Scaling Connected Health lessons in …...Incidents resulting in physical violence (Trust-wide, excluding Luton and Beds) per 1000 occupied bed days (OBD) - U Chart Impact at organisation-level

Scaling Connected Health –

lessons in implementation from

improvement science

Welcome and opening remarks

Dr Maria Quinlan

Research Lead, ARCH

[email protected]

@maria_quinlan

1

mailto:[email protected]

Background and Context

2

1. Analysis of CH in Ire, UK and

US…barriers and enablers

2. Industry consultation

What can we learn from Orgs. at the cutting edge of

implementing CH?

What can we learn/influence at a

national level?

Significant org-level

barriers. We need to

know…..

• How to implement CH at

scale

• How to engage and

motivate HCPs

Track real-world

implementation of

eHealth in Ire.

Collaboration with

OoCIO HSE;

eHealthIreland

• eReferral

• CCIO

US Integrated Care research

• In-depth qualitative

interviews with senior

KOLs/HCPs tasked with

implementing HC

transformation projects

• Director level insight

Research Progression

3

Learning from others…

Key learnings…

Working with the OoCIO HSE & eHealthireland…

• 1991: initial focus identifying and spreading best-practice

• Matured into the idea of the ‘Triple Aim’

• Framework to optimise health system performance - focusing on

three care dimensions: improve the patient experience, improve

population health, and reducing the per capita cost

• Goal = person and family-centred care

• Clear, obvious overlap between what we are trying to

achieve with Connected Health…right info, right place,

right time…more efficient system overall

The Institute for Healthcare Improvement

7

IHI vision: Everyone has the best care and health possible.

‘Purpose of digitisation is not to digitise, it’s to

improve quality, safety, efficiency, patient

experience’

Dr Bob Wachter

• To discuss how we place Connected Health/eHealth into the

context of the overall quality improvement agenda

• How can we leverage improvement science methods as we

move from pilot to scale?

Aim of Today

8

9

Agenda @arch_ie_ucd1.45-2.30 Using Quality Improvement to achieve results at scale in health and healthcare – lessons as we digitize our

system

Pedro Delgado, Head of Europe and South America, Institute for Healthcare Improvement (IHI)

2.30-3.00 Large scale transformation - small scale testing and integration with an EHR: results achieved and lessons

learned

Dr David Vaughan, Consultant Pediatrician and Director of Quality and Patient Safety at

Children’s Hospitals Group

3.00-3.30 Coffee and networking

3.30-4.00 Reflections on Scaling eHealth Nationally

Richard Corbridge, CIO HSE and CEO eHealthireland

Gemma Garvan, Project Manager, Healthlink and Programme Delivery Director for Access to Information,

OoCIO HSE and eHealthireland

Using Quality Improvement to achieve results at scale in health and healthcare -lessons as we digitize our systemDublinOct 18, 2016

Pedro DelgadoHead of Europe and Latin AmericaInstitute for Healthcare Improvement

@pedroIHI / [email protected]


www.ihi.org

Puente del Rio Choluteca 1938…1996 Honduras

Huracán Mitch - 1998

Partnering to Achieve Big Aims

Singapore Healthcare

Improvement Network

Qulturum, Region Jönköping

Danish Society for

Patient Safety - Denmark

Qatar

http://www.google.com/url?sa=i&rct=j&q=&source=images&cd=&cad=rja&docid=AZbAkZBawtqShM&tbnid=HZMkBURBHtdiAM:&ved=0CAUQjRw&url=http://www.disability-marketing.com/profiles/cincinnati-childrens.php4&ei=0_S1UfXsDquB0QGijYCgDA&bvm=bv.47534661,d.dmQ&psig=AFQjCNEzjXfW-AFMTBpAHuJaqRa0-FcjdQ&ust=1370965541671153

http://www.google.com/url?sa=i&rct=j&q=&source=images&cd=&cad=rja&docid=AZbAkZBawtqShM&tbnid=HZMkBURBHtdiAM:&ved=0CAUQjRw&url=http://www.disability-marketing.com/profiles/cincinnati-childrens.php4&ei=0_S1UfXsDquB0QGijYCgDA&bvm=bv.47534661,d.dmQ&psig=AFQjCNEzjXfW-AFMTBpAHuJaqRa0-FcjdQ&ust=1370965541671153

Organizing Framework – The Triple Aim

Lessons learned

1. Head and heart – in the service of what?

2. Partner with staff and users

3. Use an improvement method

4. Use a scale up method

5-7 / 1000

~2-3 / 1000

• Morti-morbilidad

• Costos• Salud

poblacional

Adiós Bacteriemias

Reduce the rate of CLABSI in Latin American ICUs by 50% from local baseline

by July 31, 2015

Evidence-based interventions

Knowledge sharing and

dissemination

Surveillance/measurement/fe

edback

Change packages

Model for improvement

Implementation

Measurement

Data reporting

Virtual

Adoption and adaptation of central line insertion and

maintenance bundle

Implementation guidelines

Measurement guidelines

Online platform

Learning sessions

Checklists

Checklists to assess compliance with insertion and maintenance

bundles

AIM

PRIMARY DRIVERS SECONDARY DRIVERS SPECIFIC CHANGES TO TEST

PDSA cycles

Face-to-faceLocal nodes / workshops /

conferences

Bundles of care

Posters / abstracts / newsletters / publications

Written

FeedbackContinuous and constant

feedback via email and during learning sessions

Data collection tools

Access to subject matter experts

How Many Members havePre-diabetes?

