Senior Leadership and Direct Service Providers Team Up for Improving Patient Care
November 6, 2006Phil Hassen, Dr. Peter Norton, and Dr. Ward Flemons
Campaign To Continue Beyond December 2006
Moving forward with implementation, spread and measurement beyond December 2006
Phil Hassen, CEO Canadian Patient Safety Institute
Campaign Structure
Partner Network
Peer SupportNetwork
CAPHC
Measurement Working Group & CMT Education & Resource
Working Group
Clinical Support
Canadian ICU Collaborative
ISMPCanada
Operations
Teams
Other Canadian Faculty
Communication Working Group
Atlantic
NodeOntario
Node
Western Node
Campaign SupportSHN National Steering Committee
Secretariat - CPSI
Patients
CCHSA CIHI
Quebec
Node
IHI
Teams Continue to EnrollSaferhealthcare Overview Total # Enrolled Teams
September 2005 to November 2006
118
296
403443
491
535
0
100
200
300
400
500
600
Total # of Teams EnrolledTeams
Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Oct-06
Safer Healthcare Now! Enrollment by Province & Territory
Province/Territory Number of Teams
New Brunswick 23
Newfoundland 13
Nova Scotia 46
Prince Edward Island 0
Quebec 9
Ontario 240
Alberta 51
British Columbia 98
Manitoba 36
Northwest Territories 1
Saskatchewan* 17
Yukon 1
Total 535As at November 2, 2006
Push Towards December 2006Why?
• Measurement and reporting are integral to demonstrating at the local, nodal and national levels that it is possible to achieve and sustain improvements in the safety of patients within the Canadian health system.
*64.1% of enrolled organizations across Canada have submitted their data to the Central
Measurement Team.
Goal:• Broaden the Campaign’s reach and impact later next
year through the incorporation of new interventions that impact other healthcare settings in addition to acute care.
Pan-Canadian Survey• Purpose:
• Determine how many teams intend to submit data by December 2006
• Identify key challenges/barriers that maybe hindering teams
• Use the feedback to develop a targeted campaign of support strategies to assist teams
• Response rate - ~ 41% (156 respondents, representing 208 teams)
Pan-Canadian Survey Results
• Lack of time/resources for data collection 86.2%
• Lack of staff engagement 41.5%
• Lack of internal QI knowledge and technical skill to submit measurement forms 30.8%
• Other (e.g. insufficient population base, ongoing resource challenges) 29.8%
• Insufficient senior management/clinical leadership support 21.2%
Top 5 barriers/challenges identified by teams:
Pan-Canadian Survey Results
• Workshops (e.g. hands on sessions with concurrent tools & data collection, spread strategies) 82.6%
• Tools to facilitate internal communication (e.g. aimed at Senior management, front line staff) 63.8%
• Teleconferences (e.g. spread strategies, including internal QI capability) 60.9%
• More information on the Community of Practice (e.g. sample concurrent data collection tools) 39.1%
• Facilitate access to the Safety Improvement Advisor 30.4%
Top 5 Responses to: “which resources would you find helpful?
Phil Hassen
Canadian Patient Safety Institute
Suite 1414, 10235 – 101 Street
Edmonton, AB T5J 3G1
(780) 409-8090 or 1.866.421.6933
For additional information please contact:
Debbie Barnard, SHN Project Manager @ [email protected]
www.patientsafetyinstitute.ca
A story – SSI in the Calgary Health Region
Dr. Peter Norton
University of Calgary
SSI – Calgary Health Region
• 3 adult urban acute care sites
• Antibiotic timing project not sustainable
• Focus on total joints to begin
• Correct timing tended to be 30% or less
• Process measures vs. outcome measure
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aug n=12 Sept n=7 Oct n=13 Nov n=19 Dec n=20 Jan n=25 Feb n=175 Mar n=237
Per
cent
t
Target
27%
0%
92%
84%
90%88%
93%95%
Month
'On Time' Antibiotic - All Total Joints PLC - Calgary Health Region
'If you cannot MEASURE it, you
cannot IMPROVE it'.
Lord Kelvin, International Electrotechnical Commission’sfirst President (1906)
How good is our health care system?
What is the “Defect Rate”?
