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Boards on Board
Don Berwick
• Put the patient first
• Put the vulnerable first
• Start at scale
• Give the money back
• Act locally
“The tendency exists to argue that the science of improvement may be a lesser way of knowing,
because it concerns itself primarily with a wide range of applications in uncontrolled
settings; that is, the real world as we find it every day”
Rocco Perla
Moving beyond safety
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.
• 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.
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
Three Part Problem...
• Improve Individual Experience
• Improve Population Health
• Control Inflation of Per Capita Costs
The Triple Aim
Evidence based medicine Evidence based care delivery
17 years to get 14% of evidence into practice
“Conquering the world on horseback is easy: it is dismounting and governing that is hard”
Genghis Khan
“quality improvement”The combined and unceasing efforts of everyone – health care professionals,
patients and their families, researchers, payers, planners, administrators,
educators – to make changes that will lead to
better patient outcome, better system performance, and better professional
development.
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3
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
HSMR
Hospital Standardised Mortality Ratio
Scotland – 8.4% reduction in HSMR
0.5
1.0
1.5
Oct-Dec2006
Apr-Jun
2007
Oct-Dec2007
Apr-Jun
2008
Oct-Dec2008
Apr-Jun
2009
Oct-Dec2009
Apr-Jun
2010
Oct-Dec
2010p*
Apr-Jun
2011p
Sta
ndar
dise
d M
orta
lity
Rat
io
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Sta
ndard
ised M
ort
alit
y R
atio
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Stan
dard
ised
Mor
tality
Rat
io
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Sta
ndar
dised
Mor
talit
y R
atio
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Sta
ndard
ised M
ort
alit
y R
atio
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Sta
ndar
dise
d M
orta
lity
Rat
io
0.5
0.8
1.0
1.3
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec
2010*
Jan-Mar
2011p
Sta
ndard
ised M
ort
alit
y R
atio
HSMR results 2008-2011
Scotland level results
Central line infection rate (per thousand line days)
0
2
4
6
8
10
12
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
March 2011:zero central line infections
in whole country
VAP rate (per thousand ventilator days)
02468
101214161820
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
9.11
3.49
62% reduction
% ICU mortality
10
12
1416
18
20
2224
26
28
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
18.2%
15.7%
14% improvement
General ward C.Difficile rate(per thousand patient days)
0
0.5
1
1.5
2
2.5
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
1.18
0.14
88% reduction
How has the frontline done it?
• Get goals.• Get bold.• Get together.• Get a model (and
stick with it)• Get patients and
families
• Get the facts.• Get to the field.• Get a clock.• Get the numbers.• Get the stories.
How has NHSScotland done it?
Policy Leadership Execution
Structure Process Outcome
Donabedian, A.
Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment.1980.
Having the best professionals in the world
is no longer enough
© 2010 Institute for Healthcare Improvement
To build a sustainable infrastructure that produces highly reliable QI excellence
by (fill in the date).
How good? By when?
The Capacity and Capability Aim
© 2010 Institute for Healthcare Improvement
Who needs to be developed?
Governance?Executives?Managers?
Supervisors?Front Line Workers?
Improvement Advisors (IAs)?
Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006
© 2010 Institute for Healthcare Improvement
√
How many quality experts do we need?
Two suggestions for determining this number:
Number of employees
Or…consider that no employee should be more than 2 steps (individuals)
away from a QI expert.
Where next?
• Sepsis/VTE• Paediatrics• Primary care• Mental health• Maternity
• Person-centred care• Early years
1941, William A. Foster
"Quality is never an accident; it is always the result of high
intention, sincere effort, intelligent direction and
skillful execution; it represents the wise choice of
many alternatives.”