960,000

KP

members KP membership age 18-85

Preliminary CMI Analysis October 2012. Pre-diabetes defined according to ADA definition using lab values.

Copyright © 2015 Kaiser Permanente

KP diabetes burden to surge over time

13

Pre-diabetes

20121

960,000

1 – Preliminary data; CMI Analysis October 2012. Pre-diabetes defined according to ADA definition using lab values.

2 – Diabetes Prevention Research Group; Diabetes Prevention Program

3 – Preliminary data; CMI Analysis, as of March 31 2012. CORE KP HEDIS Diabetes cohort, minus expected % of Type 1 diabetes per CDC national prevalence

4 – Based on average annual medical expenditure estimates, Vojta et al, Hlth Aff, Jan 2012. Effective Interventions for Stemming Diabetes and Pre-Diabetes

New cases of diabetes by 2015

482,630

New cases of diabetes by 2022

499,200

= $3.64 B/year4

29% develop diabetes over 3

years2

52% develop diabetes over 10 years2

KP members with type 2 DM in 20123

477,383

= $3.48 B/year4

Copyright © 2015 Kaiser Permanente14

Lessons learned





Change the Balance of Power

The Old Way

Ryhov Hospital in Jönköping had traditional hemodialysis

and peritoneal dialysis center.

But in 2005, a patient, Christian, asked about doing it

himself.

The New Way

Christian taught a 73-yr-old woman how to do it…

…and they started to teach others how to do it.

Now, they aim to have 75% of patients to be on

self-dialysis

They currently have 70% of patients

The New Way

Lessons to Date

From Christian (patient):

– “I have a new definition of health.”

– “I want to live a full life. I have more energy

and am complete.”

– “I learned and I taught the person next to me,

and next to her. The oldest patient on self-

dialysis is 83 years old.”

- “Of course the care is safer in my hands.”

From Anette (nurse leader):

– Surprised at design differences between

patients, family, and staff

– Managing at 1/2 – 1/3 less cost per patient

– Evidence of better outcomes, lower costs, far

fewer complications and infections

– “We brought in the county’s employment,

helped the patients make or update the CVs,

and trained them for a new career.”

Lessons to Date

Update

Now calculated costs at 50% of costs in other

hemo-dialysis units

Complications dramatically reduced and

subsequent expensive care avoided

Measuring success by “number of patients

working”

• Agitated & violent behaviour constitutes 10% of all emergency psychiatric admissions 1

• 65,000 violent incidents (patient on staff) reported in the NHS each year 2

Violence

0

10000

20000

30000

40000

50000

60000

70000

80000

2004-2005 2005-2006 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014

Nu

mb

er o

f in

cid

ents

Number of patient on staff Violent Incidents reported in the NHS

Three times as many violent incidents occur in mental health services than other NHS services

Violence levels over the last few years…

Local Context

Service users feeling threatened

and fearful

Physical injury

Psychological: Stress, Fear, Trauma

Staff sickness

Ward team depleted

Staff leave

Morale drops

Negative feelings amongst team Changes service users

behaviour (e.g. staying in rooms

Impact…

Dread of work

Experience often resonates with

histories of abuse

Impedes recovery

Bank staff won’t take shifts on ward… Service users spend longer on ward

Staff desensitized

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

5.4

2.8

UCL

LCL0

2

4

6

8

10

12

14

16

Mar-

14

Apr-

14

May-1

4

Ju

n-1

4

Ju

l-14

Aug

-14

Sep

-14

Oct-

14

No

v-1

4

De

c-1

4

Ja

n-1

5

Feb

-15

Mar-

15

Apr-

15

May-1

5

Ju

n-1

5

Ju

l-15

Aug

-15

Sep

-15

Oct-

15

No

v-1

5

De

c-1

5

Ja

n-1

6

No.

of In

cid

en

ts

Incidents resulting in physical violence (Clerkenwell ward, Forensics) - C Chart

48% reduction

57% reduction

14% reduction

8.04

6.32

UCL

LCL

3

4

5

6

7

8

9

10

11

120

6-J

an-1

4

20

-Jan

-14

03

-Feb

-14

17

-Feb

-14

03

-Mar

-14

17

-Mar

-14

31

-Mar

-14

14

-Ap

r-1

4

28

-Ap

r-1

4

12

-May

-14

26

-May

-14

09

-Ju

n-1

4

23

-Ju

n-1

4

07

-Ju

l-1

4

21

-Ju

l-1

4

04

-Au

g-1

4

18

-Au

g-1

4

01

-Sep

-14

15

-Sep

-14

29

-Sep

-14

13

-Oct

-14

27

-Oct

-14

10

-No

v-1

4

24

-No

v-1

4

08

-Dec

-14

22

-Dec

-14

05

-Jan

-15

19

-Jan

-15

02

-Feb

-15

16

-Feb

-15

02

-Mar

-15

16

-Mar

-15

30

-Mar

-15

13

-Ap

r-1

5

27

-Ap

r-1

5

11

-May

-15

25

-May

-15

08

-Ju

n-1

5

22

-Ju

n-1

5

06

-Ju

l-1

5

20

-Ju

l-1

5

03

-Au

g-1

5

17

-Au

g-1

5

31

-Au

g-1

5

14

-Sep

-15

28

-Sep

-15

12

-Oct

-15

26

-Oct

-15

09

-No

v-1

5

23

-No

v-1

5

07

-Dec

-15

21

-Dec

-15

04

-Jan

-16

18

-Jan

-16

01

-Feb

-16

15

-Feb

-16

29

-Feb

-16

14

-Mar

-16

28

-Mar

-16

11

-Ap

r-1

6

25

-Ap

r-1

6

09

-May

-16

No

. of

Inci

de

nts

pe

r 1

00

0 O

BD

Incidents resulting in physical violence (Trust-wide, excluding Luton and Beds)per 1000 occupied bed days (OBD) - U Chart

