SSC COMPONENT QUB MEDICAL STUDENTS: FRIDAY, 17 FEBRUARY 2012

One small step for man … …

The Model for Improvement (keep it small and simple)

TODAY YOU WILL:



Be able to outline the background to patient safety in health and social care

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Have a basic understanding of the person vs system approach to error

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Explain the Model for Improvement and be able to apply this to a specific example

1 in 10 = 551,000; 55,000, more likely 3 in 10 = 165,000 -

“Between the healthcare we have and the healthcare we could have lies not just a gap, but a chasm”  ◦ ◦ ◦ ◦ Why? Little reliability (80%) despite best intentions ◦ Best-known science is not reliably applied (60%) Widespread inefficiencies waste precious resources (20%) Patients are being harmed at alarming rates (10%; 30-40%) Failure to recognise, to rescue, to plan, to communicate Variation in practice (ie inappropriate variation not determined by patient need)  So we work on… ◦ Not the individual (blame, myopic view): ‘to err is human’ – ◦ ◦ “we cannot change the human condition, but we can change the conditions under which humans work” The system!

(James Reason); but on

Get in Get diagnosed Acute care Get treated

SAFELY

Get out Get on Systematic accurate diagnosis, early intervention, implementation of practices that are known to be safe and moving patients effectively along a care pathway* * Health Commission Report: Safe in the Knowledge, 2009

•No needless deaths, harm or suffering •No delays •No waste •No feelings of helplessness S T AFE IMELY E E EFFECTIVE FFICIENT E QUITABLE P ATIENT CENTRED

   Variation is intrinsic in health care. It is the result of clinical variability (number of patients presenting with certain clinical conditions), flow variability (the ebb and flow of patients arriving throughout the day), and professional variability (the variation in skill levels and techniques among providers).

Some kinds of variability (so-called “random variability”) cannot be eliminated, or even reduced; they must be managed . This is true of patient variability. We cannot eliminate the many types of problems from which patients suffer, nor can we control when they arrive in the emergency department.

Other types of variability (“non-random”), on the other hand, are often driven by individual priorities, resulting, for example, in surgical schedules that are heavy on Wednesdays but light on Fridays due to surgeons’ preferences rather than actual demand. Non-random variability should not be managed; it should be eliminated .

(Ref: IHI – Optimizing Patient Flow, 2003)

Defining Domains of Quality Problems Overuse - Examples of include hysterectomies, cardiac catheterizations, tympanostomy, antibiotics, tranquilizers, sedatives, carotid endarterectomy, cardiac pacemakers, upper gastrointestinal endoscopy, and non-steroidal anti-inflammatory drugs Underuse - Example, providers routinely fail to administer a variety of evidence-based tests and treatments to heart attack victims and individuals with diabetes and congestive heart failure. Misuse - Medical errors represent the most common form of misuse within the health. Examples drug misuse, hospital-acquired infections, diagnostic, surgical errors, and incorrect use of medical equipment.

Waste -unnecessary administrative activities is prevalent. In addition to driving up costs, waste can have a direct negative impact on service quality (e.g., waiting times), clinical quality, and access to care. Waste may also crowd out needed spending in other areas of health care.

Patient Safety Incident

• Any unintended or unexpected incident/s that could or did lead to harm for one or more patients

•Patients and families • Healthcare staff -the second victims • Financial-additional hospital stays alone estimated to cost £2000m annually in UK

 If a professional is highly trained and tries hard enough he/she will not make errors  the punishment myth if we punish people when they make errors they will make fewer of them

   healthcare organisations

will make errors

conscientious competent individuals trying

 ◦ ◦ An individual failing ◦ Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis ◦ It will not solve the problem--it will probably in fact make it worse because it fails to address the problem Professionals will hide errors May destroy many staff (inadvertently (the second victim)

 ◦ A systems failure This is the starting point for redesigning the system and reducing error

“Every system is perfectly designed to get the results it gets”

The First Rule of Improvement

SWISS CHEESE MODEL

(James Reason - 1990)

  

Will

to do what it takes to change to a new system

Ideas

on which to base the design of the new system

Execution

of the ideas

“Improvement requires a will to improve, Ideas to test and execution of a plan” Frank Frederico, IHI, Doug Bonacum, Kaiser Permanante Health Exec., Jan 2010 Im

5 P’s Purpose

What is the role of the team and what are you trying to achieve.

Professionals

•

Who contributes to the service / care e.g.:-

•

Ancillary and General

•

Nursing

•

Doctors

•

AHPs Processes How are the services planned What are the current practices and procedures you use Patterns Patients Who is the service / care provided to / for.

What do you know about how well your service performs e.g.:- Length of stay Pt satisfaction Staff Rotas Clinical Risk Complaints Team Meeting

No Have you sufficient information to identify areas for service improvement

Review analysis gaps and measure as required This model has been adapted from the Dartmouth Institute

Yes

Move to Stage 2

Identified areas for improvement Theme 1 No

Review analysis as requiredr

Theme 2

Identify themes

Theme 3 Theme 4

Prioritises themes (Consider) 1.

2.

3.

