Sustainability in quality improvement

Dr. Frances MortimerMedical Director, Centre for Sustainable Healthcare, Oxford

February 2017

Sustainability in Quality Improvement training materials, developed by the Centre for Sustainable Healthcare with grant funding from North Bristol NHS Trust.

Aims – you should be able to:

1. Recognise sustainability as a domain of quality in healthcare and discuss its relationship to other domains.

2. Review the environmental, social and economic inputs to a given health system, and identify relevant carbon hotspots.

3. Apply the principles of sustainable clinical practice in the design of a QI intervention.

4. Identify outcome and activity measures in order to evaluate impact on sustainability / sustainable value.

“Our vision of sustainable health and care: A sustainable health and care system works within the available environmental and social resources protecting and improving health now and for future generations.”

Sustainability as a domain of quality

SustainablePatient Centred

Equitable

Efficient

Effective

Timely

Safe

Dr Donal O’DonoghueNational Clinical Director for

Kidney Care 2007-13

See also: Atkinson, S. et al. Defining Quality and Quality Improvement. Clin Med vol. 10, no. 6 537-539 (2010)

But quality is not enough - we need to improve value

Future Healthcare Journal 2018, Vol 5, No 2: 88-93

The SusQI framework

1. Setting QI goalsIncluding sustainability within your project aims (how will this affect engagement with colleagues and wider stakeholders?)

Aim of Sustainable QI:

“to deliver care in a way that maximises positive health outcomes and avoids both financial waste and harmful environmental impacts, while adding social value at every opportunity.”

2. Studying the systemUnderstanding environmental and social resource use and impacts

Carbon hotspots

Environmental hotspotsEnv impact Hotspots

Greenhouse gas emissions Inhalers, anaesthetic gases, medical equipment, pharmaceuticals, operating theatres, energy use

Air pollution Staff travel, patient travel, energy use

Deforestation Gloves - rubber plantations

Water consumption Dialysis, laundry, cotton linen

Scarce resources Conflict minerals in medical instruments

Plastic pollution Single use (133,000 tonnes plastic/year)

Eco-toxicity (PBT) Antibiotics, OCP, antidepressants, propofol

Ozone depletion Nitrous oxide (maternity, emergency care, theatres)

Understanding env/soc/£ impacts: process map

Social impacts – on whom?

👤 Patient👥 Staff👥 Carers👥 Dependants👥 Local community👥 Distant communities (e.g. supply chain workers)

Social impacts on distant communities

“Labourers in surgical instrument manufacture are often paid less than US$1 per day, have poor job security, have woefully inadequate protection of health and safety, and many employees are children, some as young as seven years old.”BMA Medical Fair & Ethical Trade Group

Social sustainability• Basic needs, including housing and environmental health• Education and skills • Employment• Equity• Human rights and gender • Poverty• Social justice• Demographic change (ageing, migration and mobility)• Social mixing and cohesion• Identity, sense of place and culture• Empowerment, participation and access• Health and Safety• Social capital*• Wellbeing, Happiness and Quality of Life

*defined as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups” (OECD)

Source: Colantonio, A. & Dixon, T. (2009) Measuring Socially Sustainable Urban Regeneration in Europe. Oxford Institute for Sustainable Development (OISD)

Scanning for social impactsPatients Carers Community Supply chain Staff

Housing

Poverty

Health

Education

Employment

Safety/security

Satisfaction

Participation

Social gradient

3. Designing your QI interventionApplying the principles of sustainable clinical practice

How will 80% carbon reduction be achieved?

Sustainable clinical practice: principles

Reduce carbon without reducing

health

Reduce activity

Prevention

Self care

Lean pathways

Reduce carbon intensity

Low carbon alternatives

Operational resource use

Mortimer-F. The Sustainable Physician Clinical Medicine 2010, Vol 10, No 2: 110–11

Sustainable clinical practice

Outcome needed

Secondary drivers

Primary driver

Primary driver

Estates & clinical

e.g. dry powder inhalers (1/20 x carbon of MDI)

Improve sustainability of respiratory inhaler prescribing

1. Prevent avoidable respiratory disease

Reduce smoking Review referral rates to smoking cessation service

Reduce cold/mould exposure Investigate housing improvement referral scheme

Reduce air pollutant exposureInput to local transport policy

Ensure patients receive air quality health advice

2. Empower patients to improve disease management

Co-production

Ensure yearly care planning

Rescue packs for acute exacerbations

Social prescribing Singing/ pulmonary rehab referral forms

3. Ensure lean prescribing and dispensing systems

Lean communications Introduce paperless prescribing/ repeat requests

High value prescribing Introduce annual inhaler reviews

4. Switch to lower carbon alternatives Preferential use of DPI vs MDI inhalers

Update prescribing guidelines

Write article for local GP newsletter

5. Improve operational resource useInhaler recycling Signpost recycling points

Waste, energy, travel Relevant actions

Lean systems… spotting waste

• Out of date stock• Single use items• Cancellation• Packaging• Standby• Non compliance• Waiting time• Commuting time• …can you add 2 more euphemisms for waste?

