This document discusses quality improvement in healthcare. It begins by posing questions about defining quality, what quality improvement is, and how quality can be improved. It then discusses the safety paradox in healthcare - that despite highly trained staff and technology, errors are common and patients are frequently harmed. Several studies on adverse event rates in hospitals are summarized. The document discusses concepts for safety and quality improvement like reliability, variation, measurement, and change management. It provides examples of quality improvement tools and approaches like process mapping, care bundles, measurement, and the PDSA (Plan-Do-Study-Act) cycle. Overall, the document provides an overview of key issues and approaches related to quality and safety in healthcare.

2. Questions to be answered today
• How do we define Quality in healthcare?
• What is Quality Improvement?
• HOW CAN WE IMPROVE QUALITY?
• How can we ensure that "change" is really an
improvement?
• What tools and approaches can we use to promote
successful improvement/change?

5. The safety paradox
 Healthcare staff are:
 Highly trained & motivated
 Committed to their patients
 Use sophisticated technology
 Errors are common and patients are frequently
harmed

6. Video
How safe is your care?

7. Potentially an average of 7,300 patients per year per trust suffer an adverse
event …
Double Decker bus seats 73 people…
100 bus loads of patients per year per trust …
Nearly 2 bus loads per week per trust
Safety in Acute Hospitals

8. Adverse Events
• Due to healthcare management rather than to the underlying disease
• May or may not be preventable
• Effect 8-12% of hospitalised patients (one or more adverse events)
• Older people are particularly vulnerable
• Voluntary reporting systems are poor at measuring adverse events but
useful for learning about vulnerabilities

9. Epidemiology of harm
Study Authors Date of admissions Number of hospital
admissions
Adverse event rate
(% admissions)
Harvard Medical Practice
Study (HMPS)
Brennan et al, 1991;
Leape et al, 1991
1984 30195 3.7
Utah-Colorado Study
(UTCOS)
Thomas et al, 2000 1992 14052 2.9
Quality in Australian Health
Care Study(QAHCS)
Wilson et al, 1995 1992 14179 16.6
** United Kingdom Vincent et al, 2001 1999 1014 10.8 **
Denmark Schioler et al, 2001 1998 1097 9.0
New Zealand Davis et al, 2002 1998 6579 11.2
Canada Baker et al, 2004 ???? 3745 7.5
France Michel et al, 2007 2004 8754 6.6% per 1000 days
admission
** United Kingdom Sari et al, 2007 2004 1006 8.7 **
Spain Aranaz-Andre et al, 2008 2005 5624 8.4
The Netherlands Zegers et al, 2009 2006 7926 5.7
Sweden Soop et al, 2009 2006 1967 12.3

10.  Clinical information available in hospital outpatient
clinics
 Prescribing for hospital inpatient
 Equipment availability in the operating theatre
 Equipment available for inserting peripheral
intravenous lines

12. Copyright ©2008 BMJ Publishing Group Ltd.
Vincent, C. et al. BMJ 2008;337:a2426
Changes in rates for 9 AHRQ derived patient safety indicators.
Hospital Episode Statistics 1996-7 to 2005-6 (England)

13. Trends in rates of patient harm:
United States
Landrigan et al, NEJM 2011

14. How can we improve quality?
 Leaders who understand and use QI
techniques (e.g. MFI, Lean)
 Quality Improvers who have Leadership
skills
Leadership
QI skills

17. wrong

18. Concepts for Safety & QI
 Reliability
 Variation (lack of)

19. Relative risk of death from intestinal
obstruction (not hernias) by hospital in one
SHA
0
20
40
60
80
100
120
140
160
180
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Relative Risk
Relative Risk

20. Safety climate by hospital
Safest
Least safe

21. “Use of drug X by GP practice”
“Referrals to OPD with GI symptoms”

22. QI requires CHANGE
 Will
 Ideas
 Execution

23. Get a small
group of
interested
people
together
Learn about
different
contributions
to the system
or service
Analyse and
understand
current system
Continue to
learn and
improve
Look at
ideas for
how things
might be
different
Test ideas and
experiment with
different ways of
working
Improved service
Improved
understanding of
how things work
More control over
work
Better outcomes
and experience for
patients
. .
Our Improvement Framework…

