The big picture for improvement:•Making systems more reliable•Linking innovations in service delivery with new technologies•Involving and engaging staff

Hugh RogersAssociate, Service Transformation30th September 2005

• NHSU

• Leadership Centre

• Modernisation Agency

• National Innovation Centre

• Delivering Quality & Value• A No Wait system• Primary care & LTCs• HealthCare Associated Infection

Agreed programme

priorities

Service Transformation

Product & Technology Innovation

(NIC)

Leadership Learning

Agreed programme

priorities

Service Transformation

Product & Technology Innovation

(NIC)

Leadership Learning

The NHS Institute for Innovation and Improvement

The Goal: towards reliable healthcare

• No needless delay

– Treat me quickly and appropriately

• No waste

– Use the resources we give you to greatest effect

• No feelings of helplessness

– Treat me with respect and empower me

• No needless suffering

– Give me effective treatments and relieve my pain

• No needless deaths

– Protect me and heal me

• No inequity

– Treat me fairlyAdapted from ‘Crossing the Quality Chasm’, Institute of Medicine 2001

What is reliability?

• “The capacity to perform a given function under given conditions for a specified period of time”

• A reliable health care system is one that is designed to ensure that every patient consistently receives evidence-based, effective care every time he or she needs it.

• An important outcome of reliability would be patient and public confidence in the NHS

“Reliability means keeping a promise” (Don Berwick)

Measuring reliability

Reliability

Approach to achieving reliability

10-1 Intent, vigilance, hard work

10-2 DesignDesign informed by reliability science and human factors

10-3 or more

Design of Highly Reliable Organisations (HROs)

Technical solutions (After Nolan & Weick)

Compare Reliability and Safety

Safety• Errors of commission• special cause strategies• reactive• focused projects

Reliability• Errors of omission• common cause strategies• proactive• creation of reliable systems

When failure has high impact

Current Reliability

• Good people working hard will not be able to overcome the complexities of today’s systems of care to prevent errors

• Studies show that human beings make errors– Misreading errors 3 in 1000– Omission in the absence of reminders 1 in 100

(BMJ March 18 2005 Tom Nolan)

• NCEPOD report on critical care (May 2005) shows:– 27% of hospitals have no early warning system

– 44% of hospitals have no outreach service– 66% of admissions to ICU were unstable for >12hrs (in hospital >24hrs)

– 25% were not reviewed by consultant intensivist in first 12 hrs

– ICU care ‘less than good’ in 47%

– Deficiencies may have contributed to death in 11%

10 High Impact Changes

High Impact Changes # 3 #4 and #6

3. Manage variation in patient discharge thereby

reducing length of stay

4. Manage variation in the patient admission

process

6. Increase the reliability of therapeutic interventions

through a “care bundle” approach

Principles of improved reliability

• Understand why LOS varies so much– Benchmarking can help– Variation partly due to variation in clinical care

• Establish what care processes need to be standardised to achieve more consistent LOS

• Put in place systems whereby this care becomes the default (care bundles)

• Establish failsafe mechanisms

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Delivering Quality & ValueSystems & Operational Levels

PATIENT PATHWAY

PATIENT PATHWAY

PATIENT PATHWAY

PATIENT PATHWAY

OPERATIONAL LEVELS

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IMPROVING CLINICAL & SERVICE QUALITY WHILE CONTROLLING COSTS

System level Performance targets Financial balance Variation in Practice

Operational level Productivity & efficiency

variation Poor benchmarking

Focus on improving and standardising core clinical processes

Lean principles to reduce waste and apply best practice

Hip replacement

Lower quartile – 10 daysUpper quartile – 8 daysTop 10 performance – 6.3 days

If all trusts moved to perform like the top 10 the NHS would save £48.6 million p.a.

LOS for Fractured Neck of Femur

Variation in LOS for different types of hospital

Lower quartile – 19 daysUpper quartile – 13 daysTop 10 performance – 8 days

Potential saving £81.4 million p.a.

Stroke

Potential saving £74.3 million p.a.

