A public-private sector collaborative campaign to

accelerate the spread of evidence-based practice

to improve patient outcomes

Dr Gary Kantor, Dr Dena van den Bergh

Best Care Always Task Team

2

“Not since the first democratic elections in 1994 has there

been so much hope and expectation for a better health

system, with improved health outcomes for all, in

South Africa.

The country is at an important crossroads.….

The challenges are great.”

South Africa's health: departing for a better future? Lancet 25 August 2009

3

Best Care ? Gap Between Evidence & Practice

• In developed countries, patients receive

“recommended care” ~ 50% of the time.

• Adverse events in 10% of hospital patients.

– 50% preventable.

– 7.5% of these patients die.

1. NEJM 2003; 348:2635-2645

2. Qual Safety in Health Care 2008;17:216-223

• Making improvements

• Holding the gains over time

• Spreading results within health care organizations

• Spreading results among health care organizations

Challenge for all Nations

5

Current improvement initiatives?

TARGET – Sustainable,

consistent, best practice

6

Individual champions of improvement

7

Finding leverage and synergy to achieve

sustainable, high quality health care

…more quickly

…at greater scale

Power of leverage and synergyLeverage - Doing something smart that has a

much bigger impact.

Synergy takes place when two or more people produce more together than the sum of what they could have produced

separately.

8

A systematic, co-ordinated,

focused quality improvement

campaign that leads to consistent

and sustainable best practice “at

the bedside”…and real benefits

9

The Opportunity

• What if a few “simple” interventions could

markedly reduce common, serious, adverse

events in hospitalized patients?

• What if we already knew what those

interventions are?

• What if we implemented all of them, always,

on every eligible patient?

1 in 7 patients in SA Hospitals at risk for HAIBrink A et al, SAMJ 2006; 96(7)

9.8% prevalence, 28% in ICUA Duse

11

Begin with 5 Interventions

ALIGNED TO INTERNATIONAL BEST PRACTICE

1. Prevention of central line infections (CLI)*

2. Prevention of ventilator-associated pneumonia (VAP) *

3. Prevention of surgical site infection (SSI)*

4. Prevention of catheter associated urinary tract infections

5. Improving antibiotic stewardship…

* As per IHI 100K lives and Safer Healthcare Now bundles

12

Potential SA

Private Sector

Savings:

~R150 million?

Health Affairs Sep-Oct 2009 28(5):1475

“Quality”

13

Patient-centred

Efficient

Effective

Timely

Safe

Equitable

14

Launch August 2009

The Best Care Always Campaign....

• A national campaign working together to make a bigger

impact on patient care than we could each do alone

• To join the campaign, a hospital must be willing to:

a) Implement evidence-based interventions at a faster pace

b) Share information, experiences and successes with others

c) Commit to measurement

Improve health systems rapidly, at scale

• Building Will– Motivating

– Imagining a better health system

• Harvesting Ideas– Finding or inventing new approaches

• Implementation to get Results– Support, methods & tools for teams to take action

17

Who?

• Private hospital groups– Clinix, Life Healthcare, Medi-Clinic, Netcare, NHN

– Hospital Association of S Africa (HASA)

• NDoH and public sector– Endorsement by National Dept of Health

– Public sector hospitals (Gauteng)

• Funders– Discovery Health

• Professional community – CCSSA, FIDSSA, SAMA, SASA, ICSSA

• Sponsors– Discovery Health - Platinum Founding

– Janssen-Cilag - Gold Founding

– Media sponsor - Medical Chronicle

18

Implementation

Sharing Ideas, Data, Measures

Vertical Node Leaders

Public Sector

• Gauteng

• W Cape

Private Sector

• Life Healthcare

• MediClinic

• Netcare

• Independents

• W Cape

Web-based Support

Mentor

Hospitals

Pilot

Hospitals

http://www.bestcare.org.za

• Hand hygiene

• Maximal barrier precautions

• Chlorhexidine skin antisepsis

• Optimal Catheter site selection, with subclavian vein as the

preferred site for catheters in adults

• Daily review of line necessity with prompt removal of

unnecessary lines

PREVENT CENTRAL LINE INFECTIONS

20

Evidence-Based Best Care

What Is a Bundle?

