Ovret Sdo Patientsafety4 June09


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Ovret Sdo Patientsafety4 June09

  1. 1. Patient safety - what works? 4 th June 2009 See safety folder on web site http://homepage.mac.com/johnovr/FileSharing2.html <ul><li>John Øvretveit, </li></ul><ul><li>Director of Research, Professor of health innovation and implementation, Karolinska Medical Management Centre Sweden and Professor of Health Management, Faculty of Medicine, Bergen University </li></ul>08/03/09
  2. 2. . <ul><li>. </li></ul>08/03/09 Once upon a time… In a parallel universe… Not so far from here…..
  3. 3. <ul><li>Dr Anna Johansson, </li></ul><ul><ul><li>Director of Internal Medicine, Shockholm sjukhus. </li></ul></ul><ul><li>Unusually, </li></ul><ul><li>called Jon Tviet over </li></ul><ul><ul><li>Director of research, Katolinksa Medical School. </li></ul></ul><ul><ul><ul><li>(You know that look when…) </li></ul></ul></ul><ul><li>Wanted to know, “We’ve got to improve patient safety… </li></ul><ul><li>– quickly, cheaply, saving the most suffering, and costs” </li></ul>08/03/09
  4. 4. Don’t complicate things – what works …? Proven safety solutions recommended or mandated by authoritative bodies <ul><li>(See SDO safety folder on web site) </li></ul><ul><li>Do you use any of these? </li></ul><ul><li>AHRQ 2001 – The first 11 “Nike no-brainers” – just do it! </li></ul><ul><li>NQF top 30 </li></ul><ul><li>IHI 100k and 5m lives solutions (& country versions) </li></ul><ul><li>WHO list </li></ul><ul><li>Joint commission safety goals </li></ul><ul><li>ACHS etc & … You pays your money…t </li></ul>
  5. 5. Clinical safety practices: changes for common problems <ul><li>Two of 11 AHRQ 2001 “just do its” (others in the 680p report) </li></ul><ul><li>Antibiotic-impregnated central venous catheters to prevent infection </li></ul><ul><li>Pressure relieving bedding materials to prevent pressure ulcers. </li></ul><ul><li>Inappropriate prescribing for people over 65 </li></ul><ul><li>Information on medications for patient transfers (NCH (2000)) </li></ul><ul><li>Every patient, every time, every place as appropriate? </li></ul><ul><li>What’s the cheapest? </li></ul>
  6. 6. Katolinska Sjukhus toilets – quick/low cost video cams & poster 08/03/09
  7. 7. Katolinska Sjukhus 08/03/09
  8. 8. Good cost/effectiveness – direct communication with patients 08/03/09
  9. 9. We will do these 2 because these are a problem for us <ul><li>1 Infection rates: Antibiotic prophylaxis </li></ul><ul><li>2 Failure to rescue (arrests, emergency admit to ICU): critical care outreach team </li></ul>08/03/09
  10. 10. How do you know these work? <ul><li>Evidence: see Øvretveit, 2004, 2007, 2009 reviews of research for WHO and SKL </li></ul><ul><li>Antibiotic prophylaxis </li></ul><ul><ul><li>Clinical trial standardised full implementation and excluded other explanations : intervention to physiology – “mechanical” causal pathways </li></ul></ul><ul><li>Critical care outreach team </li></ul><ul><ul><li>Less sure: social intervention to social system – people are unpredictable, especially when together… </li></ul></ul><ul><ul><ul><ul><li>Not fully implemented, long pathway, but makes sense! </li></ul></ul></ul></ul>08/03/09
  11. 11. <ul><li>You have not convinced me, but to sell to my colleagues: </li></ul><ul><li>Would it work here? </li></ul><ul><li>How much would it cost? </li></ul><ul><li>and what’s effective for implementation? </li></ul><ul><li>Little research on this </li></ul><ul><li>Effective implementation to get the changes? </li></ul><ul><li>Which contexts necessary or help and hinder? </li></ul><ul><li>Probable that supportive context more important than you or implementation strategy </li></ul><ul><li>Come with me to see the CEO, to get this… </li></ul><ul><li>But keep it simple… </li></ul>
  12. 12. Sven Angstrom: the Dr Darth Viking of Shockholm sjukus & the Local Context King <ul><li>Look at this research Dr Darth…. </li></ul><ul><li>Jon, do you have a cat… </li></ul>
  13. 13. Can you grow pineapples in Shockholm? 08/03/09 Seed Gardener/planting & nurture Climate / soil The point is, choose plants you see growing in similar environments – and change which aspects of climate you can Can Darth change the micro or macro climate? Anna, supported by Darth
  14. 14. Say again Jon? <ul><li>Environment + Evidence +Implementation = Quality </li></ul><ul><li>Supportive infrastructure </li></ul><ul><li>+ Proven change </li></ul><ul><li>+ Effective implementation </li></ul><ul><li>= Higher quality </li></ul><ul><li>Anna needs help with the context bit…that’s Darth’s department… </li></ul>
  15. 15. Later… back at the Katolinska Research Centre …Jon calls together the research group 08/03/09
  16. 16. Jon enthuses the research team - we can make a difference… <ul><li>Fantastic opportunity – no research on this: </li></ul><ul><li>1)Before/After complex changes: effective? </li></ul><ul><li>2)Implementation strategies: effective for getting the before/after change? </li></ul><ul><li>3)Supportive contexts: group, departmental, organisational, external - what is necessary to help the implementation? </li></ul><ul><li>4) Also, not just evaluation & implementation research </li></ul><ul><ul><li>Eg patients view about how to involve them in improving safety </li></ul></ul><ul><ul><li>(choose 2 – quickest and lowest cost?) </li></ul></ul>08/03/09
