Senior Leadership and Direct Service Providers Team Up for Improving Patient Care November 6, 2006...

Senior Leadership and Direct Service Providers Team Up for Improving Patient Care

November 6, 2006Phil Hassen, Dr. Peter Norton, and Dr. Ward Flemons

Campaign To Continue Beyond December 2006

Moving forward with implementation, spread and measurement beyond December 2006

Phil Hassen, CEO Canadian Patient Safety Institute

Campaign Structure

Partner Network

Peer SupportNetwork

CAPHC

Measurement Working Group & CMT Education & Resource

Working Group

Clinical Support

Canadian ICU Collaborative

ISMPCanada

Operations

Teams

Other Canadian Faculty

Communication Working Group

Atlantic

NodeOntario

Node

Western Node

Campaign SupportSHN National Steering Committee

Secretariat - CPSI

Patients

CCHSA CIHI

Quebec

Node

IHI

Teams Continue to EnrollSaferhealthcare Overview Total # Enrolled Teams

September 2005 to November 2006

118

296

403443

491

535

0

100

200

300

400

500

600

Total # of Teams EnrolledTeams

Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Oct-06

Safer Healthcare Now! Enrollment by Province & Territory

Province/Territory Number of Teams

New Brunswick 23

Newfoundland 13

Nova Scotia 46

Prince Edward Island 0

Quebec 9

Ontario 240

Alberta 51

British Columbia 98

Manitoba 36

Northwest Territories 1

Saskatchewan* 17

Yukon 1

Total 535As at November 2, 2006

Push Towards December 2006Why?

• Measurement and reporting are integral to demonstrating at the local, nodal and national levels that it is possible to achieve and sustain improvements in the safety of patients within the Canadian health system.

*64.1% of enrolled organizations across Canada have submitted their data to the Central

Measurement Team.

Goal:• Broaden the Campaign’s reach and impact later next

year through the incorporation of new interventions that impact other healthcare settings in addition to acute care.

Pan-Canadian Survey• Purpose:

• Determine how many teams intend to submit data by December 2006

• Identify key challenges/barriers that maybe hindering teams

• Use the feedback to develop a targeted campaign of support strategies to assist teams

• Response rate - ~ 41% (156 respondents, representing 208 teams)

Pan-Canadian Survey Results

• Lack of time/resources for data collection 86.2%

• Lack of staff engagement 41.5%

• Lack of internal QI knowledge and technical skill to submit measurement forms 30.8%

• Other (e.g. insufficient population base, ongoing resource challenges) 29.8%

• Insufficient senior management/clinical leadership support 21.2%

Top 5 barriers/challenges identified by teams:

Pan-Canadian Survey Results

• Workshops (e.g. hands on sessions with concurrent tools & data collection, spread strategies) 82.6%

• Tools to facilitate internal communication (e.g. aimed at Senior management, front line staff) 63.8%

• Teleconferences (e.g. spread strategies, including internal QI capability) 60.9%

• More information on the Community of Practice (e.g. sample concurrent data collection tools) 39.1%

• Facilitate access to the Safety Improvement Advisor 30.4%

Top 5 Responses to: “which resources would you find helpful?

Phil Hassen

Canadian Patient Safety Institute

Suite 1414, 10235 – 101 Street

Edmonton, AB T5J 3G1

(780) 409-8090 or 1.866.421.6933

For additional information please contact:

Debbie Barnard, SHN Project Manager @ [email protected]

www.patientsafetyinstitute.ca

http://www.patientsafetyinstitute.ca/

A story – SSI in the Calgary Health Region

Dr. Peter Norton

University of Calgary

SSI – Calgary Health Region

• 3 adult urban acute care sites

• Antibiotic timing project not sustainable

• Focus on total joints to begin

• Correct timing tended to be 30% or less

• Process measures vs. outcome measure

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aug n=12 Sept n=7 Oct n=13 Nov n=19 Dec n=20 Jan n=25 Feb n=175 Mar n=237

Per

cent

t

Target

27%

0%

92%

84%

90%88%

93%95%

Month

'On Time' Antibiotic - All Total Joints PLC - Calgary Health Region

'If you cannot MEASURE it, you

cannot IMPROVE it'.

