Transcript Introduction

Mid Staffordshire report
www.ihi.org
Outcome 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 > w/in
range
• MRSA Bloodstream Infection: 30% reduction
• Crash Calls: 30% reduction
Managing change.....
In a nutshell?
• Have a compelling vision and aim high!
• Be sure of your evidence base
• Measure, measure, measure!
– The measures are backed by guidance that
makes it easier to think through the on the ground
requirement to deliver
• Grow knowledge in improvement and reliability
science for you and your teams
• Develop a supportive learning community that are
trying the same things in different ways and sharing
their developments.
The “Quality Curve”
Shift and narrow the curve:
What is the norm?
1
Cut the tail:
What is unacceptable?
2
3
Extend the ambition:
What is great? (What is possible?)
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
“Society’s huge investment in technological
innovations that only modestly improve efficacy,
by consuming resources needed for improved delivery of
care, may cost more lives than it saves.”
“Health, economic, and moral arguments make the case
for spending less on technological advances and more
on improving systems for delivering care.”
Number of reported events:
high and medium risk
British Airways air safety reports, 1994-99
Total reported events
High/medium
risk events
Total events
9000
140
8000
120
7000
100
6000
80
5000
60
4000
3000
40
2000
20
1000
0
0
1994
Source:British Airways (NPSA adapted)
1995
1996
1997
1998
1999
Sound impossible? – Here are some examples of success
Ascension Healthcare
Who they are: Largest Catholic and largest non-profit health system in the US, with 73 hospitals
across 20 states and over 100,000 employees
2005 Goal: No preventable injuries or death by July of 2008
Board actions
What they achieved
• 1500 fewer deaths in 2007/2008
• Focused on 8 ‘Priorities for action’, all
2006
Source: David B. Pryor MD – CMO, IHI Learning Lab, 12/08/2008
2007
Jul
Apr
Jan
Oct
Jul
Apr
Jan
•
3.0
2.0
1.0
0
Oct
•
System VAP rate per 1,000 vent days
Jul
•
Apr
•
(unadjusted preventable harm) vs. expected
• > 20% reduction in mortality 2006-2008
– 60% reduction in VAP
– 60% reduction in birth trauma
– 50% reduction in pressure ulcers
Jan
•
with clear measures
Began with bottom up clinical
engagement, by communicating harm and
having staff identify goals and opportunities
Adopted care bundle scoring approach
(all or nothing)
Launched 5 initiatives on ‘how we work
together’ (organisational learning and
cultural change)
Provided additional support to poorer
performing hospitals from highest
performers
Emphasised the business case for quality
2008
Month
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
Interventions
• Critical Care
– Ventilator acquired pneumonia bundle, central line
• Ward
– Early rescue , peripheral catheters,
– Communication
• Medicines
– Medicines reconciliation
• Theatres
– Surgical pause
– Infection prevention/control
• Leadership
– Safety walkrounds
– Executive leadership board patient safety profile
What is a Bundle?
• It is a set of evidence based steps
that experts believe are critical
• Having the steps joined provides a
“forcing function.”
