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"Can organisational restructuring of hospitals improve quality and safety"
- 1. “Can organisational restructuring of hospitals improve quality and safety?” The experience at Sydney Children’s Hospitals Network 27th IHI Scientific Symposium, 7 Dec 2015 Dr Glen Farrow MBBS MBA FRACS MRACMA Director of Clinical Governance and Medical Administration
- 2. The Sydney Children’s Hospitals Network was created in June 2010 in response to concerns regarding the performance of the NSW Health system
- 3. Independent Competitive Finance & performance focus Separate universities Different demographics wealthy eastern suburbs; working class west. Little sharing of ideas staff research fundraising Challenges ≤ 2010 Single vision “children first and foremost” Collaborative and Competitive Patient focus University research collaboratives Single multicultural demographic Respect the differences, bring ideas to the table Sharing of ideas, staff, research Networked management structures ≥ 2011
- 4. Strategy 1. Alignment Mission, structure, committees, agendas, reports and language aligned with the 10 National Quality and Safety Standards
- 5. Sydney Children’s Hospital Clinical Practice Improvement Unit Quality Manager 1.0 Patient Safety Officer 0.84 Policy and Procedure Coordinator 1.0 Clinical Pathways 0.63 Patient Friend 1.0 Medico-legal 1.0 Deputy Director of Clinical Governance The Children’s Hospital at Westmead – Clinical Governance Structure 1 Head of the CGU 1.0 HSM 4 cc:680938 Director of Clinical Governance & Medical Administration 6 Patients’ Friend 1.0 HSM 3 7 Clinical Risk Manager Staff Specialist (0.4) 8 Policy & Procedure Coordinator 1.0 HSM 2 5 Patient Safety Manager 1.0 HSM 3 5b IIMS Manager (0.6) HSM 2 5a Medication Safety Pharmacist - (0.6) Senior Pharmacist 4 Consumer Participation Coordinator 1.0 HSM 3 9 Carer Support Coordinator (0.6) HSM 2 9a Carer Support Project Officer - (0.8) HSM 1 3 Clinical Practice Improvement Coordinator 1.0 HSM 3 10 Administrative Officer (Job share NW & RG) 1.0 AO LEVEL 5 11 Administrative Officer 1.0 AO LEVEL 3 2 Improvement Coordinator 1.0 HSM 3 2b Service Improvement Project Officer 1.0 HSM 2 5c Best Practice Project Officer 1.0 HSM 2 2a Clinical Improvement Project Officer HSM 2 (0.8) Executive Assistant to DGM 1.0 HSM 1 Executive Manager Corporate Governance Risk 1.0 HSM 4 Chief Resident Medical Officer 1.0 Strategy 2. Networks replacing silos
- 6. Strategy 3. Situational awareness Situational awareness of frontline clinical staff 1. If you don’t know the risks how can you watch out for them? 2. If the organisation does not know the risks how can structures be put in place to prevent them? 3. If the organisation does not know how it is performing, how can it improve? Alerts from the DCG Dissemination of adverse event details Benchmarking
- 7. Timeline Prior to 2010 Two individual hospitals with limited collaboration 2008 Garling Review 2010 SCHN formation 2012 Clinical Governance Portfolio restructure 2015 Current state
- 8. The study In order to assess the impact on quality and safety, data from both before and after SCHN formation has been reviewed and is presented within accepted domains of quality. Total inpatient activity data was used as the denominators for all graphs and calculations Two populations were defined, pre and post SCHN formation. Statistical significance was calculated using both the Chi squared and Z score (for comparing two non-parametric populations) and then calculating the p score. Split control charts were created using NSW Clinical Excellence Commission data collection tools found at: http://www.cec.health.nsw.gov.au/__data/assets/excel_doc/0009/258399/data-collection- tools.xls Comparisons have also been made with solutionsforpatientsafety.org
- 9. Framework IHI dimensions of quality; providing care that is • safe, • effective, • patient-centred, • timely, • efficient, • and equitable
- 10. Inpatient Activity Years SCH CHW Total 2005 13868 26,702 40570 2006 14182 26775 40957 2007 14556 27625 42181 2008 15025 25732 40757 2009 14987 27347 42334 2010 15617 28880 44497 2011 17994 28987 46981 2012 18284 29415 47699 2013 18862 29985 48847 2014 18878 31800 50678 25 % increase in activity Ratio of staff to patients has been maintained Bed increases limited due to structural limitations and funding New models of care 1,000,000 occasions of service in 2014
- 11. Safety: SAC 1 and 2 incidents (potentially preventable harm) as a % of separation Z = 1.5735. P = 0.05821. The result is significant at p <0.10. SAC 1&2 Total ≤ 2010 247 251296 ≥ 2011 204 240813 The current average rate for SAC 1 and 2 incidents within SCHN is 0.08% of admissions whereas in NSW it is 0.20% of admissions 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Rate % 0.0012 0.0008 0.0011 0.0007 0.0012 0.0007 0.0009 0.0008 0.0012 0.0008 0.0006 Mean (Average) 0.0010 0.0010 0.0010 0.0010 0.0010 0.0010 0.0008 0.0008 0.0008 0.0008 0.0008 Upper control limit 0.0014 0.0014 0.0014 0.0014 0.0014 0.0014 0.0013 0.0013 0.0013 0.0013 0.0013 Lower control limit 0.0005 0.0005 0.0005 0.0005 0.0005 0.0005 0.0004 0.0004 0.0004 0.0004 0.0004 0.0002 0.0004 0.0006 0.0008 0.0010 0.0012 0.0014 0.0016 %ofseparations SAC1 and 2 incidents SCHN
- 12. Safety: SAC 1 events The numbers of SAC 1 events are always very low, but they appear to be less frequent.
