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The Saskatchewan Surgical Initiative:Lessons Learned

Health Quality Summit, Saskatoon, May 7th 2014

Presenters: Donna Davis, Dr. Peter Barrett, Terry Blackmore (Patient & Family Advisor) (Physician Leader) (A/Exec. Director, Saskatchewan Health)

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Where we were: March 31, 2010:Backlog of 27,580

patients awaiting surgery

1 in 5 waited > 1 year for surgery

Pace of improvements was very slow (no real change in previous year)

Patients deserved better!

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The Environment Sept. 2008 – “Releasing Time to Care” work

leads health leaders to Britain’s National Health Service; see the 18-week wait time work first-hand.

May 2009 – Best Brains exchange on Managing Wait Times.

Change management principles. IHI model for improvement.

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The Environment

October 2009:Patient First Review released;Speech from the Throne

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September 2009 – First Surgical Guiding Coalition and Executive Sponsorship Group meeting held in Saskatoon

A biannual event Shared ownership

Building the Team

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Guiding Coalition RHA reps from across value stream, physicians, health provider

organizations, unions, academics, Ministry reps and patients. Champions combining expertise, enthusiasm, Started with 30; now approx. 90 people

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Executive Sponsorship Group Leaders from Ministry, RHAs, HQC, provider orgs (SMA, SRNA,

SUN), physician leaders, patients 20-25 participants Established the broad vision and objectives Ongoing role included:

Breaking down barriers Win hearts and minds in system – highly visible Make it uncomfortable to maintain status quo Demonstrate courage and commitment – stay the course Create incentives; remove disincentives Establish mandates and directives Support physician leadership and engagement Bring resources to the table; investments and disinvestments

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March 2010 – The Plan is Announced

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March 2010 – The Plan is AnnouncedSooner, Safer, Smarter: A Plan to Transform the

Surgical Patient Experience Developed collaboratively (Guiding Coalition and

Executive Sponsorship Group included over 80 individuals)

Clear, Publicly-Stated Goal: “No one will wait more than 3 months for surgery by March 31, 2014”

Incremental targets – 18 months, 12 months, 6 months…

Safety and quality remain priorities, not to be jeopardized at the expense of “Sooner”

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What was different? Emphasis on patient experience, quality, safety, access and

sustainability Looking at every stage of the patient journey

DiagnosticsLaboratory

DiagnosticsLaboratory

Referral to Specialist Home

Rehab

Health Promotion Prevention

Post-OpRecovery/Ward

TherapiesPrimary

CarePre-Op / PAC

Surgery

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“Listening doesn’t mean you have heard, and looking

doesn’t mean you have seen.”

Involving Patients and Families

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Patient advisors

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Lesson Learned: Patient Representation “Nothing about me without me.” The means may be debated, but the end goal is shared

by all: improve the experience of our surgical patients. The most powerful motivator is a patient’s story. Patient involvement must be meaningful. Patient Safety is paramount. Patients and Families included in Guiding Coalition and

Executive Sponsorship Group from the very beginning.

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SAFER “Sooner, Safer, Smarter” should have been re-ordered. Ministry established the Patient Safety Unit to dedicate resources

to safety initiatives. Focus on Safety included:

Surgical Safety Checklist Surgical Site Infection Bundle Medication Reconciliation Falls prevention

Stop the Line being piloted Many Mistake-Proofing projects completed, more underway The acceptable defect rate is ZERO. It is possible.

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SAFER – Results:Surgical Volume and Checklist Compliance (Saskatchewan)

0

1,000

2,000

3,000

4,000

5,000

6,000

Apr-1

2

May

-12

Jun-

12

Jul-1

2

Aug-1

2

Sep-1

2

Oct-12

Nov-12

Dec-12

Jan-

13

Feb-1

3

Mar

-13

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-1

3

Sep-1

3

Oct-13

Nov-13

Dec-13

Jan-

14

Feb-1

4

Mar

-14

Date

# o

f S

urg

erie

s P

erfo

rmed

0

10

20

30

40

50

60

70

80

90

100

Ch

eckl

ist

Co

mp

lian

ce

(%)

# of surgeries performed

Checklist Compliance (%)

Data Source: Saskatchewan Health Quality Council website

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SAFER: Good Catches!

Decision made to perform a different procedure following

Briefing.

Identified that a patient was on Warfarin. The

procedure was cancelled.

Identified abnormal bloodwork at the

Briefing and surgery was cancelled.

Identified that a medication

administered pre-op was not documented

on the anesthesia

record.

Identified incorrect patient chart

brought into OR.

Found more than one operative site

listed in the documentation.

Identified that a patient was positive for MRSA

but this was not indicated in the chart.

Identified that patient consent

was missing.

Identified that blood type and screen had been done but results not

ready.

Two procedures scheduled; OR

slate only listed one.

Patient did not have

ID wristband.

Identified that patient was allergic to skin preparation

prior to surgery.

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“Insanity is doing the same thing over and over again and expecting different results”

– Albert Einstein

The Surgical Initiative asked “How can we work differently?”

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Don't ask “What's the matter”; ask “What matters to you?”

