the access to care and continuity
of care;• delivering clinical excellence
The perfect storm? Where values and expectations align
The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.
• Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
Quality Outcome Measures• Care Experience• Staff Engagement and Potential• Healthcare Associated Infection• Emergency Admission Rate/Bed
Days• Adverse Events• Hospital Standardised Mortality Rate• Under 75 mortality rate• Patient Reported Outcome Measures
(PROMs)• Self-assessed general health• Percentage of time in the last 6
months of life spent at home or in a community setting
4 ways to deliver public services (LeGrand 2007)
But……….% Annual Real Growth Rate in Scottish DEL Budgets
•IFS predictions – Dec 2009
•Reflects current use of EYF
International comparisons of quality and cost
The impact of variation in chronic care
NHS Scotland’s Integrated approach to Quality and Value
• Reduce harm, error and re-work (Safe)• Mutuality and Co-production (Person-
Centred)• Increase reliability and reduce variation
(Effective)
It’s complicated….
Too bad all the people who know how to run the country are busy driving cabs and cutting hair.
-- George Burns
But it can be done!
" i am so proud to be a nurse"........i just want to get
back to work ....get on and do something"
LS7 participant
If I had shown you the following results in January 2007 would have believed
them possible?
5% reduction in HSMR
73% reduction in central line infections
43% reduction in ventilator associated pneumonia
72% reduction in critical care c.diff
14% increase in ward hand hygiene
58% decrease in ward c.diff
Kotter’s Eight Steps for Successful Large Scale Change
• Increase urgency• Build a guiding team• Get the vision right• Communicate for buy-in• Empower action• Create short-term wins• Don’t let up• Make change stick
More from those smart people at IHI
So, putting all of that together…
• Need goals and aims• Need to influence/create the operating
environment • Need capacity to deliver/execute• Need to do better than the status quo• Need change agents who are credible
• i.e. Need Organisational Effectiveness
Reasons for Hope
Lessons from my visits to Dundee…
47
Alcohol-
48
Alcohol hand gel
• Pants
49
• Johnnys
50
???
My reason for hope?
I have never said any of these in an address
again!
51
Real Reasons for Hope
52
The IHI Open School
• The IHI Open School has made tremendous strides in building and strengthening a vibrant network of students, faculty, and mentors in the improvement community. There are 283 IHI Open School Chapters in 38 countries and in 44 of the 50 US states.
53
Centers for Medicare and Medicaid
• Change the way we think about performance• Support and create partnerships• Promote teamwork• Defeat secrecy• Improve information systems• Balance mindfulness and protocols
54
• Growing partnerships to support quality and quality improvement
• Widespread and growing acceptance of standardized measurement
• Information systems are finally taking hold • Population focus
55
Fives Alive!
56
5s Alive! Results - Overall Collaborative Postnatal Care – June 2008 to present (Coverage)
9 CEm0C neonatal results •
NCFR reduction by 22 % reduction in 2008 vs 2007
Neonatal Death Rate for 9 CEmOC Facilities 2006-2008
-
1.00
2.00
3.00
4.00
5.00
6.00
Jan-
06
Mar-
06
May
-06
Jul-0
6
Sep-0
6
Nov-0
6
Jan-
07
Mar-
07
May
-07
Jul-0
7
Sep-0
7
Nov-0
7
Jan-
08
Mar-
08
May
-08
Jul-0
8
Sep-0
8
Nov-0
8
Month-Yr
%N
ND
s
%NNDs
Median May - Dec 2006
Baseline Median = 2.57%
Missing data in some
Facilities
9 Cemoc maternal Case Fatality Rate.
Baseline Median = 0.37%
deathrate 2007= deathrate 2008= 0.38%.
2008 9 Cemoc annual deliveries 9%
9% =2700 deliveries 2007 vs 2008
1,500
1,700
1,900
2,100
2,300
2,500
2,700
2,900
3,100
3,300
Jan-
06
Mar-
06
May
-06
Jul-0
6
Sep-0
6
Nov-0
6
Jan-
07
Mar-
07
May
-07
Jul-0
7
Sep-0
7
Nov-0
7
Jan-
08
Mar-
08
May
-08
Jul-0
8
Sep-0
8
Nov-0
8
Month
No.
of
Del
Deliveries
Median Jan - Jun 2006
62
HIVQUAL-UgandaBerlin
March, 2009
Kayita Godfrey MD, MPH
Ministry of Health, Uganda
Quality Management Program
HIVQUAL-Uganda
63
Background
Popn – 30mPHAs – 1.1mPrev. – 6.4 (UHBS 04/05)
AIMInstitutionalization of QI in national health care delivery systems
18-May-11
63
Data Report & QI Projects
• HIV immunological monitoring (CD4)
• 7 health facilities
• Prevention Education
• 5 health facilities
• TB assessment and screening
• 5 health facilities
• HAART adherence
• 3 health facilitiesKey CD4 or TLC HIV Monitoring (CD4 counts or TLC every 6 months) COC Continuity of Care (Clinic visits every 3 months) CP Prophylaxis (Cotrimoxazole or Dapson) within 6 months PE Prevention Education every 3 months ART ARV Therapy and adherence to ARV Therapy AA Documentation of adherence assessment every 3 months TBA/TBS TB Assessment and TB Screening within 6 months
Challenges• Communication• Limited resources
Next steps• Roll out QI– in all ART accredited sites– In all HIV program areas– activities beyond HIV• Consumer involvement in
QI• Continued capacity
building – ToTs and Mentoring sessions
For Us….
