Symposium 8 - BAPEN...Clinical audit is a quality improvement process that seeks to improve patient...
Transcript of Symposium 8 - BAPEN...Clinical audit is a quality improvement process that seeks to improve patient...
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Symposium 8 How to Succeed in Audit
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5 year Audit Data on ‘MUST’:
How Audit has Targeted Practice
Dr Sorrel Burden
Lead Dietitian/ Research Fellow
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Introduction
Screening has been recommended by the following reports:-
• Food and Nutritional Care in Hospitals
• Nutrition Support in Adults
• Patient Environment Action Teams Assessment
• Quality Care Commission
• Essence of Care Benchmarking for Food and Drink
• Quality Care Commission
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Aim of Audit
• To evaluate the implementation of MUST on 32
wards over 3 hospital sites
Objectives
• Determine the rate of nutrition screening within
24 hrs of admission
After 7 days
• Audit recording of weight, height & BMI
• Identify low, medium and high risk malnutrition.
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Method
• ‘MUST’ was implemented in July 2006.
• 850 ward nurses by 14 dietitians & 2 NNS.
• Jan 2007-Mar 2011 screening rates were audited.
• 1 week every month.
• NLN collected data using standard form
• Submitted electronically for collation to Audit Department
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Audited Standards
• Screened within 24 hrs of admission.
• Screened weekly thereafter.
• Weight, height & BMI should be
recorded.
• Action plan should be followed for all
identified at risk of malnutrition.
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Wards submitting data 2007-2011
0
10
20
30
40
50
60
70
80
90
100
2007 2008 2009 2010 2011
no. wards
% wards
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Number of patients audited
2007-2010
Number of patients audited 2007-2010
17, 836 patients over 5 years
0
1000
2000
3000
4000
5000
6000
7000
8000
No. patients
2007 2008 2009 2010
Year
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Screening rates at 24hrs & 7 days
0 50 100
2007
2008
2009
2010
2011
year
% of patients
7 days
24 hrs
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High & moderate risk of Malnutrition
0
5
10
15
20
25
30
35
2007 2008 2009 2010 2011
Year
% patients 24 Hours
7 days
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Recorded weight, height & BMI
0
20
40
60
80
100
2007 2008 2009 2010 2011
year
% p
atie
nts
weight
height
BMI
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Screening 2007-2010
'MUST' screening incidence January 2007 - October 2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-07
Mar-0
7
May
-07
Jul-0
7
Sep
-07
Nov
-07
Jan-08
Mar-0
8
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-09
Mar-0
9
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-10
Mar-1
0
May
-10
Jul-1
0
Sep
-10
Nov
-10
Months
Perc
en
tag
e o
f p
ati
en
ts
Screened with 24
hours of admission
Rescreened within
the previous 7 days
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Recording of components of ‘MUST’
Elements of 'MUST' recorded (those rescreened within the previous 7 days) 2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Janu
ary
Feb
ruar
y
Mar
chApr
ilM
ay
June Ju
ly
Aug
ust
Sep
tembe
r
Octob
er
Nov
embe
r
Dec
embe
r
Months
Pe
rce
nta
ge
of
pa
tie
nts
% of patients with recorded BMI.
% of patients with a % weight loss recorded.
% of patients with acute disease effect recorded.
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MUST >2 (2008-2010)
Incidence of scoring 2 or more on 'MUST' screening tool
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
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
Months
Perc
en
tag
e o
f p
ati
en
ts
24 hours of
admission
Within the last
7 days
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Why ‘MUST’ was not completed?
