Transforming Care at the Bedside

Using reliable techniques to improve patient safety and patient’s experience of care Annette Bartley RGN BA(hon) MSc MPH Head of Modernisation NHS North Wales (Central)

Facts

• Increased Technology • Better treatment options • Outcomes improving • So WHY are patients consistently complaining about the NHS • Everyone of us can tell a story • What is going wrong?

The Context

• In the last 20 years the average length of stay in hospitals has declined significantly • Nurses are spending an average of between 24%-35% or even less of their time in direct patient care • 13-28% of their time in patient care documentation

Korst 2003, Pabst 1996, Smeltzer 1996, Upeniecks 1998

• Total time ALL health care workers spent in direct patient care and assessments on a med surg unit is a median of 1.7 hours in a 12 hour period

IOM, Keeping Patients Safe, 2004

Background to TCAB

• Issues with recruitment and retention of nurses in US • Patient satisfaction deceasing • • Patient Safety

As many as 90,000 people die annually from mistakes – an error rate unacceptable in any other industry. There are more deaths due to medical errors than deaths from accidents, breast cancer, or AIDS

(IOM Committee on Quality).

TCAB USA

• Three Phases – Phase 1-three hospitals – Phase 2 10 hospitals – Phase 3 spread AONE & IHI • Local data collection • Run Chart-Time series analysis • Data compared ‘within’ hospitals rather than ‘between’ • Research evaluation (UCSF)

TCAB core themes 1. Transformational Leadership 2. Teamwork &Vitality 3. Patient and Family centred care 4. Value-added Care (Lean element) 5. Safety &Reliability

TCAB-aims

1.

2.

3.

4.

5.

Increase the amount of time nurses spend in value-added/direct care to

70 %

Reduce hospital acquired pressure ulcers by

50%

Reduce the number of in patient falls by

50%

Increase the patients satisfaction with their experience of care to

>95% (

i e pt –reporting excellent care) Increase staff satisfaction to

>95%

Content Area Drivers

Transformational Leadership Value-Added Care

Transform Care at the Bedside in the two development sites by 2010

Safety & Reliability Patient Centred Care Teamwork & vitality

Interventions

Establish, oversee and communicate system levels aims for improvement Align measures, strategy & projects and leadership learning system Channel leadership attention to quality improvement and safety Build the right team Align Quality projects to Finance.

Engage Physicians in improving care at all levels Build improvement capability Increase the percentage of time spent in direct/value-added care to 70% by: Eliminating waste & Improve work flow processes for admissions, hand offs an discharge Improving work environment through physical space re-design Enhancing efficiency with technology Reducing duplication & time spent in documentation Reduce the adverse events rate in pilot wards Prevent Falls by implementing falls bundle Prevent Pressure Ulcers by implementing Skin bundle Support and involve patients and families Ensure patients physical comfort Optimise care transitions to home or elsewhere Create Patient- Centred Healing Environments Provide Emotional & Spiritual Support Ensure Patients rights to privacy & dignity is maintained Empower ward managers to create care teams with the authority to act and transform care Build capability of front line staff and mid level managers in Innovation and Improvement Utilise clinical micro system model & tools Enhance physical environment for staff &prevent staff injuries Optimise communication across the care team Develop staff and match roles to responsibility

Improvement Methodology

• Innovation/ Prototype testing • Ideas Generation – ‘The Deep Dive’ / ‘Snorkel’/ Paddle • The IHI Model for Improvement • PDSA • Lean methodology • Learning from Industry

Collaborative Care Patient Progression

Tollgate 1 Tollgate 2 Tollgate 3 Tollgate 4 Tollgate 5 PT Care Are we progressing care?

PT Care Are we progressing care?

PT Care Are we progressing care?

PT Care Are we progressing care?

PT Care Are we progressing care?

PT Care NO NO NO NO Problem Solve Problem Solve Problem Solve Problem Solve Collaborative Care Value Stream Metrics NO Problem Solve Copyright 2006 © All Rights Reserved. Patent Pending.

World-Wide Sites Replicating TCAB

England, Ireland, Scotland & Wales Sweden & the Netherlands Singapore New Zealand

Time in Direct Patient Care – 8 South Surgical Pilot

100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 4th Qtr '04 1st Qtr '05 2nd Qtr '05 3rd Qtr '05 4th Qtr '05 1st Qtr '06 2nd Qtr '06 3rd Qtr '06 4th Qtr '06 1st Qtr '07 2nd Qtr '07 3rd Qtr '07 4th Qtr '07 Jan '08 Feb '08

A model for improvement...

