BC Provincial
Perioperative Improvement Program
Proposal Presentation & Discussion
Panel Members
Margi Bhalla, Director, Surgical Services, Ministry of Health – Provincial Surgical
Advisory Committee Co-Ch...
Agenda
Background and program proposal
The Productive Operating Theatre
Overview & Experiences

Margi & Andy – 5 minutes
D...
Background
The Provincial Surgical Advisory Council (PSAC) was established in
2009 to inform the strategic direction of su...
Proposed Provincial Program Overview
Extended Site Team

Expert
Trainer
Core Site
Team

Provincial Team
&
Project Manager
...
Proposed Provincial Program Overview
Provide comprehensive support for sites to implement a quality
improvement methodolog...
Proposed Provincial Program Overview
Provincial team will receive training and provide support to sites
Could include repr...
The Productive Operating Theatre
Overview
Primary concerns: Quality and efficiency
Toolkit
2 overview guides
11 modules
Mo...
The Productive Operating Theatre
Experience (Dermot & Felicia)

• Felicia and Dermot
The Productive Ward Experience
Releasing Time to Care
Vancouver Coastal Health

RT2C Education

February 2013
VCH Lean Edu...
NHS productive series
Modules: based on Lean thinking
• Leadership support
• Foundational modules for sustaining improvements
Productive operating theatre
Productive ward
• Set of modules designed to guide you through the processes
• Efficiency gui...
Aim: to improve 4 key dimensions of quality
Releasing Time to Care/Productive Ward
•
•
•
•

Understand what is happening now
Display measures on a board
Use huddles o...
Improvements
• Staff-led data collection and audits
• Daily huddles around data board
Process

Action

Change

Shift repor...
Patient Safety
& Reliability of
care

Falls: Improvement actions and results
12

Goal: To reduce falls by 50% by Dec
2013 ...
Patient Safety
& Reliability of
care

Falls: projected cost-avoidance
What if we are reaching the goal of reducing falls b...
Patient
Experience

Patient experience – 3S Richmond

47.6%

Do you feel confident with your current discharge plan and
su...
Patient
Experience

Patient experience – Squamish

Were you provided with the equipment you needed to go home
with?

100.0...
Staff unplanned absence- Squamish
Background

•

•

Staff well being has been shown to
impact absence rate
Identified high...
“This is the first time in my 30 years of
nursing where I've seen frontline staff
get involved with any quality
improvemen...
Comprehensive Unit-based Safety
Program (CUSP) at Royal
Columbian Hospital
Dr. Peter Blair, RCH Surgeon Champion &
FH Surg...
Purpose of CUSP
• Strategic framework for improving patient
safety
• Integrates communication, teamwork, and
leadership to...
CUSP’s Beginnings
• First applied in more than 100 Intensive Care Units in
Michigan in 2003
• 5 evidence-based procedures ...
Five Steps:
Using CUSP to Reduce SSIs
1.
2.

Staff educated on the science of safety
Staff complete patient safety culture...
Learning from Defects
Defect = any clinical or operational event or situation
that you would not want to happen again.
1) ...
Two Questions
1. Ask staff two questions:
a) How is the next patient going to get an SSI on
this unit?
b) How can we preve...
SSI Bundle & Results
1) Standardization of skin prep and use of
chlorhexidine wash cloths
2) Mechanical bowel prep with or...
CUSP Participating Sites
• Ronald Reagan UCLA Medical Centre, Los
Angeles
• New York Hospital of Queens, Flushing
• Mills ...
CUSP at RCH
1. Safety Attitudes Questionnaire showed ample
room for improvement in RCH safety culture
2. RCH was invited t...
Results of 1st Safety Assessment

October 28, 2013

CUSP at Royal Columbian Hospital

32
OR Traffic Audit
• 8 cases observed over 614 minutes
• Average case was 77 minutes (35-134
min)
• Doors swung open 354 tim...
Normothermia Initiative
Reviewed charts of PACU surgical patients, recorded their temperature
(pre, intra, post op) and ty...
Results of 2nd Safety Assessment

October 28, 2013

CUSP at Royal Columbian Hospital

35
Next Steps for RCH
• Document CUSP process, share tools
• Confirm executive support & commitment
• Get team on a regular m...
Surgical Provincial
Coaching Team
Safety Climate – 14 BC Hospitals
75 surgical units - 2012
Perceptions of Local Management
14 Hospitals – 75 BC surgical units - 2012
Risk of Failure
Potential Problem
• 6 months after project lose
the improvements
• Long term sustainability

End Goal
• Im...
Training and Commitment
• Coaching Team Training (2 face to face meetings and monthly
webex training over 24 months)
• Exp...
Who can Join?
• Up to two people from each site that is
participating
• Total up to 20 people
Discussion & Questions
Next Steps

For more information on the
Provincial Perioperative Improvement Program, please contact:
Margi Bhalla
250 952...
BC Provincial Perioperative Improvement Program
BC Provincial Perioperative Improvement Program
BC Provincial Perioperative Improvement Program
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BC Provincial Perioperative Improvement Program

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This presentation was delivered by Margi Bhalla and Andy Hamilton at the BC Surgical Quality Action Network's 2013 annual meeting.

