Welcome to the Inaugural Event

3 February 2011

1630 hours

Sandy Watson, OBE, DLChairman

NHS Tayside

John ConnellDean

University of Dundee

Gerry MarrChief Executive

NHS Tayside

Welcome and Opening Remarks

Responding to the Quality Challenge

Derek FeeleyActing DG Health and Social Care

Chief Executive NHSScotland

I’ll cover

• Nature of the challenge• Lessons from patient safety• Implications (and a reason for you to celebrate)

Building from a strong base

Really good people too

4 Improvement Aims• Health (prevention and anticipation)• Healthcare Quality• Value (i.e. quality/cost)• Integration

Six Dimensions of Quality

In this for the long haul…Patients want speedy treatment and quick access to care, but they want more than that. They also want a health service that is compassionate and treats them with dignity; they want to see real partnership between clinicians, patients and others; they want services to be provided in a clean and safe environment; they want hospital food to be good; they want continuity right though their journey of care; and, of course, they want to have confidence in the quality and effectiveness of any treatment.Achieving all that for every patient, every time that they use the NHS, is what the quality strategy is all about. At its heart is a simple but very ambitious aim: to make the NHS in Scotland a world leader in the quality of health care services that it delivers.That aim is not just good for patients, it is also right for staff. There is real enthusiasm across the NHS for the quality strategy—something that I would be the first to accept cannot always be said about Government initiatives.

Nicola Sturgeon, Scottish Parliament 13/5/10

Potential for political consensus?I welcome the opportunity to discuss the NHS quality strategy and I congratulate the Scottish Government on introducing it. I find little to disagree with in the document and I am sure that that view will be shared among members across the chamber. We all want safe, clinically effective and person-centred treatment, which is at the heart of the quality strategy. We all want Scotland to become a world leader in the delivery of health care. It is right that we should continually strive to improve our delivery of services and the outcomes that we achieve for people throughout the country.The ambition is right, and I am sure that the cabinet secretary will acknowledge that achieving that ambition will be dependent on leadership at all levels of the NHS, shared ownership of the objectives and, of course, partnership with staff, patients and carers. All that will be critical if we are to achieve change on the scale that is required and to begin to meet the objectives and take the direction of travel that the strategy sets out.

Jackie Baillie MSP, Scottish Parliament 13/5/10

What patients see as high quality healthcare?

• caring and compassionate health services;

• collaborating effectively with clinicians, patients and others;

• confidence and trust in health services;• providing a clean and safe care

environment;• improving the access to care and continuity

of care;• delivering clinical excellence

The perfect storm? Where values and expectations align

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.

• Clinically 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.

Quality Outcome Measures• Care Experience• Staff Engagement and Potential• Healthcare Associated Infection• Emergency Admission Rate/Bed

Days• Adverse Events• Hospital Standardised Mortality Rate• Under 75 mortality rate• Patient Reported Outcome Measures

(PROMs)• Self-assessed general health• Percentage of time in the last 6

months of life spent at home or in a community setting

4 ways to deliver public services (LeGrand 2007)

But……….% Annual Real Growth Rate in Scottish DEL Budgets

•IFS predictions – Dec 2009

•Reflects current use of EYF

International comparisons of quality and cost

A contribution to the business case?

www.phc4.org – hospital data for 2007

The impact of variation in chronic care

NHS Scotland’s Integrated approach to Quality and Value

• Reduce harm, error and re-work (Safe)• Mutuality and Co-production (Person-

Centred)• Increase reliability and reduce variation

(Effective)

It’s complicated….

Too bad all the people who know how to run the country are busy driving cabs and cutting hair.

-- George Burns

But it can be done!

" i am so proud to be a nurse"........i just want to get

back to work ....get on and  do something"

LS7 participant

If I had shown you the following results in January 2007 would have believed

them possible?

5% reduction in HSMR

73% reduction in central line infections

43% reduction in ventilator associated pneumonia

72% reduction in critical care c.diff

14% increase in ward hand hygiene

58% decrease in ward c.diff

Kotter’s Eight Steps for Successful Large Scale Change

• Increase urgency• Build a guiding team• Get the vision right• Communicate for buy-in• Empower action• Create short-term wins• Don’t let up• Make change stick

More from those smart people at IHI

So, putting all of that together…

• Need goals and aims• Need to influence/create the operating

environment • Need capacity to deliver/execute• Need to do better than the status quo• Need change agents who are credible

• i.e. Need Organisational Effectiveness

Reasons for Hope

Lessons from my visits to Dundee…

47

Alcohol-

48

Alcohol hand gel

• Pants

49

• Johnnys

50

???

