Breaking Bad: A User’s Guide to Quality Improvement

Julie-Clare Becher

Consultant Neonatologist and Honorary Senior Lecturer

Royal Infirmary of Edinburgh

Clinical Research vs Quality Improvement

Research and RCTs QI and Statistical Process Control

• Creation of new knowledge

• One tightly controlled comparison with current practice

• Fixed hypothesis

• ‘Just in case’ data

• Slow, cumbersome and expensive

• Harder to repeat

• Implementation of knowledge

• Flexible hypothesis

• ‘Just enough’ data

• Sequential small tests of change

• Real time and immediate information

• Easily repeatable

Florence Nightingale

Ignaz Semmelweiss

Early Pioneers of Healthcare QI

Marginal Gains Theory: “If you broke down everything you could think of that goes into riding a bike, and then improved it by one percent, you will get a significant increase when you put them all together” Dave Brailsford Performance Director of the GB Cycling Team

Hudson plane crash 2009: A miracle? ‘That’s what we’re trained to do’ Sullenberger, Pilot

Neonatal benchmarking networks: • North America: VON, CNN-EPIC, CPQCC, iNeo, NICHD,

Pediatrix

• Australia: ANZNN

• UK: NNAP

?CQC

NICORE Neonatal SPSP MBRRACE

‘The habit for evidence-based thinking The habit for change The habit for systems thinking The habit for collaborative learning’

“We can only be sure to improve what we can actually measure” Lord Darzi, High Quality Care for All, 2008

If all variation were bad, solutions would be easy. The difficulty is in reducing the bad variation, which reflects the limits of professional knowledge and failures in its application, while preserving the good variation that makes care patient centred. Mulley 2010

Horbar et al. Pediatrics 2012 MBRRACE Jun 2015

Mortality and Morbidity in VLBW, VON 2000-2009

Reducing Unwanted Variation in Practice

The Scottish Patient Safety Programme

• Overall Aim: to reduce hospital mortality by 15%

• ‘one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland’s healthcare leaders – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of healthcare’ Don Berwick DoH England

Key Highlights since 2008

• Reduction in mortality by 16% (10,500 lives)

• Reduction in surgical mortality by 25%

• 80% reduction C Diff and MRSA

• Surgical pause, VTE and Sepsis 6 (70-95%)

Key objectives of the initial Neonatal SPSP

By December 2015 to achieve a 30% reduction in ‘avoidable harm’ in Scottish Neonatal Services by seeking to reduce:

• harm from mechanical ventilation

• harm from invasive lines

• high risk medicines

• NEC

• harm from transitions of care

• undetected deterioration

NeoSPSP: Challenges of the first phase

• Too ambitious- 47 different measures

• Too little capacity in the workforce, no ‘Champions’

• Definitions did not match other national targets

• Burden of data collection precluded QI

• Suboptimal engagement

• National Survey of the Neonatal Community: ▫ Momentum for ongoing QI and PS work

▫ Sharing of challenges and of improvement strategies

▫ Commitment to shape the next steps of the programme Feb 2015. Becher JC, Jackson A and Staines J

‘Next Steps’ of the NeoSPSP 2016-

• Clinicians leading in format and design

• Branding focus on QI and not only PS

• Staged and flexible approach – centre-relevant aims ▫ Building a QI and safety culture in every unit- standards

▫ Improving specific outcomes using national guidance

• Benchmarkable and transparency at a national level

• Congruence with other data organisations

• Streamlined solution for national data collection/analysis

• National learning for both QI and adverse events

The Model for Improvement

What change can we make that will result in improvement?

Plan

How will we know that a change is an improvement?

Measurement: outcome, process and balancing

What are we trying to accomplish?

Outcome

Langley, Nolan et al 1996

The Lothian story: The Newborn Care Collaborative

▫ Established November 2013

▫ Provides oversight of all improvement work- >50 projects

▫ Strategic vision for improvement

▫ Avoid duplication of effort and time and provide project support

▫ Led by multidisciplinary committee

QI team

Patient safety including HAI

Audit

Guidelines

Pharmacy

Postnatal and Labour ward representatives

Parents

▫ Aims to listen to every voice

Implementing change: Understanding people factors

‘’There are only

two things I hate:

Change, and the way things are..’’

Not enough

time Too much change

Loss of power

Top down approach

Who’s sharing

this with me?

What’s in it for me?

I don’t like your

style

No one told me

Is this solution the right

one?

Not all change is for better

20% → effective change

Diffusion of Innovation Theory

THERE ARE ONLY TWO THINGS I HATE….

