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Leading the Best Care...Always! Campaign. Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh May 10 th 2011 Cape Town. Agenda. Welcome Introductions Best Care…... Always! (BCA) Fundamentals of the QI approach Measuring for BCA A framework for leading BCA - PowerPoint PPT Presentation
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Leading the Best Care...Always!
Campaign
Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh
May 10th 2011
Cape Town
Agenda
• Welcome• Introductions• Best Care…... Always! (BCA)• Fundamentals of the QI approach• Measuring for BCA• A framework for leading BCA• LUNCH• QI in action• Next steps
The Burden of Healthcare-Associated Infection
Prof Shaheen MehtarUIPC, TBH & SUN
Cape Town
Situation Analysis of LMI countries
• Rates of HAI are higher in LMI countries• IPC programmes are poorly supported• Little accountability by Health Care Workers• Clinical commitment essential - Duty of Care
Comparative data- HIC and LMIC Burden of endemic health care associated infection in developing countries: systematic review and
meta analysis- B Allegranzi et al, Lancet, 2011, 377: 228-41
HAIs are at least 3 x more common in LMI countries
Crude HAI Infection Rate: TBH. Impact of an established IPC programme
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42006 2007 2008 2009 2010
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
4.33.9 4.0
3.6
4.4
3.7
3.1
3.6
4.4
3.3
1.5
2.4
3.6 3.5
3.13.3
2.8 2.72.4
2.8
Crude Infection Rates
Infection Rates
Comparing TBH to meta-analysis
Site Meta analysisMedian/1000 device days
TBH / 1000 patient days
VAP 28 ETA 1- 3
CR BSI 18 CVP & B/C 0.5-1.3
SSI 1.2-23.6/1000 surg op
NO DATA
Summary• Surveillance shows a statistically significant
decrease in HAI with device-related infection.• Policies and SOPS are necessary for compliance by
clinical staff• Bundling is a highly specialised system of reducing
HAI with zero tolerance• Questions to be answered
─ Who will ensure 2 people available for each procedure carried out?
─ Who will do the data collection?─ Who will make sure that the same bundle is followed each
and every time a procedure is carried out?─ How will this be enforced?
The BCA Quality Improvement approach
• All learn all teach• Learning by doing• Building a shared sense of the
system and the approach to improvement
• Applicable across disciplines
The impact of Healthcare Associated Infections on the
hospitals
The impact of HAIs on the hospitals
• Mortality and morbidity• Lab and pharmacy costs• Antibiotic use• Bed occupancy• Work load
The impact of HAIs on your hospital
• Fill in the column graphs - peripheral vascular catheter-associated infection (PVCAI)
- central line-associated bloodstream infection (CLABSI)
- ventilator-associated pneumonia (VAP)- catheter-associated urinary tract infection (CAUTI)
- surgical site infection (SSI)
The fundamentals of the Quality Improvement
approach used in BCA
A brief history of systems improvement
IHI Lean Overview Andy Brophy
Quality Improvement requires two Types of Knowledge
Subject Matter Knowledge
Subject Matter Knowledge: Professional, content, evidence based knowledge.
Improvement Knowledge (Deming): The interaction of the theories of systems, our ‘theory of knowledge’, variation in measurement, and psychology.
Improvement Knowledge
‘What’
‘How’
Improvement
Improvement Knowledge
Subject Matter Knowledge
Improvement: develop effective changes that lead to an improvement.
Langley: Improvement Guide p76
‘Where’
‘How’
‘What’
Improvement Knowledge
Subject Matter Knowledge
Improvement Knowledge
W.E. Deming (1900-1993)
System of Profound Knowledge
Improvement Knowledge
Subject Matter Knowledge
4 fields of interaction - theories of systems - our ‘theory of knowledge’ - psychology of change- variation in measurement
Improvement Knowledge
Complex Dynamic Systems
• Step 1 – Everyone stand up• Step 2 – Without speaking; pick two
people but don’t say who they are or point at them (Keep it a secret)
• Step 3 - Move to be equidistant from both of the people
• Step 4 – Move one person and repeat
The power of the system
Step 1: Pick a number
from 3 to 9
Step 2: Multiply your number by 9
Step 3:Add 12 to the
number from step 2
Step 7: Write down thename of a city
that begins with your letter
Step 4: Add your 2
digits together
Step 5:Divide # from step 4
by 3 to get a 1 digit number
Step 6:Convert your
Number to a letter:1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 8: Go to the next Letter: A to B, B to C, C to D,
etc.
