Questions to be answered today

• How do we define Quality in healthcare?

• What is Quality Improvement?

• HOW CAN WE IMPROVE QUALITY?

• How can we ensure that "change" is really an improvement?

• What tools and approaches can we use to promote successful improvement/change?

The safety paradox

Healthcare staff are:Highly trained & motivatedCommitted to their patientsUse sophisticated technology

Errors are common and patients are frequently harmed

VideoHow safe is your care?

Potentially an average of 7,300 patients per year per trust suffer an adverse event …

Double Decker bus seats 73 people…

100 bus loads of patients per year per trust …

Nearly 2 bus loads per week per trust

Safety in Acute Hospitals

Adverse Events

• Due to healthcare management rather than to the underlying disease

• May or may not be preventable

• Effect 8-12% of hospitalised patients (one or more adverse events)

• Older people are particularly vulnerable

• Voluntary reporting systems are poor at measuring adverse events but useful for learning about vulnerabilities

Epidemiology of harmStudy Authors Date of admissions Number of hospital

admissionsAdverse event rate

(% admissions)

Harvard Medical Practice Study (HMPS)

Brennan et al, 1991; Leape et al, 1991

1984 30195 3.7

Utah-Colorado Study(UTCOS)

Thomas et al, 2000 1992 14052 2.9

Quality in Australian Health Care Study(QAHCS)

Wilson et al, 1995 1992 14179 16.6

** United Kingdom Vincent et al, 2001 1999 1014 10.8 **

Denmark Schioler et al, 2001 1998 1097 9.0

New Zealand Davis et al, 2002 1998 6579 11.2

Canada Baker et al, 2004 ???? 3745 7.5

France Michel et al, 2007 2004 8754 6.6% per 1000 days admission

** United Kingdom Sari et al, 2007 2004 1006 8.7 **

Spain Aranaz-Andre et al, 2008 2005 5624 8.4

The Netherlands Zegers et al, 2009 2006 7926 5.7

Sweden Soop et al, 2009 2006 1967 12.3

Clinical information available in hospital outpatient clinics

Prescribing for hospital inpatient

Equipment availability in the operating theatre

Equipment available for inserting peripheral intravenous lines

Copyright ©2008 BMJ Publishing Group Ltd.Vincent, C. et al. BMJ 2008;337:a2426

Changes in rates for 9 AHRQ derived patient safety indicators.Hospital Episode Statistics 1996-7 to 2005-6 (England)

Trends in rates of patient harm: United States

Landrigan et al, NEJM 2011

How can we improve quality?

Leaders who understand and use QI techniques (e.g. MFI, Lean)

Quality Improvers who have Leadership skills

Leadership

QI skills

Understanding why things go wrong

Concepts for Safety & QI

Reliability

Variation (lack of)

Relative risk of death from intestinal obstruction (not hernias) by hospital

in one SHA

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 210

20

40

60

80

100

120

140

160

180

Relative Risk

Relative Risk

Safety climate by hospitalSafest

Least safe

“Use of drug X by GP practice”“Referrals to OPD with GI symptoms”

QI requires CHANGE

Will

Ideas

Execution

Get a small group of interested people together

Learn about different contributions to the system or service

Analyse and understand current system

Continue to learn and improve

Look at ideas for how things might be different

Test ideas and experiment with different ways of working

♦ Improved service♦ Improved

understanding of how things work

♦ More control over work

♦ Better outcomes and experience for patients

. .

Our Improvement Framework…

COLLABORATIVES

MEASUREMENT

Running monthly average (per

1000 risk days)

Days between!

Measurement video

100%

80%

86%

57%

57%

83%

94%

Sepsis is an EMERGENCY!

100%

80%

86%

57%

57%

83%

94%

Sepsis Run Charts

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100

Observations Recorded M

ed

ian

(%)

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100High flow O2

Med

ian

(%)

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100Blood Cultures taken

Med

ian

(%)

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100

IV Fluids M

ed

ian

(%)

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100

Antibiotics within 1 HR

Media

n (

%)

Mar-1

2

Apr-1

2

May-1

2

Jun-

12

Jul-1

2

Aug-1

2

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

2

Jan-

130

20

40

60

80

100

Serum Lactate

Media

n(%

)

SepsisRun Charts

100%

80%

86%

57%

57%

83%

94%

ED (early) management of sepsis% compliance

ED (early) management of sepsis% compliance

ED (early) management of sepsis% compliance

Ventilator Care Bundle Compliance

Steps taken by one UK site to reach 95% compliance

Feedback

VAP Rate

Quarterly running average

Start > 9 VAPS/1000 vent days

End < 2 VAPS/1000 vent days

Process MappingStroke: assessment, imaging, thrombolysis

Patient telephones 999

Ambulance arrives at home

Ambulance leaves home

Paramedics pre-alert stroke team

Hospital

Registration

Bed in Resusitation Area

Process Mapping

Nursing Staff

IV placement

ECG

Monitor Hook up

Vital signs monitoring

Blood glucose

Blood tests

Weight estimate

Process Mapping

Clinical Assessment

History

Medication

Allergies

Identification Of Witness

Time of Onset/when last well

Witness difficult to locate?