Variation in LOS for Caesarian Section

Potential saving £49.1 million

Initial focus for HRGs - episodes

50 HRGs account for 50% of all Finished Consultant Episodes

Cumulative % FCEs by HRG 2003/04 for England

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10%

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1 101 201 301 401 501 601

HRGSource : HES

% A

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How can we improve flow?

• Ensure access to a bed

– Smooth out elective flow

• Expedite simple discharges (across the week and within the day)

– Set the discharge date at admission

– Patient tracking to record what needs to be done

• Make optimum care the default

– Standardise care bundles, build in reliability

• Maintain decision making throughout the week

– Delegation of authority every day

– Nurse led discharge

• Getting systems right to achieve discharge

– Pharmacy, transport, external partnersMedical patients

Length of stay by days - April to July 2002

Note: average LOS = 7.24 days

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NumbersdischargedLength of stayA&E

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AdmitPresents at A&E

NumbersdischargedLength of stayA&E

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AdmitAdmit

Defining the optimal clinical process

• High volume, high variance clinical groups– Cost, LoS, Staff, Supplies etc.

• Study high and low performance• Identify defining characteristics of high performing

processes• Field test principles• Design and package for NHS

Potential gain for the NHS with the top 50 HRGs:

£1,500,000,000 (approx)

Win! Win! Win!

Improving and standardising care processes:

– Reduces LOS

– Reduces staff stress

– Improves clinical outcomes• Readmissions

• HCAIs

But also:

Hogarth’s take on clinical variation

Mortality vs Reference costs

Hospital standardised mortality rates by reference costs

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Reference costs 2002

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Source: ‘Pursuing Perfection’ programmeNo relationship between cost and mortality

Applying systems thinking to mortality

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UCL Median Weekly deaths LCL

Some specific interventions

• Reliability in wards – observations – recognition – responsiveness [hospital at night -> hospital 24/7?]

• Critical Care Outreach services and ‘Crucial care’ rounds

• Eliminate medical outliers

• Eliminate unnecessary delay – access to specialist, higher level care, tests etc

• Hospital Infection: ‘Saving Lives’ change package

• High risk medications

• Decision, planning and diagnostics on admission

Blackburn Hospital

Daily Medical Outliers Blackburn

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Nov 2003 - April 2005

Indiv

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Special Cause Flag

non-elec weekly deaths 2003-2005

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101520

2530

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Special Cause Flag

May ‘04

Culture for improvement

Changing culture

• Leadership strategies for openness and mindfulness

• Measurement demonstrating change is an improvement

• Staff capability – team working – communication up hierarchies

Measuring reliability in Luton

Mortality Project Improvement All observations 'complete'from monthly case note reviews

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• Observations on wards improving• New focus on responsiveness• Testing colour banded EWS and response algorithms• Looking at models of outreach / medical emergency teams• Focus on increase uptake of ALERT training by doctors

The Potential for technology

• Frimley Park

• Portsmouth

• Sydney

3 NHS Trusts (Pursuing Perfection), trends of annual HSMRs

80

85

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95

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105

110

115

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

HS

MR

(95

% C

Is)

3 NHS Trusts, original Community of Practice

295 ‘lives saved’ since April 2004

High Impact Change # 6Increase the reliability of therapeutic interventions through a “care bundle” approach

• Example for reducing ventilator associated pneumonia:

– Elevating the head of the bed >30o (Drakulovic 1999)

– DVT prophylaxis (Cook et al 2001)

– Peptic ulcer prophylaxis (Yang & Lewis 2003)

– Managing sedation effectively with sedation Holds (Kress 2000)

– Tight Control of Blood glucose 4.4-6.1 mils (Van den Berghe 2001)

• Can be applied to

• Surgical site infection

• Central line management

• Myocardial Infarction

• etc etc

West Middlesex Hospital

West Middlesex Hospital

Reducing LOS at West MiddlesexGuess when the new hospital opened?

New Hospital Opened

May 2003

Reducing Mortality at West MiddlesexFrom 1.2 to 0.93 = ~25%

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New Hospital Opened

May 2003

Conclusion

By increasing the reliability of clinical care we could:

• Save 10,000 Lives per year

• Save £1.5 billion per year

• The 10 High Impact Changes are just a start

• We can only achieve this by changing our organisations and educating our staff