National Efforts to Improve Quality and Safety: Reflections on LargeScale Change International Forum

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National Efforts to Improve Quality and Safety
Reflections on Large-Scale ChangeInternational
Forum on Quality and Safety in Health Care
April 25, 2008
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Presenters

• Phil Hassen, CEO, Canadian Patient Safety
  Institute
• Beth Lilja, Head of Patient Safety, Danish
  Society of Patient Safety
• Jason Leitch, National Clinical Lead for Safety
  and Improvement, Scottish Government
• Joe McCannon, Vice President, Institute for
  Healthcare Improvement

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Ground to Cover

• An Overview of National Efforts to Improve Health
  Care Safety and Quality
• Case Studies and Reflections from Canada, Denmark
  and Scotland
• Moderated questions for panelists and open
  discussion

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IHIs Rings of Activity
Prototype
Innovation
Dissemination
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Dissemination Science

• Networking science
• Logistics
• Communications and knowledge management
• Benchmarking spread approaches (e.g., emergency
  management)
• Pure spread versus redesign or transformation

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An International Movement of Movements?
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An International Movement of Movements? (cont)

• National-scale improvement initiatives are
  underway in
• Canada
• Denmark
• Scotland
• Wales
• Japan
• Brazil
• Russia
• South Africa
• Ghana
• Laboratories for large-scale change

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Crucial Differences

• Scale
• Pace
• Resources
• National interest (felt need)
• Local skill
• Tolerance of media and policymakers

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Forces of Note in Transforming Health Care
(Complex Dynamics)

• Consumers
• Caregivers
• Policy/politics
• Payers/Purchasers
• Media
• Research Community
• Information Technology
• Push for Transparency

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What is Our Theory on How National Change Will
Occur?

• Alignment?
• Joint support?
• Coordinated regulations?
• Shared infrastructure (e.g., videoconference)?
• Pay for Performance?
• Collaboration?

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A Sequence of Change

• An innovative discovery
• A demonstration in 50 hospitals
• Outstanding results in 4 states
• Interest from purchasers and payers
• A state law in 14 states
• A national mandate
• A part of graduate-level training
• An expectation and a standard
• Confidence in ability to make change
• More ambitious aims

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Common Characteristics of Successful Initiatives

• Crisp Aims
• Creativity and Opportunism
• Leadership Attention
• Simplicity
• Networks and Collaboration
• Optimism
• Trust
• Obsession with Logistics

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• Canada

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Canadian Population in 2006 was at 32.5
Million Canadian health-care spending for 2007
will reach 160.1 billion. Public-sector health
care spending forecast projected to reach
70.6. Private-sector health-care spending
forecast projected to reach 29.4.
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Canadian Health SystemSystème de santé canadien
Canadian Government Involvement L'engagement du
gouvernment canadien

• one fully socialized health care system,
  substantially under provincial jurisdiction
• Federal government funds the provincial
  government as long as they abide by the Canada
  Health Act which explicitly prohibits end user
  billing for procedures covered through the
  publicly funded system
• Does not cover non-cosmetic dental, prescription
  drugs, some specialist visits and in some
  provinces optometry

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Canadian Health System
Regionalization in Canada La régionalisation au
Canada

• All provinces except Ontario have "mature"
  Regions
• These are vertically and horizontally integrated
  under one organization (hospital, homecare,
  public health, etc.)
• Provides for fully integrated health and health
  care
• Focuses as much on population as individual
  health
• Funds move easily between community and hospital
  and other elements of care

• Life expectancy 2005 80.1 yrs

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OECD Health Data 2004
OECD Health Data 2007, October 2007
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OECD Health Data 2005
GDP
OECD Health Data 2007, July 2007
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• We envision a Canadian health system where
• Patients, providers, governments and others work
  together to build and advance a safer health
  system
• Providers take pride in their ability to deliver
  the safest and highest quality of care possible
  and
• Every Canadian in need of healthcare can be
  confident that the care they receive is the
  safest in the world.
• What We Know
• Adverse Events in Canadian Hospitals (Baker, R.
  Norton, P. et al. (2004)
• Incidence rate of 7.5 in hospitals (2000)
• 70,000 preventable adverse events (est.)
• 9,000 - 24,000 preventable AE deaths in Canada
  (2000)

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Safer Healthcare Now Objectives

• Significantly increase the rate of participation
  among Canadian healthcare organizations in
  targeted patient safety interventions.
• Increase knowledge transfer and uptake of
  learning among organizations participating in
  Safer Healthcare Now!
• Increase the capacity of participating
  organizations to effect change that leads to
  safer patient care.
• Build a reusable national infrastructure for
  change

8
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Safer Healthcare Now!