• Emergence surgery
• Short stay assessment units/ETU
• Transfer of patients
• Application of the disease severity score if weight & heights not recorded
• Poor compliance with screening tool in some areas
• Amputees and BMI
• Confusion & dementia patients
• Rapid discharges within 24-48hrs
• Pre-selecting patients for screening by ward staff ‘eye ball assessment’
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Incidence of malnutrition on admission (scores one or more) 2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
January February March April May June July August September October November December
Months
% o
f p
ati
en
ts Low risk (score zero)
Moderate risk (score 1)
High risk (score 2 or more)
Screening not completed
Admission score (2010)
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Scores at >7 days (2010)
Incidence of malnutrition (scores one or more) at > 7 days - 2010
0%10%20%30%40%50%60%70%80%90%
100%
January
February
March
April
May
June
July
August
Sep
tember
October
November
December
Months
Percen
tag
e o
f p
atien
ts
Low risk (score
zero)
Moderate risk
(score 1)
High risk (score
2 or more)
Screening not
completed
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Risk category 24 hours screen
(7,312 pts)
7 days screen
(5,235 pts)
moderate 438 471
high 950 1465
Moderate & high 1388 1936
Numbers of patients
(one audit week/12 months 2010)
Dietetics Dept -2,736 nutrition support referrals
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Moderate risk
22 pts
High risk
33 pts
Care plan followed 12 (54) 17 (51)
Food charts completed 14 (63) 19 (58)
Weekly weights 16 (72) 19 (58)
Referred to dietitian - 19 (58)
Actions completed from 100
patient’s care plans audited
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Comparison with national survey data
(2010)
BAPEN
2010
7 Days
CMFT
24 hrs
CMFT
Moderate 14 9 6
High 21 19 13
Moderate &
high
34 28 19
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Conclusion
• Continual audit has allowed areas in the hospital to be
targeted for specific training.
• Affect of training on screening rates has been
monitored.
• Modern Matron round (Jan 2009) increased the use of
‘MUST’ at ward level improved rates of screening.
• Audit has assisted in identifying the reasons for
missing data.
• Developed net work of Nutrition link Nurses at ward
level
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Conclusion cont:
• Helped change the ward culture
• Embedded screening into ward based practice
• Engaged senior nurses in screening programme
• Assisted introduction of ‘MUST’ into pre-operative clinics (ERAS protocols)
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Work still to be done
• ‘MUST’ in outpatients patient self
assessment.
• ‘MUST’ care plan development and audit
• QCC report.
• Maintenance of screening programme is a
dynamic process.
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Acknowledgments
• Mrs Ruth Brierley Nutrition Nurse
Specialist
• Department of Nutrition and Dietetics
• Nutrition Link Nurses on all the wards
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References
1. Council of Europe. (2003) Food and Nutritional Care in Hospitals: How to Prevent Undernutrition. Nutrition Programmes in Hospitals Group for the Committee of Experts on Nutrition, Food & Safety and Consumer Health. Strasbourg: Council of Europe.
2. National Collaborating Centre for Acute Care. (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guideline 32, London: National Collaborating Centre for Acute Care.
3. National Patient Safety Agency (2010) Patient Environment Action Team Assessment. National Patient Safety Agency, London.
4. Department of Health (2010) Essence of Care Benchmarking for Food and Drink. Her Majesty’s Stationery Office, United Kingdom.
5. Westergren A, Wann-Hansson C, Bergh Börgdal E, Sjölander J, Strömblad R, Klevsgård R, Axelsson C, Lindholm C Ulander K,. (2009) Malnutrition prevalence and precision in nutritional care differed in relation to hospital volume – a cross-sectional survey Nutrition Journal 8: 1-8
6. Russell C & Elia M., (2008) Nutrition Screening Survey in the UK in 2008. British Association of Enteral and Parenteral Nutrition
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Measuring quality of nutritional care through audit:
Developing a national clinical audit of Essence of Care
(Food and Nutrition)
Emma Parsons MNutr RD
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Clinical Audit
“Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria.
Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery”
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The commission
• A one year development plan to consider how a national clinical audit relating to Essence of Care – Food and Nutrition could be undertaken
• In health and social care settings
• To reflect the requirements of the Department of Health’s Nutrition Summit Stakeholder Action Plan
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Objectives • To define the types of organisations
• To identify:
– The process and outcome criteria – The data collection methods
• To carry out a pilot audit
– Testing the feasibility of the audit tools
• To consider: – How the data should be analysed – To consider how the results should be fed back to
participating units
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Audit standards
• Standards were produced based on: – National guidance
– Input from the project advisory board
• Covered both health and social care
• Feedback on the standards was sought from: – Project team
– Project advisory board
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Essence of Care - Food and Drink Agreed person-focussed outcome (2010):
People are enabled to consume food and drink (orally) which meets their needs and preferences
Factors Promoting health Environment
Information Screening and assessment
Availability
Planning, implementation, evaluation and revision of care
Provision Assistance
Presentation Monitoring
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Supporting Guidance
The Nutrition Action Plan, (DH, 2007)
Nutrition Support for Adults, (NICE, 2006)
From Malnutrition to Wellnutrition: Policy to practice, (ENHA, 2006)
Essential Standards of Quality and Safety, (CQC, 2010)
Dignity Factors: Eating and Nutritional Care, (SCIE, 2010)
Managing food waste in the NHS, (DH, 2005)
Patient Environment Action Team Assessments, (NPSA, 2010)
Meeting quality standards in nutritional care, (BAPEN, 2010)
National Service Framework for Older People, (DH, 2001)
Still Hungry to Be Heard, (Age UK, 2010)
10 Key characteristics of good nutritional care, (NACC, 2010)
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Project Advisory Board • Key national organisations
• High level practitioners, patient, resident & carer groups
Key nutritional themes
Process and outcomes Communication
Nutritional care Transfer of care
Food service and delivery Personalised approach
Workforce
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Audit Tools
• Tools were produced based on the audit standards:
– Organisational
– Staff
– Patients’ / Residents’ experiences
– Patients’ / Residents’ records
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Pre – audit feedback on audit tools • Feedback on the audit tools was sought from:
– Project team
– Project advisory board
– Lambeth and Southwark care home support team
– District general hospital’s nutrition team
Hospitals
• Organisational
• Ward
• Staff
• Patients’ experiences
• Patients’ records
Care homes
• Organisational
• Staff
• Residents’ experiences
• Residents’ records
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Pilot Sites
Hospitals (n=3) Care Homes (n=4)
Teaching (1) Residential (1)
District Generals (2) Nursing (1)
Dual Registered (2)
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Contact with Pilot Sites
June 2011 Contact made via telephone, email
June-July 2011 Initial meeting with managers
July 2011 Ethical approval granted (KCL ethics)
August 2011 Pilot audit started
November 2011 Pilot audit completed
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Pilot Audit
• All sites provided with a ‘master pack’ – Instruction sheet
– Information sheets
– Audit tools
• All audit tools were available on the project website
• Audit tools were collected by researchers as sections of the audit were completed
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Number of completed audit tools
Hospitals Care homes Total
Organisational 3 4 7
Ward 6 6
Staff 85 36 121
Patients’ / Residents’ experiences
78 74 152
Patients’ / Residents’ records
69 105 174
Total number of completed forms = 460
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Co-ordination of the Pilot Audit • Communication with sites during the audit
• Use of GANTT charts to record progress
• Updates during audit:
– Newsletters
– Website (www.kcl.ac.uk/nutrition-audit)
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Resource Implications
• Production of audit packs
• Who should complete audit tools?
– Nurses
– Dietitians
– Other?
• Computer Access
• Returning completed audit tools
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Practical Constraints
• Time period for the audit
• Time to produce copies of audit materials
• Availability of staff to complete the questionnaires
• Selection of staff, patients and residents
• Consent
• Interruptions
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Results – Organisational Level
Present at all sites All sites use ‘MUST’
Hospitals: weekly Care homes: monthly
Hospitals: Staff ask patients Care homes: All record preferences
Hospitals: Use red tray systems
Care homes: Encourage staff and
family to assist
Nutrition Policy
Screening Tool
Needs and Preferences
Assistance with meals
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Staff Training: Hospitals
0102030405060708090
RGN Healthcare Assistant
Sufficient Training
Pe
rce
nta
ge
Malnutrition Screening Assistancen=84
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Staff Training: Care Homes n=36
0
20
40
60
80
100
RGN Senior Carer Care Assistant
Pe
rce
nta
ge
Malnutrition Screening Assistance
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Patients’ & Residents’ Characteristics Patients (n=69) Residents (n=105)
Age (y) 60.4 ± 21.0 79.9 ± 10.8
Gender 50% male, 50% female 42% male, 58% female
05
101520253035
Dementia Diabetes Stroke CVD Cancer
Pe
rce
nta
ge
Patients Residents
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Prevalence of Malnutrition
0
5
10
15
20
25
30
35
Medium High At Risk
Pe
rce
nta
ge
‘MUST’ Category
Hospitals Care Homes
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Use of Screening Tools & Care Plans
0102030405060708090
Screened Care Plan Specific Goals
Patients Residents
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Patients’ & Residents’ Experiences
Patients Residents
Asked about weight loss 27% 48%
Asked about food & drink preferences
26% 80%
Meal service explained to them 33% 81%
24hr Access to drinking water 99% 100%
Able to store food 63% 63%
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Summary
• Clinical audit is an important tool in improving care for patients and residents
• Audit design should take into consideration:
– Setting
– Time
– Types of audit tools
– Data collection methods
– Feedback to participating centres
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Acknowledgements
Project Team at KCL
Project Advisory Board
All participating pilot sites
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Translating Audit Into Improvement
Dr Emma Donaldson
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Aims
• A structured approach to clinical improvement
• Using data for improvement
• The importance of variation
• Making change and designing for reliability
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• Identifies current performance against agreed standards
• Identifies areas of underperformance that require improvement
• Provides assurance that standards are being achieved
• Identify reasons for underperformance
• Identify interventions which will result in improvement
• Correlate audit results and changes implemented
What audit does and does not do
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MAKING IMPROVEMENTS IN CLINICAL SERVICES
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If you always do what you have always done, you will always get
what you have always got.
