HAI event March 29
Thanks and an apology
A Project
Moving a Big Dot
TM 10
Scottish Patient Safety Alliance (SPSA) Driver Diagram Improve Safety of Healthcare Services in Scotland Primary Drivers Scottish Government Sets PSA as Strategic Priority Boards Endorse Safety as Key Strategic Priority Deliver the programme Build a Sustainable Infrastructure for Improvement Align SPSP with national improvement programmes and measures Secondary Drivers National leaders openly endorse SPSP aims, failure is not an option for execs -Time and space given for improvement (not a target) -Royal Colleges serve in official capacity -Safety is an element of all programmes -National - Board development strategy -Ownership of agreed upon set of outcomes and measures -Quality and safety comprises 25% of agenda --Development of infrastructure that supports improvement and measurement -Clear improvement aims in strategic plan -Segment hospitals, customize approach -In-country support for Boards -Spread strategy community hosp., primary care -One Team - Everyone in the tent -One Team -Develop experts in imp. methods and coaching -In-country measurement system, culture survey -Safety work migrates to appropriate agency -Training programmes developed in Scotland -Work with IST, QIS and HES to develop unified improvement approach -Align aims and measures with national programmes -Develop a portfolio and execution model -Build connection to safety in national work -Define within clinical governance framework
Driver 5 Hold integration meetings with national programme leaders Align aims and measures with national programmes Align SPSP with National Improvement Programmes and Measures Define within clinical governance framework Develop a portfolio and execution model
Alignment Policy Programmes People Methodologies Aims Measures Education
What does real alignment look like? Vision Values
Jean Boal
Attribution Error
Will Ideas Execution
Outcome Aims Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 3 days between Central Line Bloodstream Infection: 0 or 3 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction
Primary Outcomes Develop and build a quality improvement and patient safety culture in our hospitals Build in long term sustainability and capability to drive this approach at all levels
What Will it Take? Winning the hearts and minds of the staff Focusing on improvement not targets Leadership Integration into daily work Tying it all together Creating infrastructure Creating capability and capacity Measurement that has meaning
BEST BEST
All models are wrong, some are useful
The Model for Improvement
Basics Aims Measures Changes Testing
The Improvement Guide, API
Aim What are we trying to accomplish?
Aims create systems Deming
The first law of improvement Every system is perfectly designed to achieve exactly the results it gets. Peter Senge The Fifth Dimension
Aim Aligned Timed Numeric Unachievable (by hard work alone) Non-negotiable (once set)
Aim Statements Outcomes, Process, Relative or Absolute? Achieve 1% compliance with appropriate selection and timing of prophylactic antibiotic administration in 3 months Reduce Central Line Infections in the ICU by 75 percent within 11 months Medications reconciled at 10-3 within 6 months
Measures
The Improvement Guide, API
When you have two data points, it is very likely that one will be different from the other. W. Edwards Deming R Lloyd, Institute for Healthcare Improvement
Cycle Time (min.) 80 70 60 50 40 30 20 10 0 70 35 Avg Before Change Avg After Change
Cycle Time (min.) 1 90 80 70 60 50 40 30 20 10 0 Change Made Unit 1 Cycle time results for units 1, 2 and 3 Cycle Time (min.) 1 90 80 70 60 50 40 30 20 10 0 date Jan Feb Mar Apr May Change Made Jun Jul Aug Sep Unit 2 date Jan Feb Mar Apr May Jun Oct Nov Dec Jul Aug Sep Oct Cycle Time (min.) Nov Dec 1 90 80 70 60 50 40 30 20 10 0 Change Made Unit 3 date Jan Feb Mar Apr R Lloyd, Institute for Healthcare Improvement May Jun Jul Aug Sep Oct Nov Dec
Seek Usefulness Not Perfection
Outcome, Process, Balancing Measures Outcome - Voice of the customer/patient. Direct link to AIM: Process - Voice of the workings of the system. What we work on to get to aim: Balancing - Looking at a system from different directions or dimensions.
Minimum Standard for Monthly Reporting in the Collaborative: Annotated Time Series 60 Huddles tried Cycle Time in Office Nurses start early Patient moved into rooms ASAP Minutes 50 40 Lab Changes 30 Goal 20 6/12 7/12 8/11 9/10 10/10 11/9
Family of Measures for Asthma Chronic Care 4 3.5 Emergency Department for Asthma % of pilot pop 3 2.5 2 1.5 1 0.5 0 Goal Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 01 Feb- 01 Mar- 01 Apr- 01 Avg pop. percent 1 90 80 70 60 50 Symptom-free days Goal 40 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 01 Feb- 01 Mar- 01 Apr- 01 1 90 Treatment with maintenance anti-inflammatory medication Goal percent 80 70 60 50 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 01 Feb- 01 Mar- 01 Apr- 01
Changes
The Improvement Guide, API
Change Concepts
Selecting Changes Copy: use the literature, experience of others, hunches and theories Be strategic: set priorities based on the aim, known problems, and feasibility Avoid low impact changes The Improvement Guide Langley et al.
Testing
The Improvement Guide, API
The PDSA Cycle for Learning and Improvement What change can we make that will result in an improvement? Act What changes are to be made? Next cycle? Study Complete the analysis of the data Compare data to predictions Summarize what was learned Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection Do Carry out the plan Document problems and unexpected observations Begin analysis of the data
Why Test Changes? To increase the belief that the change will result in improvements in your setting To learn how to adapt the change to conditions in your setting To evaluate the costs and side-effects of changes To minimize resistance when spreading the change throughout the organization
A P S D Repeated Use of the Cycle D S DATAP A A P S D Changes That Result in Improvement Hunches Theories Ideas A P S D
Testing exercise
The Peg Exercise 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
6-1, 4-6, 1-4, 7-2, 13-4, 2-7, 11-4, 14-5, 10-3, 3-8, 4-13, 12-14, 15-13.
Opportunity No of different professionals here today Learning from others industry / boards / professionals Today is just part of the process of change Ideas to take away to test Integration Multidisciplinary team working Patients Collectively the difference we can make
jane.murkin@nhs.net jason.leitch@scotland.gsi.gov.uk