The Good NewsLots of progress worldwideLearning from the world
Important problems to improve
Common problems
The ChallengeSame problems are seen
worldwideSeeing ourselves as part of
that worldNo easy answers to the
problemsDeveloping common
solutions
66
Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system.
Donabedian, Health Affairs
Autobiography in 5 ChaptersPortia Nelson from: The Tibetan Book of Living
and Dying
1. I walk down the street There is a big hole in the sidewalk I fall in the hole. I am lost….I am hopeless. It isn’t my fault. It takes forever to get out.
2. I walk down the street There is a big hole in the sidewalk I pretend I don’t see it. I fall in again. I can’t believe I’m in the same place. It isn’t my fault. It still takes a long time to get out.
3.I walk down the street There is a big hole in the sidewalk I see it is there. I still fall in – it’s a habit. My eyes are open, I know where I am. I get out immediately.
4.I walk down the street There is a big hole in the sidewalk I walk around it.
5. I walk down another street.
Dundee IHI Open School Chapter
Thomas Johnston Liam ShieldsFraser Pryde
Overview IHI Open School Chapter achievements Clinical Academic Track
Interprofessional Education Leadership and Quality Improvement
Learning from Errors Advanced case study Improvement practicum
Key messages
pgdavey 31/01/2011Changed from "Academic tract"
Fatal medication errors
DP Phillips, GEC Barker. A July Spike in Fatal Medication Errors: A Possible Effect of New Medical ResidentsJGIM 2010. 25; 8: 774-779.
10% increase in mortality from medication errors above expected level
August killing season
Medication Incident Analysis Framework
Coombes et al. Why do interns make prescribing errors? The Medical journal of Australia 2008; 188: 89-94.
Multiple system failures
“Advance health care improvement and patient safety competencies
in the next generation of health professionals worldwide.”
IHI Open School Mission
Globe spanning network of chapters
Over 200 chapters now world wide
International approach to improving patient safety
Dundee Chapter
Global AimPromote teaching and assessment in QI and PS
The Origin of the Dundee Chapter
Medicine Nursing ComputingDentistry
Dundee Chapter
September 2008
AIM – Promote inter-professional student learning in QI and PS
Achievements Achievements
IHI courses
NHS Tayside
IHI courses
NHS Tayside
Patient Safety SSC
Patient Safety SSC
Improvement projectsImprovement projects
Inter-Profession
aleducation
Inter-Profession
aleducation
Reducing Harm
Improving Care
Conference
Reducing Harm
Improving Care
Conference
http://www.dundee.ac.uk/dcat/
•13 Teams took part•Dundee students led the only team from outside North America
Aim statement and tests of change>95% of all newly admitted patients on Warfarin will have their INR measured, documented and acted upon, prior to leaving the acute
medical or surgical admission ward within 3 months
Test Cycle 1 Is there a Warfarinsed patient admitted today?
Test Cycle 2 Can the drug dispenser be used to quantify number of warfarinised patients?
Test Cycle 3 Ask SCN/Consultants about holding patients until INR result recorded acted on
Warfarin Handover Alert SheetDate Patient
name/CHI no.
Time since admissionINR reported
INR INR within rangeY/N
Action required?(Please refer to protocol for guidance)
Held or continued
Warfarin Chart completed
Target INR On admission
85
NB: If INR > 5 or < 1.5 please contact your senior/follow protocol/contact on call Haematologist for advise - bleep 3047
Incident
Adverse Incident
Manage the
incident Report to manager
Type Impact
Risk
Red
Fast Track NHS QISMHRA
Confidential EnquiriesProcurator
FiscalCNORIS
NHS TaysideProfessional
bodies NMC GMC
Review /analyseForward to H&S
Amber
Green
Report internally
Chief Exec /Executive team
Staff Response
Line Manager Internal Organization
External
LearnChangeImprove
Root Cause Analysis
Trend Analysis
Learn and disseminate Implement and monitorimprovement strategies
Feedback to local staff
Learning from Errors: Core Teaching in Systems Thinking & Human Factors•132 Final Year students doing Incident Reviews in 2010-11•Strong support from Senior Charge Nurses & NHS Tayside
Incident
Adverse Incident
Manage the
incident Report to manager
Type Impact
Risk
Red
Fast Track NHS QISMHRA
Confidential EnquiriesProcurator
FiscalCNORIS
NHS TaysideProfessional
bodies NMC GMC
Review /analyseForward to H&S
Amber
Green
Report internally
Chief Exec /Executive team
Staff Response
Line Manager Internal Organization
External
LearnChangeImprove
Root Cause Analysis
Trend Analysis
Learn and disseminate Implement and monitorimprovement strategies
Feedback to local staff
Organisational Learning:Recommendations for Change•17th December: Clinical teams, Safety Governance & Risk•14th February: Tayside Drug & Therapeutics Committee
Advertising for 2011Student scholarship to develop Leadership & QI Course for Years 2 and 3
Aims: •Expose students to improvement methods early in their careers•Develop their potential to be leaders for safe practice.