Step 9: Write down the nameof an animal (not bird,
fish, or insect) that begins with your letter
from Step 8
Step 10:Write down the color of
your animal
Do you have a 2-digit Number?
NO
YES
Output:
Color____________
Animal___________
City__________
Understanding Systems
“Every system is perfectly designed to achieve the results it gets” Paul Batalden
Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family MedicineThe Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.
Hand washing practice in the PICU
from a Report of a participative observational study done during
January and March 2006Candice Bonaconsa and Minette Coetzee
Child Nurse Practice Development Initiative
Prof Andrew Argent, Red Cross Hospital
Actual x 100 = %
Opportunity
How we did this:
Calculating the % of hand washing
Comparitive Table of Hand Washing - Bed Space
24%
38%
7%
75%
0%10%20%
30%40%50%60%
70%80%
Docters Nurses Other Visitors
Goal 90%
Time Opportunities Used Opportunities %10:00-11:00 12 2 16.711:15-12:15 11 2 18.221:30-22:30 14 3 21.422:30-23:30 7 1 14.314:15-15:15 11 1 9.115:20-16:20 7 3 42.910:45-11:45 28 5 17.911:45-12:45 10 2 20.010:30-11:30 15 3 20.011:30-12:30 8 3 37.511:30-12:30 15 1 6.712:30-13:30 10 1 10.013:30-14:30 5 2 40.014:30-15:30 8 1 12.515:30-16:30 4 0 0.014:00-15:00 19 1 5.315:00-16:00 9 0 0.012:00-13:00 16 1 6.313:00-14:00 10 0 0.0
elsewhere in the hospital …
Force Field Analysis
1. The current situation2. The desired situation3. The situation if no action is taken4. Forces driving toward desired situation5. Forces resisting change6. ……
Forces in the system keeping hand washing rates where they are
Time
A B
Lewin K (1951)Field Theory in Social ScienceNew York: Harper
Understanding Systems
“Every system is perfectly designed to achieve the results it gets” Paul Batalden
“All improvement needs a changeNot all change is an improvement”
Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family MedicineThe Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.
Improvement Knowledge
Subject Matter Knowledge
4 fields of interaction - theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement
Improvement Knowledge
Theory of knowledge
Our understanding of why things are the way they are.
The Implementation Gap
PLAN
IMPLEMENT
FAIL
PROBLEM
EVIDENCE-BASED SOLUTION
“typical” attempts to change
GREAT IDEAS
SYSTEM ANALYSIS to identify barriers to care
DO
STUDY
ACTIMPLEMENT
SUCCEED/ SUSTAIN
PROBLEM
PLAN
Overcoming barriers at the frontline of care
QualityImprovementMentoring
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?
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
Improving many parts of the system at once
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
Bundle 1 Bundle 2Unit 1 Unit 2
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
Improvement Knowledge
Subject Matter Knowledge
4 fields of interaction- theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement
Improvement Knowledge
Psychology of Change
Population
Innovators
Source: E. Rogers. Diffusion of Innovation
Early Adopters
Early Majority Late Majority
Traditionalists
Improvement Knowledge
Subject Matter Knowledge
4 fields of interaction - theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement
Improvement Knowledge
Understanding Variation
• Walter Shewhart’s (1891-1967) – understanding variation through Statistical Process Control (SPC)
Flip a coin
1 2 3 4 5 6 7 8 9 10 11 12 13 14 150
2
4
6
8
10
12
# heads up in 10 flips of a coin
Consecutive turns
# he
ads
up
July Aug Sep Oct5/7 13/8 7/9 5/10
5/7 9/9 8/10
6/7 12/9 15/10
11/7 15/9 19/10
25/7 20/10
27/7 21/10
25/10
ICU: VAP infections 2010
MeasurementCommon mistakes• Using bar graphs rather than run charts• Not enough data points (12 at least to
understand normal variation)• Not making allowances for normal
variation when interpreting data• Not measuring trends over a long enough
period - cut off at year end or financial year end
Reacting to Variation
Measuring forBest Care….Always!