Lord Kelvin, International Electrotechnical Commission’sfirst President (1906)

How good is our health care system?

What is the “Defect Rate”?

Key Numbers from the Canadian Adverse Events Study

• The overall AE rate found in the study was 7.5% [CI 5.7 -9.3] – this means 1 in 13 adult hospital patients in year 2000 experienced an AE

• 2.8% of patients had one or more preventable AEs [CI 2.0 – 3.6] (i.e. 37.3% of AEs are preventable)

• Preventable AE rates were the same across the 3 hospital types

• An estimated total of 1.6% of people hospitalized in Canadian hospitals in 2000 had an AE and died [CI =0.9 to 2.2%] or approximately 16,000 per year [CI= 9250 to 23, 750]

• Assuming an average LOS of 3.5 days and 95% occupancy, then a 500 bed Canadian hospital would have an average of 100 preventable AEs per month

Defect rate of 25%+

Health Quality Council of Saskatchewan, 2004

Ambulatory Care

• In 2004 Manitoba researchers lead by A. Katz used administrative data in a study

• They measured the proportion of eligible patients received 13 types of recommended care in the Winnipeg Health Region

• Only 37% of diabetics saw on ophthalmologist or optometrist the last year

• Only 35% of patients with a 30-day supply of anticoagulants who at least one blood clotting test in 45-daysA. Katz, et. al. Using Administrative Data to Develop Indicators of Quality in Family Practice. Winnipeg: Manitoba Centre for Health Policy, 2004. http://www.umanitoba.ca/centres/mchp/reports/pdfs/quality_wo.pdf

What do the Citizens say?

• 2004 Commonwealth Fund International Health Policy Survey in Australia, Canada, New Zealand, the United Kingdom, and the United States

• Adults

• 1400 per country and 3061 in the UK

Schoen C, et. al. Primary care and health system performance: Schoen C, et. al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood). 2004 adults' experiences in five countries. Health Aff (Millwood). 2004 Jul-Dec;Suppl Web Exclusives:W4-487-503.Jul-Dec;Suppl Web Exclusives:W4-487-503.

Rank 1 is best, 5 is worst

Australia

CanadaNew

ZealandUK US

Patient Safety 2.5 4 2.5 1 5

Patient-Centerednes

s2 3 1 5 4

Timeliness 2 5 1 4 3

Efficiency 1 4 2 3 5

Effectiveness 4.5 2.5 2.5 1 4.5

Equity 2 4 3 1 5

Slide from Don Berwick August 2005

The Goal is Clinical Effectiveness

• "The best possible Health Care"

• An environment where all patients can consistently say:

• "I got exactly the care I was in need of exactly when I needed it!"

Clinical Effectiveness- Definition

Evaluating and improving health care delivery and enhancing patient outcomes through the collaborative application of best available clinical evidence

Identifying the most appropriate, ethical and cost-effective means of providing health care services

Compliance-Driven Quality Management

• Reactive in nature• Designed to meet standards• Clinicians often not engaged in process• Clinician leadership not essential• Indicators become the goal• Difficult to sustain clinical improvement over

time & across organization

Patient-Centered Clinical Effectiveness

• Proactive in nature• Evidence-based foundation• Clinicians actively engaged in process• Clinician leadership critical to success• Best and safest care as the goal, indicators as

markers of success• Sustainable improvement over time and across

organization

Achieving Clinical Effectiveness

“This time, like all times, is a very good one, if we but know what to do with it”

- Ralph Waldo Emerson

Safer Healthcare Now!

• Implementation of six targeted and proven interventions in hospital based patient care

• Credible evidence that these six interventions can make a real difference in reducing avoidable adverse events and lead to reduced mortality and morbidity

• All are ‘low tech’

The Interventions

• Deployment of Rapid Response Teams

• Delivery of reliable, evidenced based care for acute myocardial infarctions

• Prevention of ADEs

• Prevention of central line infections

• Prevention of surgical site infections

• Prevention of ventilator- associated pneunomia

Eg. Surgical Site Infections

• Four specific activities– Don’t shave the skin but clip the hair– Make sure prophylactic antibiotics are given

(and stopped) on time– Carefully monitor and control the blood sugar

during the operation– Carefully monitor and control the body

temperature during surgery

Key Campaign Principles

• “Some is not a number; soon is not a time.”