- 13. Total incidents reported SCHN and facility as a percentage of separations 2007 2008 2009 2010 2011 2012 2013 2014 2015 CHW 0.062226244 0.068941396 0.065491644 0.07465374 0.075654604 0.07254802 0.071168918 0.064213836 0.08 SCH 0.097554273 0.100366057 0.08774271 0.09220721 0.059575414 0.056442792 0.056356696 0.061447187 0.083 SCHN 0.074417392 0.080526045 0.073368923 0.080814437 0.069496179 0.066374557 0.06544926 0.063183235 0.0815 NSW 0.081 0.0825 0.088 0.09 0.093 0.093 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% 11.00% 12.00% SCH decrease Z = 22 p<0.01 CHW increase Z=-4.868. p <0.01 SCHN Z = 9.981. p = 0. The result is significant at p <0.01.
- 14. Time delay in years between incident and legal action 1y 2y 3y 4y 5y 6y >6y Claims 109 30 24 9 4 4 9 57% 73% 86% 91% 93% 95% 100% 0 20 40 60 80 100 120 SCHN claims 1986 - 2013 n=189 incidents
- 15. Safety: new medico legal cases by year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Rate % 3.9367% 2.7114% 3.1741% 4.2673% 3.6803% 3.0708% 5.1689% 2.3414% 2.9351% 2.4567% 1.5786% Mean (Average) 0.0372 0.0372 0.0372 0.0372 0.0372 0.0372 0.0372 0.0233 0.0233 0.0233 0.0233 Upper control limit 0.0539 0.0539 0.0539 0.0539 0.0539 0.0539 0.0539 0.0345 0.0345 0.0345 0.0345 Lower control limit 0.0205 0.0205 0.0205 0.0205 0.0205 0.0205 0.0205 0.0120 0.0120 0.0120 0.0120 0.0000% 1.0000% 2.0000% 3.0000% 4.0000% 5.0000% 6.0000% %ofseparationsX100 Medicolegal cases SCHN The Z-Score is 2.7184. The p-value is 0.00652. p <0.01. M Legal Total ≤ 2010 109 291939 ≥ 2011 45 194205 24 cases less than predicted = $43M
- 16. Benchmarking: CVAD infections per 1000 line days SCHN Current rate 0.13% North America 0.000% 0.020% 0.040% 0.060% 0.080% 0.100% 0.120% 0.140% SCHN CVAD infections per 1000 line days Rate % Mean (Average) Upper control limit (2sd + mean) Lower control limit (2sd - mean) North America 0.132
- 17. Benchmarking: SCHN Medication and IV fluids adverse event rate 2014-15 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% SCHN medication& IV fluids errors by separation 2014-15 Rate % Mean (Average) Upper control limit (2sd + mean) Lower control limit (2sd - mean) North America 3.2%
- 18. Safety: Annual Medication Error Rate including IV fluids SCHN 0.0200 0.0220 0.0240 0.0260 0.0280 0.0300 0.0320 0.0340 %ofseparations SCHN medication error rate including IV fluids 2009 -14 Rate % Mean (Average) Linear (Rate %) North America 3.2% The Z-Score is 2.3075. The p-value is 0.02088. The result is significant at p <0.05. Increasing incident notification 6.5% to 8%
- 19. Safety: Total number of unexpected arrests per 1000 admissions SCHN 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 SCHC total number of ward cardiorespiratory arrests per 1000 admissions SCHN Total number of Cardiorespiratory Arrests per 1000 admissions Linear (SCHN Total number of Cardiorespiratory Arrests per 1000 admissions) SCHN 0.21 per 1000 CCH 0.31 per 1000
- 20. Effective: Readmissions as a percentage of separations pre and post Network 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 YTD SCH 3.03 2.28 2.46 2.39 2.63 2.56 3.62 3.23 3.62 3.25 3.24 2.1 CHW 3.8 4.05 4.1 3.21 3.62 3.09 3.1 3.12 3.42 3.87 4.09 3.5 SCHN 3.63 3.44 3.53 2.92 3.27 2.9 3.31 3.16 3.4 3.66 3.8 3.1 USA 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 1.5 2 2.5 3 3.5 4 4.5 SCHN Z = 2.7898. p = 0.00528. p <0.05.