Impact at organisation-level

150

200

250

300

350

400

450

500

550

2013 2014 2015

No

. of

Inci

de

nts

Physical violence to patients (per 100,000 occupied bed days)

300

400

500

600

700

800

900

2013 2014 2015

No

. of

Inci

de

nts

Physical violence to staff (per 100,000 occupied bed days)

25% reduction

Service user involvement in providing governance and assurance

Structures and processes

• Members of our QI Board and steering group

• Metrics on service user involvement in QI reported to the Board

• Service user steering group to oversee and support user & carer involvement

• People participation leads across every area of the organisation

Supporting the service user voice

• Stories and experiences within key meetings (eg Board)

• Service user surveys (qualitative and quantitative)

• Service user auditors

Service user involvement in improvement

Co-design and co-creation

• Two service users within the central QI team

• Co-created service user involvement strategy

• Co-design the visibility wall and joint newsletters for staff & service users

Genuine partnership

• Service users involved in QI projects alongside staff members

• Service user led QI projects starting to emerge

Staff experience and engagement

3.5

3.6

3.7

3.8

3.9

4

2010 2011 2012 2013 2014 2015

Sco

re

Overall Engagement Score

ELFT Score

National Median

3.5

3.6

3.7

3.8

3.9

4

4.1

4.2

2010 2011 2012 2013 2014 2015

Sco

re

Staff Motivation to Work

3.3

3.4

3.5

3.6

3.7

3.8

3.9

4

4.1

2010 2011 2012 2013 2014 2015

Sco

re

Staff job satisfaction

55

60

65

70

75

80

85

90

2010 2011 2012 2013 2014 2015

Sco

re (

%)

Staff able to contribute towards improvements at work

@ELFT_QI qi.elft.nhs.uk [email protected]

Lessons learned


An applied science that emphasizes innovation, rapid-cycle testing in the field, and spread in order to generate learning about what changes, in which contexts, produce improvements. It is characterized by the combination of expert subject knowledge with improvement methods and tools. It is multidisciplinary — drawing on clinical

science, systems theory, psychology, statistics, and other fields.

Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P.

(2009). The improvement guide: A practical approach to enhancing

organizational performance (2nd Ed.). San Francisco: Jossey-Bass. P.24.

QualityBetter Worse

Action taken on all

occurrences

The other way….

OBESITY PREVENTION

Plan & DoGoal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms

Sugar sweetened beverages

Water consumption

PDSA Health – Obesity preventionClassroom Centro Parvulario


A P

S D

A P

S D

Ciclo 1: Make a pitcher of water & individual cups available to children.

Ciclo 2: communicate to parents that juices and soda are no longer permitted – send home beverages sent to school

Ciclo 3: Develop simple , child-centered measurement



A P

S D

A P

S D

Ciclo 1: Make a pitcher of water & individual cups available to children.

Ciclo 2: communicate to parents that juices and soda are no longer permitted – send home beverages sent to school

Ciclo 4: Serve water with lunch

Ciclo 3: Develop simple , child-centered measurement

Ciclo 5: use plants to show scientific benefits to drinking water over soda

UCL

LCL0%

10%

20%

30%

40%

50%

60%

4/2

/12

4/3

/12

4/4

/12

4/5

/12

4/9

/12

4/1

0/1

2

4/1

1/1

2

4/1

2/1

2

4/1

3/1

2

4/1

6/1

2

4/1

7/1

2

4/1

8/1

2

4/1

9/1

2

4/2

0/1

2

4/2

3/1

2

4/2

4/1

2

4/2

5/1

2

4/2

6/1

2

4/2

7/1

2

5/2

/12

5/3

/12

5/4

/12

5/5

/12

5/7

/12

5/8

/12

5/9

/12

5/1

0/1

2

5/1

1/1

2

5/1

4/1

2

5/1

5/1

2

5/1

6/1

2

5/1

7/1

2

% de Ninos q Trajeron Jugo -- Centro ParvulariaPercent

UCL

LCL

0

0.5

1

1.5

2

2.5

4/2

/12

4/3

/12

4/4

/12

4/5

/12

4/9

/12

4/1

0/1

2

4/1

1/1

2

4/1

2/1

2

4/1

3/1

2

4/1

6/1

2

4/1

7/1

2

4/1

8/1

2

4/1

9/1

2

4/2

0/1

2

4/2

3/1

2

4/2

4/1

2

4/2

5/1

2

4/2

6/1

2

4/2

7/1

2

5/2

/12

5/3

/12

5/4

/12

5/5

/12

5/7

/12

5/8

/12

5/9

/12

5/1

0/1

2

5/1

1/1

2

5/1

4/1

2

5/1

5/1

2

5/1

6/1

2

5/1

7/1

2

N Vasos de Agua Tomados por Ninos PresentesRate



Sugar sweetened beverages

Water consumption

Diffusion of Innovations

Everett M Rogers

Diffusion of Innovations

Everett M Rogers

• Relative advantage• Compatibility with current

system • Simplicity• Testability• Observability - ability to

observe the idea and its impact

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,

and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

High-Impact Leadership:Improve Care, Improve the Health of Populations, and Reduce Costs

New Mental ModelsHow leaders think about challenges and solutions

Swensen, Pugh, McMullan, Kabcenell. High-Impact Leadership: Improve Care, Improve the Health

of Populations & Reduce Costs. Institute for Healthcare Improvement; 2013. Available: www.ihi.org.