A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.

The science behind the bundle is so well established that it should be considered standard of care.

Bundle elements are dichotomous and compliance can be measured: yes/no answers.

Bundles require “all or none” approach rather than piecemeal application.

At the same time - recognize the complexity of care, acknowledge that further aspects of “best care” may exist and that the science behind best practice will continue evolve over time

23

The decision to accelerate pace, scale and spread

Implementing all elements of each bundle to every patient every time

What is new and how we have done …

24

TOTAL enrolled = 192 facilities

~3000 beds

>900 ORs

~85% of private hospital beds

• Clinix - 6

• LHC - 48

• Medi-Clinic - 52

• Netcare - 53

• NHN – 18

• Public Sector • Gauteng - 14 hospitals

• Free State workshop

• Western Cape Feb 2011

25

Prevent Ventilator Associated Pneumonias - 143

Prevent Central-line Associated Blood Stream Infections - 150

Prevent Surgical Site Infections - 144

Prevent Catheter Associated Urinary Tract Infections - 154

Antibiotic stewardship – goal - 6 pilot sites

HOSPITALS ALREADY SIGNED UP

Compliance measurement and checklists

commenced in many hospitals

26

The work brings clinical teams together and creates the capacity, will and

motivation for further improvement work .

What is new and how we have done …

27

Unit Manager of one of the ICUs, Hennie van der Walt, said the team was especially excited to have

had zero CLABSI infections for April and May 2010.

Expanding the initiatives and adding impetus to results

Additional improvement initiatives that could further reduce the infection rate were explored. For example,

working with physiotherapists highlighted an infection risk in suction procedures and it was decided to switch

to using a disposable cup and a new suctioning catheter for each patient to address the risks. In April 2010,

the unit was very pleased to have had the first month without any incidence of the multi drug

resistant organism Acinetobacter baumanii.

To reduce UTI‟s, the staff were required to undergo a mindset change regarding the correct procedure for

catheter care, as well as fixation of the catheter. Persistent training by the Nursing Standards Manager, team

of nursing education specialists and IPS, coupled with detailed attention to the use of the right catheter for

long-stay patients, has resulted in zero UTI’s for the period from February to May 2010

Multidisciplinary approach positively impacts on CLABSI

infections

Physicians attending the weekly antibiotic rounds were quick to

realize the significance of the correct preparation for and

application of the aseptic technique during the central line

insertion procedure. They volunteered to be the first to make

use of a checklist to evaluate the insertion technique. A number

of surgeons and anesthetists added their support by ensuring

that best practices for central line insertions were followed in

the operating theatre.

28

Improvement measurement – South African data

29

Ho

sp

ita

l 1

Ho

sp

ita

l 2

ho

sp

ita

l 3

ho

sp

ita

l 4

Ho

sp

ita

l 5

HAI Own Hospital

Total number of HAI Own Hospital 1 2 8 6 0

Number of CLABSI 0 0 2 0 0

Number of VAP 0 1 2 3 0

Number of SSI 0 0 1 2 0

Number of CAUTI 1 0 2 1 0

HAI not listed above 0 1 1 0 0

HAI in ICU & HC & NNICU only 0 2 5 3 0

Hospital Associated Bloodstream Infections (HA BSI)Number of HA BSI cultured with both sensitive and

resistant (MRSA) staphylococcal aureus 0 0 2 0 0

Number of HA BSI cultured with MRSA 0 0 1 0 0

MRSA as a % of total HA BSI 0% 0% 50% 0% 0%

PPD's & Days

Total hospital PPD's 3 272.00 2 611.00 6 467.00 2 469.00 1 464.00

ICU, HC & NNICU PPD's 396.50 410.50 1 084.50 691.00 -

Central Line Days 273.00 82.00 683.00 200.00 26.00

Catheter Days 281.00 71.00 1 030.00 600.00 66.00

Ventilator Days 168.00 78.00 229.00 189.00 12.00

Number of Theatre Cases 515.00 339.00 775.00 489.00 298.00

Other statistics

Colonisations 5.00 34.00 16.00 5.00 8.00 TB Patents:

