BC Provincial Perioperative Improvement Program

Proposal Presentation & Discussion

BC ProvincialPerioperative Improvement Program

Panel Members

Margi Bhalla, Director, Surgical Services, Ministry of Health – Provincial Surgical Advisory Committee Co-Chair

Andy Hamilton, Medical Director, Surgical Services, Interior Health Authority – Provincial Surgical Advisory Committee Co-Chair

Dermot Kelly, Director, Medical Administration & Surgical Services, Vancouver Coastal Health

Felicia Laing, Project Manager, Quality & Patient Safety, Vancouver Coastal Health Peter Blair, Program Medical Director, Surgery, Fraser Health Susann Camus, NSQIP Quality Improvement Consultant, Fraser Health Adrian Leung, Executive Lead, Specialist Services Committee, British Columbia Medical

Association Marlies van Dijk, Director, Clinical Improvement, BC Patient Safety & Quality Council

Agenda

Background and program proposal Margi & Andy – 5 minutes The Productive Operating Theatre

Overview & Experiences Dermot & Felicia – 10 minutes Comprehensive Unit-Based Safety Program

Overview & Experiences Peter & Susann – 10 minutes Coaching Team Marlies – 5 minutes Discussion & Questions All – 30 minutes

Background

The Provincial Surgical Advisory Council (PSAC) was established in 2009 to inform the strategic direction of surgical services in BC

Perioperative Improvement Sub-Group formed following release of BCMA’s ‘Enhancing Surgical Care in BC – Improving Perioperative Quality, Efficiency and Access’ Developed multi-year master plan for improvement in the perioperative

environment Provincial OR inventory and identification of provincial indicators underway Front-line initiatives to address common barriers to perioperative

improvement

Provincial Team &

Project Manager

Expert Trainer

Extended Site Team

Core Site Team

Core Site Team

Extended Site Team

Core Site Team

Exte

nded

Site

Tea

m

Core Site Team

Extended Site Team

Proposed Provincial Program Overview

• Provincial coaching team – trained experts provide support to sites

• Sites – selected based on demonstration of patient safety oriented culture, readiness for project, clear plan to commit local resources, identified measurable goals


Provide comprehensive support for sites to implement a quality improvement methodology

Support could include: Module materials Provincial project management Funding clinical time QI methodology expert consultation (e.g., Maggie Morgan-Cooke, Dr. Liza Wick)

1-2 face-to-face meetings Coaching team site visits Coordinated peer support


Provincial team will receive training and provide support to sites Could include representatives from program sites and from sites across the

province using other improvement methods (e.g. LEAN) as well as others who are interested

Method to be chosen by site, and could include: Productive Operating Theatre (TPOT) Comprehensive Unit-Based Safety Program (CUSP) “Building Local Expertise” Coaching Model LEAN or other QI methodologies

The Productive Operating Theatre Overview

Toolkit 2 overview guides 11 modules Module materials:

Handbooks & DVDs Planning & evaluation tools

Primary concerns: Quality and efficiency

The Productive Operating Theatre Experience (Dermot & Felicia)

• Felicia and Dermot

RT2C Education

February 2013

VCH Lean Education

The Productive Ward ExperienceReleasing Time to CareVancouver Coastal Health

NHS productive series

Modules: based on Lean thinking

• Leadership support• Foundational modules for sustaining improvements

Productive operating theatreProductive ward

• Set of modules designed to guide you through the processes • Efficiency guidelines to achieve significant and lasting

improvements, thereby allowing extra care time for patients• Tested and proven to be successful in many health care

settings:– Ontario, Manitoba, BC– US, CareOregon– UK, Sweden, European countries– Australia, New Zealand

Aim: to improve 4 key dimensions of quality

• Understand what is happening now• Display measures on a board• Use huddles on performance to drive improvement• Regularly update information

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Releasing Time to Care/Productive Ward

Improvements

Process Action Change

Shift report •From 45-60 min to 15 min per shift report•Earlier vital signs assessments•On time patient readiness for meals•On time meds admin

67%

Wait time to DI •Wait time in hallway range 1 to 38 min•Porter now helps ready patient – no wait time

100%

Admission kits •Pre-assembled patient supplies•From 73.5 min to 4 min per week•Dedicated time admitting patient•Dedicated time getting handover report

95%

Meal trays •Delivery time changed to offset staff breaks•More time for patients to eat, food is warm

Interruptions •From 15.8 to 10.0 per hour•189 interruptions per shift reduced to 120•General staff queries, patient status

37%

• Staff-led data collection and audits• Daily huddles around data board

Falls: Improvement actions and resultsPatient Safety & Reliability of

care

May Jun July Aug Sept Oct Nov Dec Jan 2013

Feb Mar Apr May Jun Jul Aug Sep 2013

# Falls (Safety Cross) 10 6 8 1 5 5 12 9 4 1 3 5 6 4 6 5 4

1

3

5

7

9

11

13

Number of patient falls

Goal: To reduce falls by 50% by Dec 2013 to two falls per month.