Visit http://bcpsqc.ca/clinical-improvement/sqan/ to learn more about the event.

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  • The structure of the program is still being finalized, but we’re looking at establishing QI teams at each participating site, which will be supported by a Provincial Team.The Provincial Team will involve 1-2 leaders from each participating site. We’re looking to also engage BC health providers with expertise in a range of QI methodologies (such as Lean, TPOT, CUSP, Six Sigma). This team will receive training and as-needed support from methodology-specific experts, and the team will ideally serve as an in-province resource- and support-base for the participating sites.The entire program will be supported by at least 1 Project Manager.
  • The Perioperative Improvement Program is still very much in the planning stages, but it is an initiative out of the Provincial Surgical Advisory Council (PSAC). The overall goal of the program will be to provide a handful of sites from across BC with comprehensive support to introduce a quality improvement program that is designed for the operating room. The details of the support depends on site needs, but could include:supporting program materials (such as handbooks, dvds, etc.)provincial project managementcovering physician time through SSC fundingguidance, training, and as-needed support from QI expertsholding 1-2 in person meetings with site teams from across the provincecovering the costs to send the coaching team to sitescoordinating peer support from the other participating sites, and
  • In the next slides, there will be:an overview of TPOT, CUSP, and Building Local Expertisefirst hand experiences of implementing the programs at BC sites
  • Created by the NHS InstituteIs a structured program based on Lean principles that provides a solid foundation of QI knowledge for program participantsThe main driving aim of TPOT is Quality and Efficiencyquality initiatives focus on:team-working and communication, such as implementing structured pre- and post-op team briefingspatient preparation, both through team-based initiatives (e.g., checklists) and patient-based initiatives (e.g., patient self-prep handouts)efficiency initiatives focus on:organizing resources so that they’re used in the most efficient manner (such as adjusting the OR layout, and reviewing equipment and consumable ordering procedures)implementing procedures to ensure that OR time is used in the most efficient manner (such as exploring new, standardized OR booking procedures, standardized session start-up processes, and standardized patient turnaround practices)The toolkit includes:Overview guides for Executive and Program leadersHandbooks for each of the 11 modulesExamples of tools to facilitate project planning, tracking, and evaluation.Could be used in conjunction with ERAS pathways and NSQIP
  • -Every productive has key modules that lead to sustaining improvements-Builds leadership support-Creates a foundation of skills in healthcare teams-Structured process improvements for different work environment yet flexible
  • Set of modules that provide an overall strategy Achieves significant and lasting improvements, thereby allowing extra care time for patients and improved patient outcomes.
  • Total average cost per serious fall (difference between fallers and non-fallers) $30,696 Extended LOS 34 daysCIHI information in 2000-2001 Total average costs in 2011-12 $11,254 with Average extended LOS 5 daysEstimating the Cost of Serious Injurious Falls in a Canadian Acute Care Hospital Zecevic A., Chesworth B., Zaric G., Huang Q. Candian Journal of Aging Volume 31, Number 2 (2012), p. 139-147
  • Preventing CAUTIs, ventilator associated pneumonia, patient falls, medical administration errors
  • System Level SupportBuild Provincial Capacity Provide Support to LeadershipSustainability
  • BC Provincial Perioperative Improvement Program

