Qualidade do Cuidado de Saúde e Segurança do Paciente: aspectos conceituais


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Aula de Jonathan Riddell Bamber, Gerente de Pesquisa da Health Foundation (Reino Unido), foi proferida durante o II Seminário Internacional sobre Qualidade em Saúde e Segurança do Paciente - evento do Qualisus - que ocorreu dias 13 e 14 de Agosto de 2013, no Ministério da Saúde, em Brasília.

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  • Obrigado…Gostaria de agradecer ao senhor ministro da saúde Alexandre Padilha para o convidar para falar hoje Falo alguns portugueses, mas o meu inglês é muito melhor, por isso penso que é melhor que eu continue no ingles
  • Claudia:presentation the Health Foundation work , what is your main scope of action, main audience, most successful areas, how is your relation to the NHS, how you influence the NHS, research.
  • The hf works to improve the quality of health care in the UK. Based in London we work across the UK (England, Scotland, Wales and Northern Ireland)…and have links with similar organisations across the world – such as the Institute for Healthcare Improvement in the US and more recently, Proqualis. The work referred to today can all be found on our website for free download. It is, unfortunately only in English at the moment, but Claudia and CamilaLajolo from Proqualis have been working with us to produce Portuguese translations of parts of our website and some of our major publications.We have focused on quality and safety improvement since 2003, and have built up a wealth of experience of what works and what doesn’t work in improvement in healthcare. My own background is in translating health knowledge and health research, having commissioned, managed and disseminated a range of improvement research over the last six years. I will concentrate this short presentation on the experience gathered by the Foundation which, I hope, will resonate with you all here today.Before I start, it might help to provide a little background into the UK health context for those not familiar with it (apologies for those that are!)The NHS
  • How much spent on NHS?NHS England net spend £49.021B 2001/02 to £104.333bn in 2011/1Per capita £1,287 03/04 to £1,979 in 10/11 (source nhs confederation)How much spent on health research?NIHR – approximately 900m a year (2009/10)GOVERNMENT PARTNERSHIP CRUCIAL IF CHARITIES ARE TO GROW RESEARCH FUNDING IN CHALLENGING FINANCIAL CLIMATEWe have released our latest research expenditure figures today which show that whilst medical research charities continue to fund over £1 billion of research a year in the UK, in large part thanks to the public who make medical research their number one charitable cause, maintaining investment is becoming increasingly difficult because of falls in charitable donations - approximately 9.4 million people gave to medical research charities each month in 2012, down from 11.2 million in 2011 - and the need to maintain funding for other charitable activities such as support and advice to patients.Charities and the government through the research councils including MRC, NIHR and higher education have long been partners in investing in science and this has made the UK a world leader in health research, attracting further industry investment. We need the ring fence on the science budget to be maintained and this delicate funding ecosystem to stay intact. Charities cannot take up this slack.And more than that, we need the government’s commitment to continue partnering charities to fund medical research via the Charity Research Support Fund (CRSF).http://www.amrc.org.uk/news_2013_our-latest-research-expenditure-data How much spent on h s rch? NihrNIHR – approximately 900m a year (2009/10)In 2009, Brazil’s government spent $367 per person on health care, according to the United Nations Development Program. That’s one-fourteenth as much as Luxembourg’s government, the world’s biggest per-capita spender. It’s less than one-eighth the $3,074 spent by the U.S. government. Brazil’s federal government spends 3.6 percent of the nation’s gross domestic product on health care, according to SérgioPiola, a researcher at Ipea, Brazil’s Applied Economics Research Institute. That represents some $56 billion out of the $2.03 trillion GDP that Brazil, the world’s eighth-largest economy, generated last year. According to Piola, Brazil must spend at least 6.5 percent of its GDP, or $132 billion a year, if it wants to fulfill its goal of a functioning universal health care system.Even compared to the rest of Latin America, Brazil’s government is well down the list of health spenders. Neighboring Argentina allocates more than twice as much—some $758 per capita annually—while Cuba spends $329 and Mexico $327. All three countries have better health care ratings and higher UN social-development rankings than Brazil. In the private sector, when private health care outlays are added, Brazil’s spending leaps to 8.4 percent of gross domestic product—about $855 per person. In other words, this developing economy spends almost the same percentage of its national income on health care as the developed countries that form the OECD, where spending is about 9 percent of GDP.
