Getting started at the national level from demonstration to spread

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Apresentação de Derek Freeley durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
Derek Freeley é Vice Presidente Executivo do Institute for Healthcare Improvement (IHI), tem responsabilidades executivas por conduzir estratégias do IHI em cinco áreas de atuação: desenvolvimento de habilidade; cuidado centrado no paciente e família; segurança do paciente; qualidade; custo e valor; e grande foco em populações. Antes de integrar a equipe do IHI em 2013, foi diretor geral de saúde e assistência social e diretor executivo do National Health Service (NHS) na Escócia.

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Getting started at the national level from demonstration to spread

  1. 1. Getting Started At the National Level: From Demonstration to Spread 1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs November 4, 2013 São Paulo, Brazil Derek Feeley Executive Vice President
  2. 2. NHS Scotland 3 c. 5.1 million population Devolved (since 1999) 14 Regional Boards Integrated system ( e.g. no purchaser/ provider split) Integration of health and social care underway Tax funded/ 20bn CAD budget, cash limited Equal access on basis of need Free at the point of care
  3. 3. Why Patient Safety? 4 United States: 3.7% of admissions 44,000 – 98,000 deaths United States: 3.7% of admissions 44,000 – 98,000 deaths Australia: 16% of admissions 50,000 permanent disability 250,000 adverse events 10,000 deaths Australia: 16% of admissions 50,000 permanent disability 250,000 adverse events 10,000 deaths Denmark: 9% of admissions Denmark: 9% of admissions New Zealand: 10% of admissions New Zealand: 10% of admissions United Kingdom: 11% of admissions 850,000 adverse events United Kingdom: 11% of admissions 850,000 adverse events DoH ECRI 2002 Knox K et all
  4. 4. Global Trigger Tool Reviews 5 3 Exemplar Hospitals (900 notes) 40 Bed rural Hospital (300 notes) 10 Hospital Research Project (240 notes) 7 Hospital System (3000 notes) Multi-state Tertiary System (2000 notes) Events/1000 Days 83 90 NA 119 86 Events/100 admissions 45 40 37 41 38 Admissions with adverse events 32% 30% 30% 29% 30%
  5. 5. Not Just Numbers 6
  6. 6. So what do we know? At least 10% of patients admitted to hospital suffer harm Traditional incident reporting – tip of the iceberg Variation in mortality rates Human beings will always make mistakes Lack of standardisation – clinician preference Best known science is not reliably applied
  7. 7. Lack of Reliable Processes Create…. Islands of great care in a sea of variation Inconsistent performance & outcomes Chaos as clinicians create ‘work-arounds’ just to get the work done A culture where it is difficult to learn and improve Care that is more complex and often more unsafe
  8. 8. Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on outcomes tends to exaggerate the reliability within healthcare giving clinicians a false sense of security Permissive clinical autonomy creates and allows wide performance margins The Reliability Gap
  9. 9. What We Asked Ourselves - Policy How do we reduce harm in the NHS in Scotland? How do we reduce mortality in Scottish hospitals? What could we learn about improving quality more generally?
  10. 10. No Shortage of Analysis
  11. 11. It’s complicated…… 12 “Too bad all the people who know how to run the country are busy driving cabs and cutting hair.” - George Burns Updated for 2013: “It's too bad that everyone who has a solution for everything is at home commenting on the internet.” - Twitter user Rasta Pasta (@rastahipsta)
  12. 12. Policy Options Do what we’ve always done Let’s get more data Run a pilot project Run a campaign Let Boards and hospitals decide what to do Run a mandatory national improvement program
  13. 13. Why Did Scotland Go National? 14 The context was right Our size helped Clinicians and managers were receptive A good match with ‘values’ The evidence was good enough – the ‘Tayside Effect’ It felt like the right thing to
  14. 14. The Right Foundations . . . 15 100,000 Lives Campaign Safer Patients Initiative Political support at the highest level Leadership prepared to be transparent about harm and to build the will to improve
  15. 15. . . . And Missing Ingredients 16 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.
  16. 16. Policy Risks – do nothing (new) We’ll always get what we always got. There will continue to be avoidable harm (even more perhaps as care gets more complex) The debate continues to be about reporting rather than improving. Its not denial, I am just selective about the reality I accept. (Bill Waterson – Calvin and Hobbes)
  17. 17. Making Policy as a Metaphor for Spread policy1n pl -cies1. (Government, Politics & Diplomacy) a plan of action adopted or pursued by an individual, government, party, business, etc UK National School for Government 2006 Evidence Experience & Expertise Judgment Resources Values Habits & Traditions Lobbyists & Pressure Groups Pragmatics & Contingencies
  18. 18. Spread and Sustainability Spread = The process through which new working methods developed in one setting are adopted, perhaps with appropriate modifications, in other organizational contexts Sustainability = The process through which new working methods, performance enhancement, and continuous improvements are maintained for a period appropriate to a given context Buchanan D, Fitzgerald L, Ketley D. The Sustainability and Spread of Organizational Change: Modernizing healthcare. Abingdon, Oxon: Routledge; 2007.