    1. 1. BC Provincial Perioperative Improvement Program Proposal Presentation & Discussion
    2. 2. Panel Members Margi Bhalla, Director, Surgical Services, Ministry of Health – Provincial Surgical Advisory Committee Co-Chair Andy Hamilton, Medical Director, Surgical Services, Interior Health Authority – Provincial Surgical Advisory Committee Co-Chair Dermot Kelly, Director, Medical Administration & Surgical Services, Vancouver Coastal Health Felicia Laing, Project Manager, Quality & Patient Safety, Vancouver Coastal Health Peter Blair, Program Medical Director, Surgery, Fraser Health Susann Camus, NSQIP Quality Improvement Consultant, Fraser Health Adrian Leung, Executive Lead, Specialist Services Committee, British Columbia Medical Association Marlies van Dijk, Director, Clinical Improvement, BC Patient Safety & Quality Council
    3. 3. Agenda Background and program proposal The Productive Operating Theatre Overview & Experiences Margi & Andy – 5 minutes Dermot & Felicia – 10 minutes Comprehensive Unit-Based Safety Program Overview & Experiences Coaching Team Discussion & Questions Peter & Susann – 10 minutes Marlies – 5 minutes All – 30 minutes
    4. 4. Background The Provincial Surgical Advisory Council (PSAC) was established in 2009 to inform the strategic direction of surgical services in BC Perioperative Improvement Sub-Group formed following release of BCMA’s ‘Enhancing Surgical Care in BC – Improving Perioperative Quality, Efficiency and Access’ Developed multi-year master plan for improvement in the perioperative environment Provincial OR inventory and identification of provincial indicators underway Front-line initiatives to address common barriers to perioperative improvement
    5. 5. Proposed Provincial Program Overview Extended Site Team Expert Trainer Core Site Team Provincial Team & Project Manager Core Site Team Extended Site Team Core Site Team Extended Site Team Extended Site Team Core Site Team • Provincial coaching team – trained experts provide support to sites • Sites – selected based on demonstration of patient safety oriented culture, readiness for project, clear plan to commit local resources, identified measurable goals
    6. 6. Proposed Provincial Program Overview Provide comprehensive support for sites to implement a quality improvement methodology Support could include: Module materials Provincial project management Funding clinical time QI methodology expert consultation (e.g., Maggie Morgan-Cooke, Dr. Liza Wick) 1-2 face-to-face meetings Coaching team site visits Coordinated peer support
    7. 7. Proposed Provincial Program Overview Provincial team will receive training and provide support to sites Could include representatives from program sites and from sites across the province using other improvement methods (e.g. LEAN) as well as others who are interested Method to be chosen by site, and could include: Productive Operating Theatre (TPOT) Comprehensive Unit-Based Safety Program (CUSP) “Building Local Expertise” Coaching Model LEAN or other QI methodologies
    8. 8. The Productive Operating Theatre Overview Primary concerns: Quality and efficiency Toolkit 2 overview guides 11 modules Module materials: Handbooks & DVDs Planning & evaluation tools
    9. 9. The Productive Operating Theatre Experience (Dermot & Felicia) • Felicia and Dermot
    10. 10. The Productive Ward Experience Releasing Time to Care Vancouver Coastal Health RT2C Education February 2013 VCH Lean Education
    11. 11. NHS productive series
    12. 12. Modules: based on Lean thinking • Leadership support • Foundational modules for sustaining improvements
    13. 13. Productive operating theatre Productive ward • Set of modules designed to guide you through the processes • Efficiency guidelines to achieve significant and lasting improvements, thereby allowing extra care time for patients • Tested and proven to be successful in many health care settings: – – – – Ontario, Manitoba, BC US, CareOregon UK, Sweden, European countries Australia, New Zealand
    14. 14. Aim: to improve 4 key dimensions of quality
    15. 15. Releasing Time to Care/Productive Ward • • • • Understand what is happening now Display measures on a board Use huddles on performance to drive improvement Regularly update information 15
    16. 16. Improvements • Staff-led data collection and audits • Daily huddles around data board Process Action Change Shift report •From 45-60 min to 15 min per shift report •Earlier vital signs assessments •On time patient readiness for meals •On time meds admin 67% Wait time to DI •Wait time in hallway range 1 to 38 min •Porter now helps ready patient – no wait time 100% Admission kits •Pre-assembled patient supplies •From 73.5 min to 4 min per week •Dedicated time admitting patient •Dedicated time getting handover report 95% Meal trays •Delivery time changed to offset staff breaks •More time for patients to eat, food is warm Interruptions •From 15.8 to 10.0 per hour •189 interruptions per shift reduced to 120 •General staff queries, patient status 37%