• Welcome anyone at any level.

• We do this together (i.e. we are forming ‘communities of practice’)

Some successes

• Several organizations with no VAP for six months

• Several pediatric hospitals with no CL infections for six months

• Early indications of reduced mortality in the ICUs of several hospitals

Why Participate in SHN?“To not participate is not an option, It is not about spending additional

health care dollars, rather it is about our obligation to provide a safe clinical experience for the patients who walk through our doors and put their trust in us.” David Rowe, Senior Vice-President, Credit Valley Hospital, Ontario.

“The SHN has provided us with leadership and coordination of the interventions. As well, there has been excellent information sharing and collaboration with those participating in the interventions within and across the nodes.” Kim Cook, Vice-President of Patient Services & Chief Nursing Officer, Headwaters Health Care Centre, Alberta.

Organizational Leadership & Accountability

W. Ward Flemons MD FRCPC FACP

Vice-President

Quality, Safety & Health Information

Strategy for Quality

Quality Assurance Quality Improvement

StructuresProcesses

Every system is perfectly designed to produce the results that it gets.

If you want improved results you must redesign the system.

Paul Batalden / Don Berwick

SAFETY FRAMEWORK

ORGANIZATIONAL STRUCTURE

LEADERSHIP / ACCOUNTABILITY

RESOURCESCULTURE· REPORTING· J UST (TRUSTING)· LEARNING· FLEXIBLE

Copyright © 2005 Calgary Health Region

POLICIE

S & P

ROCEDURESCOMMUNICATION & EDUCATION

SAFETYMANAGEMENT

HAZARD· IDENTIFICATION· ANALYSIS· RECOMMENDATIONS

PERFORMANCE· MEASUREMENT· EVALUATION· RESEARCH

SYSTEMI MPROVEMENT· STRATEGIES / DESIGN· TESTING· IMPLEMENTATION

QUALI TY FRAMEWORK

ORGANIZATIONAL STRUCTURE

LEADERSHIP / ACCOUNTABILITY

RESOURCESCULTURE· REPORTING· J UST (TRUSTING)· LEARNING· FLEXIBLE

Copyright © 2005 Calgary Health Region

QUALITYMANAGEMENT

OPPORTUNITY· I DENTIFI CATI ON· ANALYSIS· RECOMMENDATIONS

PERFORMANCE· MEASUREMENT· EVALUATI ON· RESEARCH

SYSTEMIMPROVEMENT· STRATEGI ES / DESI GN· TESTING· I MPLEMENTATION

Quality Management Cycle

QUALITYMANAGEMENT

OPPORTUNITY· IDENTIFICATION· ANALYSIS· RECOMMENDATIONS

PERFORMANCE· MEASUREMENT· EVALUATION· RESEARCH

SYSTEMIMPROVEMENT· STRATEGIES / DESIGN· TESTING· IMPLEMENTATION

Safer Healthcare Clinical Process Improvement Designing for Higher Reliability

OUTCOME

Process Process Process Process Process Process

Process Process Process Process Process Process Process Process Process Process Process Process


Improved AMI Care Clinical Process Improvement Designing for Higher Reliability

AMI MORTALITY

ASA on Admission

Reperfusion(PCI / Thrombolysis)

ASA at Discharge

β Blocker at Discharge

Smoking Cessation

Counseling /Rx

ACE or ARB at Discharge(LV Dysfunction)



Reliability – Improving Performance Measured as the inverse of failure rate

10-1, 10-2, 10-3, 10-4, 10-5, 10-6

Example: Reliability of administering prophylactic antibiotics in surgery

Nolan T, Resar R, Haraden C, Griffin F. 2004Improving the Reliability of Health Care. IHI Innovation Series White Paper

Three Step Model1. Prevent failure

• a breakdown in operations or functions

2. Identify and mitigate failure• identify failure and intercept before harm or mitigate harm

3. Redesign• processes based on the critical failures that are detected

Three Step Model

Prevent Failure 10-1 Performance• starts with an intent to follow a uniform process or guideline