Process Mapping

Clinical Assessment

NIHSS

Neurological Examination

Lab samples - FBP/ PT/UE

Transport of blood to labs

Process Mapping

Imaging

Bed to CT Scanner

Disconnect monitor

CT Scan

CT Report

Transport from CT – Stroke Unit

Reconnect Monitor

Process Mapping

Drug Preparation

Calculate dose

Prepare TpA

Give bolus

Start Infusion

Bundle of Care

Parallel v Serial Process for clinical assessment

ED Doctor

History

Meds/Allergies

Order CT Scan

Medical Registrar

NIHSS Stroke Scale – on-line training

Neuro Examination

Bundle of CareNursing staff in Ed asked to defer ECG

Medical staff reminded to stay with patient and assist with transport of patient to CT Scanner

Near Patient testing

Training of Reception staff in recognition of stroke symptoms

MD check list – responsiblity of nursing staff- ed and stroke,responsibilty of medical staff Ed and medical registrar.

PDSA 6

CT radiographer live in October 2012

1 3 5 7 9 11

13

15

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25

27

29

32

34

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56

58

60

62

64

66

68

70

72

74

76

78

80

0

20

40

60

80

100

120

140

Goal

CT scan (within 45 mins)

Bundle

1 3 5 7 9 11

13

15

17

19

21

23

25

27

29

32

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40

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62

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66

68

70

72

74

76

78

80

0

20

40

60

80

100

120

140

160

180

200

Median

Goal

Bundle

Door to needle time (within 60 mins)

THE M and M GAME

OR

How to run a PDSA Cycle

Act • What changes are to be made?• Next cycle?

Study• Complete analysis of data• Compare data to predictions• Summarise what was learned

Do• Carry out the plan• Document problems and unexpected observations• begin analysis of data

Plan• Objective• Questions and predictions (why?)• Plan to carry out the cycle• Plan for data collection

To Be Considered a PDSA Cycle

The test or observation was planned (including a plan for collecting data)

The plan was attempted

Time was set aside to analyze the data and study the results

Action was rationally based on what was learned

The M&M Challenge Aim – to be left as few M&Ms as

possible at the end (?only 1)

Measure – number of M&Ms left

Operational definitions:

DO NOT EAT THE M&Ms Leave one blank circle on game sheet Jump one marker over another and remove marker that is jumped over Each round lasts 1 minute

2

1

3

654

10987

1514131211

STEP 1: Plan

Objective: To test (another)approach to removing pegsPredictions: Will we leave fewer pegs?Plan: Who, what, record moves

STEP 2: Do

• Carry out the plan• Record moves• Note problems or changes to plan

STEP 3: Study

• Compare data to predictions• Summarise what was learned• Update the team’s theory (approach)

STEP 4: Act

• Does our approach leave 1 peg?• If not what new ideas should we test on next cycle?

PDSA FOR THEPEG (M&M) GAME

IN SUMMARY:

What we are told to do

What we think we should do

Behaviour

Rules and Regulations

Culture

Behaviour

Safety brings its own dangersThe price of safety is chronic unease

‘First of all, I was not in a position to challenge on the basis of my limited experience of this type of treatment. Second, I was an SHO (junior doctor) and did what I was told to do by the Registrar. He was supervising me and I assumed he hadthe knowledge to know what was being done. Dr M. was employed as a registrar ... in a centre for excellence and I did not intend to challenge him’.

Reliability of ward care

(1) How well do you understand the goals of care for this patient today?

(2) How well do you understand what work needs to be accomplished to get this patient to the next level of care?

Less than 10% of nurses or doctors could answer these questions

Pronovost et al, 2003

Team

Six things all Trust Boards should do

Setting Aims: Set a specific aim to reduce harm this year – a public commitment to measurable quality improvement

Getting Data and Hearing Stories: Review progress toward safer care as the first agenda item at every board meeting, grounded in transparency, and putting a “human face” on harm data.

Establishing and Monitoring System-Level Measures: Identify a small group of organization-wide “roll-up” measures of patient); keep up to and make transparent to the entire organszation and users.

Changing the Environment, Policies, and Culture: Commit to an environment that is respectful, fair, and just – for all those touched by avoidable harm/poor outcomes.

Learning… Starting with the Board: Learn how “best in the world” boards work to reduce harm. Expect such training for all staff.

Establishing Executive Accountability: Oversee the execution of harm reduction plan; include executive team accountability.

How do we know organisations are safe?

Reflect on yourown experiences of health care . . .

What was good?What was bad?What made you angry?What upset you?

“To the typical physician, my illness is a routine incident in his rounds while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity. I just wish he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”

Anatole Broyard

The A B C Dof dignity-conserving care

Chochinov BMJ 2007; 335: 184-187

ABC

D

Chochinov BMJ 2007; 335: 184-187

ttitude How would I feel if I was this patient?

Inappropriate assumptions?- poor quality of life; ageism; social acceptability; malingering;

Is my attitude towards the patient biased by my own experiences, anxieties, or fears?

Does my attitude towards being a healthcare provider help or hinder an empathic professional relationships with patients?

People who are treated like they no longer matter will act and feel like they no longer matter

A

ehaviourB

Chochinov BMJ 2007; 335: 184-187

Respect

Small acts of kindness

- simple comfort measures; acknowledging a photo;

Permission to examine

Acknowledge inconvenience and discomfort

Discussion after patient dressed

Good communication skills

“You, as a person, are worthy of my care and attention”

ompassionC

Chochinov BMJ 2007; 335: 184-187

Extending care beyond the intellectual level

Developed and shaped by life experience

Something that we feel

Awareness of suffering and a wish to relieve it

Non-physical communication

ialogueD

Chochinov BMJ 2007; 335: 184-187

Formal psychotherapeutic approaches

Getting to know the patient

- hobbies; family; beliefs; previous exposure to illness; what is important in their life

Acknowledging fear, distress

Identifying significant others who can support

VideoCleveland Clinic

The secret of the care of the patient is in caring for the patient

Dr Francis Peabody 1927