Key Numbers from the Canadian Adverse Events Study
• The overall AE rate found in the study was 7.5% [CI 5.7 -9.3] – this means 1 in 13 adult hospital patients in year 2000 experienced an AE
• 2.8% of patients had one or more preventable AEs [CI 2.0 – 3.6] (i.e. 37.3% of AEs are preventable)
• Preventable AE rates were the same across the 3 hospital types
• An estimated total of 1.6% of people hospitalized in Canadian hospitals in 2000 had an AE and died [CI =0.9 to 2.2%] or approximately 16,000 per year [CI= 9250 to 23, 750]
• Assuming an average LOS of 3.5 days and 95% occupancy, then a 500 bed Canadian hospital would have an average of 100 preventable AEs per month
Defect rate of 25%+
Health Quality Council of Saskatchewan, 2004
Ambulatory Care
• In 2004 Manitoba researchers lead by A. Katz used administrative data in a study
• They measured the proportion of eligible patients received 13 types of recommended care in the Winnipeg Health Region
• Only 37% of diabetics saw on ophthalmologist or optometrist the last year
• Only 35% of patients with a 30-day supply of anticoagulants who at least one blood clotting test in 45-daysA. Katz, et. al. Using Administrative Data to Develop Indicators of Quality in Family Practice. Winnipeg: Manitoba Centre for Health Policy, 2004. http://www.umanitoba.ca/centres/mchp/reports/pdfs/quality_wo.pdf
What do the Citizens say?
• 2004 Commonwealth Fund International Health Policy Survey in Australia, Canada, New Zealand, the United Kingdom, and the United States
• Adults
• 1400 per country and 3061 in the UK
Schoen C, et. al. Primary care and health system performance: Schoen C, et. al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood). 2004 adults' experiences in five countries. Health Aff (Millwood). 2004 Jul-Dec;Suppl Web Exclusives:W4-487-503.Jul-Dec;Suppl Web Exclusives:W4-487-503.
Rank 1 is best, 5 is worst
Australia
CanadaNew
ZealandUK US
Patient Safety 2.5 4 2.5 1 5
Patient-Centerednes
s2 3 1 5 4
Timeliness 2 5 1 4 3
Efficiency 1 4 2 3 5
Effectiveness 4.5 2.5 2.5 1 4.5
Equity 2 4 3 1 5
Slide from Don Berwick August 2005
The Goal is Clinical Effectiveness
• "The best possible Health Care"
• An environment where all patients can consistently say:
• "I got exactly the care I was in need of exactly when I needed it!"
Clinical Effectiveness- Definition
Evaluating and improving health care delivery and enhancing patient outcomes through the collaborative application of best available clinical evidence
Identifying the most appropriate, ethical and cost-effective means of providing health care services
Compliance-Driven Quality Management
• Reactive in nature• Designed to meet standards• Clinicians often not engaged in process• Clinician leadership not essential• Indicators become the goal• Difficult to sustain clinical improvement over
time & across organization
Patient-Centered Clinical Effectiveness
• Proactive in nature• Evidence-based foundation• Clinicians actively engaged in process• Clinician leadership critical to success• Best and safest care as the goal, indicators as
markers of success• Sustainable improvement over time and across
organization
Achieving Clinical Effectiveness
“This time, like all times, is a very good one, if we but know what to do with it”
- Ralph Waldo Emerson
Safer Healthcare Now!
• Implementation of six targeted and proven interventions in hospital based patient care
• Credible evidence that these six interventions can make a real difference in reducing avoidable adverse events and lead to reduced mortality and morbidity
• All are ‘low tech’
The Interventions
• Deployment of Rapid Response Teams
• Delivery of reliable, evidenced based care for acute myocardial infarctions
• Prevention of ADEs
• Prevention of central line infections
• Prevention of surgical site infections
• Prevention of ventilator- associated pneunomia
Eg. Surgical Site Infections
• Four specific activities– Don’t shave the skin but clip the hair– Make sure prophylactic antibiotics are given
(and stopped) on time– Carefully monitor and control the blood sugar
during the operation– Carefully monitor and control the body
temperature during surgery
Key Campaign Principles
• “Some is not a number; soon is not a time.”
• Welcome anyone at any level.
• We do this together (i.e. we are forming ‘communities of practice’)
Some successes
• Several organizations with no VAP for six months
• Several pediatric hospitals with no CL infections for six months
• Early indications of reduced mortality in the ICUs of several hospitals
Why Participate in SHN?“To not participate is not an option, It is not about spending additional
health care dollars, rather it is about our obligation to provide a safe clinical experience for the patients who walk through our doors and put their trust in us.” David Rowe, Senior Vice-President, Credit Valley Hospital, Ontario.
“The SHN has provided us with leadership and coordination of the interventions. As well, there has been excellent information sharing and collaboration with those participating in the interventions within and across the nodes.” Kim Cook, Vice-President of Patient Services & Chief Nursing Officer, Headwaters Health Care Centre, Alberta.
Organizational Leadership & Accountability
W. Ward Flemons MD FRCPC FACP
Vice-President
Quality, Safety & Health Information
Strategy for Quality
Quality Assurance Quality Improvement
StructuresProcesses
Every system is perfectly designed to produce the results that it gets.
If you want improved results you must redesign the system.