- 21. Access: Did not wait SCHN 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% 11.0% 12.0% 13.0% %ofEDpresenations "Did not wait" SCHN Rate % Mean (Average) NSW Linear (Rate %) DNW Total ≤ 2010 15797 172226 ≥ 2011 28224 340230 The result is significant at p <0.01
- 22. Patient Centred: Complaints by facility as a percentage of separations 2007 2008 2009 2010 2011 2012 2013 2014 2015 SCHN 0.0093 0.0078 0.0083 0.0078 0.0077 0.0071 0.0074 0.0083 0.0093 CHW 0.0107 0.009 0.0092 0.0089 0.0097 0.0079 0.0089 0.0095 1.0% SCH 0.0067 0.0057 0.0066 0.0056 0.0045 0.0057 0.005 0.0065 0.0078 0.20% 0.40% 0.60% 0.80% 1.00% 1.20% SCH Z=1.7264. p = 0.04182. The result is significant at p <0.10 CHW Z = 1.1969. p = 0.11507. The result is not significant at p <0.10. SCHN Z-Score is 1.1282. The p-value is 0.12924. The result is not significant at p <0.10 Increased activity by 20%
- 23. Cause and Effect: Statewide programs Prior to 2010 Two individual hospitals with little collaboration 2008 Garling Review SCHN June 2010 2012 Clinical Governance Portfolio restructure 2015 Current state BTF Jan 2010 Falls 2009 PRAT 2015 HAI 2007Hand Hygiene 2005 CEC 2004 Sepsis Kills 2012 Open Disclosure 2013 PBC Challenge 2013
- 24. Cause and effect: Situational awareness Trend of three SAC1 over six months where calling criteria had been changed Email notification from the DCG Road show “Tales of the Expected” ED transfer calling criteria enforced Attendings did not know criteria were being changed Behaviour changed
- 25. Paediatric Intensive Care Outreach Service– Urgent Calls 550 482 843 1011 1338 1370 0 200 400 600 800 1000 1200 1400 1600 2009 2010 2011 2012 2013 2014 Number Between the Flags
- 26. Cause and Effect ? My intention is to get fit Several factors influenced this goal Mother-in-law Home alone with kids Accreditation survey Fitness program Repeat fitness test Objectively I am fitter Monitoring performance, aligning activities to become fit and being aware of the pitfalls contributed to achieving the goal intended. Sync: 4 mins ago cise/355136118) Resting Heart Rate Remove tile Done66bpm resting heart rate 08 Sep Today 65 70 75 80 73 66 Your Charge HR battery level is low.
- 27. Is this new ? “A mere 7% of employees today fully understand their company's business strategies and what's expected of them in order to help achieve company goals”. “If you can measure it, you can manage it.”
- 28. Have we seen this in health? “Do large-scale hospital and system wide interventions improve patient outcomes: a systematic review” Clay-Williams et al. BMC Health Services Research 2014, 14:369 Improved outcomes were observed for studies where outcomes were measured at least two years after the intervention. Associations between organisational factors, intervention success and patient outcomes were undetermined:
- 29. Conclusion Results Significant improvement was seen in several parameters including fewer serious incidents, fewer medico legal cases, fewer medication errors, and better access to emergency departments. Complaints and readmission rates remained unchanged despite a 25% increase in activity. Conclusion At SCHN several KPIs measuring quality and safety have improved since formation of the Network. Structural alignment within agreed quality standards, network roles that share lessons between facilities and better situational awareness of frontline staff are thought to have contributed. “Organisational change requires organisational changes”
- 30. Discussion
Editor's Notes
- In New South Wales serious publicised adverse events in 2006 brought quality and safety to community attention. The Garling external review of 2008 made 139 recommendations, including the creation a single children’s hospital. This was addressed by the creation of the Sydney Children’s Hospitals Network (SCHN) in June 2010. SCHN brought together the boards and management structures of Sydney Children’s Hospital Randwick and the Children’s Hospital at Westmead. Objectives In business, restructures are often implemented to improve performance, safety and customer satisfaction, but improvement has been difficult to demonstrate in healthcare. This study asks whether quality and safety have been improved by the formation of SCHN in June 2010. Methods Quality data within IHI domains of quality (safe, effective, patient-centred, timely, efficient) has been compared with Chi squared analysis, P scores and benchmarking with data from the Clinical Excellence Commission NSW, and “Solutions For Patient Safety” a North American collaboration of 80 children’s hospitals. Restructuring of clinical governance was based on the principals of alignment, networks and improving situational awareness.