Aims What are we trying to accomplish?

Measurement How will we know that a change is an improvement?

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

Ideas, evidence, hunches, other people etc .

Act Plan

The fourth question: how to make changes

Study Do The three fundamental questions for improvement Langley, Nolan et al 1996

Health Care Processes

Current Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Desired - variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom variation Terry Borman, MD Mayo Health System

“Reliability is failure free operation over time.”

David Garvin Harvard Business School

Whose job is it?

• This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done

What are we trying to accomplish?

• Reduce Pressure Ulcer Incidence by 50% • Preventing pressure ulcers isn't difficult!

• It just requires attention to the details and re establishing good habits.

• Use rounding/bundles to implement new habits and ways of thinking can and will ultimately impact outcomes.

Process Eyes

• Make the process for preventing Pressure Ulcers (&Falls)

visible

to

ALL

• Measure it -so we can ‘see’ if it is adhered to and effective • Make it easy for others to do the right thing (simple checklists, reminders) • The right process with high % compliance

WILL

influence outcomes

Care bundles

• A “care bundle” is a collection of interventions (usually three to five) that may be applied to the management of a particular condition. It is distinct in several ways from just any checklist about patients’ care. • The elements in a bundle are best practices based on evidence, and all clinicians should know them. In routine clinical practice, these elements may not always all be done in the same way, making patient care vary. • So a bundle aims to tie them together into a cohesive unit that must be adhered to for measured in an

every patient, every time “all or none”

executed together rather than individually.

. All the tasks are necessary and must all occur in a specified period and place. • Successfully completing a bundle is clear cut, and compliance is approach, as its proponents argue that better outcomes are achieved when interventions are

Using bundles to improve reliability • Bundles demand “all or none” thinking and measurement. • Bundles facilitate identifying failures.

• Failures are actively used to redesign the process.

• Teamwork & communication improve

Compliance (6 or non-compliant) 1.

Risk assessment on admission 2. Communication of risk status-Verbal & Visual Cue

3. S

urface-

4. K

eep patients turning- care round

5. S

kin Inspection-care round

6. N

utritional assessment- care round

ALL OR NONE-COMPOSITE MEASURE

Y/N x x x

TLC Rounds

• Created more time-less bell calls – Pressure areas checked – Position changed – Pain assessment – Nutrition-check (fluids encouraged where appropriate) – Obstacles & Call bells –Call don’t fall – Personal Hygiene – Emotional support

Exemplars of success

New Jersey Hospital Association – Educational programs, e-mail information distribution list, monthly conference calls with experts – 70% reduction in pressure ulcer incidence and 30% reduction in prevalence

“No ulcers”

Nutrition and fluid status Observation of skin Up and walking or turn and position Lift (don’t drag) skin Clean skin and continence care Elevate heels Risk assessment Support surfaces for pressure redistribution

Exemplars of success

Ascension Health – Nurses throughout the organization created and implemented care methods under the SKIN bundle – Reduced pressure ulcer incidence to about 1.4 per 1,000 patient days system-wide – Six hospitals had no pressure ulcers for 1 year – Almost all that did occur were Stage I or II SKIN bundle

S

urface selection

K

eep turning

I

ncontinence management

N

utrition

Design in Implementing the Ventilator Bundle Baseline Education Feedback on compliance Integrate daily goals with MDR to identify defects as a RT built into 1 hour scheduled vent checks as a)

Steps to reliable care

• Do the acid test?

• Segment your population • Design an articulated process goal, • Agree a clear outcome goal connected to the process with some good medical evidence. • In addition you have now set up a theoretical design using the prevent, identify, mitigate and with the knowledge of failures how to redesign • design your first test of change • Determine the tempo of change you will “dance to ”

Safety is No 1

• Safety Walk-rounds • Safety first agenda item in every meeting • Safety Briefings at shift handover • SBAR (Situation/ Background/ Assessment / Recommendations ) – MEWs reporting – Transfer/Discharge • C-DIFF & MRSA • Admission/Discharge nurse • Admission Trio

THANK-YOU Questions?

Contact details: Annette Bartley [email protected]