• Phase I (Started Sept. 2005) Same as IHIs Save
  100,000 Lives
• Deploying rapid response teams
• Improved care for acute myocardial infarction
• Prevention of adverse drug effects
• Prevention of central line-associated bloodstream
  infection
• Prevention of surgical site infectionPrevention
  of ventilator associated Pneumonia

Phase II (Starting April 2008) 7. MRSA
Prevention 8. (VTE) Venous
thromboembolism 9. Adverse drug events in long
term care 10. Falls in long term care
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Campaign Structure
Campaign Support SHN National Steering
Committee Secretariat - CPSI
Baker/Norton
Clinical Supports
Peer Support Network
CIHI
CAPHC
RNAO
Operations
Quebec Campaign
Teams
ISMP Canada
VON
Western Node
Partner Network
Atlantic Node
Patients
Canadian ICU Collaborative
Ontario Node
IHI
PHAC (with CHICA CCAR)
Other Canadian Faculty
Sunnybrook Health Science Centre
CCHSA
Measurement Working Group CMT
Communication Advisory Group
Education Resource Working Group
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Teams Continue to Enroll
Updated August 21, 2007
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Teams Working on Each Intervention

• Date Nov /05 Feb/08
• RRT 41 53
• AMI 43 115
• Med Rec 82 317
• Central line 35 82
• SSI 53 155
• VAP 42 109
• Total 296 841

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13
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SHN End of Phase I - December 2006

• Med Rec Results Unintentional
• discrepancies
• ? from 1.16 to 0.65 per patient (goal of 0.30)

Central Line-Associated Blood Stream
Infections ?bloodstream infections 4.8 per 1,000
central line days to 1.6
Ventilator-associated Pneumonia ? in the national
rate for VAP from a baseline of 19.88 per 1,000
ventilator days to 3.76 after 13 months, (goal
was 7.00)

• Rapid Response Team
• national rate of Codes (occurring outside ICU)
  per 1,000 discharges from 7.46 to 4.61,

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SatisfactionSource KOC, team leader, and senior
leader surveys
Courtesy PRA, 2007
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Challenges

• Leadership without ownership
• 14 Health Systems in Canada
• Each somewhat independent

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Lessons Learned

• Leadership without ownership
• Physician engagement
• It is always more complex than we think
• Collaboration is tough with clear goals more
  likely sustainable
• Health Care Professionals want to do better - and
  Do as a result

• Large scale change is small scale change
  repeated
• in many settings
• at different times
• Sustaining spread requires building upon the
  change (e.g. SHN Phase ll identified areas to
  evolve based on lessons learned and skills
  developed in Phase l)

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Lessons Learned
Lessons Learned

• Large Scale Change Tips
• It is always more complicated than is initially
  believed.
• It inevitably
• Large scale change happens in small increments.
• Change is leveraged by identifying the right
  individuals to lead. The right individual is not
  necessarily the obvious first choice.
• Listen and communicate, often.

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• Denmark

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Overview National Demographics
Population 5.5 million
HC Organization 5 regions and 98 municipalities


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Overview Health Care System

• Health care is a public task
• Number of hospital units 38 but continously
  decrease in number of hospital units and
  geografic sites

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Problem National Challenges in Quality and
Safety

• Danish study of adverse events 9 of patients
  admitted to hospital experience an adverse event
  (AE)1
• A national survey including 26.045 patients
  admitted to hospital show that 20 experienced an
  error and gt 50 of these patients detected the
  error themselves2
• In a cultural survey among hospital staff 51
  states that work overload is a threat to patient
  safety3
• 1) Schiøler T et al, UgeskrLæger 2001
• 2) Region Hovedstaden, Enheden for
  Brugerundersøgelser Den landsdækkende
  undersøgelse af patientoplevelser, spørgeskema
  blandt 26.045 indlagte patienter (2006)
• 3) Region Hovedstaden (2007) Medarbejdernes
  vurdering af patientsikkerhedskulturen 2006

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Prior National Improvement Efforts in the Country

• Existing
• National Indicator Program
• The Danish Patient Safety Act (2003) ,
  establishing a non-punitive reporting system on
  Adverse Events
• Forthcomming
• Danish Accreditation Model, to be introduced in
  June 2008

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Current Work - Aims

• Organization
• A National Campaign
• Launched 16. april 2007
• 18 months campaign period
• A National Steering Committee with all
  stakeholders represented
• Financed by