Measurement
• Builds will• Assesses impact• Drives improvement• Keeps the project alive• Sustains the gains
Measurement• Data must be visually appealing and
accessible─Owned and used at the frontline of care─Routinely reviewed at monthly management
meetings • An active, encouraging feedback loop from
management to frontline staff
MeasurementLeaders need to know i) what measures are being used for
─ incidence of HAIs─ bundle compliance (implementation of
bundles)ii) how data is being presentediii) how to
─ interpret the data─ respond to the data
Measurement for BCA
• Outcome measures (HAIs)• Process measures (bundle compliance)• Balancing measures• Morbidity and mortality reviews
Outcome measures
• the incidence of HAIs• impact of changes made
Infection Rates • Total number of infective cases per 1,000 device days:
Total No. of VAP cases
Ventilator daysX 1,000
Numerator
Denominator
Good for aggregate data but high variation for units when events are rare (<10%)
Welsh Safety Calendar
IDeveloped by Annette Bartley, Welsh 1000 Lives Campaign
Welsh Patient Safety Project
Measuring rare events
Events that occur < 10% of the time
Measuring rare events –days between events
Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana
Date of infection
# Days since last infection
Days Be-tweenInfection
Sequence of Infections
IMeasuring rare events and time-between measures. James Benneyan IHI
Number of infections against annual target
Laurel SimmonsAssoc. Dir. for Quality ImprovementStockport NHS Foundation Trust
Target - 6for the year
(Set for eachHospital forEach HAIby DOH)
Dashboard of measures
Eastern sub-district HIV/AIDS Improvement project reportMarch 2009
Process measures
• Bundle compliance drives the improvement• Target must be set at 95% for each bundle
element and therefore the whole bundle (reliability theory)
Mar
-09
Apr-
09
May
-09
Jun-
09
Jul-0
9
Aug-
09
Sep-
09
Oct
-09
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar
-10
Apr-
10
May
-10
Jun-
10
Jul-1
0
Aug-
10
-
2.00
4.00
6.00
8.00
10.00
12.00
14.00
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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%
Ventilator Associated Pneumonias- Bundle Compliance and Infection Rate
Mar 09 - Aug 10
Infection Rate VAP
61
Bundle compliance
A Framework for Leading Best Care….Always!
Framework for Leading Improvement
Leading BCA
Dr Hannes LootsRegional Clinical ManagerWestern Cape RegionMedi-Clinic Southern Africa
(9 mins)
Removing the Status Quo
Making the future attractive
1.Set Direction: Mission, Vision & Strategy
Setting Direction: Mission, Vision and Strategy
PULLPUSH
Removing the Status Quo
• Make the status quo uncomfortable
─There are too many Healthcare Associated Infections (HAIs)
66
Look to the Future
• Making the future state attractive
─ No more unnecessary deaths and suffering from HAIBest practice shows it is possible to reduce HAI
between 20 – 80%There are evidence based protocols and practices
to do thisWe will be part of a national and international
campaign
67
IHI Whitepaper 2008 Seven Leadership Leverage Points for Organizational-Level Improvement in Healthcare pg 4
3,4,5: Will, Ideas and Execution
Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare
Improvement; 2007. (Available on www.IHI.org)
Will
Ideas Execution
Will, Ideas and Execution
• Why are we spending our time and energy on this project?
Will, Ideas and Execution• Leaders play a significant role in building and
maintaining will─ Clear, desirable aims─ Making it doable
start smallallocate time and resources remove obstaclesbring in the right people/teams culture of learning vs blame and shame
─ Keep the project alivedemonstrate interestmonthly review of data
Will, Ideas and Execution
• Engaging doctors
Will, Ideas and Execution• Overcoming the implementation gap
Multidisciplinary teams
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?
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
Accelerating change and improvement through networking and collaboration.
Expert Meeting and
Planning Group formed
Learning session
1
Learning session
2
Repeated improvement
cycles:
Repeated improvement
cycles:
Learning session
3
18 -24 months
Mentoring and support
Resources
• BCA www.bestcare.org.za• IHI www.ihi.org
Handouts
• Getting Started Kits – including peripheral line• Presentation handout• Framework for leading improvement • Run chart article