TB Cases (Clinical/confirmed) 7.00 4.00 2.00 - 1.00

TB Cases (MDR) - 3.00 - - -

TB Cases (XDR) - - - - - TB Staff:

TB Cases (Clinical/confirmed) - - - - -

TB Cases (MDR) - - - - -

TB Cases (XDR) - - - - -

Significant Organisms

Methicillin Resistant Staphylococcus aureus (MRSA) 2.00 2.00 3.00 2.00 -

Extended Spectrum Beta Lactamases (ESBL) 3.00 - 7.00 2.00 -

Pan resistant Pseudomonas - - 2.00 - -

Pan resistant Acinetobacter - - 1.00 1.00 -

Vancomycin Resisitant Enterococci (VRE) - - - - -

Multi Drug Resistant (MDR) Organisms - other - - 8.00 - -

Clostridium Difficile - - - - -

Total Significant Organisms 5.00 2.00 21.00 5.00 -

Rates

Overall HAI Rate per 1000 PPD's 0.31 0.77 1.24 2.43 -

ICU, HC & NNICU HAI Rate per 1000 PPD's - 4.87 4.61 4.34 -

CLABSI Rate per 1000 Central Line Days - - 2.93 - -

VAP Rate per 1000 Ventilator Days - 12.82 8.73 15.87 -

SSI Rate per 1000 Theatre Cases - - 1.29 4.09 -

CAUTI Rate per 1000 Catheter Days 3.56 - 1.94 1.67 -

5.6

3.9

5.7

4.2

7.2

5.05.2

2.0 2.1 2.0

3.22.9

3.4

2.6

3.1

2.5

3.5

2.93.0

2.12.3

2.2

1.6

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Oct-

08

Nov-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Mar-

09

Apr-

09

Ma

y-0

9

Ju

n-0

9

Ju

l-09

Aug-0

9

Sep-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-10

Apr-

10

Ma

y-1

0

Ju

n-1

0

Ju

l-10

Aug-1

0

Life Healthcare : Acute CareCLABSI Rate per 1000 CL Days

FY 09 - FYTD as at Aug-10N=40 hospitals

Rate Mean Upper control limit Lower control limit

Central Line Associated Blood Stream Infections - CLABSI

31

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

Tota

l C

om

plia

nce %

65% 73% 72% 57% 66% 75% 68%

1.1.If hair is removed, it is only done with clippers or

dipilatory cream12% 76% 50% 23% 57% 52% 45%

1.2.Antibiotics are given within an hour of incision

82% 72% 73% 60% 57% 58% 67%

1.3.

Glucose is maintained above 4 and below 8 after the

initial post operative assessment in ICU (Major

Cardiac Surgery)82% 55% 81% 52% 64% 91% 71%

1.4.

The patients temperature is maintained at >36.5 and

<37.2 after the initial post operative assessment in

ICU (Colorectal & major abdominal surgery)82% 90% 85% 92% 88% 100% 89%

61% 71% 80% 59% 60% 56% 65%

2.1Handwashing procedure was followed

48% 50% 58% 4% 13% 27% 33%

2.2Maximal barrier precautions were used by the doctor

as per checklist8% 50% 52% 4% 9% 27% 25%

2.3Chlorhexidine skin prep is done and allowed to dry

before insertion40% 45% 52% 4% 13% 27% 30%

2.4 Central line sited in the subclavian vein 60% 55% 97% 100% 89% 9% 68%

2.5A daily review is done of the need to keep the line

(CVP)88% 100% 100% 100% 100% 100% 98%

2.6The line is properly secured e.g. with a special

dressing /device or stitched92% 100% 100% 100% 100% 100% 99%

2.7 The dressing is visibly clean and intact 92% 100% 100% 100% 98% 100% 98%

SS

I

SSI

CL

RI

CLRI

Best Care Always Compliance Sheet

YTD

Hospital:

Completed by:

HAI : CLABSI RATE

4.95

5.22

2.01 2.10

2.01

3.22

2.93

3.36

2.58

3.12

2.46

3.48

2.90 2.98

2.08

2.33 2.17

1.57

70%

87%

83% 83%

78%

83%85%

83%85% 84% 84%

88% 87% 87% 87% 87%90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

-

1.00

2.00

3.00

4.00

5.00

6.00

Mar

-09

Ap

r-0

9

May

-09

Jun

-09

Jul-

09

Au

g-0

9

Sep

-09

Oct

-09

No

v-0

9

Dec

-09

Jan

-10

Feb

-10

Mar

-10

Ap

r-1

0

May

-10

Jun

-10

Jul-

10

Au

g-1

0

Central Line Associated Blood Stream Infections - Bundle Compliance and Infection Rate

Mar 09 - Aug 10

Infection Rate

CLABSI

9.4 9.610.2

11.2

13.8

15.5

13.0

11.8

11.0

9.2

12.5

10.9

12.112.6

8.1

14.9

9.6

12.012.012.7

12.411.811.8

8.3

13.0

9.8 9.9

6.7

9.1

8.6

10.0

9.2

7.2

5.6

8.6

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

Oct-

07

No

v-0

7

De

c-0

7

Ja

n-0

8

Fe

b-0

8

Ma

r-08

Apr-

08

Ma

y-0

8

Ju

n-0

8

Ju

l-08

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Ma

r-09

Apr-

09

Ma

y-0

9

Ju

n-0

9

Ju

l-09

Aug-0

9

Sep-0

9

Oct-

09

No

v-0

9

Dec-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-10

Apr-

10

Ma

y-1

0

Ju

n-1

0

Ju

l-10

Aug-1

0

Life Healthcare : Acute Care VAP per 1000 ventilator days

FY 08- 09 - FYTD as at Aug -10N=40

Rate Mean Upper control limit Lower control limit

Ventilator Associated Pneumonia VAP

11.97 12.00

12.66 12.35

11.83 11.82

8.28

12.96

9.78 9.94

6.70

9.06 8.58

10.01

9.17

7.16

5.63

8.61

69%

82%

77%

71%

86%88%

91% 91% 91%89% 89%

92%

88%

93% 93% 92% 93%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

-

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Mar

-09

Ap

r-0

9

May

-09

Jun

-09

Jul-

09

Au

g-0

9

Sep

-09

Oct

-09

No

v-0

9

Dec

-09

Jan

-10

Feb

-10

Mar

-10

Ap

r-1

0

May

-10

Jun

-10

Jul-

10

Au

g-1

0

Ventilator Associated Pneumonias- Bundle Compliance and Infection RateMar 09 - Aug 10

Infection Rate

VAP

35

VAP – Benchmarking:

7.38

3.2

2.40

5

10

15

20

25

30

Oct-02 Dec-02 Feb-03 Apr-03 Jun-03 Aug-03 Oct-03 Dec-03 Feb-04 Apr-04

Baseline FY 2002 Average FY 2003 VAP Rate Average FY 04YTD

Baptist Memorial DeSoto

1.4

1.2

2.7

1.1

1.3

1.6

1.3 1.3

1.5

1.21.3

1.1

1.61.6

2.2

1.3

1.9

2.1

1.5

2.1

1.9

1.3

1.9

1.3

1.1

1.8

1.6

1.4

1.21.2

1.6

0.9

1.4

0.9

1.4

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Oct-

07

No

v-0

7

De

c-0

7

Ja

n-0

8

Fe

b-0

8

Ma

r-08

Apr-

08

Ma

y-0

8

Ju

n-0

8

Ju

l-08

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Ma

r-09

Apr-

09

Ma

y-0

9

Ju

n-0

9

Ju

l-09

Aug-0

9

Sep-0

9

Oct-

09

No

v-0

9

Dec-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-10

Apr-

10

Ma

y-1

0

Ju

n-1

0

Ju

l-10

Aug-1

0

Life Healthcare : Acute CareSSI per 1000 theatre cases

FY 08- 09 - FYTD as at AUG-10

Rate Mean Upper control limit Lower control limit

Surgical Site Infections – SSI

2.10

1.52

2.13

1.93

1.30

1.94

1.30

1.09

1.80

1.59

1.38

1.16 1.21

1.57

0.95

1.37

0.93

1.38 59%

74% 75%78%

74% 73%

78% 77%79% 78%

81%84% 85%

83% 83% 83%85%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

-

0.50

1.00

1.50

2.00

2.50

Mar

-09

Ap

r-0

9

May

-09

Jun

-09

Jul-

09

Au

g-0

9

Sep

-09

Oct

-09

No

v-0

9

Dec

-09

Jan

-10

Feb

-10

Mar

-10

Ap

r-1

0

May

-10

Jun

-10

Jul-

10

Au

g-1

0

Overall Surgical Site Infections - Bundle Compliance and SSI RateMar 09 - Aug 10

Infection Rate

SSI Compliance

HAI : SSI RATE

BCA : COMPLIANCE : SSI

Bundle Compliance to SSI

Period: JUNE-10

57%

89% 89%

96%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

If hair is removed, it is only done with

clippers or dipilatory cream

Antibiotics are given within an hour of

incision

Glucose is maintained above 4 and

below 8 after the initial post operative

assessment in ICU

The patients temperature is

maintained at >36.5 and <37.2 after

the initial post operative assessment

in ICU

39

Collaboration - different stakeholders within the private sector and between

the private sector and public sector

Shared learning - We have agreed to share our learnings and help each other

achieve the objective of best care to every patient every time.

Partnerships - clinical leadership organizations have agreed to partner with us to

support implementation and to elevate skills and knowledge of health

professionals in the identified areas.

What is new and how have we done …

40

Provincial Intervention

• Frontline health professionals and

• CEOs and senior leadership

41

Learning network of hospitals

Learning

session 2

Learning

session 1

PDSA

cycles

PDSA

cycles

Learning

session 3

intensive support

Model for Improvement

What can we

change that will

result in an

improvement?

PLAN

DO

STUDY

ACT

How will we

know that a

change is an

improvement?

What are we trying

to accomplish?AIM

MEASUREMENTCHANGE

42

Measurement is critical

• Know what you are measuring

and what the measure is(percentage or rate need a numerator and denominator,

days between numerator and count of days)

• Collect the dataTools to do this

• Collate, display and analyzetools, graph

43

Designing the Outcome Measure

What is the measure for HAI?Rate or Days between (CLABSI, VAP, UTI)

Days or cases between SSI

Collecting data:

What (definition)

Where

How (tools)

Who

When

44

45

VAP/CLABSI

VAP/CLABSI INFECTION

Measuring rare events and time-between measures.

James Benneyan IHI46

47

• Feedback reports are being tracked and used to adapt the methodology.

• 14 of the original 15 hospitals have committed to implementation of at least

one BCA infection prevention bundle.

• sustained attendance (over 95% of 14 hospitals) & expansion of some teams

• Nearly 100 frontline health professionals including ICU unit managers,

infection prevention and quality assurance practitioners, doctors, theatre

matrons and pharmacists are participating in local improvement teams and

the learning collaboratives.

• All 14 hospitals have set up a BCA team some include the CEO

• 12 of the 14 hospitals have commenced with specific measures for their

interventions.