The Lean approach: 7 types of waste

1. Overproduction e.g. automatically requesting blood tests for pre-op assessments or duplicating patient information across different teams.

2. Inventory e.g. inappropriately using inpatient beds for patients who are waiting for tests but could be discharged safely, or ordering excess medical equipment because supply is unreliable.

3. Waiting e.g. surgeons waiting for a theatre to become available.

4. Transportation e.g. moving a patient to an inpatient bed for review at post-op ward round and then to another ward for discharge.

5. Defects or errors e.g. an inaccurate patient history or incorrect recording of a blood test.

6. Staff movement e.g. separate sites for outpatient clinics or large distances between clinically related areas.

7. Unnecessary processing Using complex equipment or processes to undertake simple tasks. e.g. a referral to a specialist service that involves having to be reviewed by several different people before acceptance.

Your service - sustainable clinical practice

Principle Opportunities?

1. Prevention

2. Patient empowerment and self care

3. Lean systems

4. Low carbon alternatives

Your service – overuse/underuse

Type of waste Opportunities?

Overuse of low value interventions

Underuse of high value interventions

Targeting overuse

Your service – operational resource useResource use Opportunities?

Energy

Travel (staff, patients)

Medical supplies

Non-medical supplies

Water

Waste

Prioritise

Opportunity Impact (1-3) Feasibility (1-3)

4. Measuring environmental and social costs/impacts

Future Healthcare Journal 2018, Vol 5, No 2: 88-93

Environmental Costs

Carbon footprint - the sum of greenhouse gas emissions released in relation to an organisation, product or service, expressed as carbon dioxide equivalents (CO2e).

Carbon footprint: what is included?(operational boundaries)

Scope 3: Indirect emissions

(other)

Scope 2: Indirect emissions

(electricity)

Scope 1: Direct emissions

• Supply chain• Travel• Waste disposal

• Electricity use

• Energy generation• Vehicle emissions• HFCs, N2O, etc.

Top downinput-output

Bottom upprocess-based

Emissions factors applied to components of a process or product, e.g. materials, energy use

Emissions factors applied to spend in different economic sectors

Hybrid

Methods

Available from http://www.ukconversionfactorscarbonsmart.co.uk/

Greenhouse gas emissions factors – UK Govt

Care Pathways Guidance on Appraising Sustainability (SDU, 2015)

Carbon by units of healthcare activity

Measuring environmental costs - exampleA primary care team noticed that some patients who were referred for hip and knee replacements were being

referred back to the GP surgery after pre-operative assessment at the local hospital. This was because parameters, such as blood pressure, were either outside the target range or were not communicated properly

in the referral information. An audit revealed that 1 in 6 patients looped through the system – 10/ year.

Activity Outcome £’s CO2e Social

Extra GP consult [delay to surgery]

£451 18 kg2 Patient & carer time/ stress

Extra Hospital consult [delay to surgery]

£1121 23 kg2 Patient & carer time/ stress (parking…)

Total (for 10 loops) £1570 410 kg

1. Unit Costs of Health and Care, PSSRU, December 2015. Available at: http://www.pssru.ac.uk/project-pages/unit-costs/2015/index.php2. Carbon Hotspots update for the health and care sector in England 2015, Sustainable Development Unit, January 2016.

Charlie Kenward, Severn GP ST3 Sustainability Scholar 2014-15

Social Impacts – identifying outcome measures

Group affected Impact area Outcome measure

e.g. carers employment % in employment / time off work

Can you identify outcome and activity measures to evaluate sustainability impact of…?

• Introducing one-stop service, e.g.• Breast lump assessment• Peripheral vascular disease• Back pain

• Integrating preventative services, e.g.• Vascular clinic – smoking cessation etc• Gallstones pathway – dietetics

• Overnight > day case surgery, e.g.• Laparoscopic cholecystectomy• Robotic prostatectomy

Thinking sustainably within a QI project

1. Apply sustainability approach at the different stages of ANY project

2. Choose a project area that relates closely to sustainability, e.g.a. Prevention, patient empowerment, etc.b. Reducing pharmaceutical wastec. Reducing over-investigation / over-treatment

Sustainability in QI Education project (2019-21)1. Demonstrate the inclusion of sustainable healthcare

principles within undergraduate and postgraduate health professions education on QI

2. Evaluate the impact on student learning, including engagement with QI

3. Accelerate the adoption of successful approaches by UK universities, Foundation Schools and other education providers

Dr Stuart D’Arch Smith CSH Education Fellow

2019-20

Resources

“Sustainability in Quality Improvement: Redefining Value”Mortimer, F., Isherwood, J., Wilkinson, A., Vaux, E. Future Healthcare Journal, 2018 Vol.5(2):88-93

“Sustainability in Quality Improvement: Measuring Impact” Mortimer, F., Isherwood, J., Pearce, M., Kenward, C., Vaux, E. Future Healthcare Journal, 2018 Vol.5(2):94-97

SusQI open access learning resources: http://networks.sustainablehealthcare.org.uk/sus-qi-resources

www.sustainablehealthcare.org.uk/susqifrances.mortimer@sustainablehealthcare.org.uk