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The Model for
Improvement
Improvement from current audit position to attain / exceed gold standard care
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AIMS
• S - specific
• M - measurable
• A – attainable (but challenging!)
• R - realistic
• T – time limited
95% patients, admitted to general medical wards, to receive a MUST assessment within 6 hours of admission by April 2011.
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A Driver Diagram
• Reinforces the aim statement as the goal
• Clarifies the big picture
• Identifies primary system components
• Aids in development of measurement
Most importantly: Helps teams to articulate their contribution to the overall aim and avoid missing important system components
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MUST completion
within 6 hours for 95% of
admissions to L2, L3, L8
Education & leadership
Process standardization
Patient/Carer involvement
Measurement
Ward nurse training Nutritional link nurse Dietitian review
Purple paper work=nutrition MDT meal ward rounds Catering involvement
Relative input at meal time Patient preferences Breakfast Club
MUST compliance (EPR) MUST Accuracy
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Question 1 - summary
• Have a SMART aim
• Use a driver diagram to conceptualise change
• Avoid focussing on one driver
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The Model for
Improvement Data!
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Why are we measuring?
Research Judgement Improvement
Aim New knowledge Achieve a target Improve a service
Testing strategy One large test No tests Sequential tests
Sample Size “Just in case” data Obtain 100% of available, relevant data
“Just enough” data
Hypothesis Fixed hypothesis No hypothesis Flexible hypothesis
Variation (Bias) Design to eliminate unwanted variation
Adjust measures to reduce variation
Accept consistent variation
Is change an Improvement?
Statistical tests No change focus Run charts or Shewhart control charts
Source: Robert Lloyd IHI 2006
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Limits of Descriptive Statistics
Average Before=8 hours delay Average After=3 hours delay
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Data for Improvement
• Time series • Multiple small datasets • “Real time” • Annotated with changes
tested Ave Days Wait for Colonoscopy
80
90
100
110
120
130
140
150
160
Jan
06
M M J S N J-
07
M M
Av
e D
ay
s
Match demand/capacityConfirmation
Wk backlog
% Patients Waiting for Colonoscopy < 90 Days
30
40
50
60
70
80
Jan
06
M M J S N J-
07
M M
Percen
t
Match demand/capacityConfirmation
Wk backlog
• Demonstrates variation in the system
• Ownership
• Motivate front-line staff
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Data for Improvement
• Outcome Measures
– The “big dot”
• Process Measures
– Shown to contribute to the outcome
– Will see changes before the big dot moves
• Balancing Measures
– Avoid unforeseen consequences
• Identify variation in the system
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Understanding variation
• The outcome of every process is affected by lots of little things
• Each of these little things varies naturally
• All these little variances add up
• This makes the process vary over time
Time to first dose antibiotics in pneumonia
Wait to see doc Time to get
CXR Time to XR
review Time to
prescription Time to draw up
Time to admin
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0
50
100
150
200
250
1 2 3 4 5 6 7 8
Antibiotic drawn up
Antibiotic prescribed
Xray seen
Xray
Porters
Order Xray
Clerk/exam
See doc
0
50
100
150
200
250
1 2 3 4 5 6 7 8
0
5
10
15
20
25
30
Common Cause Variation
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• A system can also be affected by a big, unusual influence
• The size of the change produced is BIG in relation to the common cause variances
• It happens much less frequently than the common cause variances
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0
50
100
150
200
250
300
350
400
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Antibiotic drawn up
Antibiotic prescribed
Xray seen
Xray
Porters
Order Xray
Clerk/exam
See doc
Major Incident
Special Cause Variation
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Question 2 - Summary
• Ensures that the changes are actually improving the system
• Show that the improvements are being sustained
• Motivate staff to continue testing changes and make improvements
• Prove that improvements are occurring (even before the “big dot” moves!