  19. 19. “Up to 70% of improvement projects never spread.” Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012; 53(4): 43-50.
  20. 20. Planning for Spread Preparing for spread Establishing an aim for spread Developing an initial spread plan Executing and refining the spread plan In Scotland the spread plan was to start with all, just not with everything, everywhere. We told hospitals to start where they were good and to get to complete coverage in 2 years.
  21. 21. Implementing at scale….can it be done? Execution Ideas Will
  22. 22. W Edwards Deming “By what method? Only the method counts.” 23
  23. 23. The Typical Approach 24 Conference RoomConference Room DESIGN DESIGN DESIGN DESIGN APPROVE IMPLEMENTReal WorldReal World
  24. 24. DESIGN TEST & MODIFY TEST & MODIFY APPROVE IF NECESSARY Conference Room Conference Room Real World Real World TEST & MODIFY The Quality Improvement Approach START TO IMPLEMENT
  25. 25. IHI Breakthrough Series – sticking with it Select Topic (develop mission) Planning Group Develop Framework & Changes Participants (10-100 teams) Prework LS 1 P S A D P S A D LS 3LS 2 Supports Email Visits Phone Assessments Monthly Team Reports Congress, Guides, Publications etc. A D P SExpert Meeting
  26. 26. Where We Started: SPSP Outcome Aim Set in 2008 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 within Range (ITU/HDU): 80% or > w/in range – MRSA Bloodstream Infection: 30% reduction – Crash Calls: 30% reduction 27 To be achieved across the nation by 2012 Mortality aim amended to 20% by 2015
  27. 27. What We Set Out to Improve Acute Program – 5 Workstreams Critical Care Perioperative Care General Ward Care Medicines Management Leadership for Safety 28
  28. 28. 0,8 0,9 1,0 1,1 Oct-Dec 2006 Apr-Jun 2007 Oct-Dec 2007 Apr-Jun 2008 Oct-Dec 2008 Apr-Jun 2009 Oct-Dec 2009 Apr-Jun 2010 Oct-Dec 2010 Apr-Jun 2011 Oct-Dec 2011 Apr-Jun 2012 StandardisedMortalityRatio HSMR up to September 2012 8497 less than expected deaths 12.4% reduction
  29. 29. 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 Harm from Anti-coagulation: Reduction in INRs > 6 All process measures will be > 95% reliable AHO3 Adverse Events Rate per 1000 patient days .0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 AHO3 Adverse Events Rate per 1000 patient days .0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 CCP2 VAP Prevention Bundle Percent 80.0 85.0 90.0 95.0 100.0 7 11 9 11 11 11 1 12 3 12 5 12 7 12 CCP2 VAP Prevention Bundle Percent 80.0 85.0 90.0 95.0 100.0 7 11 9 11 11 11 1 12 3 12 5 12 7 12 CCO1 VAP Rate Rate per 1000 ventilated days .0 2.0 4.0 6.0 8.0 10.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 CCO1 VAP Rate Rate per 1000 ventilated days .0 2.0 4.0 6.0 8.0 10.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 CCO2 Central Line Infection Rate per 1000 patient days .0 2.0 4.0 6.0 8.0 10.0 6 11 8 10 12 2 4 6 12 CCO2 Central Line Infection Rate per 1000 patient days .0 2.0 4.0 6.0 8.0 10.0 6 11 8 10 12 2 4 6 12 CCO6 Optimal Glucose Control Percent 70.0 75.0 80.0 85.0 90.0 95.0 100.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 CCO6 Optimal Glucose Control Percent 70.0 75.0 80.0 85.0 90.0 95.0 100.0 6 11 8 11 10 11 12 11 2 12 4 12 6 12 MMP3C Filtered INR>6 Percent 0.0 0.1 0.2 0.3 0.4 0.5 0.6 7 11 9 11 11 11 1 12 3 12 5 12 7 12 MMP3C Filtered INR>6 Percent 0.0 0.1 0.2 0.3 0.4 0.5 0.6 7 11 9 11 11 11 1 12 3 12 5 12 7 12 Process reliability achieves improved outcomes! 697 days! 596 days! Where We Started: Outcomes & Achievements
  30. 30. Safety is Contagious – In A Good Way
  31. 31. A Strategy and a Roadmap 32
  32. 32. 33 3 Quality Ambitions Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times. The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
  33. 33. 3-Step Improvement Framework for Scotland’s Public Services 34 1. Change the World 2. Create the conditions 3. Make the Improvements Macro System: Vision, Aim & Context Meso System: Culture, Capacity, & Challenge: How much and by when? Micro System: Implementation, measurement, & improvement
  34. 34. Creating the Conditions 6 Questions for Every Change Program 35 1. Does everyone in the system know what we are trying to achieve? 2. Are we prioritizing the improvements likely to have the biggest impact on the aim and stopping those that have little impact? 3. Is everyone clear about the means of securing improvements towards our aim? 4. Are we able to measure and report progress on our aim? 5. Do we know how and when to deploy resources when improvement is slower than required? 6. Do we have a way of testing and innovation and then spreading new learning?
  35. 35. Investing One Generation Ahead – The Method Works Here, Too
  36. 36. The Early Years Collaborative - Ambition To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.
  37. 37. The Early Years Collaborative - Aims 1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidence by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015). 2. To ensure that 85% of all children with each Community Planning Partnership have reached all of the expected development milestones at the time of the child’s 27-30 month child health review, by end-2016. 3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected development milestones at the time the child starts primary school, by end-2017.
  38. 38. Front Line Staff – How Did They Do It? Get goals Get bold Get together Get a method (and stick with it) Get patients and families Get the facts Get to the field Get a clock Get the numbers Get the stories
  39. 39. 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.”

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