Getting Started At the National Level: From Demonstration to Spread1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs

November 4, 2013

São Paulo, Brazil

Derek Feeley

Executive Vice

President

NHS Scotland 3

c. 5.1 million populationDevolved (since 1999)14 Regional BoardsIntegrated system ( e.g. no purchaser/ provider split)Integration of health and social care underwayTax funded/ 20bn CAD budget, cash limitedEqual access on basis of needFree at the point of care

Why Patient Safety? 4

United States:3.7% of admissions44,000 – 98,000 deaths

United States:3.7% of admissions44,000 – 98,000 deaths

Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths

Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths

Denmark:9% of admissionsDenmark:9% of admissions

New Zealand:10% of admissionsNew Zealand:10% of admissions

United Kingdom:11% of admissions850,000 adverse events

United Kingdom:11% of admissions850,000 adverse events

DoH ECRI 2002 Knox K et all

Global Trigger Tool Reviews5

3 Exemplar Hospitals (900 notes)

40 Bed rural Hospital (300 notes)

10 Hospital Research Project (240 notes)

7 Hospital System (3000 notes)

Multi-state Tertiary System (2000 notes)

Events/1000 Days

83 90 NA 119 86

Events/100 admissions

45 40 37 41 38

Admissions with adverse events

32% 30% 30% 29% 30%

Not Just Numbers6

So what do we know?

At least 10% of patients admitted to hospital suffer harmTraditional incident reporting – tip of the icebergVariation in mortality ratesHuman beings will always make mistakesLack of standardisation – clinician preferenceBest known science is not reliably applied

Lack of Reliable Processes Create….

Islands of great care in a sea of variationInconsistent performance & outcomesChaos as clinicians create ‘work-arounds’ just to get the work doneA culture where it is difficult to learn and improveCare that is more complex and often more unsafe

Current Improvement methods in healthcare are

highly dependent on vigilance and hard work

The focus on outcomes tends to exaggerate the

reliability within healthcare giving clinicians a false

sense of security

Permissive clinical autonomy creates and allows

wide performance margins

The Reliability Gap

What We Asked Ourselves - Policy

How do we reduce harm in the NHS in Scotland?How do we reduce mortality in Scottish hospitals?What could we learn about improving quality more generally?

No Shortage of Analysis

It’s complicated……12

“Too bad all the people who know how to run the country are busy driving cabs and cutting hair.”

- George Burns

Updated for 2013:

“It's too bad that everyone who has a solution for everything is at home commenting on the internet.”

- Twitter user Rasta Pasta (@rastahipsta)

Policy Options

Do what we’ve always doneLet’s get more dataRun a pilot projectRun a campaignLet Boards and hospitals decide what to doRun a mandatory national improvement program

Why Did Scotland Go National? 14

The context was rightOur size helpedClinicians and managers were receptiveA good match with ‘values’The evidence was good enough – the ‘Tayside Effect’It felt like the right thing to

The Right Foundations . . .15

100,000 Lives CampaignSafer Patients InitiativePolitical support at the highest levelLeadership prepared to be transparent about harm and to build the will to improve

. . . And Missing Ingredients16

We needed a partner to help us with design and execution. We needed to overcome clinical (mainly medical) resistance.We needed to convince leaders and managers that this was not just “another initiative.” We needed to start somewhere.

Policy Risks – do nothing (new)We’ll always get what we always got.There will continue to be avoidable harm (even more perhaps as care gets more complex)The debate continues to be about reporting rather than improving.

Its not denial, I am just selective about the reality I accept. (Bill Waterson –Calvin and Hobbes)

Making Policy as a Metaphor for Spreadpolicy1n pl -cies1. (Government, Politics & Diplomacy) a plan of action adopted or pursued by an individual, government, party, business, etc

UK National School for Government 2006

Evidence

Experience &

Expertise

Judgment

Resources

ValuesHabits &

Traditions

Lobbyists &

Pressure

Groups

Pragmatics &

Contingencies

Spread and Sustainability

Spread = The process through which new working methods developed in one setting are adopted , perhaps with appropriate modifications, in other organizational contexts

Sustainability = The process through which new working methods, performance enhancement, and continuous improvements are maintained for a period appropriate to a given context

Buchanan D, Fitzgerald L, Ketley D. The Sustainability and Spread of Organizational Change:

Modernizing healthcare. Abingdon, Oxon: Routledge; 2007.

“Up to 70% of improvement projects never spread.”

Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012;53(4): 43-50.

Planning for Spread

Preparing for spreadEstablishing an aim for spreadDeveloping an initial spread planExecuting and refining the spread plan

In Scotland the spread plan was to start with all, just not with everything, everywhere. We told hospitals to start where they were good and to get to complete coverage in 2 years.

Implementing at scale….can it be done?

ExecutionIdeas

Will

W Edwards Deming

“By what method?Only the method counts.”