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The Model for
Improvement
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EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS THAT IT GETS
Paul Batalden
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Obstacles to making change
1. More of the same
“This would not be a problem if we had more….” people, money, resource x, etc.
2. Utopia syndrome
Trying to identify the perfect change before doing anything at all – paralysis by analysis
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Two Types of Change
• Reactive (first order) – Keep the system running – Solve or react to problems – Return system to prior condition – Trade off among measures – Short term
• Fundamental (second order) – Create a new system – Design or redesign – Necessary if you are to improve beyond problems – Impacts several measures – Long term
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The PDSA Cycle Plan • What are you going to test? • What do you predict will happen? • Develop the test (Who? What? When? Where? Data?)
Do • Try out the test on a small scale • Observe & document results
Study • Analyse data • Study the results • Compare results & predictions
Act What will you do next? • Adapt • Adopt • Abandon
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Why test change before implementing it?
• It involves less time, money and risk
• The process is a powerful tool for learning; from both ideas that work and those that don't
• It is safer and less disruptive for patients and staff
• Because people have been involved in testing and developing the ideas, there is often less resistance
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Multiple PDSA Cycle Ramps
Primary Drivers
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• “Human beings are fallible” • “They make mistakes even when they’re trying to do
the right thing and even when they think they’re doing the right thing.”
• He estimates that, in health care delivery, a defect
(error / omission / other failure to accomplish an intended action) occurs, on average, 10 to 20 percent of the time
• This compared to .0001 percent of the time for airlines and nuclear power plants
Roger Resar, MD, Senior Fellow at the Institute for Healthcare Improvement (IHI)
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The Critical Question
“Why, with all the good intentions and talent available in medicine, are clinical processes backed by solid medical evidence carried out at such low
levels of reliability?” • Few people come to work with the intention of
performing poorly
• Although the system may be defective, this answer may not be particularly helpful in detailing how to improve the clinical processes
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IHI’s Learning:
• Current improvement methods in health care are excessively dependent on vigilance and hard work
• The current practice of benchmarking to mediocre
outcomes in health care tends to give clinicians and leaders a false sense of process reliability
• A permissive attitude toward clinical autonomy
creates and allows for wide, and unjustifiable, performance variation
• Processes are rarely designed to meet specific,
articulated reliability goals
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Improvement Concepts to get you to 80–90% reliability
• Common equipment, standard order sheets, multiple
choice protocols, and written policies/procedures
• Personal check lists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training
(Primarily can be described as intent, vigilance, and hard work – basic failure prevention, identification and mitigation)
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Improvement Concepts to get you to 95% reliability
• Decision aids and reminders built into the system
• Desired action the default (based on scientific evidence)
• Redundancy utilised
• Habits and patterns known and taken advantage of in the
design
• Standardisation of process based on clear specification and
articulation is the norm
(Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation)
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Question 3 - summary
• Not all change will result in improvement so changes must be tested first
• Multiple tests can take place simultaneously
• Hard work and vigilance, although commendable, are not good design principles
• If 95% reliability change concepts do not make up at least 25% of the improvement effort on a given project the team should rethink the design
• Education & awareness alone are not enough!
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Key points
• Good audit vital for assurance
• Identifies areas for improvement efforts
• Need to undertake further investigation to explain why a system is underperforming
• Making change requires a similarly robust framework to be successful
• Using data is key to improvement efforts
• Test changes before implementing
• Design for reliability
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Thank you