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,

and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

III. IHI High-Impact Leadership FrameworkWhere Leaders Focus Efforts

High-Impact Leadership BehaviorsWhat leaders do to make a difference

Swensen, Pugh, McMullan, Kabcenell. High-Impact Leadership: Improve Care, Improve the Health

of Populations & Reduce Costs. Institute for Healthcare Improvement; 2013. Available: www.ihi.org.

Newcastle University. Anthrozoos, Berg Publishing. November 27, 2008

Keltner. Psychological Review. Goleman. Harvard Business Review. Dec 2013. Rise in ranks and gain power, their ability maintain personal connections suffers psychic attrition. focus their gaze less on lower-ranking staff more likely to interrupt and monopolize conversation

1) GoalsAim Statement

2) Content TheoryDriver Diagram or ChangePackage

3) Execution TheoryLogic Model

4) Data Measurement & LearningMeasurement Plan

5) DisseminationDissemination & Spread Plan

Five Core Design Components

1) GoalsAim Statement

2) Content TheoryDriver Diagram or ChangePackage

3) Execution TheoryLogic Model

4) Data Measurement & LearningMeasurement Plan

5) DisseminationDissemination & Spread Plan

1. What are we trying to accomplish?

3. What changes will we make that will result in

improvement?

2. How will we know that a change is an improvement?

The Model for ImprovementFive Core Design Components &

NEW PUBLIC MANAGEMENTTargets, sanctions, inspections

QUALITY IMPROVEMENT

MOBILISING SOCIAL ACTION

Ou

tcom

es

Time

Getting to the Third Curve

Sharing power

Keeping power

Ceding power

Lessons learned





Adoption Mechanisms

Set-up Build Scalable Unit

Test Scale-Up Go to Full-Scale

Support Systems

Phases of Scale-up

Leadership, communication, social networks, culture of urgency and persistence

Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up,

sustainability

Ghana Fives Alive

Phases of Scale Up

• Introduction of a new evidence based intervention for

system-wide scale-up

OR

• Adaptation and Scale up of a successful innovation in

one part of the system to the rest of the system

1 Patient, health professionals and community

buying in

2 Redesign care processes for pregnant women

2.4.1 Establish some indicators to follow-up the care for pregnant women

2.4.2 Establish, implement protocols for C-sections

Primary drivers Change conceptsAim

Promoting Healthier Moms and Babies by

achieving 40% of Natural Child Birth

among Unimed Jaboticabal’s (UJ) clients by August

2013 (Phase I)

2.1.4 Pre-natal > 36 weeks should be performed by the team in the hospital

2.1.1 Deliveries should be performed by OB hospitalist and nurses

3 Payment reform

1.1 Educate and engage families for the new model based on natural birth

2.1 Team care

2.2 Better care transition design

1.1.1 New educational program: new delivery care flow and natural birth

3.1 .2 Financial incentives for natural birth

3.1 Payment based on quality

Secondary drivers

2.5 Improve experience of pregnancy, specially the first one

3.1.1 OBs will be paid on monthly (not fee-for-service)

2.5.1 Offer analgesia for natural delivery when asked by the mother

2.3.1 Establish the flow in the hospital

1.2 Educate and engage health professionals for the new model based on

natural birth

1.2.1 Educational programs with providers with the best performance

2.5.2Natural delivery: episiotomy when recommended, no fasting, no trichotomy, no

fleet enema

2..4.3 Protocols for prenatal care

1.3 Educate and engage community in the new model

1.3.1 Educational sessions with medical and mother associations, government

organizations

2.1.2 Nurse new role in the new care delivery model

2.1.3 Pediatrician new role in the new model

2.3 Redesign the new model based on the experience of patients and caregivers

2.3.2 Patient centered prenatal care

2.4 New care delivery based on evidence

2.4.4 Protocols on labor induction

Jaboticabal experience: its possible

Phases of Scale Up

• Establish Aim, theory of change, basic measurement strategy

• Analyze existing programming strategies and protocols, and

assemble best practices (expert group)

• Collect baseline data

• Engage with stakeholders (leaders, managers, frontline staff,

patients, communities) - understand their roles and contributions.

• Build will with leadership

• Identify prototype test sites, early adopters, and potential

“champions”

85

~20

• Morti-morbilidad

• Costos• Salud

poblacional

De 20% a 40% de partos vaginales en 18 meses. 26 hospitales

October

Phases of Scale Up

• Scalable unit: an administrative unit that is replicated

across the system you are trying to scale-up

• Includes similar key activities, players and support

systems that are found across the system you are trying

to scale up.

• Prototype and intensive testing phase

• By the end of this phase will have demonstrated results,

generate a set of context-sensitive interventions for testing

on a broader scale (“change package”)

Maximización del tiempo instruccionalMeta : Que todas las salas logren un promedio de 60 minutos o más de actividades

instruccionales de lenguaje por día, al menos 4 meses del año.

Indicadores: Tiempo dedicado a actividades instruccionales de lenguaje por día (N minutos).

Instrumento: calendario, auto-reporte de las educadoras

Interacciones efectivasMeta: Lograr un nivel medio (4) o más en cada dominio del CLASS: en apoyo emocional,

organización del aula, apoyo pedagógico, cada mes.

Ninguna sala termina con menos de un 4 en apoyo emocional y organización del aula, y un 3.25

en apoyo pedagógico.

