Examples of large systems transformations:

NSW as world leader

Jeffrey Braithwaite, PhD

Founding Director and Professor

Australian Institute of Health Innovation, UNSW Medicine

Monday 28th October 2013

Australian Institute of Health Innovation

Australian Institute

of Health Innovation’s mission

… to enhance local, institutional and

international health system decision-

making through evidence; and use

systems sciences and translational

approaches to provide innovative,

evidence-based solutions to specified

health care delivery problems.

http://www.med.unsw.edu.au/medweb.nsf/page/ihi

Australian Institute of Health Innovation

• Professor Jeffrey Braithwaite Professor of Health Systems Research, Director, AIHI; Director, Centre for Clinical Governance Research

• Professor Enrico Coiera Professor of Health Informatics, Centre for Health Informatics, AIHI, UNSW

• Professor Ken Hillman Professor of Intensive Care, Simpson Centre for Health Services Research, AIHI, UNSW

• Professor Johanna Westbrook Professor of Health Informatics, Centre for Health Systems and Safety Research, AIHI, UNSW

Background - the Centre

The Centre for Clinical Governance

Research undertakes strategic research,

evaluations and research-based

projects of national and international

standing with a core interest to

investigate health sector issues of

policy, culture, systems, governance

and leadership.

http://www.med.unsw.edu.au/medweb.nsf/page/ClinGov_About

Part 1: Introduction

“After decades of improving the

health care system, patients still

receive care that is highly variable,

frequently inappropriate, and too

often, unsafe”

We have done studies at scale

MERIT study

• Medical Emergency Teams in NSW [Hillman et al Lancet 2005]

IPL study

• Large scale inter-professional learning [Braithwaite et al IJQHC 2012]

Weekend mortality

• Weekend hospital treatment [Coiera et al BMJ Quality & Safety 2013]

We have done studies at scale

Electronic medication systems

• Reductions in medication errors by 50% [Westbrook et al PLoS Medicine 2012]

Accreditation study

• How accreditation is associated with leadership and culture [Braithwaite et al IJQHC 2010]

On line evidence to clinicians

• Use of CIAP by 55,000 clinicians [Westbrook et al JAMIA 2004]

We have done studies at scale

CareTrack Study

• Proportion of appropriate care delivered to adults in Australia: 57% [95% CI 54-60%] [Runciman et al MJA 2012]

CareTrack Kids Study

• Proportion of appropriate care delivered to children in Australia: ?% [Braithwaite et al NHMRC Partnership Grant application approved for $2.5M, 2013-2016]

A key facet of the problem

• Current understanding of how to effect

large scale system change is poor

• Challenges:

• Translation [Implementation]

• Take up [Evidence]

• Diffusion [Spread]

The initial solution

• To do this we need partnerships:

• Researchers

• Policymakers

• Managers

• Clinicians

• Patients

Part 2: Celebrated

international successes

Celebrated successes

• Pronovost US; Matching Michigan UK

• Aim: reduce catheter-related bloodstream

infections in 103 ICUs across Michigan

• Results: mean rate of 7.7 infections per

1000 catheter days reduced to 1.4 at 18

months

• Conclusion: Evidence-based intervention

worked; and again in the UK [Pronovost et al 2006; see also Brion, et al, 2013]

Celebrated successes

• Haynes et al “Safe Surgery Saves Lives”

• Aim: 19-item surgical safety checklist

implemented in 8 hospitals in 8 cities

• Results: Rate of death was 1.5% and

complications, 11% before the checklist; and

0.8% and 7% afterward

• Conclusion: Reduced death, complications

[Haynes et al, 2009; see also de Vries et al, 2010]

Part 3:

What about other systems

improvement at scale?

