Reducing Harm at a National Level:The Scottish Story1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs

November 4, 2013

São Paulo, Brazil

Derek Feeley

Carol Haraden

“By what method?...

only the method counts”

W Edwards Deming

Emphasis on Method

Our Change Theory

A clear and stretch goalA methodPredictive, iterative testing

3

Where We Started:SPSP Outcome Aim Set (2008)

Mortality: 15% ReductionAdverse Events: 30% Reduction– Ventilator Associated Pneumonia: 0 or 300 days between– Central Line Bloodstream Infection: 0 or 300 days between– Blood Sugars within Range (ITU/HDU): 80% or > w/in range– MRSA Bloodstream Infection: 30% reduction– Crash Calls: 30% reduction

4

To be achieved across the nation by 2012Mortality aim amended to 20% by 2015

Developments in Acute Care Hospitals5

Aims: To Further Improve the Safety of People in Acute Adult Healthcare

1. Reduce Harm95% of people in acute adult health care free from harms in the Scottish Patient Safety Index by 2015:

Cardiac ArrestCatheter Acquired Urinary Tract InfectionsPressure UlcersFalls

2. Reduce Hospital Associated MoralityReduce HSMR by 20% by 2015

Further improve the safety of

people in Acute Adult Healthcare

Reduce Harm:95% of people in acute adult health care free from harms in SPSI:• Cardiac Arrest• CAUTI• Pressure Ulcers• Falls

Reduce HSMR by 20%

By December 2015

Strategic Priority

Pointof Care

Infrastructure

• Ensure safety and quality are organisational priorities

• Provide leadership & oversight to ensure delivery of programme

• Actively develop your safety culture• Essentials of Safety are

comprehensively implemented

• Reliable person centered response to deteriorating patients

• Reliable recognition & care delivery for patients with Sepsis

• Reliable care delivery for patients with Heart Failure

• Prevent avoidable Pressure Ulcers• Reduce SSI• Reliable risk assessment to prevent VTE• Prevent CAUTI• Reduce Falls• Safer Use of Medicines

• Develop & utilise local capacity & capability in QI

• Effective measurement systems• Programme Management• Effective Communications• Manage transitions of care

Back to the start: What We Set Out to Improve

Acute Program: 5 workstreamsCritical CarePeri-operative CareGeneral Ward CareMedicines ManagementLeadership for Safety

7

How do we improve?

The Improvement Trilogy

Will

Ideas

Execution

What We Know Works

Leadership is criticalClear Aim and PurposeStrong TeamThe Use of Data and MeasureTesting on a Small ScaleDeliberate Spread of Innovation

Three Separate and Critical Competencies

1. Building successful prototypes2. Implementation of the successful prototype3. Spreading the change

Skills to Support Improvement

Using DataDeveloping a ChangeTesting a ChangeImplementing a ChangeWorking With People

Critical Care 13

Care Bundles to Support

Peripheral Vascular Catheter (PVC) Bundle (HPS)Check to ensure the PVC in situ are still requiredRemove PVCs where there is extravasation or inflammationCheck PVC dressings are intactConsider removal of PVS in situ longer than 72 hoursPerform hand hygiene before and after all PVS procedures

14

Peri-operative 15

General Ward 16

Medicines Management 17

Leadership 18

0,8

0,9

1,0

1,1

Oct-Dec2006

Apr-Jun2007

Oct-Dec2007

Apr-Jun2008

Oct-Dec2008

Apr-Jun2009

Oct-Dec2009

Apr-Jun2010

Oct-Dec2010

Apr-Jun2011

Oct-Dec2011

Apr-Jun2012

Sta

ndar

dise

d M

orta

lity

Rat

io

HSMR Scotland: January 2008 -September 2012

8497 less than expected deaths

12.4% reduction

HSMR – Annual Rolling Averages20

0,8

0,9

0,9

1,0

1,0

1,1

1,1

1,2

1,2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

SM

R

Quarters

HSMR - Annual Rolling AveragesYear Ending Oct-Dec 2002 to Jul-Sep 2012

1.4% (Annualised Reduction)Oct-Dec 2002 to Jan-Mar 2010

4.0% (Annualised Reduction)Apr-Jun 2010 to Jul-Sep

Dec 2009:

General ward C.Difficile rate (per thousand patient days)

21

0

0.5

1

1.5

2

2.5

Jan-

08Apr

-08

Jul-0

8Oct-

08Ja

n-09

Apr-0

9Ju

l-09

Oct-09

Jan-

10Apr

-10

Jul-1

0Oct-

10Ja

n-11

Apr-1

1Ju

l-11

Oct-11

1.15

0.12

90% reduction

VAP Prevention Bundle Reliability(average Scottish ICUs)

22

VAP Prevention Bundle Reliability and VAP rate/1000 ventilated days

(average across Scottish ICUs)