Objectives:•Understand and apply the model for improvement.•Use micro-systems thinking to investigate safety incidents•Develop clinical leadership skills through Plan Do Study Act (PDSA) cycles
Key messages
Students are part of the solution, not part of the problem!
All members of MDT educated in QI + PS
The ward ready novice MDT
Improvement is everyone's business
pgdavey 01/02/2011I have added "novice", meaning that we want novices who know how to work with and learn from experienced staff
Copyright ©2007 BMJ Publishing Group Ltd.
Batalden et al. Qual Saf Health Care 2007;16:2-3
Linked aims of improvement
Can we make it better?
What is “it”?Health?
Health care?Safety?
“quality improvement”
The combined and unceasing efforts of everyone – health care professionals, patients and their
families, researchers, payers, planners, administrators, educators – to make changes that
will lead to better patient outcome, better system performance, and better professional
development.
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3
What will it take to be the best in the world?
"While the literature often portrays an organisation's quest for change like a brisk march along a well-marked path, those in the middle of change are more likely to describe their journey as a laborious crawl towards an
elusive, flickering goal, with many wrong turns and missed opportunities along the way. Only rarely does an
organisation know exactly where it's going, or how it should get there."
Kanter et al, The challenge of organisational change, 1992
Four steps to world-leading
• Be reliable• Be disruptive• Be person-centred • Be transparent
Be reliable
NEJM 2009;360:491-9
8 hospitals5809 beds
160 theatres
46% reduction in surgical site infection
47% reduction in mortality
Using care bundles to reduce in-hospital mortality: quantitative survey
Robb et al. BMJ 2010:340:1234
Care bundles used
COPD
Central venous cathetersDiarrhoea and vomiting
Ventilator acquired pneumonia
MRSA
Heart failure
Surgical site infections
Results
• HSMR fell from 89.6 (2006-07) to 71.1 (2007-08)
• SMRs fell in 11 of 13 targeted diagnoses• 5.7% increase in admissions, 7.9% increase in
expected deaths and 14.5% decrease in actual deaths
"A limitation of this type of study is the difficulty establishing whether there is a casual relationship
between introducing the targeted care bundles and the reduced mortality. A randomised trial design was not
practical in this clinical situation. However, the significant reduction in mortality occurred only at the site where the
care bundles were predominantly used....it occurred in the year in which they were introduced, starting in the month
of introduction....it occurred for the targeted diagnoses and not for the non-targeted diagnoses."
Discussion
from R Resar, Institute for Healthcare Improvement
Healthcare processes
Be disruptive
109
Doing what we do today, better
Creating what we will do tomorrow
DisruptiveSustaining
(Comfort Zone) (Risk Taking)
Spectrum of Innovation
"Leaders can adopt ideas that have worked elsewhere, but they need to create their own
one-of-a-kind change model through experimentation, learning, blue-print creation and
most of all a strong focus on results"
Bate, Mendel, Robert et al. 2008
Set a bold ambition
Healthcare That Is Safe is defined by our Clinical Excellence goal The care we deliver will be safe and effective. We commit to having excellent clinical care with no preventable injuries or deaths by July 2008
1
Two steps from an ‘expert improver”
Leadership
• Every patient, every time – checklists?• Behaviour – ties?• Hierarchy – first names?• Competence – improvement science?
114
It is not the strongest of the species that survive, nor the most
intelligent, but the ones most
responsive to change.
Charles Darwin
Who is the best in the world at this?
Be person-centred
Don Berwick, Health Affairs 2009
Patient and family councilsFeedback and action
Be transparent
Source:British Airways (NPSA adapted)
British Airways air safety reports, 1994-99 Total reported events
Total events
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1994 1995 1996 1997 1998 1999
High/medium risk events
0
20
40
60
80
100
120
140
Number of reported events: high and medium risk
http://tinyurl.com/ihi-scae
“We trained hard ... but it seemed that every time we were beginning to form up into teams we would
be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency,
and demoralization.”
Gaius Petronius Arbiter (27–66AD)
Kotter’s Eight Steps for Successful Large Scale Change
• Increase urgency• Build a guiding team• Get the vision right• Communicate for buy-in• Empower action• Create short-term wins• Don’t let up• Make change stick
How will you know you’ve achieved anything?
Panel Discussion…
www.t-coe.org.uk