Indicadores: puntajes CLASS

Instrumento: pauta de observación CLASS mensual/CLASS video completo.

Asistencia permanente de los niños (as)Meta: Disminuir el % de niños q faltan 2 días o más en la quincena con respecto a los datos de

2014.

Indicador: número de niños que faltan dos o más días en una quincena.

Instrumento: planilla registro asistencia

DIAGRAMA CONDUCTOR 2014-2015

OBJETIVO¿Qué queremos lograr?

Aumentar los niveles de

logro en vocabulario,

comprensión oral y

escritura en la evaluación

de lenguaje 25% (Marzo –

Junio) y otro 15% (Junio –

Noviembre).

Ningún niño/a lograra

menos de 70% al fin de

año.

Indicadores: Porcentaje

de logro evaluación

Lenguaje.

www.fundacionoportunidad.cl

UN BUEN COMIENZO - CHILE

UBC : COMUNAS AS SCALABLE UNITS

Niños UBC

Niños en grupo

comparación Identificación

de letras y

palabras

DictadoComprensión

de textos

Diferencia en desarrollo de lenguaje de niños UBC versus grupo de comparación

8 meses 14 meses 16 meses

Phases of Scale Up

• Test and further develop preliminary change

package in a broader range of contexts

representing the predicted full-scale

environment

Innovation, adaptation, adoption

innovation

adaptation

adoption

Methods deployed at each phasePhase Set-up Build Prototype Test Scale-up Go to Full-scale

and Sustain

Methods Surveys

Brainstorm

Expert

meetings

Scans

Site visits

Interviews

Model for

Improvement

Collaborative

learning (e.g.,

adaption of

BTS)

Model for

Improvement

Deployment

and

refinement of

change

package

Site redesign

Collaborative

learning

Change

agents

Model for

Improvement

Extension

agents

Affinity groups

Collaboratives

Wave sequence

Site re-design

Campaigns

Executive

mandate/policy

Hybrid

approaches

Phases of Scale Up

• Rapid deployment phase - well-tested set of

interventions are deployed at large scale,

adopted by frontline staff.

• Focus on replication and sustainability

National hub (Einstein and IHI supporting; ANS

endorsing)

Cohort hub

Cohort hub

Cohort hub

Cohort hub

Cohort hub

Cohort hub

Cohort hub

Cohort hub

Hospital team Hospital

team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

Hospital team

2017-2018: 100-150 hospitals (25 public)New aims, strong theory of change and change package

2018-2020: National Campaign

Adoption Mechanisms

• Included in all phases but most emphasis is in rapid deployment phase - well-tested set of interventions are deployed at large scale, adopted with minimal further adaptation by frontline staff.

• Focus on replication and sustainability

• Strong reference to leadership, social networks, communication and attributes of the intervention (IHI’s Spread Framework)

• Culture of urgency and persistence

• Reference to other frameworks (e.g. Mayo “managed diffusion”, Kaiser “spread toolkit”)

Support Systems

• Build human capability for scale-up . – Leadership team to guide the process

– Reference to 5x thinking framework – phased training from volunteers to trained, dedicated improvement specialists

– QI-based programs for those who need additional training. (start before scale-up begins).

– QI teams

• Build infrastructure for scale-up: – Balance targeted resource addition vs system redesign.

– reconfiguration of existing resources (e.g., examination room design, lab needs, data system infrastructure)

– additional tools (e.g., checklists, data capture systems),

– communication tools, and

– key personnel (e.g., data capturers, quality improvement mentors)

• Build reliable data collection and reporting systems– track and provide feedback on the performance of key processes

– Data systems for improvement vs monitoring

• Develop learning systems:– Mechanisms for collecting, vetting, and rapidly sharing change ideas or interventions.

Readiness for Scale: looking ahead

We have a set of best practices or tested change ideas that are ready test or

spread to the sites of the next phase of work.

We have a compelling theory of change.

We can show the evidence base for our theory from previous studies and/or we

have resultsthat show how the theory has been applied to our own

improvement work.

If we are testing scale or going to full scale, improvement has been sustained in

the sites where we are currently testing or implementing changes

We have identified test/implementation sites most likely to adopt a new

approach for the next phase of the work.

TOTAL Next Phase of Scale-up Score

Compared to other programs and initiatives, the community that we are

planning to scale-up into (adopter community) regards the improvement

initiative as a top priority.

The adopter community shares a sense of urgency in closing the gap in

performance or outcomes around our main aim.

The adopter community/organization recognizes the benefits of participating in

this improvement initiative.

The adopter community believes the approach we are advocating will reach our

goals faster relative to other initatives.

The adopter community understands that the approach we are advocating is

simple to understand, easy to try out and easy to measure.

The improvement approach we are advocating aligns with the culture and

values of our community/organization.

Leaders and champions of the adopter community have been identified and

have shown a willingness to advocate for the improvement intiative in their

community.

TOTAL Adoption Mechanism Score

Adequate human capacity (resources, dedicated time, seniority) is available to

support the scale-up of improvements across the community/organization.

Adequate improvement capability exists to support the planned work of the

next phase.

Capability exists in managers and leaders to facilitate the changes required for

improvement.

Health and care workers across our community/organization see improvement

and scale-up work as an integral part of their daily work.

Data collection and reporting tools are available for scale up.

Other anticipated resources are/will be available to undertake this work.

A learning system exists to spread knowledge from improvement initiatives

systematically across the organization; i.e. learning loops back into quality

planning.

