247 Every Patient, Every Time

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24/7 Every Patient, Every Time

• Jason Leitch
• Jane Murkin
• Pat OConnor

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• Discuss why healthcare isnt as reliable as it
  could or should be
• Outline the approach being taken by NHS Scotland
  in partnership with the Institute for Healthcare
  Improvement to make acute care safer
• Describe some examples of where this innovative
  approach has begun to change frontline patient
  care

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The first law of improvement

• Every system is perfectly designed to achieve
  exactly
• the results it gets.
• Peter Senge The Fifth Dimension

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How many people are harmed in our healthcare
system?
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A Project
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Moving a Big Dot
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• 17 years to apply 14 of research knowledge to
  patient care!
• Balas EA, Boren SA. Managing clinical knowledge
  for health care improvement. Yrbk of Med
  Informatics 2000 65-70

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• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)
• Conclusion The Defect Rate in the technical
  quality of American health care is approximately
  45

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The Three Faces of Performance Measurement
Improvement, Accountability and ResearchbyLief
Solberg, Gordon Mosser and Sharon
McDonaldJournal on Quality Improvement vol. 23,
no. 3, (March 1997), 135-147.

• We are increasingly realizing not only how
  critical measurement is to the quality
  improvement we seek but also how
  counterproductive it can be to mix measurement
  for accountability or research with measurement
  for improvement.

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Improvement vs. ResearchContrast of
Complementary Methods

• Improvement
• Aim
• Improve practice of health care
• Methods
• Test observable
• Stable bias
• Just enough data
• Adaptation of the changes
• Many sequential tests
• Assess by statistical significance

• Clinical Research
• Aim
• Create New clinical knowledge
• Methods
• Test blinded
• Eliminate bias
• Just in case data
• Fixed hypotheses
• One fixed test
• Assess by statistical significance

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Safe
Timely
Efficient
Equitable
Patient centered
Effective
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Quality Improvement

• Health Care Quality Improvement is a broad range
  of activities of varying degrees of complexity
  and methodological and statistical rigor through
  which health care providers develop, implement
  and assess small-scale interventions and identify
  those that work well and implement them more
  broadly in order to improve clinical practice.
• Mary Ann Bailey, The Hastings Center

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Campaign Participants
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Making acute care safer in NHS Scotland Jane
Murkin National Coordinator
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Scottish Patient Safety Alliance- Key Partners

• Scottish Government
• NHS Scotland
• QIS
• Royal Colleges and Professional bodies
• World leading experts on patient safety
• Patients
• NHS Education
• HPS

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The vision Scotland leading the way in Patient
Safety

• Scotland at the forefront - a whole healthcare
  system approach
• A strategic development priority for NHS Scotland
• An explicit and tested approach to improving
  patient safety
• Build on foundations laid through audit, clinical
  effectiveness and clinical governance
• Alignment with wider NHS QIS Patient Safety work

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Working together

• IHI
• National leads x 3
• Scottish faculty
• NHS Boards
• Practical approach supporting frontline staff to
  test and reliably implement changes
• Actively aligned and integrated national
  initiatives National approach
• Advisory board CMO
• National steering group
• Collaborative approach

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Building on experience

• What's already been achieved
• Tried and tested interventions
• Improve safety and reliability of boards and a
  safety focused culture
• Capacity and capability for improvement
  methodology
• Spread and sustainability

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Outcome Aims

• 15 reduction in mortality
• 30 reduction in adverse events
• Reduce healthcare associated infections
• Reduce adverse surgical incidents
• Reduce adverse drug events
• Improve critical care outcomes
• Improve the organisational and leadership culture
  on safety
• Data for improvement

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Key objectives
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Programme / Learning sessions

• Pre work period Oct Dec
• Jan 08 LS1 3 day event, work stream breakout
  sessions , all boards present
• Collaborative approach
• Model for improvement PDSA
• Networking events Nov 2007, March 2008, May
  1st, Aug 27th
• LS2 May 6th and 7th
• Building capacity event June 12th / 13th
• Site visits June
• LS3 Jan 2009

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The Improvement Guide, API
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SPSP Engine and Timeline
Organisational Self Assessment
P
P
P
A
D
D
A
D
A
S
S
S
2 day Kickoff
2 day LS
2 day LS
2 day LS

Continued Supports
Alignment with national work
Supports Expert clinical faculty Networking
events Listserv Site Visit Phone conf
Assessments Monthly Reports via web
Key Changes Improvement Measures
Jan 09
Jan 11
Jun 08
Jun 09
Jan 08
Oct 07
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Team Scotland

• Experience , support, advise and guidance
• Day to day contact
• Site visits
• Develop effective networks
• Networking, sharing and learning opportunities
• Dissemination of best practice

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www.patientsafetyalliance.scot.nhs.uk
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Change in frontline care Pat OConnor
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NHS Scotland

• Everyday
• extraordinary
• things are done
• by ordinary people

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What does it mean?

• F E B A

Forward Edge of Battle Area
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The Results

• 63.5 reduction in adverse events(case note
  review)
• Over 320 days since last infection in
  orthopaedics (elective)
• Over 633 days since last CLI in ICU
• 91 reduction in medication errors rates on
  admission
• 66 reduction of line infections in renal and ICU
• 60 reduction of MRSA bacteremias in surgery
• SSI bundle 95 compliance
• 50 reduction in VAP

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What does a successful team look like?

• Organised teams
• Busy environment
• Complexity of care
• Safety as a priority
• Tremendous will to change
• A dedicated plan of action

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Plan to change

• Need to act in a different way to get different
  results
• Led, designed and implemented by the front line
• Measurement is a key motivator -data ownership
• Share changes with patients and families

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• Joke pic

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Movement of safer systems

• A system to measure improvement
• The system designed and owned at the frontline
• Shared within multi disciplinary teams hospital
  and community
• Engaged and supportive leadership

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Local progress

• Testing
• Customisation
• Standardisation
• Ownership of the data
• Leadership support and removing barriers
• Responsibilities for spread

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Adopter Categories

Source E.M. Rogers, Diffusion of Innovations
(1995)
Late Majority
Early Majority
Early Adopters
Laggards
Innovators
2.5
13.5
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What does a successful team look like?
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Look at the Relationships
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Seven Key Points

• Cant be person dependent
• Regularly review current position and progress
• Let your Leaders understand what you need them to
  do
• Relentless focus and perseverance
• Dont get lost in detail empower others
• Build it into existing systems-use whats already
  there to plan for spread- empower teams
• Visit other sitesand steal shamelessly
• .

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Thoughts for the day

• Obstacles are the things we see when we take our
  eyes off our goals
• Zig Ziglar
• "Good ideas are not adopted automatically. They
  must be driven into practice with courageous
  patience." Admiral Hyman Rickover