23

The Typical Approach24

Conference RoomConference Room

DESIGN DESIGN DESIGN DESIGN APPROVE

IMPLEMENTReal WorldReal World

DESIGN

TEST & MODIFY

TEST & MODIFY

APPROVEIF NECESSARY

Conference RoomConference Room

Real WorldReal World

TEST & MODIFY

The Quality Improvement Approach

START TO IMPLEMENT

IHI Breakthrough Series – sticking with it

Select

Topic (develop

mission)

Planning

Group

Develop

Framework

& Changes

Participants (10-100 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email Visits

Phone Assessments

Monthly Team Reports

Congress,

Guides,

Publications

etc.

A D

P

SExpert

Meeting

Where We Started:SPSP Outcome Aim Set in 2008

Mortality: 15% ReductionAdverse Events: 30% Reduction– Ventilator Associated Pneumonia: 0 or 300 days between– Central Line Bloodstream Infection: 0 or 300 days between– Blood Sugars within Range (ITU/HDU): 80% or > w/in range– MRSA Bloodstream Infection: 30% reduction– Crash Calls: 30% reduction

27

To be achieved across the nation by 2012Mortality aim amended to 20% by 2015

What We Set Out to Improve

Acute Program – 5 WorkstreamsCritical Care Perioperative CareGeneral Ward CareMedicines ManagementLeadership for Safety

28

0,8

0,9

1,0

1,1

Oct-Dec2006

Apr-Jun2007

Oct-Dec2007

Apr-Jun2008

Oct-Dec2008

Apr-Jun2009

Oct-Dec2009

Apr-Jun2010

Oct-Dec2010

Apr-Jun2011

Oct-Dec2011

Apr-Jun2012

Sta

ndar

dise

d M

orta

lity

Rat

io

HSMR up to September 2012

8497 less than expected deaths

12.4% reduction

Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in range Harm from Anti-coagulation: Reduction in INRs > 6All process measures will be > 95% reliable

AHO3

Adverse Events

Rate per 1000 pat ient days

.010.020.030.040.050.060.070.0

611

811

1011

1211

212

412

612

AHO3

Adverse Events

Rate per 1000 pat ient days

.010.020.030.040.050.060.070.0

611

811

1011

1211

212

412

612

CCP2

VAP Prevention Bundle

Percent

80.0

85.0

90.0

95.0

100.0

711

911

1111

112

312

512

712

CCP2

VAP Prevention Bundle

Percent

80.0

85.0

90.0

95.0

100.0

711

911

1111

112

312

512

712

CCO1

VAP Rate

Rate per 1000 ventilated days

.02.04.06.08.0

10.0

611

811

1011

1211

212

412

612

CCO1

VAP Rate

Rate per 1000 ventilated days

.02.04.06.08.0

10.0

611

811

1011

1211

212

412

612

CCO2

Central Line Infection

Rate per 1000 pat ient days

.02.04.06.08.0

10.0

611

8 10 12 2 4 612

CCO2

Central Line Infection

Rate per 1000 pat ient days

.02.04.06.08.0

10.0

611

8 10 12 2 4 612

CCO6

Optimal Glucose Control

Percent

70.075.080.085.090.095.0

100.0

611

811

1011

1211

212

412

612

CCO6

Optimal Glucose Control

Percent

70.075.080.085.090.095.0

100.0

611

811

1011

1211

212

412

612

MMP3C Filtered

INR>6

Percent

0.00.10.20.30.40.50.6

711

911

1111

112

312

512

712

MMP3C Filtered

INR>6

Percent

0.00.10.20.30.40.50.6

711

911

1111

112

312

512

712

Process reliability achieves improved outcomes!697 days! 596 days!

Where We Started:Outcomes & Achievements

Safety is Contagious – In A Good Way

A Strategy and a Roadmap 32

33

3 Quality Ambitions

Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

3-Step Improvement Framework for Scotland’s Public Services

34

1. Change the World

2. Create the conditions

3. Make the Improvements

Macro System :

Vision, Aim & Context

Meso System:Culture, Capacity, & Challenge: How much and by when?

Micro System:Implementation, measurement, & improvement

Creating the Conditions

6 Questions for Every Change Program

35

1. Does everyone in the system know what we are trying to achieve?

2. Are we prioritizing the improvements likely to have the biggest impact on the aim and stopping those that have little impact?

3. Is everyone clear about the means of securing improvements towards our aim?

4. Are we able to measure and report progress on our aim?

5. Do we know how and when to deploy resources when improvement is slower than required?

6. Do we have a way of testing and innovation and then spreading new learning?

Investing One Generation Ahead –The Method Works Here, Too

The Early Years Collaborative - Ambition

To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.

The Early Years Collaborative - Aims

1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidence by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).

2. To ensure that 85% of all children with each Community Planning Partnership have reached all of the expected development milest ones at the time of the child’s 27-30 month child health review, by end-201 6.

3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected development milestones at the time the child starts primary school, by end-20 17.

Front Line Staff – How Did They Do It?

� Get goals� Get bold� Get together� Get a method (and

stick with it)� Get patients and

families

� Get the facts� Get to the field� Get a clock� Get the numbers� Get the stories

1941, William A. Foster

"Quality is never an accident; it

is always the result of high

intention, sincere effort,

intelligent direction and skillful

execution; it represents the wise

choice of many alternatives.”