The Scottish Approach to Reforming Healthcare – Quality, Efficiency and Productivity
National Healthcare Conference, 22 March 2012
Frances Elliot | Chief Executive
The Scottish national context for quality in healthcare
My organisation
Our activity
What can you learn?
THE PRESENTATION
NHS SCOTLAND • 5.1 million population• One integrated NHS system• £10.3 billion• Integrated health and social care• 14 territorial boards• Special boards
– Healthcare Improvement Scotland– NHS Education for Scotland– NHS Health Scotland– NHS National Services Scotland– Scottish Ambulance Service– State Hospital– Golden Jubilee National Hospital– NHS 24
THE SCOTTISH CONTEXT
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.
There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
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.
QUALITY AMBITIONS
QUALITY AND EFFICIENCY – GETTING THE BALANCE RIGHT
NATIONAL PERFORMANCE FRAMEWORK 2011
Healthcare experience
Staff engagement and potential
Healthcare associated infection
Emergency admission rate/bed days
Adverse events
Hospital standardised mortality ratio
Under 75 mortality rate
Patient/user reported outcome measures
Self-assessed general health
Percentage of time in last 6 months of life spent at home or in a community setting
Early years indicator
Resource use indicator
QUALITY OUTCOME INDICATORS
TRANSPARENCY
Definition of transparent: allowing light to pass through so that objects behind can be easily seen; easily understood; of such a kind that the truth behind it is easily perceived; clear and unmistakeable
Often described in terms of how individuals behave and organisations function e.g. with candour, integrity, honesty, ethics, clarity, full disclosure, legal compliance
The aim: to allow us to deal fairly with each other and those we serve.
HEALTHCARE IMPROVEMENT SCOTLAND
Set up by an Act of Scottish Parliament on 1 April 2011.
Two key functions:Enhancing and protecting the safety and wellbeing of all persons who use services provided under the national health service and independent health care services.
Uniquely in the United Kingdom we fulfil both an improvement and scrutiny role with regard to health services.
VISION
To deliver excellence in improving the quality of the care and experience of every person in Scotland every time they access healthcare.
INTEGRATED CYCLE OF IMPROVEMENT
IMPROVEMENT
“The combined and unceasing efforts of everyone – healthcare 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
IMPROVEMENT
We run the Scottish Patient Safety Programme, a Paediatric Safety Patient Programme and are developing new national programmes for primary care, mental health, maternity services and person centred care
We also have a number of other improvement programmes, for example Healthcare Associated Infection (HAI), cardiovascular disease, neurological conditions
The Scottish Quality Improvement Hub
We support national initiatives such as Releasing Time to Care.
The Improvement Guide, API
SIX QUESTIONS FOR HEALTHCARE PROVIDERSDoes everyone in the system know what we are trying to achieve?Are we prioritising the improvements likely to have the biggest impact on the aim and stopping those that have little impact?Is everyone clear about the means of securing improvements towards our aim?Are we able to measure and report progress on our aim?Do we know how and where to deploy resources when improvement is slower than required?Do we have a way of testing and innovating and then spreading new learning?
Having to redo operations and interventions
Readmissions – initial problem not fixed
Healthcare associated infection
Delayed discharges
Poor communication
Drug interactions and reactions
Poor patient flow along care pathways
Complaints and litigation.
THE COST OF QUALITY
TRUST
Trust and transparency are always linked
The unimpeded flow of information is essential for healthy relationships and for organisational health
Ibsen defines “vital lies” as the operative fictions that cover a more disturbing truth in troubled families
In organisations they play a role in attempting to keep embarrassing truths from surfacing.
