Making it happen Improving quality to improve productivity The Great Ormond Street Hospital for Children Experience Can it really be done?

Making it happen Improving quality to improve

productivity

The Great Ormond Street Hospital for Children Experience

Can it really be done?

© Great Ormond Street

Key note Lord Howe

Aim to achieve best outcomes but using less Pay freeze Innovation and creativity

Aim to combine work of on care with levels of equity, excellence in clinical outcomes, free from micro management from above from a whole top down system – a system that progress of what we can do

Way forward is to have ideas flowing from the bottom up form innovation and creativity


Some of the key changes

Structural change PCTs and replacement by GP consortia – align clinical decision making with funding

All foundation trusts and competition Open health market to any willing provider –

benefits of competition Devolve power to the front line Improve quality and release funds Improve quality –patient empowerment

clinical leadership and competition


Key question to be answered

Can we look at ways of delivering health care at lower cost and with increased productivity (or value) while we increase quality and safety? (4% per year)

Most health care today is sought, created, delivered and purchased at the level of the clinical micro-system. It is there that real gains in the quality, value, and safety of care can occur.

Integration of information Measurement of outcomes Interdependence of the care

teams Supportiveness of the larger

system Constancy of purpose Connection to the community

and client involvement Investment in improvement –

want to be better Alignment of role and training

with improvement methods

More on micro-systems

J J Mohr and P B Batalden: Improving safety on the front lines: the role of clinical micro-systems 2002;11;45-50 Qual. Saf. Health Care


Is there evidence?

“Does improving quality save money? Sometimes, but sometimes not, and mostly we do not know because the research is limited. There is a great potential for savings, but it depends what we mean by quality improvement, who makes the savings and when.”


Spending more does not improve quality

CMS data: Higher spending states have poorer quality

Source: Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.

The GOSH strategy- aiming for high reliability and

zero harm

High reliability means the patient gets exactly the treatment needed when it is needed and how it is wanted …..every time

No waits

No waste

Zero harm

Working together

GOSH transformation


Increasing productivity needs a platform

Leadership Knowledge - improvement

methodology and skills Information Data Understanding the problem Resource to implement change Redesign of services


Zero Harm interventionsIncrease productivity and value by increasing safety


Work program for Zero Harm

WorkStream

Process Outcome

Critical Care VAP prevention bundleCVC bundlesDaily Goals

Reduction in VAPsReduction in BSIsImproved communication

Wards Paediatric Warning SystemsHand HygieneSafety Briefings

Recognition of deteriorationReduction in HAIsImproved communication

Peri-opeative On-time AntibioticsSurgical PauseWHO Checklist and briefing

Surgical Site InfectionsReduction in surgical incidentsImproved culture

Medicines Management Medicines ReconciliationDosage calculations

Reduction in adverse drug events

Leadership WalkRoundsSafety strategic priority

Culture of Safety

Central Venous Line (CVL) InfectionsCentral Venous Line (CVL) Infections

Relaunch of CVL Care Bundles

Practical Annual IV Competency Update

&2% Chlorhexidine/70% Alcohol

SkinDisinfection

2% Chlorhexidine/70% Alcohol

Hub Disinfection Introduction of annual IC audit programme


Impact of decreasing infections

Each infection costs from £5000 - £10000 Decrease in line infections from 30 per month

to less than 10 per month saves up to £200000 per month Decreased length of stay Decreased use of time Improved patient experience Ability to reinvest in other activities


Cost of medication errors

The direct cost of medication errors in NHS hospitals may be £200 - 400 million per year. The potential savings from reducing serious medication errors are therefore substantial. Improving medication Safety DoH 2004

Researchers conducting an AHRQ-funded study at Brigham and Women's Hospital and Massachusetts General Hospital found that, on average, ADEs increased the length of stay by as much as 4.6 days and increased costs up to $4,685Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277(4):307-11

.


Medication error reduction PICU

PICU prescribing

CICU completed charts

CICU drug errors/prescription ratio

CICU drug error per patient ratio


No waits and waste by eliminating variation

Improving productivity by decreasing flow failure Decrease waiting in outpatients

Advance Access Programme Decrease waits for procedures

MRI, interventional radiology etc Decrease waste from variation


Ways to improve productivity

Reduce length of stay Expand capacity Expand staff Increase bed capacity

and utilisationOr Increase flow by elimination

of variation


Can we understand variation?

Natural variation – must be actively managed Clinical stress affecting patient safety Stress by variation in professional abilities or teaching

responsibilities affecting both safety and efficiency

Artificial variation – must be eliminated Flow stress affecting efficiency


Can our health care delivery system become a Toyota product line?

What about Lean on its own?

NoPatients do not arrive at the same rate with the same acuity and providers are of unequal ability.


GOSH Admissions By DateProgram for Management of Variability in Health Care Delivery Boston University Health Policy Institute


Admissions By Urgency and DateProgram for Management of Variability in Health Care Delivery Boston University

Health Policy Institute


Discharges by Date: Non-holiday Weekdays


Theatre Cases by Date: Non-holiday Weekdays Only

Program for Management of Variability in Health Care Delivery Boston University Health Policy Institute


Summary

While day case patients comprise majority of admissions, true inpatients have most impact

Substantial variability in elective admissions Theatre cases comprise large majority

Wasted bed & theatre capacity Improved scheduling of elective admissions,

especially theatre cases, needed


RecommendationsRecommendations

1. Central management of admissions2. Establishment of a central ‘patient flow team’3. Central management of operationally-relevant

information systems4. Improve collection and reporting of flow data5. Separate emergency and elective beds6. Separate resources for day case and inpatients7. Determine best management strategies for ‘high

utiliser’ patients8. Reconfigure wards into larger units

And how have we responded?



The gain – 14% in activity at no cost


Cancellations


Patients:

• Reduced waiting time and improved access to care

• Reduced mortality and medical errors

Nurses:

• Reduced overtime

• Reduced workload

Outcomes


What do we need to do?

Decrease harm – adds value and decreases waste

Eliminate variation – redesign services to do more for less Consider areas where you do not know how to solve the

blocks in the system Emergency room Inpatient beds Diagnostic procedures Operating room Outpatients

Documents

Making it happen Improving quality to improve productivity The Great Ormond Street Hospital for Children Experience Can it really be done?