    17. 17. Patient Safety & Reliability of care Falls: Improvement actions and results 12 Goal: To reduce falls by 50% by Dec 2013 to two falls per month. 10 -Yconnectors with each bed alarm -Safety checks qshift -Risk assessment on admission 8 Number of patient falls -Regional rollout Falls Prevention Program 6 4 -Families pamphlet on fall prevention -Motion-sensored lights in all rooms 2 0 May # Falls (Safety Cross) Trendline Jun July Aug Sept Oct Nov Dec Jan 2013 Feb Mar Apr May Jun Jul Aug Sep 2013 10 6 8 1 5 5 12 9 4 1 3 5 6 4 6 5 4
    18. 18. Patient Safety & Reliability of care Falls: projected cost-avoidance What if we are reaching the goal of reducing falls by 50%? 2012 Reduced by 50 % Number of minor falls per year (30% RH; 54% SGH) ) Number of moderate and severe harm falls (10% RH; 5% SGH) Costs (minor harm); $ 11,254 per case1 Costs (moderate and severe harm); $ 30,696 per case2 Total Cost Avoidance Bed Days minor falls1 Bed Days moderate and severe harm falls2 Total Bed Days Bed Days Avoided 1 CIHI, 88 44 20 10 Projection Analysis $ 990,348 $ 495,174 $ 613,920 $ 306,960 $ 1,604,268 $ 802,134 $ 802,134 440 220 680 340 1120 560 560 National Trauma Registry Analytic Bulletin Hospital Costs of Trauma Admissions in Canada, 2000/2001. 2 Estimating the Cost of Serious Injurious Falls in a Canadian Acute Care Hospital Zecevic A., et al.. Canadian Journal of Aging Volume 31, Number 2 (2012), p. 139-147. •The three target wards could reach a cost avoidance of $ 802,134 by reducing their falls by 50 % • 560 Bed Days could be prevented due to an extended length of stay (LOS) •Assumption (1,2): Total extended LOS for serious falls 34 days; Extended LOS for minor falls 5 days
    19. 19. Patient Experience Patient experience – 3S Richmond 47.6% Do you feel confident with your current discharge plan and support outside the hospital? 75.0% 77.4% Did you notice that the staff wash or disinfect their hands prior and after caring? 85.7% 71.4% Were you well informed of your condition or treatment approach by your attending health care team? 71.4% 87.7% In general, during your hospital stay, did you feel treated with respect and dignity? 92.9% 0% 20% 40% 60% 80% 100% Acute Care Patient Experience 2012 - % positive score (October 2011 - March 2012) 3 South Patient Feedback - % of positive responses (Dec 2012-Jan 2013) 19
    20. 20. Patient Experience Patient experience – Squamish Were you provided with the equipment you needed to go home with? 100.0% Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand? 96.4% Did the doctors, nurses or other staff give your family or someone close to you all the information needed to help you during your stay or treatment? 89.7% Did you have good opportunity to participate in the decisions that applied to your care? 96.6% During this hospital attendance/stay did you feel you were treated with dignity and respect? 100.0% 0 Acute Care Patient Experience 2012 20 40 60 80 100 SGH Patient Feedback 20
    21. 21. Staff unplanned absence- Squamish Background • • Staff well being has been shown to impact absence rate Identified high rate of unplanned on the unit Safety cross was used to bring awareness to the unit. Unplanned absences – Day shift Number of Unplanned Absences • Staff WellBeing 14 12 10 8 6 4 2 0 Nov 2012 Dec Jan 2013 Feb Mar April May Jun 2013 21
    22. 22. “This is the first time in my 30 years of nursing where I've seen frontline staff get involved with any quality improvement. I really believe that this will work and will be sustainable.” “Since our unit has a lot of issues, and we know its potential, it inspired a lot of conversations [..].It made us more vocal and involved, and gave us a platform to speak with Allied Health.”. - Staff Nurse 22
    23. 23. Comprehensive Unit-based Safety Program (CUSP) at Royal Columbian Hospital Dr. Peter Blair, RCH Surgeon Champion & FH Surgery Medical Director Susann Camus, NSQIP Quality Improvement Consultant October 28, 2013
    24. 24. Purpose of CUSP • Strategic framework for improving patient safety • Integrates communication, teamwork, and leadership to create and support a culture of patient safety • Provides frontline staff with the tools and resources to improve quality October 28, 2013 CUSP at Royal Columbian Hospital 24
    25. 25. CUSP’s Beginnings • First applied in more than 100 Intensive Care Units in Michigan in 2003 • 5 evidence-based procedures recommended by CDC to reduce Central Line Associated Site Infections (CLABSI): hand hygiene, full-barrier precautions, Chlorhexidine gluconate skin cleansing, avoiding femoral site, minimizing use of Foley catheters • Results: Reduced CLABSI rates by 67% within 3 months • Saved more than 1,500 lives and $200 million in the first 18 months • Expanded to other settings & more types of preventable infections. October 28, 2013 CUSP at Royal Columbian Hospital 25