TOTAL Support Systems Score

Support Systems

Adoption

Mechanism

Next Phase of Scale-

Up

Readiness for Scale: Adoption Mechanisms






improvement work.





















community.





next phase.


improvement.







planning.


Support Systems

Adoption

Mechanism


Up

Readiness for Scale: Support Systems






improvement work.





















community.





next phase.


improvement.







planning.


Support Systems

Adoption

Mechanism


Up

Norms

Good luck

Pedro DelgadoHead of Europe and Latin America

Institute for Healthcare [email protected]

@pedroIHI


The role of connected health technology

within the new National Children’s Hospital

& The cultural landscape challenge of

implementing the country’s first paperless

hospital

MAKE

HEALTHCARE

GREAT AGAIN

How to manage patient deterioration. The

Qatar Early Warning System (QEWS)

A Lesson in Large Scale

Transformation

Lessons

• Large scale change

• How to align with small scale change

• How to balance paper vs. paperless solutions

Context

• Population 2.6 million; increasing >10% annually

• 1.2 bed/ 1000 population

• Hierarchical culture

• >100 nationalities employed-25,000 Staff

• Ambitious vision

– 6 new hospitals in 2016-19

– Multiple accreditations (JCI, Magnet, CAP, ACGME)

– Cerner implementation

– Academic Health System

– Qatarisation

Deteriorating patient

Patient

Condition

Time

Clinical

Review

Prevention

(excellent care)

ALS

Rapid

Response

Death

Slippery Slope of Deterioration

OBSERVATION

CHART

Adapted from Between the Flags, Education Strategy& Implementation Guide 2012

4 components to a successful Rapid Response

System

Afferent Limb

Identify Clinical

Deterioration

Efferent Limb

Response

including both

team and

equipment

Quality

Improvement;

data & audit

Governance & Leadership

Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011 Jul 14;365(2):139–46.

Challenges to Implementation

• Cultural

• Logistical

• Political

• Anthropological

• Social

• Technical

• Medical

• Financial

5 Elements of the Qatar Early Warning System (QEWS)

Governance

Standard Calling Criteria

Deteriorating Patient Response

System

Education Evaluation

Clinical ReviewRapid Response

Key Performance

Indicators

Observation Charts

Awareness Recognition &

Response ALS

Policy and Governance Plan

Adapted from Between the Flags, Education Strategy& Implementation Guide 2012

Charts and Standard Calling Criteria

• Appropriate tool chosen by senior clinicians

across HMC

• Based on Between the Flags from New South

Wales

• Charts tested on small scale across HMC in

various units using PDSA approach and

modifications made

Rapid Response Teams

1. Each facility must identify its team members

and its system to call them

2. Most use their code team, but at least one has

developed a 24/7 nurse led team

3. Identify scope of service

Education

Level 1

eLearning

Bedside Teaching (Nursing)

>11000 completed

>90% completed across all facilities

Level 2

ALERT or equivalent

Training of frontline clinical staff on-

going

Level 3

Advanced Life Support

Prioritization of training for RRT

members without ALS certification

on-going

Evaluation

• 3 corporate (mandatory) metrics

1. Cardiac arrest rate

2. Rapid Response activation rate

3. On line education

Cerner

Cerner Solution

YELLOW Zone: High and Low Thresholds

Millennium View

RED Zone

Note: Figures in RED color

signifies LOW and HIGH Red

Zone values

RED Zone: Low and High Thresholds

Outcomes

Anecdotes

• “I feel safer”

• The chart has made my job easier (ED

consultant)

• “There has been a culture change” (ED Nursing)

Brought to you by Hamad Healthcare Quality Institute

• 52% reduction in

cardiac arrest rate

• Equates to > 500

deaths averted per year

across Qatar

• Rapid Response Team

activation rate is a

world class standard

Results

Lessons Learned

1. Large scale improvement initiatives can demonstrate rapid results

2. Agree principles and allow local variations

3. Taking a systems approach is critical

4. Aligning internal stakeholders and resources

5. Clinician engagement (nurse, doctor, RT) is essential

6. Alignment with organizational strategy, accreditation and external initiatives

Acknowledgements

• Managing Director – Dr. Hanan Al Kuwari

• MARA – Prof. Michael Richmond, Dr. Hans Kerkkamp, Mr. Ross MacDonald

• Chief Nursing Officer - Prof Ann Marie Cannaby

• HHQI – Dr. Charles Pain, Ms. Minara Chaudry, Dr Adeel Butt, Mr. Colin Hackwood, Dr. Madonna Andaya, Ms. Ana Jimena, Mr. Mark Agramon, Mr. Glenn Giducos, Ms. Catherine Jamias, Mr. Dieter Burckhardt

• Steering Committee –Dr. Yousuf Khalid Al Maslamani (Chair), Prof. Alison Robertson, Ms. Michelle Hill, Ms. Judith Nelmes, Ms. Catherine Gillespie, Dr. Badriya S. Al Ali, Ms. Linda Peters, Ms. Susan Yates, Mr. Talib Hussain Yaseen, Dr. Ibrahim Mohd. Fawzy M A Hassan, Dr. Alejandro Kohn Tuli, Ms. Patricia Mary Colgan, Ms. Minara Chowdhury, Dr. Khalid A Noor A.M. Saifeldeen, Dr. Abraham Emanuel Marcus, Anne Elizabeth Topping, Dr. Ali Sanousi

• Project Team – Dr. Mylai Guerrero, Ms. Khawla Athamneh, Mr. Awad Amayreh, Ms. Shasiya Kandoth

