Reducing harm at a national level the scottish story

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Apresentação de Derek Feeley e Carol Haraden 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.

Carol Haraden é PhD, Vice Presidente do Institute for Healthcare Improvement (IHI), é membro do time responsável por desenvolver desenhos inovadores no cuidado ao paciente. Atualmente, ela lidera os trabalhos do IHI na Escócia, Sul da Inglaterra, Dinamarca e Estados Unidos.

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Reducing harm at a national level the scottish story

  1. 1. Reducing Harm at a National Level: The Scottish Story 1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs November 4, 2013 São Paulo, Brazil Derek Feeley Carol Haraden
  2. 2. “By what method?... only the method counts” W Edwards Deming Emphasis on Method
  3. 3. Our Change Theory A clear and stretch goal A method Predictive, iterative testing 3
  4. 4. Where We Started: SPSP Outcome Aim Set (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 4 To be achieved across the nation by 2012 Mortality aim amended to 20% by 2015
  5. 5. Developments in Acute Care Hospitals 5 Aims: To Further Improve the Safety of People in Acute Adult Healthcare 1. Reduce Harm 95% of people in acute adult health care free from harms in the Scottish Patient Safety Index by 2015: Cardiac Arrest Catheter Acquired Urinary Tract Infections Pressure Ulcers Falls 2. Reduce Hospital Associated Morality Reduce HSMR by 20% by 2015
  6. 6. Further improve the safety of people in Acute Adult Healthcare Reduce Harm: 95% of people in acute adult health care free from harms in SPSI: • Cardiac Arrest • CAUTI • Pressure Ulcers • Falls Reduce HSMR by 20% By December 2015 Strategic Priority Point of Care Infrastructure • Ensure safety and quality are organisational priorities • Provide leadership & oversight to ensure delivery of programme • Actively develop your safety culture • Essentials of Safety are comprehensively implemented • Reliable person centered response to deteriorating patients • Reliable recognition & care delivery for patients with Sepsis • Reliable care delivery for patients with Heart Failure • Prevent avoidable Pressure Ulcers • Reduce SSI • Reliable risk assessment to prevent VTE • Prevent CAUTI • Reduce Falls • Safer Use of Medicines • Develop & utilise local capacity & capability in QI • Effective measurement systems • Programme Management • Effective Communications • Manage transitions of care
  7. 7. Back to the start: What We Set Out to Improve Acute Program: 5 workstreams Critical Care Peri-operative Care General Ward Care Medicines Management Leadership for Safety 7
  8. 8. How do we improve?
  9. 9. The Improvement Trilogy Will Ideas Execution
  10. 10. What We Know Works Leadership is critical Clear Aim and Purpose Strong Team The Use of Data and Measure Testing on a Small Scale Deliberate Spread of Innovation
  11. 11. Three Separate and Critical Competencies 1. Building successful prototypes 2. Implementation of the successful prototype 3. Spreading the change
  12. 12. Skills to Support Improvement Using Data Developing a Change Testing a Change Implementing a Change Working With People
  13. 13. Critical Care 13
  14. 14. Care Bundles to Support Peripheral Vascular Catheter (PVC) Bundle (HPS) Check to ensure the PVC in situ are still required Remove PVCs where there is extravasation or inflammation Check PVC dressings are intact Consider removal of PVS in situ longer than 72 hours Perform hand hygiene before and after all PVS procedures 14