25. COLLABORATIVES

26. MEASUREMENT

27. Running monthly
average (per 1000
risk days)

28. Days
between!

29. Measurement video

30. 100%
80%
86%
57%
57%
83%
94%

31. Sepsis is an EMERGENCY!

32. 100%
80%
86%
57%
57%
83%
94%

33. Sepsis
Run Charts
0
20
40
60
80
100
Median(%) Observations Recorded
0
20
40
60
80
100
Median(%) High flow O2
0
20
40
60
80
100Median(%)
Blood Cultures taken

34. 0
20
40
60
80
100
Median(%) IV Fluids
0
20
40
60
80
100
Median(%)
Antibiotics within 1 HR
0
20
40
60
80
100
Median(%)
Serum Lactate
Sepsis
Run Charts

35. 100%
80%
86%
57%
57%
83%
94%

36. ED (early) management of sepsis
% compliance
0
10
20
30
40
50
60
70
80
90
100
vitalsigns
highflowO
2
IV
fluids
lactate
cultures
antibiotics
urine
UK median2011 NI median2011
NI median 8/2012

37. ED (early) management of sepsis
% compliance
0
10
20
30
40
50
60
70
80
90
100
vitalsigns
highflowO
2
IV
fluids
lactate
cultures
antibiotics
urine
UK median NI median
NI median 8/12 NI median 11/12

38. ED (early) management of sepsis
% compliance

39. Ventilator Care Bundle
Compliance

40. Steps taken by one UK site to
reach 95% compliance

41. Feedback

42. VAP Rate
Quarterly running average
Start > 9 VAPS/1000 vent days
End < 2 VAPS/1000 vent days

43. Process Mapping
Stroke: assessment, imaging, thrombolysis
 Patient telephones 999
 Ambulance arrives at home
 Ambulance leaves home
 Paramedics pre-alert stroke team
 Hospital
 Registration
 Bed in Resusitation Area

44. Process Mapping
 Nursing Staff
 IV placement
 ECG
 Monitor Hook up
 Vital signs monitoring
 Blood glucose
 Blood tests
 Weight estimate

45. Process Mapping
 Clinical Assessment
 History
 Medication
 Allergies
 Identification Of Witness
 Time of Onset/when last well
 Witness difficult to locate?

46. Process Mapping
 Clinical Assessment
 NIHSS
 Neurological Examination
 Lab samples - FBP/ PT/UE
 Transport of blood to labs

47. Process Mapping
 Imaging
 Bed to CT Scanner
 Disconnect monitor
 CT Scan
 CT Report
 Transport from CT – Stroke Unit
 Reconnect Monitor

48. Process Mapping
 Drug Preparation
 Calculate dose
 Prepare TpA
 Give bolus
 Start Infusion

49. Bundle of Care
 Parallel v Serial Process for clinical assessment
 ED Doctor
 History
 Meds/Allergies
 Order CT Scan
 Medical Registrar
 NIHSS Stroke Scale – on-line training
 Neuro Examination

50. Bundle of Care
 Nursing staff in Ed asked to defer ECG
 Medical staff reminded to stay with patient and assist
with transport of patient to CT Scanner
 Near Patient testing
 Training of Reception staff in recognition of stroke
symptoms
 MD check list – responsiblity of nursing staff- ed and
stroke,responsibilty of medical staff Ed and medical
registrar.

51. PDSA 6
 CT radiographer live in October 2012

52. Goal
0
20
40
60
80
100
120
140
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
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
CT scan (within 45 mins)
Bundle

53. Median
Goal
0
20
40
60
80
100
120
140
160
180
200
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
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
Bundle
Door to needle time (within 60 mins)

54. THE M and M GAME
OR
How to run a PDSA Cycle

55. Act
• What changes are to
be made?
• Next cycle?
Study
• Complete analysis of data
• Compare data to predictions
• Summarise what was learned
Do
• Carry out the plan
• Document problems and
unexpected observations
• begin analysis of data
Plan
• Objective
• Questions and predictions
(why?)
• Plan to carry out the cycle
• Plan for data collection

56. To Be Considered a PDSA Cycle
 The test or observation was planned
(including a plan for collecting data)
 The plan was attempted
 Time was set aside to analyze the data
and study the results
 Action was rationally based on what was
learned

57. The M&M Challenge
 Aim – to be left as few M&Ms as
possible at the end (?only 1)
 Measure – number of M&Ms left
Operational definitions:
 DO NOT EAT THE M&Ms
 Leave one blank circle on game sheet
 Jump one marker over another and
remove marker that is jumped over
 Each round lasts 1 minute
2
1
3
654
10987