SCOTTISH PATIENT SAFETY PROGRAMME
SPSP WORKSTREAMS
Critical Care– Ventilator acquired pneumonia bundle, central line
bundleGeneral Ward
– Early rescue – Communication
Medicines Management– Medicines reconciliation
Perioperative– Surgical pause, surgical checklist– Infection prevention/control, prevention of venous
thromboembolismLeadership
– Safety walkrounds– Executive leadership, board patient safety profile
MEASUREMENT AND DATA
To end of 2011:
• 61% reduction in Ventilator Associated Pneumonia rate
• 70% reduction in Central Line Bloodstream Infection rate
• There were 14 central line infections in intensive care units in Scotland in 2011
• There were zero central line infections in intensive care units in March, June and December 2011
• 19% improvement in compliance with critical care multidisciplinary rounds and daily goals
• 24% improvement in critical care mortality
• 0.5 day reduction in ICU length of stay
• 90% reduction in ward C. difficile rate
• 40% reduction in ward Staph aureus bacteraemia rate
• 20% improvement in compliance with surgical briefing
• 18% improvement in medicines reconciliation
HSMR – up to end of September 2011 improved by 9.3%
02468
101214161820
Jan-
08
Apr-0
8
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8
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09
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9
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9
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Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
VAP RATE (PER THOUSAND VENTILATOR DAYS)
9.11
3.54
61% reduction
75
80
85
90
95
100
Jun-
08
Aug
-08
Oct
-08
Dec
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Jun-
09
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10
Aug
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Oct
-10
Dec
-10
Feb
-11
Apr
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Jun-
11
Aug
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Oct
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Dec
-11
VAP BUNDLE COMPLIANCE
85%
92%
7% improvement
0
0.5
1
1.5
2
2.5
3
3.5
4
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
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Nov
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Jan-
09
Mar
-09
May
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Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep
-11
Nov
-11
CENTRAL LINE INFECTION RATE (PER THOUSAND LINE DAYS)
2.8
0.84
70% reduction
80
85
90
95
100
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
CENTRAL LINE BUNDLE COMPLIANCE
89%
94%
5% improvement
60
65
70
75
80
85
90
95
100
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
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep
-11
Nov
-11
% COMPLIANCE WITH MULTI-DISCIPLINARY ROUNDS AND DAILY GOALS
74%
93%
19% improvement
1012141618202224262830
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
% ICU MORTALITY
18.2%
13.9%
24% improvement
3
3.5
4
4.5
5
5.5
6
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
ICU AVERAGE LENGTH OF STAY
4.8
4.3
½ day improvement
0
0.5
1
1.5
2
2.5
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
GENERAL WARD C.DIFFICILE RATE(PER THOUSAND PATIENT DAYS)
1.15
0.12
90% reduction
0
0.1
0.2
0.3
0.4
0.5
0.6
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
Jan-
12
GENERAL WARD SAB RATE(PER THOUSAND OCCUPIED BED DAYS)
0.35
0.21
40% reduction
84
86
88
90
92
94
96
98
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
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep
-11
Nov
-11
Jan-
12
PERCENTAGE COMPLIANCE WITH EWS
92%
95%
50556065707580859095
100
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
PERCENTAGE COMPLIANCE WITH SURGICAL BRIEFING
74%
94%
20% improvement
PERCENTAGE COMPLIANCE WITH PERI-OP BRIEFINGS
92%
95%
50556065707580859095
100
Feb-0
8
May
-08
Aug-0
8
Nov-08
Feb-0
9
May
-09
Aug-0
9
Nov-09
Feb-1
0
May
-10
Aug-1
0
Nov-10
Feb-1
1
May
-11
Aug-1
1
Nov-11
PERCENTAGE COMPLIANCE WITH MEDICINES RECONCILIATION
64%
82%18% improvement
THE NEW TRANSPARENCY
In everyday life we live in a globally networked society
The mobile phone equipped with a camera, and CCTV, means that each of us is, more or less, always under scrutiny and on display
This new, involuntary transparency recognises that there is no such thing as secrecy
It calls for a new code of behaviour, one dictated by the reality that we can never assume we are alone or unaccountable for our actions.
RECOMMENDED READING FOR BOARD MEMBERSHow well does your organisation measure up in terms of transparency?
Do you have a mechanism to encourage difficult conversations in your senior management team, in governance committees and at the board level?
How do your staff raise sensitive and difficult issues?
What support do they receive when they do?
“Do not be content with mediocrity. Do your job so well that nobody could do it better.”
Martin Luther King
KEY MESSAGE
www.healthcareimprovementscotland.org
www.scotlandperforms.com
www.scottishpatientsafety.programme.scot.nhs.uk
USEFUL WEBSITES
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