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Getting Started At the National Level: From Demonstration to Spread1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs
November 4, 2013
São Paulo, Brazil
Derek Feeley
Executive Vice
President
NHS Scotland 3
c. 5.1 million populationDevolved (since 1999)14 Regional BoardsIntegrated system ( e.g. no purchaser/ provider split)Integration of health and social care underwayTax funded/ 20bn CAD budget, cash limitedEqual access on basis of needFree at the point of care
Why Patient Safety? 4
United States:3.7% of admissions44,000 – 98,000 deaths
United States:3.7% of admissions44,000 – 98,000 deaths
Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths
Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths
Denmark:9% of admissionsDenmark:9% of admissions
New Zealand:10% of admissionsNew Zealand:10% of admissions
United Kingdom:11% of admissions850,000 adverse events
United Kingdom:11% of admissions850,000 adverse events
DoH ECRI 2002 Knox K et all
Global Trigger Tool Reviews5
3 Exemplar Hospitals (900 notes)
40 Bed rural Hospital (300 notes)
10 Hospital Research Project (240 notes)
7 Hospital System (3000 notes)
Multi-state Tertiary System (2000 notes)
Events/1000 Days
83 90 NA 119 86
Events/100 admissions
45 40 37 41 38
Admissions with adverse events
32% 30% 30% 29% 30%
Not Just Numbers6
So what do we know?
At least 10% of patients admitted to hospital suffer harmTraditional incident reporting – tip of the icebergVariation in mortality ratesHuman beings will always make mistakesLack of standardisation – clinician preferenceBest known science is not reliably applied
Lack of Reliable Processes Create….
Islands of great care in a sea of variationInconsistent performance & outcomesChaos as clinicians create ‘work-arounds’ just to get the work doneA culture where it is difficult to learn and improveCare that is more complex and often more unsafe
Current Improvement methods in healthcare are
highly dependent on vigilance and hard work
The focus on outcomes tends to exaggerate the
reliability within healthcare giving clinicians a false
sense of security
Permissive clinical autonomy creates and allows
wide performance margins
The Reliability Gap
What We Asked Ourselves - Policy
How do we reduce harm in the NHS in Scotland?How do we reduce mortality in Scottish hospitals?What could we learn about improving quality more generally?
No Shortage of Analysis
It’s complicated……12
“Too bad all the people who know how to run the country are busy driving cabs and cutting hair.”
- George Burns
Updated for 2013:
“It's too bad that everyone who has a solution for everything is at home commenting on the internet.”
- Twitter user Rasta Pasta (@rastahipsta)
Policy Options
Do what we’ve always doneLet’s get more dataRun a pilot projectRun a campaignLet Boards and hospitals decide what to doRun a mandatory national improvement program
Why Did Scotland Go National? 14
The context was rightOur size helpedClinicians and managers were receptiveA good match with ‘values’The evidence was good enough – the ‘Tayside Effect’It felt like the right thing to
The Right Foundations . . .15
100,000 Lives CampaignSafer Patients InitiativePolitical support at the highest levelLeadership prepared to be transparent about harm and to build the will to improve
. . . And Missing Ingredients16
We needed a partner to help us with design and execution. We needed to overcome clinical (mainly medical) resistance.We needed to convince leaders and managers that this was not just “another initiative.” We needed to start somewhere.
Policy Risks – do nothing (new)We’ll always get what we always got.There will continue to be avoidable harm (even more perhaps as care gets more complex)The debate continues to be about reporting rather than improving.
Its not denial, I am just selective about the reality I accept. (Bill Waterson –Calvin and Hobbes)
Making Policy as a Metaphor for Spreadpolicy1n pl -cies1. (Government, Politics & Diplomacy) a plan of action adopted or pursued by an individual, government, party, business, etc
UK National School for Government 2006
Evidence
Experience &
Expertise
Judgment
Resources
ValuesHabits &
Traditions
Lobbyists &
Pressure
Groups
Pragmatics &
Contingencies
Spread and Sustainability
Spread = The process through which new working methods developed in one setting are adopted , perhaps with appropriate modifications, in other organizational contexts
Sustainability = The process through which new working methods, performance enhancement, and continuous improvements are maintained for a period appropriate to a given context
Buchanan D, Fitzgerald L, Ketley D. The Sustainability and Spread of Organizational Change:
Modernizing healthcare. Abingdon, Oxon: Routledge; 2007.
“Up to 70% of improvement projects never spread.”
Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012;53(4): 43-50.
Planning for Spread
Preparing for spreadEstablishing an aim for spreadDeveloping an initial spread planExecuting and refining the spread plan
In Scotland the spread plan was to start with all, just not with everything, everywhere. We told hospitals to start where they were good and to get to complete coverage in 2 years.
Implementing at scale….can it be done?
ExecutionIdeas
Will
W Edwards Deming
“By what method?Only the method counts.”