• Private hospitals, participating in the BCA Campaign, are sharing “lessons

learnt” and have agreed to form collaborative learning partnerships with

public hospitals.

• Gauteng Provincial DOH has sustained support, jointly facilitating learning

sessions, and providing opportunities to address healthcare leadership

forums.

Results so far

48

Intervention and Strategy for Change:

• Aim to develop an intervention „bundle‟ to guide antibiotic use and reduce

resistant strains.

• Pilot sites were selected by each of five private multi-hospital groups.

• Individual pilot sites are testing and measuring various interventions

• Teleconferences are held every 6-8 weeks

Measurement of improvement:

• Improvement will be measured using indicators of prescribing practice that

can be obtained from hospital and/or funder pharmacy billing records

Effects of changes:

• Stewardship sites in five hospital groups vary from a single major pilot site,

to five hospitals, to all hospitals in the group, with committees that include

pharmacists, infection prevention specialists, and doctors.

• Many physicians are keen to participate and receptive to change.

ANTIBIOTIC STEWARDSHIP

Prescribing Issues

• 1st. Empiric therapy without confirmation

• 2nd. Inappropriate agent choices

- Duplicate spectrum

- Inappropriate combinations

• 3rd. Failure to de-escalate *

• 4th. Excessive duration treatment *

• 5th. Inappropriate prophylaxis

(agent/timing/duration)

49

Duplicate spectrum

Cultures

≥10-14 days

≥4 agents

>24 hrs

* Not monitored yet

Summary

• Best Care…Always! is an inclusive national patient safety

and quality improvement initiative

• Initial focus is hospitals and in infection prevention

• BCA uses a campaign approach, promoting evidence-

based, pragmatic, data-driven improvement cycles

• BCA incorporates multiple stakeholders, mainly using

existing organizational structures

• Long term vision is to create a sustainable network for

collaboration and improvement in the health sector

50

51

Acknowledgement:

BCA Task team, Advisory panel, Front line health professionals

BCA TASK TEAM

Dr Dena Van Den Bergh (DvdB)

Dr Gary Kantor (GK)

Joy Cleghorn (JC)

Dr Trevor Frankish (TF)

Yolanda Saayman (YS)

Lesley Devenish (LD)

Yolanda Walsh (YW)

Dr Victor Litlhakanyane (VL)

Dr Arie Verburg (AV)

Isabella Mputi (IM)

Briette Du Toit (BdT)

Dirkie Theunessen (DT)

Estelle Jordaan (EJ)

Dr Michelle Youngelson (MY)

Dr Paul Soko (PS)

Dr Dumani Kula (DK)

Clair McLoughlin (CMcL)

Dr Sue Armstrong (SA)

BCA ADVISORY PANEL

Dr Adri Kok

Dr Adrian Brink

Prof Adrian Duse

Dr Andrew Whitelaw

Dr Andy Gray

Dr Carol Marshal

Dr Gene Elliot

Dr Gerry Capatos

Prof Guy Richards

Dr Heila Kluyts

Dr Ignatius Botha

Dr Inge Zietsman

Sr Janet Bell

Dr Johan De Jager

Dr Johan Moolman

Dr Kedar Mate

Prof Marc Cotton

Prof Marc Mendelson

Dr Marthinus Senekal

Prof Mervyn Mer

Prof Norman Faull

Dr Olga Petrovic

Dr Pierre Barker

Prof Shaheen Mehtar

Prof Stuart Whittaker

52

• Support and help drive this initiative.

• Pay attention, show a personal interest, seek out

forward-thinking, change-oriented individuals and

teach and empower them to make practice

improvements.

• Encourage measurement to support improvement

• Support teams in achieving bold goals

An invitation to leaders …

Design

• CEO or senior executive

• Teams that include doctors

• Periodic learning sessions

• Support in-between

• Training a cadre of improvement advisors

• Measurement

• Sharing ideas

• Testing ideas

53