CHANGE AND THE WAY THINGS ARE

Parent representatives

on NCC

Antenatal preparedness

Ready, Coming or Not

Early information

Senior communication

Empowering parents

Our Journey Together

Real-time Feedback Getting Better Together

Building relationships

Baby diaries

Parent information Babylink

Discharge survey

The essential other elements of your team….. ‘Engage, empower, and hear patients and carers throughout the entire system, and at all times’ Don Berwick 2013

Getting Better Together Tree

Parent representatives

on NCC

Antenatal preparedness

Ready, Coming or Not

Early information

Senior communication

Empowering parents

Our Journey Together

Real-time Feedback Getting Better Together

Building relationships

Baby diaries

Parent information Babylink

Discharge survey

The essential other elements of your team….. ‘Engage, empower, and hear patients and carers throughout the entire system, and at all times’ Don Berwick 2013

Specific projects and activities High level factors

needed to influence the goal

Goal

Reduce NEC

Optimise obstetric care

Increase number of women receiving antenatal steroids

Delayed cord clamping 60 seconds for all preterm infants

Improve likelihood of breast milk feeding

Improve early and sustained maternal breast milk provision

Use donor breast milk in preference to formula

Minimise antibiotics

Reduce sepsis

Reduce empirical antibiotics

Driver diagram: Reducing NEC in infants <1501g (Neonatal SPSP target)

What change can we make that will result in improvement?

Plan

How will we know that a change is an improvement?

Measurement

What are we trying to accomplish?

Early provision of MBM

Reducing NEC and late onset sepsis in infants <1501g

(Neonatal SPSP target)

Outcome

• Babies <1501g or <30 weeks should receive their own mother’s breast milk:

• 90% within 24 h

• 100% within 72h

Measurement

• Number of mothers given support to express within 6 hours

• Measurement of early MBM on a monthly basis

• (Measurement of NEC)

Plan

• Education of all staff

• Information for parents

• Facilitation of expression and of MBM provision

• Guidelines and standards

UNICEF training days

National Conference

Infant Feeding Advisors

Feedback to staff

Early expression packs

Working Group

Improvement maternal information- Milk Diaries, BF App

Guideline-led enteral feeding

Skin to Skin initiative

Standard: Expression <6h

Standard: Expression <1h

2013

2015

Colostrum for mouthcare

2014

Improving MBM in <1501g infants: <24h

30

40

50

60

70

80

90

100

Au

g-1

3

Sep

-13

Oct-

13

No

v-1

3

De

c-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Ju

n-1

4

Ju

l-14

Au

g-1

4

Sep

-14

Oct-

14

No

v-1

4

De

c-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Ma

y-1

5

% receiving MBM <24h

Target

6 month mean

Improving MBM in <1501g infants: <72h

30

40

50

60

70

80

90

100

Au

g-1

3

Sep

-13

Oct-

13

No

v-1

3

De

c-1

3

Ja

n-1

4

Feb

-14

Mar-

14

Ap

r-14

May-1

4

Ju

n-1

4

Ju

l-1

4

Au

g-1

4

Sep

-14

Oct-

14

No

v-1

4

De

c-1

4

Ja

n-1

5

Feb

-15

Mar-

15

Ap

r-15

May-1

5

Target

% receiving MBM <72h

6mo mean

Specific projects and activities High level factors

needed to influence the goal

Goal

Reduce NEC

Optimise obstetric care

Increase number of women receiving antenatal steroids

Delayed cord clamping 60 seconds for all preterm infants

Improve likelihood of breast milk feeding

Improve early and sustained maternal breast milk provision

Use donor breast milk in preference to formula

Minimise antibiotics

Reduce sepsis

Reduce empirical antibiotics

Driver diagram: Reducing NEC and late onset sepsis in infants <1501g (Neonatal SPSP target)

Minimising prolonged exposure to admission antibiotics in babies with negative cultures

Baseline data collection

Mandatory automatic stop orders for all

Single CRP measurement

Introduction of 48h automatic stop orders

Duration of admission antibiotics in babies with

negative cultures

1 2 3 4

Intervention: Baseline 48hr

Autostop

Single

CRP

CRP and

Mandatory

Autostop

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

≥5d (treatment course)

>48h <5d (avoidable doses)

≤48h of antibiotics (empirical course)

% NEC in inborn infants <1501g : RIE Edinburgh 2012-2014

0

1

2

3

4

5

6

7

8

9

10

2012 2013 2014

RIE, Edinburgh

VON mean

Final thoughts

• QI is here to stay and stands shoulder to shoulder with neonatal research ▫ ‘where is the RCT?’ is important but so is ‘what is everyone

learning?’

• QI is a journey without an end ▫ During which we learn that being good enough, isn’t good enough

• Delivering change is dependant on giving power to the people ▫ Clinicians leading in their own national QI projects ▫ Bottom up approach for engagement of frontline staff ▫ Parent partnerships in deciding what is best for their baby