23
The Typical Approach24
Conference RoomConference Room
DESIGN DESIGN DESIGN DESIGN APPROVE
IMPLEMENTReal WorldReal World
DESIGN
TEST & MODIFY
TEST & MODIFY
APPROVEIF NECESSARY
Conference RoomConference Room
Real WorldReal World
TEST & MODIFY
The Quality Improvement Approach
START TO IMPLEMENT
IHI Breakthrough Series – sticking with it
Select
Topic (develop
mission)
Planning
Group
Develop
Framework
& Changes
Participants (10-100 teams)
Prework
LS 1
P
S
A D
P
S
A D
LS 3LS 2
Supports
Email Visits
Phone Assessments
Monthly Team Reports
Congress,
Guides,
Publications
etc.
A D
P
SExpert
Meeting
Where We Started:SPSP Outcome Aim Set in 2008
Mortality: 15% ReductionAdverse Events: 30% Reduction– Ventilator Associated Pneumonia: 0 or 300 days between– Central Line Bloodstream Infection: 0 or 300 days between– Blood Sugars within Range (ITU/HDU): 80% or > w/in range– MRSA Bloodstream Infection: 30% reduction– Crash Calls: 30% reduction
27
To be achieved across the nation by 2012Mortality aim amended to 20% by 2015
What We Set Out to Improve
Acute Program – 5 WorkstreamsCritical Care Perioperative CareGeneral Ward CareMedicines ManagementLeadership for Safety
28
0,8
0,9
1,0
1,1
Oct-Dec2006
Apr-Jun2007
Oct-Dec2007
Apr-Jun2008
Oct-Dec2008
Apr-Jun2009
Oct-Dec2009
Apr-Jun2010
Oct-Dec2010
Apr-Jun2011
Oct-Dec2011
Apr-Jun2012
Sta
ndar
dise
d M
orta
lity
Rat
io
HSMR up to September 2012
8497 less than expected deaths
12.4% reduction
Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in range Harm from Anti-coagulation: Reduction in INRs > 6All process measures will be > 95% reliable
AHO3
Adverse Events
Rate per 1000 pat ient days
.010.020.030.040.050.060.070.0
611
811
1011
1211
212
412
612
AHO3
Adverse Events
Rate per 1000 pat ient days
.010.020.030.040.050.060.070.0
611
811
1011
1211
212
412
612
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
711
911
1111
112
312
512
712
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
711
911
1111
112
312
512
712
CCO1
VAP Rate
Rate per 1000 ventilated days
.02.04.06.08.0
10.0
611
811
1011
1211
212
412
612
CCO1
VAP Rate
Rate per 1000 ventilated days
.02.04.06.08.0
10.0
611
811
1011
1211
212
412
612
CCO2
Central Line Infection
Rate per 1000 pat ient days
.02.04.06.08.0
10.0
611
8 10 12 2 4 612
CCO2
Central Line Infection
Rate per 1000 pat ient days
.02.04.06.08.0
10.0
611
8 10 12 2 4 612
CCO6
Optimal Glucose Control
Percent
70.075.080.085.090.095.0
100.0
611
811
1011
1211
212
412
612
CCO6
Optimal Glucose Control
Percent
70.075.080.085.090.095.0
100.0
611
811
1011
1211
212
412
612
MMP3C Filtered
INR>6
Percent
0.00.10.20.30.40.50.6
711
911
1111
112
312
512
712
MMP3C Filtered
INR>6
Percent
0.00.10.20.30.40.50.6
711
911
1111
112
312
512
712
Process reliability achieves improved outcomes!697 days! 596 days!
Where We Started:Outcomes & Achievements
Safety is Contagious – In A Good Way
A Strategy and a Roadmap 32
33
3 Quality Ambitions
Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.
The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
3-Step Improvement Framework for Scotland’s Public Services
34
1. Change the World
2. Create the conditions
3. Make the Improvements
Macro System :
Vision, Aim & Context
Meso System:Culture, Capacity, & Challenge: How much and by when?
Micro System:Implementation, measurement, & improvement
Creating the Conditions
6 Questions for Every Change Program
35
1. Does everyone in the system know what we are trying to achieve?
2. Are we prioritizing the improvements likely to have the biggest impact on the aim and stopping those that have little impact?
3. Is everyone clear about the means of securing improvements towards our aim?
4. Are we able to measure and report progress on our aim?
5. Do we know how and when to deploy resources when improvement is slower than required?
6. Do we have a way of testing and innovation and then spreading new learning?
Investing One Generation Ahead –The Method Works Here, Too
The Early Years Collaborative - Ambition
To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.
The Early Years Collaborative - Aims
1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidence by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).
2. To ensure that 85% of all children with each Community Planning Partnership have reached all of the expected development milest ones at the time of the child’s 27-30 month child health review, by end-201 6.
3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected development milestones at the time the child starts primary school, by end-20 17.
Front Line Staff – How Did They Do It?
� Get goals� Get bold� Get together� Get a method (and
stick with it)� Get patients and
families
� Get the facts� Get to the field� Get a clock� Get the numbers� Get the stories
1941, William A. Foster
"Quality is never an accident; it
is always the result of high
intention, sincere effort,
intelligent direction and skillful
execution; it represents the wise
choice of many alternatives.”