- IHI Conference

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SMARTER – Continuous Improvement

Surgical Initiative the first system-wide project to benefit from Lean methodology:Standardized processVisible targets and resultsReplicating results

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SMARTER - Appropriateness

Appropriateness work is underway. Appropriateness is conceptually tied to “clinical variation”. Unexplained variation implies a quality problem. Working to understand variation and reduce clinical variation in 4

clinical groups (Variation and Appropriateness Working Groups)

“Variation is the breeding ground for error.”Dr. Richard Shannon

Quality Summit, April 2011

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Dr. Brent James – Intermountain, Utah

1. Well-documented, massive, variation in practices

(beyond the level where it is even remotely possible that all patients are receiving good care)

2. High rates of inappropriate care (2 - 32% of all care delivered, depending on specific condition examined)

3. Unacceptable rates of preventable care-associated patient injury and death

4. A striking inability to "do what we know works"

5. Huge amounts of waste ( >50%, by best recent measures), spiraling prices, and limited access

SMARTER - Appropriateness

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SMARTER – Clinical Pathways

Pathways promote timely and appropriate care aligned with the patient’s preference.

Clinical pathways implemented:1. Hip/knee2. Spine3. Pelvic floor4. Prostate5. Bariatric Surgery

Acute Stroke Care and Lower Extremity Wound Care pathways are in development

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“Only those that provide the care can improve the care.”

- Don Berwick, IHI, Orlando; Dec 7, 2011

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Lesson Learned – Physician Engagement

Critical to engage physicians in improvement work. We’re learning how to do a better job of physician

engagement. Accurate, meaningful data is persuasive.

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Laurel Trujillo, M.D., Medical Director of QualityPalo Alto Medical Foundation

Create a dataset about costs for common problem Present data to MDs with goal of triggering conversation Allow group to define their own practice standard Communicate standard to all Provide follow-up data to track changes

Lesson Learned – Physician Engagement

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Lesson Learned – Shared Vision

Committed, consistent leadership: Drive itNo other optionProvide the tools and resources

But, those closest to the work must fix itOwn itDrive itCelebrate the successesLearn from the failures

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01

00

00

20

00

03

00

00

Saskatchewan: All Specialties: Number Waiting by Time Already Waited

Month End Dates (Data Source: 30Mar2014 refresh of the SK Surgical Patient Registry)

Nu

mb

er

of C

ase

s W

aiti

ng

at M

on

th E

nd

28Feb2005 28Feb2006 28Feb2007 29Feb2008 28Feb2009 28Feb2010 28Feb2011 29Feb2012 28Feb2013 28Feb2014

28,679 28,923

27,229 26,67127,756 27,799

25,345

21,843

19,544

15,776

18,85218,012

16,79315,766 15,978 16,003

12,950

9,291

7,868

4,380

13,57012,420

11,10310,456 10,387 10,075

7,686

4,645 3,920

1,691

8,0926,874

5,5995,051 4,678 4,150

2,763

1,060 947 319

4,5583,852

2,823 2,526 2,002 1,706 872

275 165 80

Wait Time Colour Key (% change from: 28Feb2010 to 28Feb2014, 31Mar2010 to 28Feb2014)

All (-43%, -43%) > 3 mth (-73%, -71%) > 6 mth (-83%, -83%) > 12 mth (-92%, -92%) > 18 mth (-95%, -95%)

Change from

Mar 31 2010 to

Feb. 28 2014:

- 43 % (total)

- 71 % (>3 month)

- 83 % (>6 month)

- 92 % (>12 month)

- 95 % (>18 month)

Initiative Begins

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SOONER RHAs implemented many improvements – OR allocation, case

cart standardization, better patient flow, better communication, better relationships.

Pooled referrals and the Specialist Directory have helped level the workload amongst specialists, allowing patients to accept the first available appointment if they choose.

Third party service delivery offered additional surgical capacity. Mid size regions are offering surgery as close to home as

possible. Additional perioperative nurse training.

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Lesson Learned: Importance of Leadership

Executive Sponsorship Group & Guiding Coalition Committed leadership – senior leaders, physicians

and front-line Common vision – Think and Act as One Patient and family involvement in decision-making Bold, clear goals Transparent results, shared widely

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Lesson Learned: Transition Planning

Keep it Visible Consultations across the system on:

Design of future governance; Ensuring continuous improvement; and How to engagement system partners.

Provincial Surgical Oversight Team established Patients, physician leaders and system administration involved Will monitor results and report to Provincial Leadership Team

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Results for the Health System

More than shortening wait timesSystem wide culture shift to patient-centred care and continuous improvementSimultaneously improved quality, safety and efficiencyServe the patient as a whole person – consider the entire patient journeyVisible incremental targets and measures

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Results for the Health System

Strengthened partnerships and relationships Patient advisors have become the norm Province wide approach to safety and continuous

improvement Willingness to share results and learn from each other as well

as high performing organizations

Questions?Contact Me:

Terry BlackmoreA/Executive Director, Saskatchewan Health

Terry.Blackmore@health.gov.sk.ca

www.qualitysummit.ca

#QS14