    26. 26. Five Steps: Using CUSP to Reduce SSIs 1. 2. Staff educated on the science of safety Staff complete patient safety culture assessment 3. Senior hospital executive partners with unit to improve communications and educate leadership 4. Staff learn from unit defects 5. Staff use tools such as checklists to improve teamwork, communication, collaboration October 28, 2013 CUSP at Royal Columbian Hospital 26
    27. 27. Learning from Defects Defect = any clinical or operational event or situation that you would not want to happen again. 1) What happened? 2) Why did it happen? 3) What did you do to reduce the risk? 4) How do you know that risks were reduced? October 28, 2013 CUSP at Royal Columbian Hospital 27
    28. 28. Two Questions 1. Ask staff two questions: a) How is the next patient going to get an SSI on this unit? b) How can we prevent this from happening? October 28, 2013 CUSP at Royal Columbian Hospital 28
    29. 29. SSI Bundle & Results 1) Standardization of skin prep and use of chlorhexidine wash cloths 2) Mechanical bowel prep with oral antibiotics 3) Patient warming 4) Enhanced sterile technique 5) Antibiotic timing and dosage 33% reduction in SSIs $168,000 - $280,000 cost savings per year at 1 site Source: Wick et al., 2012 Implementation of a Surgical Comprehensive UnitBased Program to Reduce Surgical Site Infections, JACS 2012:215(2), Aug 2012. October 28, 2013 CUSP at Royal Columbian Hospital 29
    30. 30. CUSP Participating Sites • Ronald Reagan UCLA Medical Centre, Los Angeles • New York Hospital of Queens, Flushing • Mills Peninsula Health Services, Burlingame • Saint Elizabeth Medical Centre, Utica • The Ottawa Hospital, Ottawa • Royal Columbian Hospital, New Westminster October 28, 2013 CUSP at Royal Columbian Hospital 30
    31. 31. CUSP at RCH 1. Safety Attitudes Questionnaire showed ample room for improvement in RCH safety culture 2. RCH was invited to join CUSP 3. Steering Team assembled 4. Defects were identified and prioritized through safety assessments October 28, 2013 CUSP at Royal Columbian Hospital 31
    32. 32. Results of 1st Safety Assessment October 28, 2013 CUSP at Royal Columbian Hospital 32
    33. 33. OR Traffic Audit • 8 cases observed over 614 minutes • Average case was 77 minutes (35-134 min) • Doors swung open 354 times, or 44.25 times per case (18-101 times) • Doors were open 19% of the time, disrupting air flow in the OR October 28, 2013 CUSP at Royal Columbian Hospital 33
    34. 34. Normothermia Initiative Reviewed charts of PACU surgical patients, recorded their temperature (pre, intra, post op) and type of procedure after 2 days in April 2013, 5 hours per day: October 28, 2013 CUSP at Royal Columbian Hospital 34
    35. 35. Results of 2nd Safety Assessment October 28, 2013 CUSP at Royal Columbian Hospital 35
    36. 36. Next Steps for RCH • Document CUSP process, share tools • Confirm executive support & commitment • Get team on a regular meeting schedule (e.g. every two weeks) • Identify potential quick win (scrubs storage?) • Post notes, SSI rates, all documentation every month, and prominently for OR October 28, 2013 CUSP at Royal Columbian Hospital 36
    37. 37. Surgical Provincial Coaching Team
    38. 38. Safety Climate – 14 BC Hospitals 75 surgical units - 2012
    39. 39. Perceptions of Local Management 14 Hospitals – 75 BC surgical units - 2012
    40. 40. Risk of Failure Potential Problem • 6 months after project lose the improvements • Long term sustainability End Goal • Improvements held • Leaders behave the same as before project • Leaders are on the units doing walk rounds and using visual display boards and participate in huddles • Identification and change in systems/tactics • Systemic changes not made • Improvement sustained
    41. 41. Training and Commitment • Coaching Team Training (2 face to face meetings and monthly webex training over 24 months) • Expert Led – tentative: Allan Frankel, Ontario Coach Support and others • Identify are of need! (using local data) • Co-create a local plan which aims at improvement at a system wide level/organizational goals • Attendance to at least 2 site visits (other Transformation sites) over the duration of 2 years
    42. 42. Who can Join? • Up to two people from each site that is participating • Total up to 20 people
    43. 43. Discussion & Questions
    44. 44. Next Steps For more information on the Provincial Perioperative Improvement Program, please contact: Margi Bhalla 250 952 1040 munjeet.bhalla@gov.bc.ca Andy Hamilton 250 870 4778 andy.hamilton@interiorhealth.ca

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