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Slides from the QI workshop run by the HSC Safety Forum at MLS2013. www.medleadsymposium.co.uk
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Questions to be answered today
• How do we define Quality in healthcare?
• What is Quality Improvement?
• HOW CAN WE IMPROVE QUALITY?
• How can we ensure that "change" is really an improvement?
• What tools and approaches can we use to promote successful improvement/change?
The safety paradox
Healthcare staff are:Highly trained & motivatedCommitted to their patientsUse sophisticated technology
Errors are common and patients are frequently harmed
VideoHow safe is your care?
Potentially an average of 7,300 patients per year per trust suffer an adverse event …
Double Decker bus seats 73 people…
100 bus loads of patients per year per trust …
Nearly 2 bus loads per week per trust
Safety in Acute Hospitals
Adverse Events
• Due to healthcare management rather than to the underlying disease
• May or may not be preventable
• Effect 8-12% of hospitalised patients (one or more adverse events)
• Older people are particularly vulnerable
• Voluntary reporting systems are poor at measuring adverse events but useful for learning about vulnerabilities
Epidemiology of harmStudy Authors Date of admissions Number of hospital
admissionsAdverse event rate
(% admissions)
Harvard Medical Practice Study (HMPS)
Brennan et al, 1991; Leape et al, 1991
1984 30195 3.7
Utah-Colorado Study(UTCOS)
Thomas et al, 2000 1992 14052 2.9
Quality in Australian Health Care Study(QAHCS)
Wilson et al, 1995 1992 14179 16.6
** United Kingdom Vincent et al, 2001 1999 1014 10.8 **
Denmark Schioler et al, 2001 1998 1097 9.0
New Zealand Davis et al, 2002 1998 6579 11.2
Canada Baker et al, 2004 ???? 3745 7.5
France Michel et al, 2007 2004 8754 6.6% per 1000 days admission
** United Kingdom Sari et al, 2007 2004 1006 8.7 **
Spain Aranaz-Andre et al, 2008 2005 5624 8.4
The Netherlands Zegers et al, 2009 2006 7926 5.7
Sweden Soop et al, 2009 2006 1967 12.3
Clinical information available in hospital outpatient clinics
Prescribing for hospital inpatient
Equipment availability in the operating theatre
Equipment available for inserting peripheral intravenous lines
Copyright ©2008 BMJ Publishing Group Ltd.Vincent, C. et al. BMJ 2008;337:a2426
Changes in rates for 9 AHRQ derived patient safety indicators.Hospital Episode Statistics 1996-7 to 2005-6 (England)
Trends in rates of patient harm: United States
Landrigan et al, NEJM 2011
How can we improve quality?
Leaders who understand and use QI techniques (e.g. MFI, Lean)
Quality Improvers who have Leadership skills
Leadership
QI skills
Understanding why things go wrong
Concepts for Safety & QI
Reliability
Variation (lack of)
Relative risk of death from intestinal obstruction (not hernias) by hospital
in one SHA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 210
20
40
60
80
100
120
140
160
180
Relative Risk
Relative Risk
Safety climate by hospitalSafest
Least safe
“Use of drug X by GP practice”“Referrals to OPD with GI symptoms”
QI requires CHANGE
Will
Ideas
Execution
Get a small group of interested people together
Learn about different contributions to the system or service
Analyse and understand current system
Continue to learn and improve
Look at ideas for how things might be different
Test ideas and experiment with different ways of working
♦ Improved service♦ Improved
understanding of how things work
♦ More control over work
♦ Better outcomes and experience for patients
. .
Our Improvement Framework…
COLLABORATIVES
MEASUREMENT
Running monthly average (per
1000 risk days)
Days between!
Measurement video
100%
80%
86%
57%
57%
83%
94%
Sepsis is an EMERGENCY!
100%
80%
86%
57%
57%
83%
94%
Sepsis Run Charts
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100
Observations Recorded M
ed
ian
(%)
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100High flow O2
Med
ian
(%)
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100Blood Cultures taken
Med
ian
(%)
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100
IV Fluids M
ed
ian
(%)
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100
Antibiotics within 1 HR
Media
n (
%)
Mar-1
2
Apr-1
2
May-1
2
Jun-
12
Jul-1
2
Aug-1
2
Sep-
12
Oct-1
2
Nov-1
2
Dec-1
2
Jan-
130
20
40
60
80
100
Serum Lactate
Media
n(%
)
SepsisRun Charts
100%
80%
86%
57%
57%
83%
94%
ED (early) management of sepsis% compliance
ED (early) management of sepsis% compliance
ED (early) management of sepsis% compliance
Ventilator Care Bundle Compliance
Steps taken by one UK site to reach 95% compliance
Feedback
VAP Rate
Quarterly running average
Start > 9 VAPS/1000 vent days
End < 2 VAPS/1000 vent days
Process MappingStroke: assessment, imaging, thrombolysis
Patient telephones 999
Ambulance arrives at home
Ambulance leaves home
Paramedics pre-alert stroke team
Hospital
Registration
Bed in Resusitation Area
Process Mapping
Nursing Staff
IV placement
ECG
Monitor Hook up
Vital signs monitoring
Blood glucose
Blood tests
Weight estimate
Process Mapping
Clinical Assessment
History
Medication
Allergies
Identification Of Witness
Time of Onset/when last well
Witness difficult to locate?
