Boards on Board

Don Berwick

• Put the patient first

• Put the vulnerable first

• Start at scale

• Give the money back

• Act locally

“The tendency exists to argue that the science of improvement may be a lesser way of knowing,

because it concerns itself primarily with a wide range of applications in uncontrolled

settings; that is, the real world as we find it every day”

Rocco Perla

Moving beyond safety

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.

• 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.

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

Three Part Problem...

• Improve Individual Experience

• Improve Population Health

• Control Inflation of Per Capita Costs

The Triple Aim

Evidence based medicine Evidence based care delivery

17 years to get 14% of evidence into practice

“Conquering the world on horseback is easy: it is dismounting and governing that is hard”

Genghis Khan

“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

Outcome Aims

• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days

between• Central Line Bloodstream Infection: 0 or 300 days

between• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in

range• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction

HSMR

Hospital Standardised Mortality Ratio

Scotland – 8.4% reduction in HSMR

0.5

1.0

1.5

Oct-Dec2006

Apr-Jun

2007

Oct-Dec2007

Apr-Jun

2008

Oct-Dec2008

Apr-Jun

2009

Oct-Dec2009

Apr-Jun

2010

Oct-Dec

2010p*

Apr-Jun

2011p

Sta

ndar

dise

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Rat

io

0.5

0.8

1.0

1.3

1.5

Oct-Dec2006

Jan-Mar2007

Apr-Jun

2007

Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

2010

Jul-Sep2010

Oct-Dec

2010*

Jan-Mar

2011p

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ndard

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0.5

0.8

1.0

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1.5

Oct-Dec2006

Jan-Mar2007

Apr-Jun

2007

Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

2010

Jul-Sep2010

Oct-Dec

2010*

Jan-Mar

2011p

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dard

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tality

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io

0.5

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1.5

Oct-Dec2006

Jan-Mar2007

Apr-Jun

2007

Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

2010

Jul-Sep2010

Oct-Dec

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0.5

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Oct-Dec2006

Jan-Mar2007

Apr-Jun

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Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

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Jul-Sep2010

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0.5

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Oct-Dec2006

Jan-Mar2007

Apr-Jun

2007

Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

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Jan-Mar2007

Apr-Jun

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Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

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Jul-Sep2010

Oct-Dec

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HSMR results 2008-2011

Scotland level results

Central line infection rate (per thousand line days)

0

2

4

6

8

10

12

Jan-

08

Apr-0

8

Jul-0

8

Oct-08

Jan-

09

Apr-0

9

Jul-0

9

Oct-09

Jan-

10

Apr-1

0

Jul-1

0

Oct-10

Jan-

11

Apr-1

1

Jul-1

1

March 2011:zero central line infections

in whole country

VAP rate (per thousand ventilator days)

02468

101214161820

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep

-08

Nov

-08

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep

-09

Nov

-09

Jan-

10

Mar

-10

May

-10

Jul-1

0

Sep

-10

Nov

-10

Jan-

11

Mar

-11

May

-11

Jul-1

1

9.11

3.49

62% reduction

% ICU mortality

10

12

1416

18

20

2224

26

28

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep

-08

Nov

-08

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep

-09

Nov

-09

Jan-

10

Mar

-10

May

-10

Jul-1

0

Sep

-10

Nov

-10

Jan-

11

Mar

-11

May

-11

Jul-1

1

18.2%

15.7%

14% improvement

General ward C.Difficile rate(per thousand patient days)

0

0.5

1

1.5

2

2.5

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep

-08

Nov

-08

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep

-09

Nov

-09

Jan-

10

Mar

-10

May

-10

Jul-1

0

Sep

-10

Nov

-10

Jan-

11

Mar

-11

May

-11

Jul-1

1

1.18

0.14

88% reduction

How has the frontline done it?

• Get goals.• Get bold.• Get together.• Get a model (and

stick with it)• Get patients and

families

• Get the facts.• Get to the field.• Get a clock.• Get the numbers.• Get the stories.

How has NHSScotland done it?

Policy Leadership Execution

Structure Process Outcome

Donabedian, A.

Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment.1980.

Having the best professionals in the world

is no longer enough

© 2010 Institute for Healthcare Improvement

To build a sustainable infrastructure that produces highly reliable QI excellence

by (fill in the date).

How good? By when?

The Capacity and Capability Aim

© 2010 Institute for Healthcare Improvement

Who needs to be developed?

Governance?Executives?Managers?

Supervisors?Front Line Workers?

Improvement Advisors (IAs)?

Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006

© 2010 Institute for Healthcare Improvement

√

How many quality experts do we need?

Two suggestions for determining this number:

Number of employees

Or…consider that no employee should be more than 2 steps (individuals)

away from a QI expert.

Where next?

• Sepsis/VTE• Paediatrics• Primary care• Mental health• Maternity

• Person-centred care• Early years

1941, William A. Foster

"Quality is never an accident; it is always the result of high

intention, sincere effort, intelligent direction and

skillful execution; it represents the wise choice of

many alternatives.”