Paul Batalden / Don Berwick
SAFETY FRAMEWORK
ORGANIZATIONAL STRUCTURE
LEADERSHIP / ACCOUNTABILITY
RESOURCESCULTURE· REPORTING· J UST (TRUSTING)· LEARNING· FLEXIBLE
Copyright © 2005 Calgary Health Region
POLICIE
S & P
ROCEDURESCOMMUNICATION & EDUCATION
SAFETYMANAGEMENT
HAZARD· IDENTIFICATION· ANALYSIS· RECOMMENDATIONS
PERFORMANCE· MEASUREMENT· EVALUATION· RESEARCH
SYSTEMI MPROVEMENT· STRATEGIES / DESIGN· TESTING· IMPLEMENTATION
SAFETY FRAMEWORK
ORGANIZATIONAL STRUCTURE
LEADERSHIP / ACCOUNTABILITY
RESOURCESCULTURE· REPORTING· J UST (TRUSTING)· LEARNING· FLEXIBLE
Copyright © 2005 Calgary Health Region
POLICIE
S & P
ROCEDURESCOMMUNICATION & EDUCATION
SAFETYMANAGEMENT
HAZARD· IDENTIFICATION· ANALYSIS· RECOMMENDATIONS
PERFORMANCE· MEASUREMENT· EVALUATION· RESEARCH
SYSTEMI MPROVEMENT· STRATEGIES / DESIGN· TESTING· IMPLEMENTATION
QUALI TY FRAMEWORK
ORGANIZATIONAL STRUCTURE
LEADERSHIP / ACCOUNTABILITY
RESOURCESCULTURE· REPORTING· J UST (TRUSTING)· LEARNING· FLEXIBLE
Copyright © 2005 Calgary Health Region
QUALITYMANAGEMENT
OPPORTUNITY· I DENTIFI CATI ON· ANALYSIS· RECOMMENDATIONS
PERFORMANCE· MEASUREMENT· EVALUATI ON· RESEARCH
SYSTEMIMPROVEMENT· STRATEGI ES / DESI GN· TESTING· I MPLEMENTATION
Quality Management Cycle
QUALITYMANAGEMENT
OPPORTUNITY· IDENTIFICATION· ANALYSIS· RECOMMENDATIONS
PERFORMANCE· MEASUREMENT· EVALUATION· RESEARCH
SYSTEMIMPROVEMENT· STRATEGIES / DESIGN· TESTING· IMPLEMENTATION
Safer Healthcare Clinical Process Improvement Designing for Higher Reliability
OUTCOME
Process Process Process Process Process Process
Process Process Process Process Process Process Process Process Process Process Process Process
Process Process Process Process Process Process Process Process Process Process Process Process
Improved AMI Care Clinical Process Improvement Designing for Higher Reliability
AMI MORTALITY
ASA on Admission
Reperfusion(PCI / Thrombolysis)
ASA at Discharge
β Blocker at Discharge
Smoking Cessation
Counseling /Rx
ACE or ARB at Discharge(LV Dysfunction)
Process Process Process Process Process Process Process Process Process Process Process Process
Process Process Process Process Process Process Process Process Process Process Process Process
Reliability – Improving Performance Measured as the inverse of failure rate
10-1, 10-2, 10-3, 10-4, 10-5, 10-6
Example: Reliability of administering prophylactic antibiotics in surgery
Nolan T, Resar R, Haraden C, Griffin F. 2004Improving the Reliability of Health Care. IHI Innovation Series White Paper
Three Step Model1. Prevent failure
• a breakdown in operations or functions
2. Identify and mitigate failure• identify failure and intercept before harm or mitigate harm
3. Redesign• processes based on the critical failures that are detected
Three Step Model
Prevent Failure 10-1 Performance• starts with an intent to follow a uniform process or guideline
• basic standardization – common equipment / order sheets / guideline• memory aids (e.g. checklists)• feedback mechanisms (e.g. compliance with standards)• awareness raising and training
Identify & Mitigate Failure 10-2 Performance (error proofing)
• building decision aids into the system
• creating redundancy / using defaults• designing protocol into the usual workflow process• strategies to identify failures to use the process ‘Identification Trigger’• design mitigation strategies
Redesign 10-3 Performance• analysis of failures to use the standard care protocols• where is it failing and why? (failure modes and causes)• cycle of continuous quality improvement• real time measures of performance & accountability
Do Healthcare Organizations need a QI Strategy?
