One small step for man … … One small step for man … …

The Model for ImprovementThe Model for Improvement((keep it small and simple))

SSC COMPONENTQUB MEDICAL STUDENTS:

FRIDAY, 17 FEBRUARY 2012

TODAY YOU WILL:TODAY YOU WILL:

Be able to outline the background to patient safety in health and social care

Have a basic understanding of the person vs system approach to error

Explain the Model for Improvement and be able to apply this to a specific example

1 in 10 = 551,000; 55,000, more likely 3 in 10 = 165,000 -

“Between the healthcare we have and the healthcare we could have lies not just a gap, but a chasm”

Why? Little reliability (80%) despite best intentions◦ Best-known science is not reliably applied (60%)◦ Widespread inefficiencies waste precious resources (20%)◦ Patients are being harmed at alarming rates (10%; 30-40%)◦ Failure to recognise, to rescue, to plan, to communicate◦ Variation in practice (ie inappropriate variation not determined

by patient need)

So we work on…◦ Not the individual (blame, myopic view): ‘to err is human’ –

◦ “we cannot change the human condition, but we can change the conditions under which humans work” (James Reason); but

on◦ The system!

Get diagnosed Get treated Get out Get on

Systematic accurate diagnosis, early intervention, implementation of practices that are known to be safe and moving patients effectively along a care pathway*

Acute care

SAFELY

Get in

*Health Commission Report: Safe in the Knowledge, 2009

•No needless deaths, harm or suffering•No delays•No waste•No feelings of helplessness

S AFET IMELYE EFFECTIVEE FFICIENTE QUITABLEP ATIENT CENTRED

Variation is intrinsic in health care. It is the result of clinical variability (number of patients presenting with certain clinical conditions), flow variability (the ebb and flow of patients arriving throughout the day), and professional variability (the variation in skill levels and techniques among providers).

Some kinds of variability (so-called “random variability”) cannot be eliminated, or even reduced; they must be managed. This is true of patient variability. We cannot eliminate the many types of problems from which patients suffer, nor can we control when they arrive in the emergency department.

Other types of variability (“non-random”), on the other hand, are often driven by individual priorities, resulting, for example, in surgical schedules that are heavy on Wednesdays but light on Fridays due to surgeons’ preferences rather than actual demand. Non-random variability should not be managed; it should be eliminated. (Ref: IHI – Optimizing Patient Flow, 2003)

Defining Domains of Quality Problems

Overuse - Examples of include hysterectomies, cardiac catheterizations, tympanostomy, antibiotics, tranquilizers, sedatives, carotid endarterectomy, cardiac pacemakers, upper gastrointestinal endoscopy, and non-steroidal anti-inflammatory drugs

Underuse - Example, providers routinely fail to administer a variety of evidence-based tests and treatments to heart attack victims and individuals with diabetes and congestive heart failure.

Misuse - Medical errors represent the most common form of misuse within the health. Examples drug misuse, hospital-acquired infections, diagnostic, surgical errors, and incorrect use of medical equipment.

Waste -unnecessary administrative activities is prevalent. In addition to driving up costs, waste can have a direct negative impact on service quality (e.g., waiting times), clinical quality, and access to care.

Waste may also crowd out needed spending in other areas of health care.

Patient Safety Incident

• Any unintended or unexpected incident/s that could or did lead to harm for one or more patients

• Patients and families• Healthcare staff -the second victims• Financial-additional hospital stays

alone estimated to cost £2000m annually in UK

If a professional is highly trained and tries hard enough he/she will not make errors

the punishment myth if we punish people when they make errors they will make fewer of them

Human beings carrying out complex and risky procedures in our time pressurized healthcare organisations will make errors

95% of errors that cause harm involve conscientious competent individuals trying hard to achieve a desired outcome –only 5% of harm is caused by incompetence or poorly intended care

We all make errors irrespective of how much training and experience we possess, or how motivated we are to do it right

An individual failing◦Only the minority of cases amount from

negligence or misconduct; so it’s the “wrong” diagnosis

◦It will not solve the problem--it will probably in fact make it worse because it fails to address the problem

◦Professionals will hide errors◦May destroy many staff (inadvertently (the

second victim)

A systems failure◦ This is the starting point for redesigning the

system and reducing error

“Every system is perfectly designed to

get the results it gets”

The First Rule of Improvement

SWISS CHEESE MODELSWISS CHEESE MODEL(James Reason - 1990)

Will to do what it takes to change to a new system

Ideas on which to base the design of the new system

Execution of the ideas

Im

“Improvement requires a will to improve, Ideas to test and execution of a plan”

Frank Frederico, IHI, Doug Bonacum, KaiserPermanante Health Exec., Jan 2010

5 P’s

PurposeWhat is the role of the team and what are you trying to achieve.

•Who contributes to the service / care e.g.:- •Ancillary and General•Nursing•Doctors •AHPs

How are the services planned

What are the current practices and procedures you use

Who is the service / care provided to / for.

Have you sufficient information to identify areas for service improvement

Review analysis gaps and measure as required

Processes Patients

Move to Stage 2

This model has been adapted from the Dartmouth Institute

Professionals

What do you know about how well your service performs

e.g.:- Length of stay Pt satisfaction Staff Rotas Clinical Risk Complaints Team Meeting

Patterns

No Yes

Identified areas for improvement

Identify themes

Theme 1 Theme 2 Theme 4Theme 3 Theme 5

Prioritises themes (Consider)1. What matters most to patients and staff2. Time and effort3. Corporate Objectives

Review analysis as requiredr

No

Move to Stage 3

YesClearly identified area for improvement

Coming up with ideas on how to improve current

state: evidence, hunches,other people etc.