• Evidence based medicine 
Evidence based care delivery
Bundle Implementation
• The steps must all be completed to
succeed
• The “all or none” feature is the source
of the bundle’s power
• Pass/fail
Peripheral Vascular Catheter
Bundle
•
•
•
•
•
Is the PVC required / still in use
No inflammation or extravasation
Dressing intact, dated, timed and signed
Reviewed/ Removed <72hrs
Hand hygiene before and after
Systems and Processes
Making it easy to do the right thing
“Every system is designed to get the
result it gets”
GRI VAP Prevention Bundle
Sampled one day per week - varied day
Aim >95% Reliability by May 2009
All 4 components of
bundle
100%
30° head up
90%
80%
DG sheet - reformatted,
Prompts added
Script of questions to
ask doctors
70%
60%
responsive to command; had
sedation hold; or described
exclusion
Re-testing at daily goals:
handing script, using
script, change daily
goals sheet
Head-up redundancy
50%
Chlorhexidine used as part of
daily mouth care
Daily Goals Sheet
described weaning target or
described exclusion
40%
AIM - how much by when
30%
8
-0
n
Ju
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-0
g
Au
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O
-0
ct
D
8
-0
c
e
9
-0
b
Fe
9
r-0
p
A
9
-0
n
Ju
09
gAu
9
O
-0
ct
D
9
-0
c
e
GRI VAP Prevention Bundle Reliability and
VAP rate per 1000 ventilator days
Aim: > 95% reliability by March 2009
25
Script of
questions to ask
Drs
100%
90%
20
15
DG sheet
DG sheet
change;
prompts added
Retesting at DG sheet;
handling sript; change
DG sheet
80%
Ventilator Associated Pneumonia
rate per 1000 ventilator days
70%
60%
Median over first 6 months
50%
10
Last VAP
02/01/2009
5
40%
30%
20%
10%
Au
g0
O 7
ct
D 07
ec
Fe 07
b0
Ap 8
rJu 08
nAu 08
g0
O 8
ct
D 08
ec
Fe 08
b0
Ap 9
rJu 09
nAu 09
g0
O 9
ct
D 09
ec
-0
9
0
Ventilator Associated Pneumonia
care bundle reliability (%)
0%
AIM
Daily Goals Set and Reviewed > 1 time in the day
Aim #1 >80% by March 2009,
Aim #2 >95% by June 2009
GRI ICU Percentage had Daily Goals Set
and Reviewed > 1 time
100%
90%
80%
100%
70%
80%
60%
60%
50%
40%
40%
30%
20%
20%
10%
UCL
LCL
Process Avg
Days
16
14
12
10
8
6
4
2
0
Daily Goals &
VAP Prevention
bundle start
9
ov
-0
N
9
09
Se
p-
Ju
l-0
M
M
ar
ay
-0
9
-0
9
09
Ja
n-
8
ov
-0
N
Se
p-
8
Ju
l-0
9
9
-0
9
ec
-0
D
O
ct
Au
g0
09
Ju
n-
GRI ICU Monthly Average Length of Stay (days)
Ja
n03
Ju
l-0
Ja 3
n04
Ju
l-0
Ja 4
n0
Ju 5
l-0
Ja 5
n06
Ju
l-0
Ja 6
n07
Ju
l-0
Ja 7
n08
Ju
l-0
Ja 8
n09
Ju
l-0
Ja 9
n10
9
-0
9
Ap
r
8
b0
Fe
8
-0
8
ec
-0
D
O
ct
08
Au
g0
Ju
n-
08
0%
0%
Perioperative Care at Forth Valley:
Better Processes
Percent On-Time Antibiotics
A shift upwards with a new
median of 97.7% of the
antibiotics administered ontime
Percent Eligible Patients with
Perioperative Glucose Control
A shift upwards with a
new median of 82.6% of
patients within range
Percent Patients with Perioperative
Normothermia
A shift upwards with a
new median of 99.5% of
the patients within the
appropriate range
Percent Patients with
Perioperative Briefings
A shift upwards with a new
median of 99.6% of the
patients receiving briefings
The Story of NHS Forth Valley
Fewer Deaths
Percent Unadjusted Raw Mortality:
A Shift Down
A Shift
Down
NHS Fife – 24 wards, peripheral vascular
catheter bundle compliance
Can we apply the principles to other areas?
• Blood Culture Contamination?
• Sepsis?
• Comprehensive Geriatric Assessment?
Future Developments
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Paediatric
Primary care
Mental health
Heart failure
VTE
Pressure ulcers
The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships
between patients, their families, and those delivering
healthcare services which respect individual needs and
values, and which demonstrate compassion, continuity, clear
communication, and shared decision making.
• Clinically Effective - The most appropriate treatments,
interventions, support, and services will be provided at the
right time to everyone who will benefit, and wasteful or
harmful variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients
from healthcare they receive, and an appropriate clean and
safe environment will be provided for the delivery of
healthcare services at all times.
Key messages
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Focus on results
Build capability quickly
Rationalise measurement
All improvement is local
Build a guiding coalition in your context
Patient voice
Enjoy the work