We identified six interventions at

scale - criteria

• Took measures before and after

• Or had a control group, or both

• Evaluated the interventions

• Demonstrated large scale

systems improvement

• Peer-reviewed

Systems improvement at scale

Study Type Design Target Findings

Larson et al,

2000

Hand

hygiene

Organisation

al climate

intervention

Non-RCT

intervention and

follow up in two US

hospitals one as

intervention the

other control

Reduced

nosocomial

infections

baseline vs

follow-up

• Frequency of

hand washing

doubled

• Culture

worsened then

improved

Nowinski et

al, 2007

Conversion

to EHR

Organisation

al electronic

health record

intervention

Intervention in three

US hospitals;

observational study

Quality

improvement

indicators

Mixed changes in

culture and

clinical outcomes

Systems improvement at scale Study Type Design Target Findings

Grayson et

al, 2011

Hand

hygiene

National

hand hygiene

initiative

Intervention in 512

Australian hospitals;

observational study

SAB infections;

introduction of

a tool;

measurement

two years

before and after

the study

• HH compliance

increased

[nursing staff

74%; medical

staff 52%]

• SAB infections

declined post

implementation

Muething et

al, 2012

Serious

safety

events and

patient

safety

culture

Collaborative

quality

improvement

intervention

Intervention in a

large US paediatric

academic medical

centre;

observational study

Reduced

serious safety

events and

improved

patient safety

culture

• SSEs per

10,000

adjusted

patient days

decreased

from 0.9 to 0.3

• Patient safety

culture initially

worsened, then

improved over

time

Systems improvement at scale

Study Type Design Target Findings

Benning et

al, 2011

Safer

Patients

Initiative

mixed

methods

evaluation

of phase 1

Multi-faceted

improvement

intervention

applying

training,

champions,

tools,

leadership

Controlled mixed

method evaluation

and follow up in four

UK hospitals

Reduced

adverse events

• Modest

penetration of

SPI knowledge

and initiatives

• Modest

improvements

in some clinical

processes eg

vital signs

monitoring; no

additional

gains

Systems improvement at scale

Study Type Design Target Findings

Benning et

al, 2011

Safer

Patients

Initiative

controlled

evaluation

of phase 2

Assessment

of staff

attitudes;

review of

case notes of

high risk

ward

patients;

surgical

patients;

evaluation of

hand hygiene

compliance;

measurement

of outcomes

Controlled before

and after design

with five sub-

studies in 20 UK

hospitals [10

interventional and

10 matched control

hospitals]

Improvements

in SPI 1 with a

longer

intervention

period and less

budget

• Improvements

across the

board on both

interventional

and control

hospitals

occurred over

an eight year

period in the

UK

• No net

detectable

additional

effect in SPI

hospitals

Part 4: What’s to be done in

NSW?

How can NSW be world leader?

• It’s done great things, e.g.,

•ACI

•BtF

•EoC

•Hand hygiene

•Decentralisation

• But …

To what extent has NSW …

• Demonstrated large scale change?

• Measured at baseline and after?

• Evaluated interventions?

• Done comparisons between

intervention groups?

• Uncovered why things work in one

setting and not so well in another?

To what extent has NSW …

• Demonstrated:

• Translation [Implementation]?

• Take up [Evidence]?

• Diffusion [Spread]?

• Answer: not as well as we

want

What would this look like?

M

e

a

s

u

r

e

M

e

a

s

u

r

e

T1 T2

What would it look like?

[Braithwaite, 2011]

Above the waterline lie the observable workplace behaviours, practices and discourse: this is ‘the way we do things round here’.

Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: ‘How we think’ and ‘why we do the things we do round here’.

The iceberg

model of culture

What would it look like?

• The Promoting Action on Research

Implementation in Health Services

framework

SI = f (e,c,f) [SI = Successful implementation; e = evidence; c = context; f = facilitation]

[Stetler et

al., 2011]

Part 5: AIHI is doing things to

help

NHMRC Program grant 2014-2018

• New proposal funded by NHMRC for

$10.85 million

• Creating safe, effective

systems of care: the

translational challenge

[Investigators: Braithwaite, Westbrook, Coiera, Day,

Runciman, Hillman]

NHMRC CRE grant 2012-2016

• Proposal funded by NHMRC for $2.5

million

• NHMRC Centre for Research

Excellence (CRE) in e-health

[Investigators: Coiera, Sintchenko, Liaw, Luxan, Magrabi, Lau, Arguel,

Lui , Glasziou]

NHMRC Partnership grant 2013-

2016

• Proposal funded by NHMRC for $2.5

million

• The appropriateness of

healthcare delivered to Australian

children: CareTrack Kids

[Investigators: Braithwaite, Jaffe, White, Cowell,

Harris]

Part 6: Conclusion

Conclusion

• NSW is already doing things at

scale

• We have to strengthen, evaluate,

demonstrate this within the State

and to the world

• Comments or questions, please?