  • Our independence allows us to focus on topics that are the most important at this point or are likely to be important in the near future. To put our work into context, I’ll mention some background to quality and safety in the NHS [insert NHS quality and safety text]1) History of safety and quality - safety can improve and we're come a long wayHealth foundation - Capacity, leadership... But also ownership- Audit etc. frSpi and Lining up - secular trendScience & art of improvement
  • Although we spend nearly £30m a year, this is relatively small when compared against the health care spend of the UK (or a country like Brazil) or compared against either the total research spend or improvement spend across the UK of around £900m).So, we our approach is to build a picture from available evidence and practical experience of the key topics to focus on (IDENDTIFY through research and expert advice)test innovative approaches that might help improve (INNOVATE through small-scale improvement projects and research)demonstrate improvement in practice (DEMONSTRATE through large-scale improvement initiatives)work with professional and government bodies to promote spread and sustainability (ENCOURAGE through joint working and promotion)Our strategy to in achieving our mission is: firstly, targeting our efforts on a few major areas selectively (so we can be experts in these fields and build relationships with professionals / govt to achieve change at scale)secondly, working on a combination of knowledge development while providing direct improvement in patient care; (not just research evidence on its own…not just improvement programmes on their own)National Institute of Health Research approx. £0.9bn 2009/10 *Medical research charities approx. £1bn 2012 **Sources (acccessed10 August 2013 * Source NIHR website;** Source: Medical Research Charities website
  • 7 - Selective focus to meet the UK’s needs in the next 5-10 years2000-8 A recognition of the need to find ways to improve safety and clinical quality was clear post to err is human and organisation with a memory.We focused on building improvement capacity through leadership development programmes on improvement (Jason Leitch is an example of a colleague who has gone through one of our improvement development programmes). State funded programmes have since mimicked these programmes although we continue to fund a range of leadership programmes.Introducing improvement approaches from industry into the NHS to demonstrate improvement to safety and quality – Deming, Lean, IHI, PSDA cycles etc. For example, Safer Patients Initiative (4, 24, 1000 Lives Campaign Wales, Scotland Patient Safety Initiative)NOTE: Not relevant to carry out this kind of campaign in UK in 2013 as these practices and improvements are largely integratedWe worked with professional bodies on the type of improvement initiatives that they related to / were comfortable with – Engaging with Quality Initiative focused largely on techniques like Clinical Audit2005 – 13 We recognised the lack of good evidence linking quality improvement with costs with a focus on Value for Money research. Post credit crunch, this research has been increasingly relevant, particularly the applied work. For example, working with Professor Gwyn Bevan at the London School of Economics, we have developed an economic modelling tool which used with community participation techniques is helping hospitals decide on which services to prioritise to achieve the best patient outcome.2008-13 A major focus of our work over the last five years has been on concepts of person-centred care – for example, how patients and their clinicians with long term conditions can better manage their conditions (Self-Management Support). This is a topic that is ideal and relevant for the UK health system right now and was not being focused on by other bodies; however, this may not have been relevant to focus on in 2000.Proactive Safety – with increasing recognition of the need to measure and reduce major patient harms (e.g. MRSA, Central-line infections, pressure ulcers)…we have increasingly turned our attention to managing risk and avoiding harm. This has led to research and improvement initiatives on measuring safety, improving reliability and understanding hazards to safety
  • None of the work we invest in would gain traction without a fundamental combination of practical improvement with rigorous evidence development. On any improvement project, we need evidnece of both outcomes and an understanding of why change was or wasn’t achieved. approximately 10-15% of funding is ring-fenced for evaluation I have been working closely with researchers such as Professor Mary Dixon-Woods to promote a focus on understanding the explanations of why an improvement works.[Lining up example]In addition, we believe that any health services research needs to be focused on making practice change, not just journal publication (though this is important)The Foundation has been pioneering in the promoting and development of the science of improvement. Although traditional QI approaches have had successes, there has been a need to develop the field of improvement as an academic discipline in its own right. We have been developing: Improvement Science Researchers – post doctorial, and PHD schemesBuilding academic and practice leaders together with regular conferences and seminars on Improvement Science and improvement approachesSupporting the use of applied improvement research through 50% ownership of the BMJ Quality and Safety journal and provision on a monthly research scan of 40,000 journals to provide a sweep of 50.