My reason for hope?

I have never said any of these in an address

again!

51

Real Reasons for Hope

52

The IHI Open School

• The IHI Open School has made tremendous strides in building and strengthening a vibrant network of students, faculty, and mentors in the improvement community. There are 283 IHI Open School Chapters in 38 countries and in 44 of the 50 US states.

53

Centers for Medicare and Medicaid

• Change the way we think about performance• Support and create partnerships• Promote teamwork• Defeat secrecy• Improve information systems• Balance mindfulness and protocols

54

• Growing partnerships to support quality and quality improvement

• Widespread and growing acceptance of standardized measurement

• Information systems are finally taking hold • Population focus

55

Fives Alive!

56

5s Alive! Results - Overall Collaborative Postnatal Care – June 2008 to present (Coverage)

9 CEm0C neonatal results •

NCFR reduction by 22 % reduction in 2008 vs 2007

Neonatal Death Rate for 9 CEmOC Facilities 2006-2008

-

1.00

2.00

3.00

4.00

5.00

6.00

Jan-

06

Mar-

06

May

-06

Jul-0

6

Sep-0

6

Nov-0

6

Jan-

07

Mar-

07

May

-07

Jul-0

7

Sep-0

7

Nov-0

7

Jan-

08

Mar-

08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Month-Yr

%N

ND

s

%NNDs

Median May - Dec 2006

Baseline Median = 2.57%

Missing data in some

Facilities

9 Cemoc maternal Case Fatality Rate.

Baseline Median = 0.37%

deathrate 2007= deathrate 2008= 0.38%.

2008 9 Cemoc annual deliveries 9%

9% =2700 deliveries 2007 vs 2008

1,500

1,700

1,900

2,100

2,300

2,500

2,700

2,900

3,100

3,300

Jan-

06

Mar-

06

May

-06

Jul-0

6

Sep-0

6

Nov-0

6

Jan-

07

Mar-

07

May

-07

Jul-0

7

Sep-0

7

Nov-0

7

Jan-

08

Mar-

08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Month

No.

of

Del

Deliveries

Median Jan - Jun 2006

62

HIVQUAL-UgandaBerlin

March, 2009

Kayita Godfrey MD, MPH

Ministry of Health, Uganda

Quality Management Program

HIVQUAL-Uganda

63

Background

Popn – 30mPHAs – 1.1mPrev. – 6.4 (UHBS 04/05)

AIMInstitutionalization of QI in national health care delivery systems

18-May-11

63

Data Report & QI Projects

• HIV immunological monitoring (CD4)

• 7 health facilities

• Prevention Education

• 5 health facilities

• TB assessment and screening

• 5 health facilities

• HAART adherence

• 3 health facilitiesKey CD4 or TLC HIV Monitoring (CD4 counts or TLC every 6 months) COC Continuity of Care (Clinic visits every 3 months) CP Prophylaxis (Cotrimoxazole or Dapson) within 6 months PE Prevention Education every 3 months ART ARV Therapy and adherence to ARV Therapy AA Documentation of adherence assessment every 3 months TBA/TBS TB Assessment and TB Screening within 6 months

Challenges• Communication• Limited resources

Next steps• Roll out QI– in all ART accredited sites– In all HIV program areas– activities beyond HIV• Consumer involvement in

QI• Continued capacity

building – ToTs and Mentoring sessions

For Us….

The Good NewsLots of progress worldwideLearning from the world

Important problems to improve

Common problems

The ChallengeSame problems are seen

worldwideSeeing ourselves as part of

that worldNo easy answers to the

problemsDeveloping common

solutions

66

Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system.

Donabedian, Health Affairs

Autobiography in 5 ChaptersPortia Nelson from: The Tibetan Book of Living

and Dying

1. I walk down the street There is a big hole in the sidewalk I fall in the hole. I am lost….I am hopeless. It isn’t my fault. It takes forever to get out.