• Aims
• Saving further 3000 lives
• Hospitals from all regions participating from
  start
• Participation of hospitals covering 75 of
  discharges

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Current Work Content (Interventions)

• Proces of development
• Interventions from 100K Lives Campaign were
  adjusted by Danish experts
• Intensive dialogue with all health care
  stakeholders before launch

• Six interventions
• Rapid Response Team
• AMI Bundle
• Medication Reconciliation
• Ventilator Bundle
• Central Line Bundle
• Surviving Sepsis Campaign

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Current Work Method of Spreading Change

• Break Through Collaboratives 100 teams and 40
  advisors
• 80 Hospital visits
• Homepage with succes stories.
• Newsletter twice monthly
• Campaign days

HSMR
HSMR
HSMR
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Current Work - Status
Compliance AMI bundle
Compliance - ventilator bundle
Days between codes
Number of calls for RRT
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Current Work Status (cont)

• HSMR 3 campaign quarters

• 316 lives saved first 3 quarters
• 25 of hospitals have analyzed inpatient
  mortality
• More hospitals are planning similar analysis
• All hospitals identified gaps in quality of care
• All hospitals take action

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Greatest Challenges

• Setting the number is a double-edged sword
• Accomplish meaningfull out-comes results
• Competition with other initiatives

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Greatest Lessons

• All Stakeholders involved from day one
• Possible to get attention and engagement
• Involvement of experts appointed by Scientific
  Societies in development of Danish guidelines
• Alignment with forthcomming Danish Accreditation
  Model
• Importance of communication and field work
• More emphasis on data analysis
• All improvement counts

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• Scotland

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Scotland
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Overview National Demographics
Population 5.5million 41 in Glasgow
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Scottish Politics

• Devolution - 1997
• Scottish Nationalist Party minority Government -
  2007
• Devolved powers
• Health
• Education
• Criminal justice
• Agriculture
• Transport

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NHS Scotland

• 10.3 billion
• Integrated health and social care
• No trusts, no internal market
• 15 territorial boards
• 4 special boards
• NHS Education for Scotland
• NHS Quality Improvement Scotland
• NHS Health Scotland
• NHS National Services Scotland

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NHS Boards

• Responsible for individual and population health
• Acute hospitals - 15,000 beds in 38 hospitals
• Rural General Hospitals
• Community Hospitals
• Community Health Partnerships
• Primary healthcare and social care

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Prior National Improvement Efforts in the Country

• NHS Quality Improvement Scotland
• Improvement and Support Team
• Scottish audit of surgical mortality
• SIGN

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Current Work - Aims

• Mortality 15 reduction
• Adverse Events 30 reduction
• Ventilator Associated Pneumonia 0 or 300 days
  between
• Central Line Bloodstream Infection 0 or 300 days
  between
• Blood Sugars w/in Range (ITU/HDU) 80 or gt w/in
  range
• MRSA Bloodstream Infection 50 reduction
• Crash Calls 30 reduction
• Harm from Anti-coagulation
• 50 reduction in ADEs
• Surgical Site Infections 50 reduction (clean)

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Current Work Content (Interventions)

• Critical Care
• E.g ventilator acquired pneumonia bundle
• Ward
• E.g. Outreach teams
• Medicines management
• E.g. Medicines reconciliation
• Theatres
• E.g. Surgical pause
• Leadership
• E.g. Safety walkarounds

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Current Work Method of Spreading Change

• Model for Improvement
• Prototype and spread
• Boards
• Primary care
• Mental health
• Board Chairs meet with Cabinet Secretary monthly
• Board Chief Execs meet with NHS Scotland Chief
  Exec monthly
• Medical Directors meet monthly

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Current Work - Status

• All boards testing
• All boards taking part in conference calls
• Learning session 1 January 08
• Learning session 2 May 08
• Site visits June 08
• Monthly data reporting began February 08

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Greatest Challenges

• Integration, integration, integration
• Scale
• Project fatigue in NHS
• History of league tables and target culture

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Greatest Lessons

• Engagement with stakeholders is key
• Staff are keen for change if they own it
• Combination of IHI expertise and
• in-country team works well
• Face-to-face visits are priceless
• Pace
• Data, data, data

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How will we know if the changes have made a
difference?
Some is Not a Number, Soon is Not a Time!

• The Numbers
• 30 Reduction in adverse events,
• 15 reduction in Mortality
• The Time January 1, 2011

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Questions for Panelists

• What keeps you awake at night?
• Where does this work fit in the larger narrative
  of total change that you seek to create? Is it a
  middle step? The last mile?
• How do you create value for participants every
  day?

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•