59. STEP 1: Plan
Objective: To test (another)
approach to removing pegs
Predictions: Will we leave
fewer pegs?
Plan: Who, what, record moves
STEP 2: Do
• Carry out the plan
• Record moves
• Note problems or changes
to plan
STEP 3: Study
• Compare data to predictions
• Summarise what was learned
• Update the team’s theory
(approach)
STEP 4: Act
• Does our approach
leave 1 peg?
• If not what new ideas
should we test on next
cycle?
PDSA FOR THE
PEG (M&M) GAME

60. IN SUMMARY:

62. What we
are told to
do
What we
think we
should do
Behaviour

63. Rules and
Regulations
Culture
Behaviour

65. Safety brings its own dangers
The price of safety is chronic unease
‘First of all, I was not in a position to challenge on the basis
of my limited experience of this type of treatment. Second, I
was an SHO (junior doctor) and did what I was told to do by
the Registrar. He was supervising me and I assumed he had
the knowledge to know what was being done. Dr M.
was employed as a registrar ... in a centre for excellence
and I did not intend to challenge him’.

66. Reliability of ward care
 (1) How well do you understand the goals of care for
this patient today?
 (2) How well do you understand what work needs to be
accomplished to get this patient to the next level of
care?
 Less than 10% of nurses or doctors could answer these
questions
Pronovost et al, 2003

67. Team

69. Six things all Trust
Boards should do
 Setting Aims: Set a specific aim to reduce harm this year – a public
commitment to measurable quality improvement
 Getting Data and Hearing Stories: Review progress toward safer
care as the first agenda item at every board meeting, grounded in
transparency, and putting a “human face” on harm data.
 Establishing and Monitoring System-Level Measures: Identify a
small group of organization-wide “roll-up” measures of patient); keep
up to and make transparent to the entire organszation and users.
 Changing the Environment, Policies, and Culture: Commit to an
environment that is respectful, fair, and just – for all those touched by
avoidable harm/poor outcomes.
 Learning… Starting with the Board: Learn how “best in the world”
boards work to reduce harm. Expect such training for all staff.
 Establishing Executive Accountability: Oversee the execution of
harm reduction plan; include executive team accountability.

70. How do we know organisations
are safe?

71. Reflect on your
own experiences of health care . . .
What was good?
What was bad?
What made you angry?
What upset you?

72. “To the typical physician, my illness is a
routine incident in his rounds while for me
it’s the crisis of my life. I would feel better if I
had a doctor who at least perceived this
incongruity. I just wish he would give me his
whole mind just once, be bonded with me
for a brief space, survey my soul as well as
my flesh, to get at my illness, for each man is
ill in his own way.”
Anatole Broyard

73. The A B C D
of dignity-conserving care
Chochinov BMJ 2007; 335: 184-187
A
B
C
D

74. Chochinov BMJ 2007; 335: 184-187
ttitude
 How would I feel if I was this patient?
 Inappropriate assumptions?
- poor quality of life; ageism; social acceptability; malingering;
Is my attitude towards the patient biased by my own
experiences, anxieties, or fears?
Does my attitude towards being a healthcare provider help
or hinder an empathic professional relationships with
patients?
People who are treated like they no longer matter will act
and feel like they no longer matter
A

75. ehaviourB
Chochinov BMJ 2007; 335: 184-187
 Respect
 Small acts of kindness
- simple comfort measures; acknowledging a photo;
 Permission to examine
 Acknowledge inconvenience and discomfort
 Discussion after patient dressed
 Good communication skills
“You, as a person, are worthy of my care and attention”

76. ompassionC
Chochinov BMJ 2007; 335: 184-187
 Extending care beyond the intellectual level
 Developed and shaped by life experience
 Something that we feel
 Awareness of suffering and a wish to relieve it
 Non-physical communication

77. ialogueD
Chochinov BMJ 2007; 335: 184-187
 Formal psychotherapeutic approaches
 Getting to know the patient
- hobbies; family; beliefs; previous exposure to illness; what is
important in their life
 Acknowledging fear, distress
 Identifying significant others who can support

78. Video
Cleveland Clinic

79. The secret of the care of
the patient is in caring for
the patient
Dr Francis Peabody 1927