- There has been an overall increase in activity of over 25% compared with 2005 activity. There has not been an equivalent increase in bed base, although with the current activity based funding model there has been a constant ratio of staff to separations since then.
- Prior to 2010 individual facility numbers have been used. The absolute number of SAC 1 and SAC 2 incidents across the SCHN has decreased bearing in mind an increase in separations of nearly 20% in 10 years. (40,643 to 52,727) Combining both SAC 1 and 2 charts to present a “serious incident” chart shows a reduction in such incidents since 2010. The change is significant at p < 0.10 Because of the large denominator (patient numbers) this small change does equate to approximately 25 less cases of serious harm over four years compared to if the trend remained unchanged. While small in number, this is the equivalent of six months free of serious incidents. The current average rate for SAC 1 and 2 incidents within SCHN is 0.09% of admissions whereas in NSW it is 0.20% of admissions (7). Distinction between safe and safer
- The overall IIMs reporting rate is steady but the pattern of reporting has been different at each hospital facility. Incident reporting has increased at CHW from 6.2% to 8%. The rate at SCH has decreased significantly from 9.7% to 8.1% of separations (p<0.01). SCH lost 2/3 of its quality staff during the SCHN restructure. Its reporting rate now mirrors SCHN Over the time since SCHN was formed the IIMS reporting rate for NSW has increased from 8.1% to currently stands at 9.3% It is inappropriate to attribute any direct relationship between the numbers of incidents reported and the safety and quality of clinical care. It is the content of notifications, not the count, which informs the system about where improvements need to occur. Fostering a reporting culture where staff speak-up about issues which they may previously not have regarded as incidents, is vital for patient safety. What we can say is that overall reporting has been maintained and increased slightly, but the numbers of serious incidents have decreased.
- It has traditionally been thought that most medico legal cases in children do not declare themselves for many years. Our data shows that over half of claims are made within 12 months, and by two years 73% of possible claims have been made. Single incidents can lead to multiple claims for family members. Over 26 years 370 claims have been made for 189 incidents. This graph shows only the incidents giving rise to the legal action. In order to account for the claims yet to occur the figures for 2014 have been doubled, and the figures for 2013 increased by 25%.
- The current CVAD infection rate at SCHN is 0.093 per 1000 line days while the NSW average is 0.365/1000 line days (8). The average rate amongst North American children’s hospitals is currently 0.13 per 1000 catheter days (11)
- The annual medication error rate including IV fluids has decreased from 3.1% in 2009 to 2.7% in 2014 over the same time.
- The number of unexpected rapid deteriorations requiring chest compressions and bag ventilation is also recorded, with similar criteria to Cincinnati Children’s Hospital. Since 2010 CHW has operated a PICU outreach team leading to increased awareness of sicker children and a decreased the incidence of unexpected arrests.
- There is a decrease from 3.63 % to 3.1% across SCHN over ten years with the trend line stable at 3.3% During the same time inpatient activity has increased 20%. The pattern differs at each facility.
- Timeliness from the patient’s perspective has been measured by “did not wait” (DNW) in the emergency departments. DNW is used by the NSW Bureau for Health Information as a measure of patient satisfaction and waiting time generates a high number of complaints for the Clinical Governance Unit. (12) Peaks correspond to the winter season where there are high numbers of respiratory presentations. The decrease in DNWs across the SCHN is statistically significant. DNW performance in NSW for the same time period was consistently lower (dotted line), with both SCHN and NSW improving their DNW performance by 2.5 to 3% over the period. (12) DNW has improved at both sites, especially CHW. DNWs in SCHN decreased from 10% in 2009 to 8% on average in 2014 and given the high number of presentations this is statistically significant (p<0.01) At CHW there has been a steady decline in peak winter DNWs since 2012, while performance at SCH has also improved, but from a lower (better) base.
- If care is appropriate and meeting patients’ and family’s needs then complaints should not arise. We know however that many dissatisfied families will not complain and so data tells only part of the story. We have measured complaints registered in IIMS and the CHW Respond complaints database. Complaints have not significantly changed
- All these programs were rolled out state wide before and after 2010. Our changes occurred after 2010
- Marked increase in the total number of urgent calls made to PICOS from the wards. Calls have more than doubled since the introduction of Between the Flags,