Suggested References 1. Braithwaite J, Coiera E. Beyond patient safety Flatland. J R Soc Med 2010; 103: 219-

225. 2. Braithwaite J, Greenfield D, Westbrook J et al. Health Service accreditation as a

predictor of clinical and organisational performance: a blinded, random, stratified study. Qual Saf Health Care 2010; 19: 14-21.

3. Braithwaite J, Travaglia J. PubMed articles on ‘engaging clinicians’. Sydney: Centre for Clinical Governance Research, University of New South Wales, 2007, 2009

4. Braithwaite J, Westbrook M, Nugus P, Greenfield D, Travaglia J, Runciman W, Foxwell

AR, Boyce RA, Devinney T. and Westbrook J. (2012) A four-year, systems-wide

intervention promoting interprofessional collaboration, BMC Health Services Research ,

12:99. 5. Braithwaite J, Westbrook, MT. Rethinking clinical organisational structures: an attitude

survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005; 10:1; 10-17.

6. Braithwaite J, Westbrook MT, Iedema R, Mallock NA, Forsyth R, Zhang K. A tale of two hospitals: assessing cultural landscapes and compositions. Soc Sci Med, 2005; 60: 1149–1162.

7. Braithwaite J, Westbrook MT, Pirone C, Robinson P, Robinson M, Michael S. Staff survey on patient safety: South Australian Council for Safety and Quality in Health Care and South Australian Department of Health. Sydney: Centre for Clinical Governance Research, University of New South Wales, 2009.

Suggested References

8. Creswick N, Westbrook JI, Braithwaite J. (2009) Understanding communication

networks in the emergency department. BMC Health Services Research; 9:247.

9. Eccles M.P, Armstrong D, Baker R, Cleary K, Davies H, Davies S, Glasziou P, Ilott I,

Kinmonth A, Leng G, Logan S, Marteau T, Michie S, Rogers H, Rycroft-Malone J. and

Sibbald B. (2009) An implementation research agenda. Implementation Science,

4:18.

10. Goldblatt EM, Lee WH. (2010) From bench to bedside: the growing use of

translational research in cancer medicine. Am J Transl Res; 2(1):1-18.

11. Lenz M, Steckelberg A, Richter B, I. M. (2007) Meta-analysis does not allow appraisal

of complex interventions in diabetes and hypertension self-management: a

methodological review. Diabetologia; 50(7):1375-83.

12. Ogilvie D, Craig P, Griffin S, Macintyre S. and Wareham NJ.(2009) A translational

framework for public health research. BMC Public Health, 9:116.

13. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, et al. (2012) Effects of Two

Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-

Patients: A Before and After Study. PLoS Med ,9(1)

Suggested References

14. Braithwaite J, Westbrook MT, Robinson M, Michael S, MacFarlane M. Staff survey on

patient safety: a comparison of results from Whanganui, Waikato and Capital & Coast

District Health Boards. Sydney: Centre for Clinical Governance Research, University

of New South Wales,2009.

15. Braithwaite J, Westbrook MT, Travaglia J. Attitudes toward the large-scale

implementation of an incident reporting system. Int J Qual Health Care 2008; 20: 184-

191.

16. Braithwaite J, Westbrook MT, Travaglia J et al. Cultural and associated enablers of,

and barriers to, adverse incident reporting. Quality and Safety in Health Care 2010;

19: 229-233.

Contact details

Jeffrey Braithwaite, PhD

Foundation Director

Australian Institute of Health Innovation

Director

Centre for Clinical Governance Research

Professor, Faculty of Medicine

University of New South Wales

SYDNEY NSW 2052

AUSTRALIA

Email: j.braithwaite@unsw.edu.au

Wiki: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite

Web: http://www.aihi.unsw.edu.au