Process Mapping
Clinical Assessment
NIHSS
Neurological Examination
Lab samples - FBP/ PT/UE
Transport of blood to labs
Process Mapping
Imaging
Bed to CT Scanner
Disconnect monitor
CT Scan
CT Report
Transport from CT – Stroke Unit
Reconnect Monitor
Process Mapping
Drug Preparation
Calculate dose
Prepare TpA
Give bolus
Start Infusion
Bundle of Care
Parallel v Serial Process for clinical assessment
ED Doctor
History
Meds/Allergies
Order CT Scan
Medical Registrar
NIHSS Stroke Scale – on-line training
Neuro Examination
Bundle of CareNursing staff in Ed asked to defer ECG
Medical staff reminded to stay with patient and assist with transport of patient to CT Scanner
Near Patient testing
Training of Reception staff in recognition of stroke symptoms
MD check list – responsiblity of nursing staff- ed and stroke,responsibilty of medical staff Ed and medical registrar.
PDSA 6
CT radiographer live in October 2012
1 3 5 7 9 11
13
15
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25
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32
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80
0
20
40
60
80
100
120
140
Goal
CT scan (within 45 mins)
Bundle
1 3 5 7 9 11
13
15
17
19
21
23
25
27
29
32
34
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0
20
40
60
80
100
120
140
160
180
200
Median
Goal
Bundle
Door to needle time (within 60 mins)
THE M and M GAME
OR
How to run a PDSA Cycle
Act • What changes are to be made?• Next cycle?
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
Plan• Objective• Questions and predictions (why?)• Plan to carry out the cycle• Plan for data collection
To Be Considered a PDSA Cycle
The test or observation was planned (including a plan for collecting data)
The plan was attempted
Time was set aside to analyze the data and study the results
Action was rationally based on what was learned
The M&M Challenge Aim – to be left as few M&Ms as
possible at the end (?only 1)
Measure – number of M&Ms left
Operational definitions:
DO NOT EAT THE M&Ms Leave one blank circle on game sheet Jump one marker over another and remove marker that is jumped over Each round lasts 1 minute
2
1
3
654
10987
1514131211
STEP 1: Plan
Objective: To test (another)approach to removing pegsPredictions: Will we leave fewer pegs?Plan: Who, what, record moves
STEP 2: Do
• Carry out the plan• Record moves• Note problems or changes to plan
STEP 3: Study
• Compare data to predictions• Summarise what was learned• Update the team’s theory (approach)
STEP 4: Act
• Does our approach leave 1 peg?• If not what new ideas should we test on next cycle?
PDSA FOR THEPEG (M&M) GAME
IN SUMMARY:
What we are told to do
What we think we should do
Behaviour
Rules and Regulations
Culture
Behaviour
Safety brings its own dangersThe price of safety is chronic unease
‘First of all, I was not in a position to challenge on the basis of my limited experience of this type of treatment. Second, I was an SHO (junior doctor) and did what I was told to do by the Registrar. He was supervising me and I assumed he hadthe knowledge to know what was being done. Dr M. was employed as a registrar ... in a centre for excellence and I did not intend to challenge him’.
Reliability of ward care
(1) How well do you understand the goals of care for this patient today?
(2) How well do you understand what work needs to be accomplished to get this patient to the next level of care?
Less than 10% of nurses or doctors could answer these questions
Pronovost et al, 2003
Team
Six things all Trust Boards should do
Setting Aims: Set a specific aim to reduce harm this year – a public commitment to measurable quality improvement
Getting Data and Hearing Stories: Review progress toward safer care as the first agenda item at every board meeting, grounded in transparency, and putting a “human face” on harm data.
Establishing and Monitoring System-Level Measures: Identify a small group of organization-wide “roll-up” measures of patient); keep up to and make transparent to the entire organszation and users.
Changing the Environment, Policies, and Culture: Commit to an environment that is respectful, fair, and just – for all those touched by avoidable harm/poor outcomes.
Learning… Starting with the Board: Learn how “best in the world” boards work to reduce harm. Expect such training for all staff.
Establishing Executive Accountability: Oversee the execution of harm reduction plan; include executive team accountability.
How do we know organisations are safe?
Reflect on yourown experiences of health care . . .
What was good?What was bad?What made you angry?What upset you?
“To the typical physician, my illness is a routine incident in his rounds while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity. I just wish he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”
Anatole Broyard
The A B C Dof dignity-conserving care
Chochinov BMJ 2007; 335: 184-187
ABC
D
Chochinov BMJ 2007; 335: 184-187
ttitude How would I feel if I was this patient?
Inappropriate assumptions?- poor quality of life; ageism; social acceptability; malingering;
Is my attitude towards the patient biased by my own experiences, anxieties, or fears?
Does my attitude towards being a healthcare provider help or hinder an empathic professional relationships with patients?
People who are treated like they no longer matter will act and feel like they no longer matter
A
ehaviourB
Chochinov BMJ 2007; 335: 184-187
Respect
Small acts of kindness
- simple comfort measures; acknowledging a photo;
Permission to examine
Acknowledge inconvenience and discomfort
Discussion after patient dressed
Good communication skills
“You, as a person, are worthy of my care and attention”
ompassionC
Chochinov BMJ 2007; 335: 184-187
Extending care beyond the intellectual level
Developed and shaped by life experience
Something that we feel
Awareness of suffering and a wish to relieve it
Non-physical communication
ialogueD
Chochinov BMJ 2007; 335: 184-187
Formal psychotherapeutic approaches
Getting to know the patient
- hobbies; family; beliefs; previous exposure to illness; what is important in their life
Acknowledging fear, distress
Identifying significant others who can support
VideoCleveland Clinic
The secret of the care of the patient is in caring for the patient
Dr Francis Peabody 1927