  • Reflections on improvement of quality and safety1)Any improvement (programme/campaign/research) must be relevant and engage professional and policy audiences[Measurement of Safety e.g.]2) making solutions relevant for your situation Importance of varying solutions to deal with local history, context and experienceLining up and Tim’s example 328 current obstetrics guidelinesApprox 10p = 35k p for labourMaking the right way, the easy way...or at least possible3) importance of understanding explanations, not just outcomes E.g. Keystone & matching Michigan Applied science - the science of improvement
  • Incident reporting in healthcare Sometimes adopting an improvement method from one sector to another results in the method being adapted so radically that it no longer functions in the way intended. For instance, the National Reporting and Learning System (NRLS) was set up in 2003 by the National Patient Safety Agency (NPSA) with the intention of emulating the rapid response to reported safety issues in aviation.  The NRLS records around 1.4 million incidents each year. This results in a massive dataset that is very little used. A top slice is taken of the most serious incidents and patient safety alerts are issued based on these data. But most data is not acted on. In contrast the aviation regulator collects a much smaller set of data, with 10,000 incidents a year. They don’t want more data because it swamps the system and distracts from the core issues. What started as an improvement tool has become an epidemiological, data science driven model, to get as much data as possible for data mining. Incident reporting is not used in that way in other industries. It is used as an immediate reactive process, to identify a problem, using a sample of one, to go and investigate and fix it. No other industry uses it as a quantitative source of data or measurement. When it was imported into healthcare the general principle from aviation was lost along the way and turned into something rather different. It is important to avoid creating systems that collect data and then ignore it, creating ‘orphan data’ that is both wasteful and dangerous if the people reporting the data assume it will be acted on but in practice it is not.
  • Reflections on improvement of quality and safety1)Any improvement (programme/campaign/research) must be relevant and engage professional and policy audiences[Measurement of Safety e.g.]2) making solutions relevant for your situation Importance of varying solutions to deal with local history, context and experienceLining up and Tim’s example 328 current obstetrics guidelinesApprox 10p = 35k p for labourMaking the right way, the easy way...or at least possible3) importance of understanding explanations, not just outcomes E.g. Keystone & matching Michigan Applied science - the science of improvement
  • I’d like to thank them for all the hard work that they have put into this work, along with our advisory panel and case study sites Dr Matthew Fogarty, Patient Safety Lead, Department of Health; Dr Mark Davies, Medical Director, the NHS Information Centre; Robin Burgess, CEO, the Healthcare Quality Improvement Partnership (HQIP); Jan Davies, Welsh Assembly Government; and Dr Alan Willson, Director, NHS Wales 1000 Lives Plus.] [Avon and Wiltshire Partnership Trust (mental health services)Central and North West London NHS Foundation Trust (mental health services) Aneurin Bevan Health Board (combined Board with acute, community, mental health and primary care services)University College Hospital NHS Foundation Trust (acute care)Great Ormond Street Hospital (specialist and acute children’s services)Intermountain Healthcare, Salt Lake City, USA (awaiting information)OneMedical (primary care company UK)NHS South West London (primary care/commissioning)North Bristol NHS Foundation Trust (obstetric care)Imperial College NHS Trust (care of the elderly)]
  • Qualidade do Cuidado de Saúde e Segurança do Paciente: aspectos conceituais

    1. 1. Healthcare quality and patient safety: Conceptual aspects International Workshop on Quality and Safety in Healthcare, Brasilia, Brazil Jonathan Riddell Bamber, 13 August 2013
    2. 2. By the end of this session you will have... www.health.org.uk - jonathan.bamber@health.org.uk • brief introduction to a UK perspective on quality and safety improvement • an overview of the Health Foundation’s involvement in quality improvement for over 10 years; and • reflections on potential relevance for the Brazilian context 2
    3. 3. The Health Foundation www.health.org.uk - jonathan.bamber@health.org.uk • An independent health charity • Working to improve the quality of healthcare in the UK: England, Scotland, Wales, and Northern Ireland • International links (e.g. the US Institute for Healthcare Improvement and Proqualis; work in Nepal and Malawi) • All information on our website in English; available through Proqualis (Fundaçao Oswaldo Cruz) in Portuguese soon • Established 1997; focus on quality 2003; my work on knowledge translation since 2007 3
    4. 4. The UK National Health Service www.health.org.uk - jonathan.bamber@health.org.uk • Created 1948 as universal free health provision • Paid for by universal employment tax (public share 82% in 2007*) • Four countries manage separately NHS England • R$171bn 2001/2 increased to R$364bn 2010/11 ** • R$7,000 per head 2010/11 (R$833 in Brazil, R$7,000 US ***) * OECD website cited Paim et al Lancet 2011; 377; 1778-97 ; ** 10 Aug 2013: http://www.nhsconfed.org/PRIORITIES/POLITICAL-ENGAGEMENT/Pages/NHS- statistics.aspx; *** 10 Aug 2013: United Nations Development Program, cited www.worldpolicy.org/blog/health-care-brazil- 300-year 4