2. I walk down the street There is a big hole in the sidewalk I pretend I don’t see it. I fall in again. I can’t believe I’m in the same place. It isn’t my fault. It still takes a long time to get out.

3.I walk down the street There is a big hole in the sidewalk I see it is there. I still fall in – it’s a habit. My eyes are open, I know where I am. I get out immediately.

4.I walk down the street There is a big hole in the sidewalk I walk around it.

5. I walk down another street.

Dundee IHI Open School Chapter

Thomas Johnston Liam ShieldsFraser Pryde

Overview IHI Open School Chapter achievements Clinical Academic Track

Interprofessional Education Leadership and Quality Improvement

Learning from Errors Advanced case study Improvement practicum

Key messages

pgdavey 31/01/2011Changed from "Academic tract"

Fatal medication errors

DP Phillips, GEC Barker. A July Spike in Fatal Medication Errors: A Possible Effect of New Medical ResidentsJGIM 2010. 25; 8: 774-779.

10% increase in mortality from medication errors above expected level

August killing season

Medication Incident Analysis Framework

Coombes et al. Why do interns make prescribing errors? The Medical journal of Australia 2008; 188: 89-94.

Multiple system failures

“Advance health care improvement and patient safety competencies

in the next generation of health professionals worldwide.”

IHI Open School Mission

Globe spanning network of chapters

Over 200 chapters now world wide

International approach to improving patient safety

Dundee Chapter

Global AimPromote teaching and assessment in QI and PS

The Origin of the Dundee Chapter

Medicine Nursing ComputingDentistry

Dundee Chapter

September 2008

AIM – Promote inter-professional student learning in QI and PS

Achievements Achievements

IHI courses

NHS Tayside

IHI courses

NHS Tayside

Patient Safety SSC

Patient Safety SSC

Improvement projectsImprovement projects

Inter-Profession

aleducation

Inter-Profession

aleducation

Reducing Harm

Improving Care

Conference

Reducing Harm

Improving Care

Conference

http://www.dundee.ac.uk/dcat/

•13 Teams took part•Dundee students led the only team from outside North America

Aim statement and tests of change>95% of all newly admitted patients on Warfarin will have their INR measured, documented and acted upon, prior to leaving the acute

medical or surgical admission ward within 3 months

Test Cycle 1 Is there a Warfarinsed patient admitted today?

Test Cycle 2 Can the drug dispenser be used to quantify number of warfarinised patients?

Test Cycle 3 Ask SCN/Consultants about holding patients until INR result recorded acted on

Warfarin Handover Alert SheetDate Patient

name/CHI no.

Time since admissionINR reported

INR INR within rangeY/N

Action required?(Please refer to protocol for guidance)

Held or continued

Warfarin Chart completed

Target INR On admission

85

NB: If INR > 5 or < 1.5 please contact your senior/follow protocol/contact on call Haematologist for advise - bleep 3047

Incident

Adverse Incident

Manage the

incident Report to manager

Type Impact

Risk

Red

Fast Track NHS QISMHRA

Confidential EnquiriesProcurator

FiscalCNORIS

NHS TaysideProfessional

bodies NMC GMC

Review /analyseForward to H&S

Amber

Green

Report internally

Chief Exec /Executive team

Staff Response

Line Manager Internal Organization

External

LearnChangeImprove

Root Cause Analysis

Trend Analysis

Learn and disseminate Implement and monitorimprovement strategies

Feedback to local staff

Learning from Errors: Core Teaching in Systems Thinking & Human Factors•132 Final Year students doing Incident Reviews in 2010-11•Strong support from Senior Charge Nurses & NHS Tayside

Incident

Adverse Incident

Manage the

incident Report to manager

Type Impact

Risk

Red

Fast Track NHS QISMHRA

Confidential EnquiriesProcurator

FiscalCNORIS

NHS TaysideProfessional

bodies NMC GMC

Review /analyseForward to H&S

Amber

Green

Report internally

Chief Exec /Executive team

Staff Response

Line Manager Internal Organization

External

LearnChangeImprove

Root Cause Analysis

Trend Analysis

Learn and disseminate Implement and monitorimprovement strategies

Feedback to local staff

Organisational Learning:Recommendations for Change•17th December: Clinical teams, Safety Governance & Risk•14th February: Tayside Drug & Therapeutics Committee

Advertising for 2011Student scholarship to develop Leadership & QI Course for Years 2 and 3

Aims: •Expose students to improvement methods early in their careers•Develop their potential to be leaders for safe practice.

