Boards on Board
Don Berwick•   Put the patient first•   Put the vulnerable first•   Start at scale•   Give the money back•   Act locally
“The tendency exists to arguethat the science of improvementmay be a lesser way of knowing,    because it concerns itself ...
Moving beyond safety
The Healthcare Quality Strategy for Scotland• Person-Centred - Mutually beneficial partnerships between   patients, their ...
-70   -60   -50   -40   -30   -20   -10   0   10   20   30   40   50   60   70
-70   -60   -50   -40   -30   -20   -10   0   10   20   30   40   50   60   70
Three Part Problem...• Improve Individual Experience• Improve Population Health• Control Inflation of Per Capita Costs    ...
Evidence based medicine Evidence based care delivery  17 years to get 14% of evidence            into practice
“Conquering the world on horseback is easy: it   is dismounting and governing that is hard”                Genghis Khan
“quality improvement”The combined and unceasing efforts of everyone – health care professionals,patients and their familie...
Outcome Aims• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days  bet...
HSMRHospital Standardised Mortality Ratio
Scotland – 8.4% reduction in HSMR                               1.5Standardised Mortality Ratio                           ...
1.5                                                                                                                       ...
Scotland level results
Central line infection rate            (per thousand line days)1210                                March 2011:            ...
0           2           4           6           8          10          12          14          16          18          20J...
10          12          14          16          18          20          22          24          26          28Jan-08Mar-08...
0              0.5                       1                           1.5                                 2                ...
How has the frontline done it?• Get goals.         •   Get the facts.• Get bold.          •   Get to the field.• Get toget...
How has NHSScotland done it?    Policy                              Leadership   Execution Structure                      ...
Having the bestprofessionals in the world   is no longer enough
The Capacity and Capability Aim      To build a sustainable  infrastructure that produces  highly reliable QI excellence  ...
Who needs to be developed?         Governance?          Executives?          Managers?         Supervisors?      Front Lin...
How many quality experts        do we need?Two suggestions for determining this number:         √              Number of  ...
Where next?•   Sepsis/VTE•   Paediatrics•   Primary care•   Mental health•   Maternity• Person-centred care• Early years
"Quality is never an accident;it is always the result of high    intention, sincere effort,    intelligent direction and  ...
Jason Leitch Quality Journey - 22 February 2012
Jason Leitch Quality Journey - 22 February 2012
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Jason Leitch Quality Journey - 22 February 2012

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  • For me, quality improvement means…or put in a graphical form…
  • Jason Leitch Quality Journey - 22 February 2012

    1. 1. Boards on Board
    2. 2. Don Berwick• Put the patient first• Put the vulnerable first• Start at scale• Give the money back• Act locally
    3. 3. “The tendency exists to arguethat the science of improvementmay be a lesser way of knowing, because it concerns itself primarily with a wide range of applications in uncontrolledsettings; that is, the real world as we find it every day” Rocco Perla
    4. 4. Moving beyond safety
    5. 5. The Healthcare Quality Strategy for Scotland• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.• Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
    6. 6. -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
    7. 7. -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
    8. 8. Three Part Problem...• Improve Individual Experience• Improve Population Health• Control Inflation of Per Capita Costs The Triple Aim
    9. 9. Evidence based medicine Evidence based care delivery 17 years to get 14% of evidence into practice
    10. 10. “Conquering the world on horseback is easy: it is dismounting and governing that is hard” Genghis Khan
    11. 11. “quality improvement”The combined and unceasing efforts of everyone – health care professionals,patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to better patient outcome, better system performance, and better professional development. Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3
    12. 12. Outcome Aims• 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• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction
    13. 13. HSMRHospital Standardised Mortality Ratio
    14. 14. Scotland – 8.4% reduction in HSMR 1.5Standardised Mortality Ratio 1.0 0.5 Oct- Apr- Oct- Apr- Oct- Apr- Oct- Apr- Oct- Apr- Dec Jun Dec Jun Dec Jun Dec Jun Dec Jun 2006 2007 2007 2008 2008 2009 2009 2010 2010p* 2011p
    15. 15. 1.5 1.5 Standardised Mortality Ratio 1.3 Standardised Mortality Ratio 1.3 1.0 1.0 0.8 0.8 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 1.5 1.5 1.3 1.3 Standardised Mortality RatioStandardised Mortality Ratio 1.0 1.0 0.8 0.8 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 0.5 Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 1.5 1.5 Standardised Mortality Ratio 1.3 1.3 Standardised Mortality Ratio 1.0 1.0 0.8 0.8 0.5 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p HSMR results 2008-2011
    16. 16. Scotland level results
    17. 17. Central line infection rate (per thousand line days)1210 March 2011: zero central line infections8 in whole country6420 08 10 09 11 8 1 9 0 9 8 0 1 0 8 9 l-0 l-1 l-1 l-0 r- 0 r- 1 r- 0 r- 1 -1 -0 -0 n- n- n- n- ct ct ct Ju Ju Ju JuApApApApJaJaJaJaOOO
    18. 18. 0 2 4 6 8 10 12 14 16 18 20Jan-08Mar-08May-08 Jul-08 9.11Sep-08Nov-08Jan-09Mar-09May-09 Jul-09Sep-09Nov-09 VAP rateJan-10Mar-10May-10 (per thousand ventilator days) Jul-10Sep-10 62% reductionNov-10Jan-11Mar-11May-11 3.49 Jul-11
    19. 19. 10 12 14 16 18 20 22 24 26 28Jan-08Mar-08May-08 Jul-08Sep-08Nov-08 18.2%Jan-09Mar-09May-09 Jul-09Sep-09Nov-09Jan-10Mar-10May-10 % ICU mortality Jul-10 14% improvementSep-10Nov-10Jan-11Mar-11May-11 15.7% Jul-11
    20. 20. 0 0.5 1 1.5 2 2.5Jan-08Mar-08May-08 1.18 Jul-08Sep-08Nov-08Jan-09Mar-09May-09 Jul-09Sep-09Nov-09Jan-10Mar-10May-10 (per thousand patient days) Jul-10Sep-10 88% reductionNov-10 General ward C.Difficile rateJan-11Mar-11 0.14May-11 Jul-11
    21. 21. How has the frontline done it?• Get goals. • Get the facts.• Get bold. • Get to the field.• Get together. • Get a clock.• Get a model (and • Get the numbers. stick with it) • Get the stories.• Get patients and families
    22. 22. How has NHSScotland done it? Policy Leadership Execution Structure Process OutcomeDonabedian, A.Explorations in Quality Assessment andMonitoring. Volume I: The Definition of Qualityand Approaches to its Assessment.1980.
    23. 23. Having the bestprofessionals in the world is no longer enough
    24. 24. The Capacity and Capability Aim To build a sustainable infrastructure that produces highly reliable QI excellence by (fill in the date). How good? By when? © 2010 Institute for Healthcare Improvement
    25. 25. Who needs to be developed? Governance? Executives? Managers? Supervisors? Front Line Workers? Improvement Advisors (IAs)? Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006 © 2010 Institute for Healthcare Improvement
    26. 26. How many quality experts do we need?Two suggestions for determining this number: √ Number of employees Or…consider that no employee should be more than 2 steps (individuals) away from a QI expert. © 2010 Institute for Healthcare Improvement
    27. 27. Where next?• Sepsis/VTE• Paediatrics• Primary care• Mental health• Maternity• Person-centred care• Early years
    28. 28. "Quality is never an accident;it is always the result of high intention, sincere effort, intelligent direction and skillful execution; itrepresents the wise choice of many alternatives.” 1941, William A. Foster

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