    5. 5. Development of quality and safety (NHS) www.health.org.uk - jonathan.bamber@health.org.uk • First organisational review of healthcare associated deaths in UK was by Florence Nightingale in 1856 • History of enquiries into failure and response, often around infection control, or maternal or child death • To err is human (IOM, 1999) • An organisation with a memory (Sir Liam Donaldson, 2000) 5
    6. 6. Our approach and strategy www.health.org.uk - jonathan.bamber@health.org.uk • Foundation approx. R$2.5bn; spend R$85-100m a year • Approach: IDENTIFY research and expert advice INNOVATE improvement projects and research DEMONSTRATE large-scale improvement initiatives ENCOURAGE joint working and promotion • Strategy 1) Target resources selectively (meeting current UK needs) 2) Combination of knowledge development AND direct improvement to patient care 6
    7. 7. 1) Selective Targeting to meet UK needs www.health.org.uk - jonathan.bamber@health.org.uk 7 2003  Leadership development for improvement Introducing quality improvement approaches (Deming, Lean, PDSA cycles etc.): - e.g. Safer Patients Initiative (4, 24, 1000 Lives, Scotland) Professional bodies - Engaging with Quality (clinical audit) 2005  Cost and quality - e.g. Resource allocation (community participation & economic modelling – see www.health.org.uk/STAR 2008  Person centred care – e.g. Self Management Support & Co- creating Health Proactive approaches to safety – measuring safety, reliability and hazard identification 2010  The science and art of improvement
    8. 8. 2) Best evidenceAND direct improvement to patients www.health.org.uk - jonathan.bamber@health.org.uk • Evidence needed from all improvement project of outcomes and explanation of why • 10-15% on evaluation on any improvement project • Lining up - Michigan Keystone and UK • Applied research – making practice change, not just publication • Improvement Science: • Capacity development (post doctorial and PhDs) • Global consensus • 50% ownership of BMJ Quality and Safety • Monthly research scan of 40,000 journals to provide a sweep of 50 articles on health care improvement 8
    9. 9. Reflections www.health.org.uk - jonathan.bamber@health.org.uk 1. Improvement must be relevant and engage professional and policy audiences 2. Adapting solutions for specific situation – local history, context and experience • e.g. 328 obstetrics guidelines; 35,000 pages!! 3. Consider the side effects of change 9
    10. 10. 3) Consider the side effects of change: Incident reporting in healthcare www.health.org.uk - jonathan.bamber@health.org.uk • National Reporting and Learning System (NRLS) 2003 • Emulating rapid response in aviation for incident reporting: • aviation 10,000 • Identify problem and investigate • NHS: 1.4m per year • Data driven epidemiological tool…little investigation 10
    11. 11. Reflections www.health.org.uk - jonathan.bamber@health.org.uk 1. Improvement must be relevant and engage professional and policy audiences 2. Adapting solutions for specific situation – local history, context and experience • e.g. 328 obstetrics guidelines; 35,000 pages!! 3. Consider the side effects of change 11
    12. 12. Thank you for listening www.health.org.uk - jonathan.bamber@health.org.uk Contact: jonathan.bamber@health.org.uk Acknowledgements: Professor Claudia Travassos, National School of Public Health, Fundaçao Oswaldo Cruz Dr Camila Lajolo, Proqualis, Fundaçao Oswaldo Cruz Professor Mary Dixon-Woods, University of Leicester Professor Charles Vincent, Centre for Patient Safety and Service Quality (CPSSQ), Imperial College London Dr Tim Draycott, Improvement Science Fellow, the Health Foundation Dr Carl MacRae, Improvement Science Fellow, the Health Foundation Professor Nick Barber, Director of Research, the Health Foundation 12
    13. 13. Has patient care been safe in the past? Ways to monitor harm include: • mortality statistics (including HSMR and SHMI) • record review (including case note review and the Global Trigger Tool) • staff reporting (including incident report and ‘never events’) • routine databases. Are our clinical systems and processes reliable? Ways to monitor reliability include: • percentage of all inpatient admissions screened for MRSA • percentage compliance with all elements of the pressure ulcer care bundle. Is care safe today? Ways to monitor sensitivity to operations include: • safety walk-rounds • using designated patient safety officers • meetings, handovers and ward rounds • day-to-day conversations • staffing levels • patient interviews to identify threats to safety. Will care be safe in the future? Possible approaches for achieving anticipation and preparedness include: • risk registers. • safety culture analysis and safety climate analysis • safe safety training rates • sickness absence rates • frequency of sharps injuries per month • human reliability analysis (e.g. FMEA) • safety cases. Are we responding and improving? Sources of information to learn from include: • automated information management systems highlighting key data at a clinical unit level (e.g. medication errors and hand hygiene compliance rates) • at a board level, using dashboards and reports with indicators, set alongside financial and access targets A framework for measuring and monitoring of safety