Acknowledgements

• Maternity EWS – Dr. Huda Saleh, Dr. Najah Mohammad Ali, Dr. Shamsa Ahmad, Dr. Mahmoud Fuad Abu Jubara, Dr. Mohamed Ibrahim Amin Alloub, Dr. Hussein Attia Sharara, Ms. Faiza Youssef A. Bahnas, Mr. Hector Roche Molina, Ms. Yolennis Martinez Fajardo, Ms. Tamara Salama Fady Al Shdafat, Ms. Eufemia Asoy Ongo

• Pediatrics EWS – Dr. Mohammad Shariff Al Janahi, Dr. Najeh Khalid, Dr. Adiba Hamad, , Dr. Magda Youssef, Ms. Fiona Riordan, Ms. Leena Varghese, Ms. Nagwa Ahmed BabikirMohd

• Neonatal EWS – Dr. Ghassan Abdo, Dr. Fouad Ghanem

• ED EWS – Dr. Stephen Hodges Thomas, Dr. Dominic William Jenkins, Dr. Kaleelullah Saleem Farook, Dr. Yogdutt Sharma, Mr. Andrew James Frazer

Acknowledgements

• Facility – Ms. Colene Yvonne Daniel, Ms. Justine Lara Waywell, Mr. Wilson Ross, Dr. Mahmoud Heidous, Mr. Philip Lowen, Ms. Elizabeth Ann Thiebe, Mr. Mohamed Al-Jusaiman, Prof. Abdulbadi AbuSamra, Dr. Amal Abousad, Dr. Hanadi AlHamad, Dr. Hani Al Kilani, Dr. Hilal Al Rifai, Prof. David Barlow, Mr. Glenn Ocampo, Mr. Ali Naimat, Mr. SeglaClaude Raymond Tro, Dr. Rahma Salim

• Critical Care Network – Mr. David John Selwood, Dr. Abdulsalam Saif, Dr. Ahmed Lutfi, Dr. Faisal Malmstrom, Mr. Maged Al Hijah

• CIS - Dr. AbdulWahab Abubaker Al Musleh, Dr Ali Amer Al Sanousi, Mr. Rida Miladi

• HICT- Mr. Grant Goodman, Dr. Kiran Hegde, Dr. Wafik Awni Musbah Sakallah, Mr. Shameer Sam, Mr. Clive Leslie Gibbons

• Cerner- Mr. Russel Mayne, Ms. Lisa jones, Mr. Baha Sayiner, Mr. Tyrone Jackson, Nursing Education- Prof Annie Topping, Tawfiq Abd Elqader

• Hamad International Training Center- Dr Khalid Abdul Noor, Mr John Tobin

• Medical Education- Dr Abdulatif Al Khal, Dr Mohammed El- Tawil, Banan Al- Arab, Amal Shaban Al Thlatheny, Zehra Mazhar, Dr Dabia Al Mohannadi, Dr. Ahmed Badar, Dr Baha, Dr Suresh

• Nursing Informatics- Dr. Wasmiyah

• Medical Records- Richard Browne

eHealth Ireland:

Reflections on scaling eHealth

[email protected]

Chief Information Officer – Health Service Executive - Ireland

Chief Executive Officer – eHealth Ireland

eHealthIreland.ie| @eHealthIreland @R1chardatron

Delivering eHealth Ireland | Office of the Chief Information Officer 2

In 673 days you can see a lot…

Reflections take a little longer to

understand…

Delivering eHealth Ireland | Office of the Chief Information Officer

The IT strategy question?

Cross

Setting

Information

Integration

Electronic

Health

Records

National

Support

Systems

Care

Delivery

Enablement

Integrated, Patient Centric,

Efficient Care Delivery

Health

Service

Insights

Knowledge & Information Delivery Transformation

Clinical & Information Governance

Knowledge & Information Plan

3



Connected Health



CULTURAL DIFFERENCE AND THE IMPACT ON THE CREATION OF A DIGITAL FABRIC…


“To improve population

wellbeing, health service

efficiencies and economic

opportunity enabled by

effective and innovative digital

solutions.”

eHealth Ireland Vision



• Over 200 Members

• Core principle to have NO

technology projects

• Successful delivery

requires clinical leadership

• Integrated care only

possible with digital

change as a catalyst

• Ireland wide benefits

Clinical Leadership

10


Epilepsy

• Investment €1.2M

• First instance of epilpesy geonomic

sequencing being included in an EHR

• 90 Lives lost in 2015

• €5m a year to be saved in 2017

Haemophilia

• Investment €1M

• Irelands first health care supply

chain management solution deployed

to patients homes

• Over €20m saving in first 3 years

Bipolar Disorder

• Investment €0.8M

• Patient mobile access to electronic

health record and ‘mood recording’

• Hackathon approach supporting

innovation and jobs

Projects - LightHouse

11


The IHI will use personal data to accurately identify a specific

individual, this data will include;

Projects - Success

12


• Replace 75 current systems

• Q1 2017 is Go live at St James

• Complete implementation by Q4 2019

• Replace or create all (17) maternity

hospital systems

• Go live Cork 3rd December,

Kerry – Q1 2017.