What matters most to patients and staff Time and effort Corporate Objectives Clearly identified area for improvement

Theme 5 Yes

Move to Stage 3

Constructing a clear aim statement Choosing right measures and planning how you will collect right information Coming up with ideas on how to improve current state: evidence, hunches, other people etc.

The Model for Improvement

What are we trying to achieve?

How will we know that a change is an improvement?

What changes can we make that will result in the improvements we seek ?

The fourth question: how to make changes testing Act Plan Study Do The three fundamental questions for improvement

Langley, Nolan et al 1996

 Leadership Support  System Leadership  Clinical Technical Expertise  Day to day leadership

 Agreed by Improvement Team  Time specific  Measurable

How do we know a change is an improvement?



Process measures



Outcome measures



Balancing measures

Research Judgement Improvement Purpose Tests Data Duration

To discover new knowledge To compare others, to rank One large trial Gather as much data as possible, just in case Public reporting quarterly or with 12 month running averages Reports structure, processes or outcomes Can require large numbers of patients and long periods of time to obtain results Ongoing data collection and quarterly public reporting To bring new knowledge into daily practice Many sequential, observable tests Small tests of significant changes, accelerates the rate of improvement Short iterative cycles in a limited number of subjects, followed by spread

1. Decide Aim

The Seven steps to Measurement are

:

Step 1

- Decide your aim 2. Choose measures

Step 2

- Choose your measures

Step 3

– Define your measures

Step 4

- Collect your baseline data

Step 5

- Analyse and present your data 3. Define measures

Step 6

- Meet to decide what it is telling you 6. Review Measures

Step 7

- Repeat steps 4-6 each month or more frequently 7. Repeat Steps 4-6 5. Analyse + present 4. Collect data In God we Trust, all others bring Data … …

MEASURES contd.

PROCESS: (Losing weight) • Number of visits to gym each week, • Number of walks per week, • Number of calories lost per day/week PROCESS: (Ventiliator acquired pneumonia bundle) • Elevation of head of bed between 30 and 45 degrees • Daily awakening: “sedation vacation” • Daily assessment of readiness for weaning • DVT prophylaxis (unless contraindicated) • Stress bleeding (peptic ulcer) prophylaxis

MEASURES contd.

Outcome: • Number of pounds lost per month OUTCOME: • Reduction in Ventilator acquired pneumonia rate OUTCOME: • Reduction in deaths each year from stroke

S + P = 0

MEASURES contd.

BALANCING: • Reduction in hours of sleep BALANCING: • Increasing Re-Admission rates BALANCING: • Increase in Waiting times in A&E

 An understanding of processes and systems of work  Challenge boundaries  Adapting known good ideas  Re-arrange order of steps  Smooth work flow

Act

• •

What changes are to be made?

Next cycle?

Plan

• •

Objective Questions and predictions

• •

(why?) Plan to carry out the cycle Plan for data collection Study

• • •

Complete analysis of data Compare data to predictions Summarise what was learned Do

• • •

Carry out the plan Document problems and unexpected observations begin analysis of data

Multiple PDSA Cycles Directed Toward a Single Aim

AIM Concept A Concept D Concept B Concept C

TIPS

•

From PDSA to SDSA

•

Only implement what you know is an improvement

•

Communication

•

Consider impact on people

•

Consider infrastructure

Tips for Improving Sustainability

      Be clear about the benefit to stakeholders ◦ Winning hearts and minds, “what's in it for me?” Pay attention to ongoing training and education needs See how you can contribute to building the improvement into the structure of your organisation and make it the new standard Build in ongoing measurement Work towards making sustainability mainstream ◦ Is it someone's responsibility? Has resource been allocated?

Celebrate, renew and set the bar higher

 The Improvement Guide: A Practical Approach to Enhancing Organizational Performance . G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey Bass Publishers., San Francisco, 1996  Achieving Safe and Reliable Healthcare; strategies and solutions. M Leonard, A Frankel, T Simmonds  Improving the Reliability of Healthcare. Institute for Healthcare Improvement Innovation Series 2004 White Paper. Available free at www.ihi.org

 Quality by Design: A Clinical Microsystems Approach. E Nelson, P Batalden, M Godfrey  To Err is Human: Building a Safer health System” Kohn LT  Clinical Microsystems Website: Dartmouth Institute: http://cms.dartmouth.edu/  National Patient Safety Agency website: www.npsa.nhs.uk

 Patient Safety First campaign – www.patientsafetyfirst.nhs.uk

 1000 Lives Welsh Patient Safety Campaign – www.wales.nhs.uk

 Scottish Patient Safety Programme: http://patientsafety.etellect.co.uk/programme  Institute for Healthcare Improvement: www.ihi.org

CONTACT DETAILS: Janet Haines-Wood, Regional Patient Safety Advisor, HSC Safety Forum [email protected]

Tel: 02892665181, Ext 4819 Levette Lamb, Regional Patients Safety Advisor, HSC Safety Forum [email protected]

Tel: 02892665181, Ext 4817 HSC Safety Forum Website:

http://www.publichealth.hscni.net/directorate-nursing-and-allied-health-professions /hsc-safety-forum