• basic standardization – common equipment / order sheets / guideline• memory aids (e.g. checklists)• feedback mechanisms (e.g. compliance with standards)• awareness raising and training

Identify & Mitigate Failure 10-2 Performance (error proofing)

• building decision aids into the system

• creating redundancy / using defaults• designing protocol into the usual workflow process• strategies to identify failures to use the process ‘Identification Trigger’• design mitigation strategies

Redesign 10-3 Performance• analysis of failures to use the standard care protocols• where is it failing and why? (failure modes and causes)• cycle of continuous quality improvement• real time measures of performance & accountability

Do Healthcare Organizations need a QI Strategy?

Where does QI fit into the agenda? Should be strategic (it’s core business)

Not off the side of someone’s desk Executive & Board Accountability

Needs to be resourced Needs to have strong leadership

Understanding of the concepts Top-down QI doesn’t work Bottom-up QI can have some short-term success Model of engagement

Sharp end (Direct Care Providers) MULTIDISCIPLINARY! Blunt end (Management)

To improve quality

document continuous improvement

(process steps)

(outcomes)

eliminate inappropriate variation

Brent James

QUALITYIMPROVEMENT

STRATEGYPERFORMANCE MEASUREMENT

BUDGETING(PBMA)

INDICATORS

QUALITYIMPROVEMENT

STRATEGY

PERFORMANCE MEASUREMENT

BUDGETING(PBMA)

INDICATORS

STRATEGIC

PERFORMANCE MEASUREMENT

Improving Quality Clinical Process Improvement Designing for Higher Reliability

What Clinical Outcomes? Gap analysis (low hanging fruit)

Solid evidence about what could (should) happen What is currently happening?

What Clinical Processes? Solid evidence about impact on outcomes

Who Decides? Clinicians who understand evidence based care Management who sign the cheques

Improving Processes Outcomes Medication Reconciliation Acute Myocardial Infarction Surgical Site Infection Ventilator Associated Pneumonia Central Line Infection

Structures Outcomes Rapid Repsonse Teams

Setting Priorities

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

From:: Associates in Process Improvement

QI Projects - Accountability Executive Sponsor – CEO / VP Medical / VP

Acute Care / Exec Director Planning & Evaluation Can send a strong message of the importance of this project to the

organization Follow outcome and process measures

Administrative Sponsor Direct accountability for the results of this care Director / Chief of Cardiology

Project (Team) Lead Understanding of QI / Change Management Understanding of the clinical context Leadership skills

Project members Reps from all disciplines that are involved in the processes

Example – Improved Care for AMI Executive Sponsor

CEO / VP Medical & VP Acute Care Adminstrative Sponsor

Chief of Medicine / Cardiology Director of Medicine

Project Lead PCM / APCM of Cardiology unit / CCU

Project Team members MDs – Internist / Cardiologist / Emerg Nursing – Emerg / Medicine Pharmacist Unit Clerk EMT Discharge Coordinator Patient Educator

Example – Improved Care for AMI What are you trying to accomplish?

Reduce AMI 30 day mortality by _____ % Improve the reliability of 6 clinical processes

How will you know that a change is an improvement? 30 day mortality

Define & collect data for the numerator/denominator

Reliability of (Percentage of patients receiving) Components - Delivering each of the 6 components of care Composite – delivering all components

What changes can you make that will result in improvement? Change package AMI Getting Started Kit

Accountability – Measures over TimeAMI 30 Day Mortality Rate

0

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Accountability – Measures over TimeReliability - ASA on Admission

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1st Test Cycle

2nd Test Cycle

VAP – outcome & process measures

Getting Focused Accountability

Place the measures in the Corporate Scorecard

Commit to an improvement target (be bold) Put into Performance Agreements

CEO BoardVPs CEODirectors / Dept Heads VPs

Organizational Risks

Understanding (or lack thereof)

How to implement a QI agenda QI tools Time commitments (People / Organization)

Expectation of quick wins Viewed as ‘flavour of the month’ Leadership (or lack thereof)

Executive Quality Improvement

Senior Leadership and Direct Service Providers Team Up for Improving Patient Care November 6, 2006...

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