-Risk assessment on admission

-Families pamphlet on fall prevention-Motion-sensored lights in all rooms-LOM on white boards

-Yconnectors with each bed alarm-Safety checks qshift

-Regional rollout Falls Prevention Program

Falls: projected cost-avoidance

• The three target wards could reach a cost avoidance of $

802,134 by reducing their falls by 50 %

• 560 Bed Days could be prevented due to an extended

length of stay (LOS)

• Assumption (1,2): Total extended LOS for serious falls 34 days;

Extended LOS for minor falls 5 days

Projection Analysis

What if we are reaching the goal of reducing falls by 50%?

Patient Safety & Reliability of

care

1 CIHI, National Trauma Registry Analytic Bulletin Hospital Costs of Trauma Admissions in Canada, 2000/2001.

2 Estimating the Cost of Serious Injurious Falls in a Canadian Acute Care Hospital Zecevic A., et al.. Canadian Journal of Aging Volume 31, Number 2 (2012), p. 139-147.

2012Reduced by 50 %Number of minor falls per year (30% RH; 54% SGH) ) 88 44Number of moderate and severe harm falls (10% RH; 5% SGH) 20 10Costs (minor harm); $ 11,254 per case1 $ 990,348 $ 495,174 Costs (moderate and severe harm); $ 30,696 per case2 $ 613,920 $ 306,960

Total $ 1,604,268 $ 802,134

Cost Avoidance $ 802,134

Bed Days minor falls1 440 220Bed Days moderate and severe harm falls2 680 340

Total Bed Days 1120 560

Bed Days Avoided 560

Patient experience – 3S Richmond

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Patient Experience

In general, during your hospital stay, did you feel treated with respect and dignity?

Were you well informed of your condition or treatment approach by your at-tending health care team?

Did you notice that the staff wash or disinfect their hands prior and after car-ing?

Do you feel confident with your current discharge plan and support outside the hospital?

0% 20% 40% 60% 80% 100%

92.9%

71.4%

85.7%

75.0%

87.7%

71.4%

77.4%

47.6%

Acute Care Patient Experience 2012 - % positive score (October 2011 - March 2012)

3 South Patient Feedback - % of positive responses (Dec 2012-Jan 2013)

Patient experience – Squamish

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Patient Experience

During this hospital attendance/stay did you feel you were treated with dignity and respect?

Did you have good opportunity to participate in the decisions that applied to your care?

Did the doctors, nurses or other staff give your family or someone close to you all the information needed to help you during your stay

or treatment?

Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

Were you provided with the equipment you needed to go home with?

0 10 20 30 40 50 60 70 80 90 100

100.0%

96.6%

89.7%

96.4%

100.0%

Acute Care Patient Experience 2012 SGH Patient Feedback

Staff unplanned absence- Squamish

Background• Staff well being has been shown to

impact absence rate

• Identified high rate of unplanned on the unit

• Safety cross was used to bring awareness to the unit.

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Staff Well-Being

Nov 2012

Dec Jan 2013

Feb Mar April May Jun 2013

0

2

4

6

8

10

12

14

Unplanned absences – Day shift

Num

ber o

f Unp

lann

ed A

bsen

ces

“This is the first time in my 30 years of nursing where I've seen frontline staff get involved with any quality improvement. I really believe that this

will work and will be sustainable.”

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“Since our unit has a lot of issues, and we know its potential, it inspired a lot of conversations [..].It made us more vocal and involved, and gave us a platform to speak with Allied Health.”.- Staff Nurse

Comprehensive Unit-based Safety Program (CUSP) at Royal Columbian

Hospital

Dr. Peter Blair, RCH Surgeon Champion & FH Surgery Medical Director

Susann Camus, NSQIP Quality Improvement Consultant

October 28, 2013

CUSP at Royal Columbian Hospital 24

Purpose of CUSP

• Strategic framework for improving patient safety

• Integrates communication, teamwork, and leadership to create and support a culture of patient safety

• Provides frontline staff with the tools and resources to improve quality

October 28, 2013


CUSP’s Beginnings• First applied in more than 100 Intensive Care Units in Michigan

in 2003• 5 evidence-based procedures recommended by CDC to reduce

Central Line Associated Site Infections (CLABSI): hand hygiene, full-barrier precautions, Chlorhexidine gluconate skin cleansing, avoiding femoral site, minimizing use of Foley catheters

• Results: Reduced CLABSI rates by 67% within 3 months• Saved more than 1,500 lives and $200 million in the first 18

months• Expanded to other settings & more types of preventable

infections.