50%

75%

100%

Feb-

08M

ay-0

8Aug

-08

Nov-0

8Fe

b-09

May

-09

Aug-0

9Nov

-09

Feb-

10M

ay-1

0Aug

-10

Nov-1

0Fe

b-11

May

-11

Aug-1

1Nov

-11

Feb-

12M

ay-1

2Aug

-12

Nov-1

2

0

6

12

18Better

Better

Ventilator Acquired Pneumonia Rate23

Surgical Safety Briefings24

Scottish Amalgamated Hospital Post-Op Surgical Mortality

25

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

1,60

1,80

Apr

- J

un 1

981

Apr

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un 1

982

Apr

- J

un 1

983

Apr

- J

un 1

984

Apr

- J

un 1

985

Apr

- J

un 1

986

Apr

- J

un 1

987

Apr

- J

un 1

988

Apr

- J

un 1

989

Apr

- J

un 1

990

Apr

- J

un 1

991

Apr

- J

un 1

992

Apr

- J

un 1

993

Apr

- J

un 1

994

Apr

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un 1

995

Apr

- J

un 1

996

Apr

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un 1

997

Apr

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un 1

998

Apr

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un 1

999

Apr

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000

Apr

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001

Apr

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002

Apr

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Apr

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004

Apr

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Apr

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Apr

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Apr

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Apr

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Apr

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Apr

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,p

% M

orta

lity

on D

isch

arge

Quarter of Discharge

P' Chart for Surgical Mortality

Scotland ICU Mortality Percentage26

0

5

10

15

20

25

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Intensive Care Unit Mortality %Units reporting via Extranet Average n = 16

National Average Annual…

14.6%

19.0% 18.3%

16.7%

14.3%

Overall reduction 25%

Scotland Average Length of Stay27

0

1

2

3

4

5

6

7

jan

/08

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Da

ys

ICU average length of stay15% reduction in median length of stay

average ICU los

median los

4.08 days

4.8 days

ICU ALOS28

6.2 days

5.1 days

18% reduction(1.1 days)

Cost saving of £990,000

How’d We Do? NHS Highland

Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in range Harm from Anti-coagulation: Reduction in INRs > 6All process measures will be > 95% reliable

AHO3

Adverse Events

Rate per 1000 pat ient days

.010.020.030.040.050.060.070.0

611

811

1011

1211

212

412

612

AHO3

Adverse Events

Rate per 1000 pat ient days

.010.020.030.040.050.060.070.0

611

811

1011

1211

212

412

612

CCP2

VAP Prevention Bundle

Percent

80.0

85.0

90.0

95.0

100.0

711

911

1111

112

312

512

712

CCP2

VAP Prevention Bundle

Percent

80.0

85.0

90.0

95.0

100.0

711

911

1111

112

312

512

712

CCO1

VAP Rate

Rate per 1000 ventilated days

.02.04.06.08.0

10.0

611

811

1011

1211

212

412

612

CCO1

VAP Rate

Rate per 1000 ventilated days

.02.04.06.08.0

10.0

611

811

1011

1211

212

412

612

CCO2

Central Line Infection

Rate per 1000 pat ient days

.02.04.06.08.0

10.0

611

8 10 12 2 4 612

CCO2

Central Line Infection

Rate per 1000 pat ient days

.02.04.06.08.0

10.0

611

8 10 12 2 4 612

CCO6

Optimal Glucose Control

Percent

70.075.080.085.090.095.0

100.0

611

811

1011

1211

212

412

612

CCO6

Optimal Glucose Control

Percent

70.075.080.085.090.095.0

100.0

611

811

1011

1211

212

412

612

MMP3C Filtered

INR>6

Percent

0.00.10.20.30.40.50.6

711

911

1111

112

312

512

712

MMP3C Filtered

INR>6

Percent

0.00.10.20.30.40.50.6

711

911

1111

112

312

512

712

Process reliability achieves improved outcomes!697 days! 596 days!

10 Interventions Now Embedded

10 Patient Safety

Essentials

Hand Washing

PVC Bundle

Surgical Brief & Pause

VAP Bundle

CVCInsertion

CVC Maintenance

General Ward Safety Brief

Early Warning Score

ICU Daily Goals

Leadership Walk rounds

Missing Ingredients31

We needed a partner to help us with design and execution. We needed to overcome clinical (mainly medical) resistance.We needed to convince leaders and managers that this was not just “another initiative.” We needed to start somewhere.

Solutions32

Improving the safety of patients

Quality of care &

patient safety above all else

Engage & empower

patients and carers

Foster staff development and growth

Embrace transparency unequivocally

Remember…..33

“Health statistics represent people with the tears wiped off.”

Sir Austin Bradford Hill (1897-1991)