  17. 17. Other points about safety – post modernist writer in residence <ul><li>Intervention is not separate from context </li></ul><ul><li>Many influences on result variables you study </li></ul><ul><li>Intervention is one, and it interacts with context </li></ul><ul><li>Research “draws a boundary” between the intervention and context </li></ul><ul><ul><li>To assess how influential intervention is on outcomes vs other influences </li></ul></ul><ul><ul><li>Don’t confuse your model with reality </li></ul></ul>08/03/09
  18. 18. Research points - 2 <ul><li>Theory informed evaluation – models of intervention in context: next is one example </li></ul>08/03/09
  19. 19. 08/03/09 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Theory informed evaluation – safety interventions evolve in context Actions: planning and preparations Result: agreed care goals, three shared centres and joint management Planning Innovation Further development actions Established Actions to develop coordinated client/patient care planning system & other systems & procedures >>>>>>>>>>>> Context factors help and hinder implementation at different times Government policy helps planning Intermediate results : coordination structures and changes in personnel behaviour 1996 2000 2004 2008 Results : Consequences for personnel Results: Consequences for clients
  20. 20. Hindrances for us researchers: <ul><li>More silos than in health organisations </li></ul><ul><li>Academic departments, disciplines </li></ul><ul><li>Ownership and branding wars confuse terminology </li></ul><ul><ul><li>Makes communication between disciples for MD and MM research more difficult </li></ul></ul>08/03/09
  21. 21. Johns safety research wish list <ul><li>Incidence and solutions to AEs outside of hospitals </li></ul><ul><ul><li>PHC, Nursing homes </li></ul></ul><ul><li>The “in-betweens” – transitions and entire episode of care </li></ul><ul><li>Costs of adverse event, Cost of 50% solution, Saving </li></ul><ul><ul><li>(MMC “saving suffering campaign” ) </li></ul></ul><ul><li>Second victim impact and costs </li></ul>08/03/09
  22. 22. Other points about safety research – 3 – address the 4 challenges <ul><li>Data validity </li></ul><ul><li>Attribution </li></ul><ul><li>Generalisation </li></ul><ul><li>Use and ultility </li></ul>08/03/09
  23. 23. Summary <ul><li>What works to reduce AEs – rigorous research in one setting </li></ul><ul><li>Where works best ? </li></ul><ul><ul><li>Which implementation and context; context insensitive/ robust? </li></ul></ul><ul><li>Why it works? </li></ul><ul><ul><li>explain pathways of influence & intermediate and ultimate effects </li></ul></ul><ul><ul><li>Helps others decide if and how to implement – will it work in my service? </li></ul></ul><ul><li>How strong evidence needs to be before acting? </li></ul><ul><ul><li>Proportionate to cost and ease of implementation and risk of harm compared to alternatives (eg no action) </li></ul></ul><ul><li>. </li></ul><ul><ul><li>. </li></ul></ul>08/03/09
  24. 24. What works? <ul><li>High certainty: </li></ul><ul><ul><li>If implemented fully, will reduce Aes in most situations </li></ul></ul><ul><ul><li>Don’t know costs or how best to implement in different situations </li></ul></ul><ul><li>Probable </li></ul><ul><ul><li>In some situations </li></ul></ul><ul><li>Possible/promising </li></ul><ul><ul><li>No research, little testing experience </li></ul></ul><ul><li>Does not work </li></ul><ul><ul><li>Research high certainty in some situations, probably, possibly </li></ul></ul>08/03/09
  25. 25. What does not work? 08/03/09 “ be more careful”
  26. 26. Patient safety - what works? <ul><li>Evidence from elsewhere about </li></ul><ul><ul><li>Efficacy in rigorous study situation </li></ul></ul><ul><ul><li>Effectiveness of implementation actions, in a context </li></ul></ul><ul><li>Find and adapt this evidence to your service </li></ul><ul><li>Look for implementation research into similar changes </li></ul><ul><ul><li>To find which context factors help and hinder </li></ul></ul><ul><li>Use iterative testing with feedback on small scale to develop the intervention locally and spread </li></ul><ul><li>More at http://homepage.mac.com/johnovr/FileSharing2.html </li></ul><ul><ul><li>. </li></ul></ul><ul><li>. </li></ul><ul><ul><li>. </li></ul></ul>
  27. 27. Researchers may need guidance … 08/03/09
  28. 28. Questions to you … <ul><li>1) How to collaborate to make the needed research practical </li></ul><ul><ul><ul><ul><li>and the practical research needed? </li></ul></ul></ul></ul><ul><li>2) This was new or surprising, for me… </li></ul><ul><li>Reviews of research download from safety folder on web site http://homepage.mac.com/johnovr/FileSharing2.html </li></ul>08/03/09
  29. 29. . <ul><li>. </li></ul>08/03/09