October 28, 2013


Five Steps: Using CUSP to Reduce SSIs

1. Staff educated on the science of safety2. Staff complete patient safety culture assessment3. Senior hospital executive partners with unit to improve communications and educate leadership4. Staff learn from unit defects 5. Staff use tools such as checklists to improve teamwork, communication, collaborationOctober 28, 2013


Learning from Defects

Defect = any clinical or operational event or situation that you would not want to happen again. 1) What happened?2) Why did it happen?3) What did you do to reduce the risk?4) How do you know that risks were reduced?

October 28, 2013


Two Questions

1. Ask staff two questions:

a) How is the next patient going to get an SSI on this unit?

b) How can we prevent this from happening?

October 28, 2013


SSI Bundle & Results

1) Standardization of skin prep and use of chlorhexidine wash cloths

2) Mechanical bowel prep with oral antibiotics3) Patient warming4) Enhanced sterile technique5) Antibiotic timing and dosage33% reduction in SSIs$168,000 - $280,000 cost savings per year at 1 site Source: Wick et al., 2012 Implementation of a Surgical Comprehensive Unit-Based Program to Reduce Surgical Site Infections, JACS 2012:215(2), Aug 2012.October 28, 2013


CUSP Participating Sites

• Ronald Reagan UCLA Medical Centre, Los Angeles

• New York Hospital of Queens, Flushing• Mills Peninsula Health Services,

Burlingame• Saint Elizabeth Medical Centre, Utica• The Ottawa Hospital, Ottawa• Royal Columbian Hospital, New

WestminsterOctober 28, 2013


CUSP at RCH

1. Safety Attitudes Questionnaire showed ample room for improvement in RCH safety culture

2. RCH was invited to join CUSP

3. Steering Team assembled

4. Defects were identified and prioritized through safety assessments

October 28, 2013


Results of 1st Safety Assessment

October 28, 2013


OR Traffic Audit

• 8 cases observed over 614 minutes• Average case was 77 minutes (35-134

min)• Doors swung open 354 times, or 44.25

times per case (18-101 times)• Doors were open 19% of the time,

disrupting air flow in the OR

October 28, 2013


Normothermia InitiativeReviewed charts of PACU surgical patients, recorded their temperature (pre, intra, post op) and type of procedure after 2 days in April 2013, 5 hours per day:

October 28, 2013


Results of 2nd Safety Assessment

October 28, 2013


Next Steps for RCH

• Document CUSP process, share tools• Confirm executive support & commitment• Get team on a regular meeting schedule

(e.g. every two weeks)• Identify potential quick win (scrubs

storage?)• Post notes, SSI rates, all documentation

every month, and prominently for OROctober 28, 2013

Surgical Provincial Coaching Team

Safety Climate – 14 BC Hospitals75 surgical units - 2012

Perceptions of Local Management14 Hospitals – 75 BC surgical units - 2012

Risk of Failure

Potential Problem• 6 months after project lose

the improvements• Long term sustainability

• Leaders behave the same as before project

• Systemic changes not made

End Goal• Improvements held

• Improvement sustained

• Leaders are on the units doing walk rounds and using visual display boards and participate in huddles

• Identification and change in systems/tactics

Training and Commitment

• Coaching Team Training (2 face to face meetings and monthly webex training over 24 months)

• Expert Led – tentative: Allan Frankel, Ontario Coach Support and others

• Identify are of need! (using local data)• Co-create a local plan which aims at improvement at a system

wide level/organizational goals• Attendance to at least 2 site visits (other Transformation sites)

over the duration of 2 years

Who can Join?

• Up to two people from each site that is participating

• Total up to 20 people

Discussion & Questions

Next Steps

For more information on the Provincial Perioperative Improvement Program, please contact:

Margi Bhalla250 952 1040

[email protected]

Andy Hamilton250 870 4778

[email protected]

BC Provincial Perioperative Improvement Program

Health & Medicine

Transcript of BC Provincial Perioperative Improvement Program