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

What are we trying toWhat are we trying toachieve?achieve?

Constructing a clear aim statement

How will we know that aHow will we know that achange is an improvement?change is an improvement?

Choosing right measures and planning how you

will collect right information

Act Plan

Study Do

The fourthquestion:

how to make changes -

testing

Thethree

fundamental

questions for

improvement

Langley, Nolan et al 1996

The Model for Improvement

Leadership SupportLeadership Support

System Leadership

Clinical Technical Expertise

Day to day leadership

Agreed by Improvement Team

Time specific

Measurable

Process measures

Outcome measures

Balancing measures

How do we know a change is an improvement?How do we know a change is an improvement?

Research Judgement Improvement

Purpose To discover new knowledge

To compare others, to rank To bring new knowledge into daily practice

Tests One large trial Public reporting quarterly or with 12 month running averages

Many sequential, observable tests

Data Gather as much data as possible, just in case

Reports structure, processes or outcomes

Small tests of significant changes, accelerates the rate of improvement

Duration Can require large numbers of patients and long periods of time to obtain results

Ongoing data collection and quarterly public reporting

Short iterative cycles in a limited number of subjects, followed by spread

1. Decide Aim

2. Choose measures

3. Define measures

4. Collect data

5. Analyse

+ present

6. ReviewMeasur

es

The Seven steps to Measurement are:

Step 1 - Decide your aim

Step 2 - Choose your measures

Step 3 – Define your measures

Step 4 - Collect your baseline data

Step 5 - Analyse and present your data

Step 6 - Meet to decide what it is telling you

Step 7 - Repeat steps 4-6 each month or more frequently

7. RepeatSteps 4-

6

In God we Trust, all others bring Data … …

PROCESS: (Ventiliator acquired pneumonia bundle)

• Elevation of head of bed between 30 and 45 degrees• Daily awakening: “sedation vacation”• Daily assessment of readiness for weaning• DVT prophylaxis (unless contraindicated)• Stress bleeding (peptic ulcer) prophylaxis

MEASURES contd.

PROCESS: (Losing weight)

• Number of visits to gym each week,• Number of walks per week,• Number of calories lost per day/week

OUTCOME:

• Reduction in Ventilator acquired pneumonia rate

OUTCOME:

• Reduction in deaths each year from stroke

Outcome:

• Number of pounds lost per month

MEASURES contd.

S + P = 0S + P = 0

BALANCING:

• Increasing Re-Admission rates

BALANCING:

• Increase in Waiting times in A&E

BALANCING:

• Reduction in hours of sleep

MEASURES contd.

An understanding of processes and systems of work

Challenge boundaries

Adapting known good ideas

Re-arrange order of steps

Smooth work flow

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

AIM

Concept B

Concept C

Concept A

Concept D

Multiple PDSA Cycles Directed Toward a

Single Aim

Collate your PDSA cycles

and when you spread so

they can understand what

processes, predictions, and

tests they went through that

lead to share them with

o

ther areas change

Do not be tempted or

pressurised into implementing

or spreading until you have

achieved a reliable process

that is fit fo

r purpose and

your are happy with

TIPS TIPS

• From PDSA to SDSA

• Only implement what you know is an improvement

• Communication

• Consider impact on people

• Consider infrastructure

Be clear about the benefit to stakeholders◦ Winning hearts and minds, “what's in it for me?”

Pay attention to ongoing training and education needs

See how you can contribute to building the improvement into the structure of your organisation and make it the new standard

Build in ongoing measurement Work towards making sustainability mainstream

◦ Is it someone's responsibility? Has resource been allocated?

Celebrate, renew and set the bar higher

Tips for Improving Sustainability

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996

Achieving Safe and Reliable Healthcare; strategies and solutions. M Leonard, A Frankel, T Simmonds

Improving the Reliability of Healthcare. Institute for Healthcare Improvement Innovation Series 2004 White Paper. Available free at www.ihi.org

Quality by Design: A Clinical Microsystems Approach. E Nelson, P Batalden, M Godfrey

To Err is Human: Building a Safer health System” Kohn LT

Clinical Microsystems Website: Dartmouth Institute: http://cms.dartmouth.edu/

National Patient Safety Agency website: www.npsa.nhs.uk

Patient Safety First campaign – www.patientsafetyfirst.nhs.uk

1000 Lives Welsh Patient Safety Campaign – www.wales.nhs.uk

Scottish Patient Safety Programme: http://patientsafety.etellect.co.uk/programme

Institute for Healthcare Improvement: www.ihi.org

CONTACT DETAILS:

Janet Haines-Wood, Regional Patient Safety Advisor, HSC Safety Forumjanet.haines-wood@setrust.hscni.netTel: 02892665181, Ext 4819

Levette Lamb, Regional Patients Safety Advisor, HSC Safety Forumlevette.lamb@setrust.hscni.netTel: 02892665181, Ext 4817

HSC Safety Forum Website:http://www.publichealth.hscni.net/directorate-nursing-and-allied-health-professions /hsc-safety-forum