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Reducing opioid-related harm and building quality improvement capability in New Zealand: a national formative collaborative
Prem Kumar
Session Code: M3The presenters have
nothing to disclose
14 November 2017
#IHIFORUM
The problem with opioids
Opioids are essential medicines for treating pain but are
the most common class of medicines that cause harm to
inpatients
Harms range from life-threatening over-sedation and
respiratory depression to less severe, such as
constipation
There is no universally accepted ‘bundle’ of evidence-
based interventions to reduce harm from opioids
This was the impetus for the safe use of opioids national
formative collaborative
1. Seddon, ME, Jackson A, Cameron C et al. The Adverse Drug Event Collaborative: a joint venture to measure medication-related
patient harm. NZMJ 25 January 2013, Vol 126
2. Institute for Safe Medication Practices (ISMP). ISMP’s List of High-Alert Medications. 2012. See:
www.ismp.org/Tools/highalertmedications.pdf
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Collaborative aim and goals
The national aim was to “reduce opioid-related harm by
25% in participating areas of hospitals by April 2016”
The goal of the collaborative was to:
Develop care bundles to reduce opioid-related harm
Increase the capability of participating teams to use quality
improvement tools and methods
Create a reusable clinical network across New Zealand for
further medication safety work
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#IHIFORUM
What did we achieve?
Results - capability buildingP6
“I guess from a professional point of view, learning about
PDSA cyclesand the methodology.
It’s been really useful for me – a different way of
thinking.” (DHB 1)
“I came into it not really understanding PDSAs and to the extent … tothe formalisation that they (the Commission) were talking about, so Iguess [not knowing] the
science behind [it]… I learned a lot.” (DHB 6)
Nearly all (98%) survey respondents reported that they would use the improvement
tools, knowledge and methods they gained during the collaborative in the future.
Learning session attendees’ knowledge of improvement science methodologies
Results - care bundlesP7
• This ‘composite’ care
bundle reflects the key
interventions that were
tested to support a
reduction in opioid-related
harms in hospitals
• Three individual harm
bundles were also created
Results - harm reductionP8
20 teams were eligible for the collaborative: 17 actively participated; 5
were excluded from the analysis because a baseline was not established.
Of the remaining teams:
• 7/12 hospitals (58 percent) showed greater than 25 percent relative reduction in
opioid related harm, with 6/12 (50 percent) exhibiting a special cause in SPC chart
• 2 hospitals showed a 0–25 percent relative reduction (one with special cause)
• 3 hospitals showed a relative increase in harm (no special cause)
Examples of analysis
Execution theory
Reduction
in harm
Sector engagement
Strong leadership
and governance
Partnership
Collaborative model
and methodology
Measurement
Co-design
Support
Drivers of change
Example of a team’s assessment
Collaborative model and methodology
Collaborative model - IHI breakthrough series
Underpinned by Model for Improvement
Inter-professional team, aim statement, driver diagram, and measurement plan were created for each DHB
Project sponsor and clinical lead identified for each team
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Co-design and partnershipP12
Commission’s national team kept DHB teams involved in
all decision-making
Consumers were involved in testing the interventions
Responsiveness to Māori – cultural appropriateness
Key documents were co-designed with DHB teams (eg,
care bundles and measures
Improvement advisors from DHBs were involved in
teaching at the learning sessions
Harm areas were chosen by DHB teams
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MeasurementP14
Teams identified their measures, developed
a data collection plan and manually collected
data on a weekly basis for their identified
outcome, process and balancing measures
DHB monthly reports were shared with the
Commission and national dashboards were
created
Data was analysed using three methods: two
sample test of proportions, statistical process
control (SPC) charts and relative percentage
change from baseline
Infrastructure and support
Four national learning sessions and four regional meetings
Monthly national teleconferences
Visits by national team to each DHB; one-on-one coaching
Connections with DHB clinical leads and project sponsors
International support (IHI), and connecting with other counties
Common platform to file all materials (shared workspace)
Newsletters and webinars
Muffins…
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Leadership and governance
Expert faculty
Steering group
National team (project manager, improvement advisor,
content specialist, clinical lead, and project sponsor)
Invitation letters sent to DHB executives
Presentations at DHB meetings
Consumers were involved in governance at a national and
DHB-level
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Lessons learnt from execution
Co-design, partnership and relationships – key elements for success at a
national level
‘Formative’ nature – teams were asked to develop interventions while learning
improvement science; many struggled with the notion of ‘building the plane,
while flying it’
Team work – successful teams had an inter-professional structure with strong
project sponsor support
Measurement – teams needed explicit direction regarding baseline data
requirements
Methodology – teams needed help with the practical use of PDSA in their
clinical settings, especially small- versus large-scale testing
Bundle creation – not easy!
Shared learning – national learning sessions were effective for bringing the
teams together to share and learn from each other
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Thank you
www.hqsc.govt.nz
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Learning session 2 – Christchurch, NZ – June 2015