  15. 15. Peri-operative 15
  16. 16. General Ward 16
  17. 17. Medicines Management 17
  18. 18. Leadership 18
  19. 19. 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 Scotland: January 2008 -September 2012 8497 less than expected deaths 12.4% reduction
  20. 20. HSMR – Annual Rolling Averages 20 0,8 0,9 0,9 1,0 1,0 1,1 1,1 1,2 1,2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 SMR Quarters HSMR - Annual Rolling Averages Year Ending Oct-Dec 2002 to Jul-Sep 2012 1.4% (Annualised Reduction) Oct-Dec 2002 to Jan-Mar 2010 4.0% (Annualised Reduction) Apr-Jun 2010 to Jul-Sep Dec 2009:
  21. 21. General ward C.Difficile rate (per thousand patient days) 21 0 0.5 1 1.5 2 2.5 Jan-08 Apr-08 Jul-08 O ct-08 Jan-09 Apr-09 Jul-09 O ct-09 Jan-10 Apr-10 Jul-10 O ct-10 Jan-11 Apr-11 Jul-11 O ct-11 1.15 0.12 90% reduction
  22. 22. VAP Prevention Bundle Reliability (average Scottish ICUs) 22 VAP Prevention Bundle Reliability and VAP rate/1000 ventilated days (average across Scottish ICUs) 50% 75% 100% Feb-08M ay-08A ug-08N ov-08Feb-09M ay-09A ug-09N ov-09Feb-10M ay-10A ug-10N ov-10Feb-11M ay-11A ug-11N ov-11Feb-12M ay-12A ug-12N ov-12 0 6 12 18 Better Better
  23. 23. Ventilator Acquired Pneumonia Rate 23
  24. 24. Surgical Safety Briefings 24
  25. 25. Scottish Amalgamated Hospital Post-Op Surgical Mortality 25 0,00 0,20 0,40 0,60 0,80 1,00 1,20 1,40 1,60 1,80 Apr-Jun1981 Apr-Jun1982 Apr-Jun1983 Apr-Jun1984 Apr-Jun1985 Apr-Jun1986 Apr-Jun1987 Apr-Jun1988 Apr-Jun1989 Apr-Jun1990 Apr-Jun1991 Apr-Jun1992 Apr-Jun1993 Apr-Jun1994 Apr-Jun1995 Apr-Jun1996 Apr-Jun1997 Apr-Jun1998 Apr-Jun1999 Apr-Jun2000 Apr-Jun2001 Apr-Jun2002 Apr-Jun2003 Apr-Jun2004 Apr-Jun2005 Apr-Jun2006 Apr-Jun2007 Apr-Jun2008* Apr-Jun2009* Apr-Jun2010* Apr-Jun2011*,p %MortalityonDischarge Quarter of Discharge P' Chart for Surgical Mortality
  26. 26. Scotland ICU Mortality Percentage 26 0 5 10 15 20 25 30 jan/… mar… mai… jul/… set/… nov… jan/… mar… mai… jul/… set/… nov… jan/… mar… mai… jul/… set/… nov… jan/… mar… mai… jul/… set/… nov… jan/… mar… mai… jul/… Intensive Care Unit Mortality % Units reporting via Extranet Average n = 16 National Average Annual… 14.6% 19.0% 18.3% 16.7% 14.3% Overall reduction 25%
  27. 27. Scotland Average Length of Stay 27 0 1 2 3 4 5 6 7 jan/08 mar/08 mai/08 jul/08 set/08 nov/08 jan/09 mar/09 mai/09 jul/09 set/09 nov/09 jan/10 mar/10 mai/10 jul/10 set/10 nov/10 jan/11 mar/11 mai/11 jul/11 set/11 nov/11 jan/12 mar/12 mai/12 jul/12 Days ICU average length of stay 15% reduction in median length of stay average ICU los median los 4.08 days 4.8 days
  28. 28. ICU ALOS 28 6.2 days 5.1 days 18% reduction (1.1 days) Cost saving of £990,000
  29. 29. How’d We Do? NHS Highland 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!
  30. 30. 10 Interventions Now Embedded 10 Patient Safety Essentials Hand Washing PVC Bundle Surgical Brief & Pause VAP Bundle CVC Insertion CVC Maintenance General Ward Safety Brief Early Warning Score ICU Daily Goals Leadership Walk rounds
  31. 31. Missing Ingredients 31 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.
  32. 32. Solutions 32 Improving the safety of patients Quality of care & patient safety above all else Engage & empower patients and carers Foster staff development and growth Embrace transparency unequivocally
  33. 33. Remember….. 33 “Health statistics represent people with the tears wiped off.” Sir Austin Bradford Hill (1897-1991)

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