Objectives:•Understand and apply the model for improvement.•Use micro-systems thinking to investigate safety incidents•Develop clinical leadership skills through Plan Do Study Act (PDSA) cycles

Key messages

Students are part of the solution, not part of the problem!

All members of MDT educated in QI + PS

The ward ready novice MDT

Improvement is everyone's business

pgdavey 01/02/2011I have added "novice", meaning that we want novices who know how to work with and learn from experienced staff

Copyright ©2007 BMJ Publishing Group Ltd.

Batalden et al. Qual Saf Health Care 2007;16:2-3

Linked aims of improvement

Can we make it better?

What is “it”?Health?

Health care?Safety?

“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

What will it take to be the best in the world?

"While the literature often portrays an organisation's quest for change like a brisk march along a well-marked path, those in the middle of change are more likely to describe their journey as a laborious crawl towards an

elusive, flickering goal, with many wrong turns and missed opportunities along the way. Only rarely does an

organisation know exactly where it's going, or how it should get there."

Kanter et al, The challenge of organisational change, 1992

Four steps to world-leading

• Be reliable• Be disruptive• Be person-centred • Be transparent

Be reliable

NEJM 2009;360:491-9

8 hospitals5809 beds

160 theatres

46% reduction in surgical site infection

47% reduction in mortality

Using care bundles to reduce in-hospital mortality: quantitative survey

Robb et al. BMJ 2010:340:1234

Care bundles used

COPD

Central venous cathetersDiarrhoea and vomiting

Ventilator acquired pneumonia

MRSA

Heart failure

Surgical site infections

Results

• HSMR fell from 89.6 (2006-07) to 71.1 (2007-08)

• SMRs fell in 11 of 13 targeted diagnoses• 5.7% increase in admissions, 7.9% increase in

expected deaths and 14.5% decrease in actual deaths

"A limitation of this type of study is the difficulty establishing whether there is a casual relationship

between introducing the targeted care bundles and the reduced mortality. A randomised trial design was not

practical in this clinical situation. However, the significant reduction in mortality occurred only at the site where the

care bundles were predominantly used....it occurred in the year in which they were introduced, starting in the month

of introduction....it occurred for the targeted diagnoses and not for the non-targeted diagnoses."

Discussion

from R Resar, Institute for Healthcare Improvement

Healthcare processes

Be disruptive

109

Doing what we do today, better

Creating what we will do tomorrow

DisruptiveSustaining

(Comfort Zone) (Risk Taking)

Spectrum of Innovation

"Leaders can adopt ideas that have worked elsewhere, but they need to create their own

one-of-a-kind change model through experimentation, learning, blue-print creation and

most of all a strong focus on results"

Bate, Mendel, Robert et al. 2008

Set a bold ambition

Healthcare That Is Safe is defined by our Clinical Excellence goal  The care we deliver will be safe and effective.  We commit to having excellent clinical care with no preventable injuries or deaths by July 2008

1

Two steps from an ‘expert improver”

Leadership

• Every patient, every time – checklists?• Behaviour – ties?• Hierarchy – first names?• Competence – improvement science?

114

It is not the strongest of the species that survive, nor the most

intelligent, but the ones most

responsive to change.

Charles Darwin

Who is the best in the world at this?

Be person-centred

Don Berwick, Health Affairs 2009

Patient and family councilsFeedback and action

Be transparent

Source:British Airways (NPSA adapted)

British Airways air safety reports, 1994-99 Total reported events

Total events

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1994 1995 1996 1997 1998 1999

High/medium risk events

0

20

40

60

80

100

120

140

Number of reported events: high and medium risk

http://tinyurl.com/ihi-scae

“We trained hard ... but it seemed that every time we were beginning to form up into teams we would

be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency,

and demoralization.”

Gaius Petronius Arbiter (27–66AD)

Kotter’s Eight Steps for Successful Large Scale Change

• Increase urgency• Build a guiding team• Get the vision right• Communicate for buy-in• Empower action• Create short-term wins• Don’t let up• Make change stick

How will you know you’ve achieved anything?

Panel Discussion…

www.t-coe.org.uk