Where does QI fit into the agenda? Should be strategic (it’s core business)
Not off the side of someone’s desk Executive & Board Accountability
Needs to be resourced Needs to have strong leadership
Understanding of the concepts Top-down QI doesn’t work Bottom-up QI can have some short-term success Model of engagement
Sharp end (Direct Care Providers) MULTIDISCIPLINARY! Blunt end (Management)
To improve quality
document continuous improvement
(process steps)
(outcomes)
eliminate inappropriate variation
Brent James
QUALITYIMPROVEMENT
STRATEGYPERFORMANCE MEASUREMENT
BUDGETING(PBMA)
INDICATORS
QUALITYIMPROVEMENT
STRATEGY
PERFORMANCE MEASUREMENT
BUDGETING(PBMA)
INDICATORS
STRATEGIC
PERFORMANCE MEASUREMENT
Improving Quality Clinical Process Improvement Designing for Higher Reliability
What Clinical Outcomes? Gap analysis (low hanging fruit)
Solid evidence about what could (should) happen What is currently happening?
What Clinical Processes? Solid evidence about impact on outcomes
Who Decides? Clinicians who understand evidence based care Management who sign the cheques
Improving Processes Outcomes Medication Reconciliation Acute Myocardial Infarction Surgical Site Infection Ventilator Associated Pneumonia Central Line Infection
Structures Outcomes Rapid Repsonse Teams
Setting Priorities
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
From:: Associates in Process Improvement
QI Projects - Accountability Executive Sponsor – CEO / VP Medical / VP
Acute Care / Exec Director Planning & Evaluation Can send a strong message of the importance of this project to the
organization Follow outcome and process measures
Administrative Sponsor Direct accountability for the results of this care Director / Chief of Cardiology
Project (Team) Lead Understanding of QI / Change Management Understanding of the clinical context Leadership skills
Project members Reps from all disciplines that are involved in the processes
Example – Improved Care for AMI Executive Sponsor
CEO / VP Medical & VP Acute Care Adminstrative Sponsor
Chief of Medicine / Cardiology Director of Medicine
Project Lead PCM / APCM of Cardiology unit / CCU
Project Team members MDs – Internist / Cardiologist / Emerg Nursing – Emerg / Medicine Pharmacist Unit Clerk EMT Discharge Coordinator Patient Educator
Example – Improved Care for AMI What are you trying to accomplish?
Reduce AMI 30 day mortality by _____ % Improve the reliability of 6 clinical processes
How will you know that a change is an improvement? 30 day mortality
Define & collect data for the numerator/denominator
Reliability of (Percentage of patients receiving) Components - Delivering each of the 6 components of care Composite – delivering all components
What changes can you make that will result in improvement? Change package AMI Getting Started Kit
Accountability – Measures over TimeAMI 30 Day Mortality Rate
0
2
4
6
8
10
12
14
16
18
Sep 0
4
Oct 0
4
Nov 04
Dec 0
4
Jan 0
5
Feb 0
5
Mar
05
Apr 05
May
05
Jun
05
Jul 0
5
Aug 05
Sep 0
5
Oct 0
5
Nov 05
Dec 0
5
Jan 0
6
Feb 0
6
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rta
lity
Ra
te
Accountability – Measures over TimeReliability - ASA on Admission
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/05
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Oct 3
1/05
Nov 7
/05
Nov 1
4/05
Nov 2
1/05
Nov 2
8/05
Dec 5
/05
Dec 1
2/05
Dec 1
9/05
Dec 2
7/05
Jan 2
/06
Jan 9
/06
Jan 1
6/06
Jan 2
3/06
Jan 3
0/06
Feb 6
/06
Feb 1
3/06
Feb 2
0/06
Feb 2
7/06
Week
Pe
rce
nt
Eli
gib
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Accountability – Measures over TimeReliability - ASA on Admission
0
10
20
30
40
50
60
70
80
90
100
Oct 3
/05
Oct 1
0/05
Oct 1
7/05
Oct 2
4/05
Oct 3
1/05
Nov 7
/05
Nov 1
4/05
Nov 2
1/05
Nov 2
8/05
Dec 5
/05
Dec 1
2/05
Dec 1
9/05
Dec 2
7/05
Jan 2
/06
Jan 9
/06
Jan 1
6/06
Jan 2
3/06
Jan 3
0/06
Feb 6
/06
Feb 1
3/06
Feb 2
0/06
Feb 2
7/06
Week
Pe
rce
nt
Eli
gib
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ati
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ts
1st Test Cycle
2nd Test Cycle
VAP – outcome & process measures
Getting Focused Accountability
Place the measures in the Corporate Scorecard
Commit to an improvement target (be bold) Put into Performance Agreements
CEO BoardVPs CEODirectors / Dept Heads VPs
Organizational Risks
Understanding (or lack thereof)
How to implement a QI agenda QI tools Time commitments (People / Organization)
Expectation of quick wins Viewed as ‘flavour of the month’ Leadership (or lack thereof)
Executive Quality Improvement