• 47,000 new digital identities and an additional 10,000 staff

given access to a digital device by Dec 2016

• Ireland is now the first EU member state to have a Cloud First

Policy in Health

Projects – End 2016

13



Starting point…


Moving from paper records

locked in organisations to a

digital patient record shared

across care settings

4 Components

Examples:

• Order Communications /

Results Reporting

• Medicines Management

• Clinical Notesstems

Examples:

• Single MPI

• Scheduling

• Clinical Notes / Records

• Screening & Surveillance

National

Shared

Record

Community

Operational

Systems

Acute

Operational

Systems

Individual Health Identifier

The “glue” that binds all this together

and maintains integrity and security

across the system

eHealth Blueprint

National EHR Registries and Domains

Stakeholders

Clinical Management / Point of Care Environment

National EHR Integration and Access Layer

Communication Layer

Core Capabilities

I.A.A.A.Layer

Pro

vid

er H

ealt

h P

ort

al

National EHR RegistriesClient Registry Provider Registry Location Registry

National EHR DomainsMedical Imaging Laboratory Results Pharmaceutical

HistoryClinical Document

RepositoryEncounter History

Message Queuing

Message Data & Transformation

Message Encoding

Service Management

Identity Management

Authentication Access Secure Audit

Single Sign On Exception Handling Context Management Terminology ServicesRecord Locator Services

Orchestration ETL PrivacyCertification and Integration Toolkit

Secure Messaging

Logging

Immunization History

Infectious Disease History

National AnalyticsPerformance Management

Population Based Analytics

Business Intelligence

Registration

National eHealth Blueprint

Healthcare Providers Patients Corporate Administrators and Managers

Legitimate Relationship Services (LRS)

Corporate Setting

Fin

an

ce M

an

age

me

nt

Pro

cure

me

nt

Hu

ma

n R

eso

urc

es

and

P

ayro

ll M

anag

eme

nt

Ass

et M

an

age

me

nt

Hea

lth

& S

afe

ty

Co

ntr

act

Man

age

men

t

Faci

litie

s M

ana

gem

ent

Ro

ste

rin

g Ti

me

Re

cord

ing

Pro

gram

Man

age

me

nt

Cu

sto

mer

Re

lati

on

ship

M

ana

gem

ent

Consumer Health & Wellbeing

Pat

ien

t to

Pro

vid

er

Secu

re M

ess

agin

g

Self

-Hea

lth

M

ana

gem

ent

Sch

edu

ling

and

A

dm

inis

tra

tio

n

Nat

ion

al P

atie

nt

Po

rtal

Vir

tual

Car

e

Edu

cati

on

&

Aw

are

ne

ss

Community Healthcare Organisations

Pat

ien

t A

dm

inis

trat

ion

Ca

se M

anag

em

en

t

Elec

tro

nic

Do

cum

ent

Man

age

men

t

Clin

ical

No

tes

and

Re

cord

s

Pat

ien

t T

est

Re

sult

s

Ca

re P

ath

way

s an

d D

eci

sio

n

Sup

po

rt

Ref

err

al M

ana

gem

ent

Mo

bile

Clin

ical

Ma

nag

em

en

t

Po

pu

lati

on

He

alth

M

ana

gem

ent

Co

mp

ute

rize

d P

hys

icia

n O

rde

r En

try

eP

resc

rib

ing

Hospital Groups

Ho

spit

al P

atie

nt

Ad

min

istr

ati

on

Ho

spit

al M

ed

ical

Imag

ing

Ho

spit

al L

abo

rato

ry

Ho

spit

al P

har

ma

ceu

tica

ls

Ca

se M

anag

em

en

t

Dis

ease

Man

age

me

nt

Ca

re P

ath

way

s an

d D

eci

sio

n

Sup

po

rt

Co

mp

ute

rize

d P

hys

icia

n O

rde

r En

try

Ref

err

al M

ana

gem

ent

Po

pu

lati

on

He

alth

M

ana

gem

ent

Elec

tro

nic

Do

cum

ent

Man

age

men

t

eP

resc

rib

ing

Elec

tro

nic

Clin

ical

No

tes

and

R

eco

rds

The Individual Health Identifier

Programme is a key enabler that

allows information to be shared about

a patient

PharmacyGP Systems

Private

Hospitals

Other healthcare providers will

access and contribute to the National

Shared Record through the

Integration Capability

EHR Programme


5 Years 10 Years

Cri

tic

al Ta

cti

ca

l

So

luti

on

sIn

no

va

tive

Sp

ec

iali

st

So

luti

on

s

National Solutions

PAS

Replacement

Initial National Shared

Record

Haemophilia

Lighthouse Project

Epilepsy

Lighthouse Project

BiPolar Lighthouse

Project

Portal

(Organisation)

Other Future

Innovation Projects

Order/Comms

Other Future

Innovation Projects

NCH Implementation

eDischarge

Single

Solution Set

Evolving to a single

solution set will require

agility and a governance

approach that supports a

dynamic environment

Other Future

Innovation Projects

National Shared Record Development

MEDLis

MN-CMS

MOCIS

Acute Operational Components – Phased Implementation in HG’s

Community Operational Components – Phased Implementation in CHO’s

NIMIS

National Solutions

ePharmacy

eRefferal

10 Year Route

17


10 Year Route

18



Digital Answers

20

Hospital PAS

SMS

ReminderDischarge

Note/Summary

Integrated Referral Management – Group/Region

Advice

Guidance

Electronic

Triage

Business

IntelligenceAppointment

Management

Waiting List

Data

Patient Portal GP System

Guidelines

& CDSS


Priorities



Person Centred


Get in touch

Richard [email protected]

@R1chardatron

@eHealthIreland

Yvonne [email protected]

@GoffHickey

@CCIO_IRL

Documents

Scaling Connected Health lessons in …...Incidents resulting in physical violence (Trust-wide, excluding Luton and Beds) per 1000 occupied bed days (OBD) - U Chart Impact at organisation-level