Case Studies in Quality Improvement using Front-Line

Ownership Dr Michael Gardam UHN, Toronto, Canada

Wednesday December 7th 2016

Case Studies in Quality Improvement using Front-

Line Ownership

Michael Gardam

University of Toronto

Outline

• What I thought I knew about leading quality improvement

• What I learned through trial and error (mostly error) and learning from others

• Some examples

The Old Me “I’m the expert”

The New Me “Humble”

Me in Transition “Dazed and confused”

WE:

• Were the experts

• Made and hung the posters

• Educated, educated and educated

• Sent admonishing emails

• Decided where product should go

• Created rewards

I AM HERE

Regina, Saskatchewan January 2008 -35o Celsius

Perhaps we:

• Don’t have the answers

• Don’t know what motivates people

• Focus too much on education

• Squash good ideas

• Assume ideas can be spread

•Are part of the problem?

Positive Deviance

Liberating Structures

3 years of pain

• Shift from talking to listening

• Leading from behind

• Stop filtering ideas

• Giving up control

• Dealing with “role guilt”

• “screaming for structure”

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0

10

20

30

40

50

60

70

80

90

100

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

No

soco

mia

l MR

SA r

ate

/10

00

0

pat

ien

t d

ays

Hand Hygiene compliance

Year

% C

om

plia

nce

UHN hand hygiene data

MRSA

Han

d H

ygie

ne

New

Zea

lan

d 2

01

6

BOZ Collaborative Phase 1 Falls: 3 years later

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Total Falls Injury falls Linear (Total Falls) Linear (Injury falls)

After Before

-36%

Mar

ylan

d P

atie

nt

Safe

ty C

ente

r

26.45%

23.15%

27.27%

22.87% 22.49% 21.45%

18.01% 19.43%

17.62%

20.57% 22.06%

19.37%

21.71%

19.42%

17.33%

19.21%

15.00%

20.00%

25.00%

30.00%

35.00%

Apr '15 May '15 June '15 July '15 Aug '15 Sep '15 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Mar '16 Apr '16 May '16 June '16 July '16

Sepsis Mortality Rate in Participating Hospitals, Cohort 2 (n=11)

18.77%

25.22%

21.19%

24.79%

27.22% 29.43% 29.85%

26.45%

20.27% 21.74%

25.46% 25.00%

29.16%

24.38%

20.82%

23.47%

21.11% 21.67% 22.44% 22.25% 21.43%

15.00%

20.00%

25.00%

30.00%

35.00%

Jul '14 Aug'14

Sep'14

Oct'14

Nov'14

Dec'14

Jan '15 Feb'15

Mar'15

Apr'15

May'15

June'15

July'15

Aug'15

Sep'15

Oct'15

Nov'15

Dec'15Jan '16 Feb'16

Mar'16

Sepsis Mortality Rate in Participating Hospitals, Cohort 1 (n=10)

-26%

-9%

• Local engagement with University Hospital Kerry • Waste management

• Communications and culture

• Training and education

• National engagement with Quality Improvement Division

• Work had to be completed in 6 months (!)

• Increase in • Equality

• Well-being

• “Pro-social” behaviours

• Resilience

• Identification and movement on improvement ideas • Increased recycling, decreased food waste

• Survey, scheduling for mandatory training

• “Hello, my name is” campaign

• Staff engagement sessions in the canteen

• Staff choir

• Staff garden

Results

The journey continues…

Front-Line Ownership Philosophy

• Accept, don’t fight complexity

• Work with willing participants

• No “right” way to spread change

• Make the invisible visible

• Include the unusual suspects

• Go slow to go fast

• Simple rules

• Nothing about me without me

• Act your way into a new way of thinking

• Encourage divergent thinking

• Ownership, not buy in

• The path to improvement is rarely linear

Thank you

Michael.gardam@uhn.ca @DrMichaelGardam