Insert name of presentation on Master Slide The Model for Improvement Wednesday 16 June 2010 Presenter: Dr Jonathon Gray

Patient safety – what’s the problem? More than one in ten people admitted to hospital are harmed unintentionally by its care. There is a one in 300 chance of accidental death through errors in care.

Hospital blunders 'kill 90,000 patients' Rebecca Smith, Medical Editor, Daily Telegraph More than 90,000 patients die and almost one million are harmed each year because of “hospital blunders”, research suggests. Researchers found that up to half of the mistakes made were preventable

Why do we need Quality Improvement? If flying Lufthansa were associated with the same rate of preventable fatalities that we currently see in hospitals… Source:McKinsey 1.Flying would be much safer 2.There would be a crash every week 3.There would be 100,000 passengers killed per year 4.There would be 17 crashes per day and 600,000 deaths per year

The First Law of Healthcare Improvement “ Every system is perfectly designed to achieve exactly the results it gets.” Therefore, although not all change is improvement, all improvement is change Source: Don Berwick, IHI (Boston)

Driver Diagrams Primary Drivers System components which will contribute to moving the primary outcome Secondary Drivers Elements of the associated Primary Driver. They can be used to create projects or a change package that will affect the Primary Driver.

Care bundles Groupings of best practices with respect to a disease process that individually improve care, but when applied together may result in substantially greater improvement. The science supporting each bundle component is sufficiently established to be considered the standard of care. The bundle approach to a small group of interventions promotes teamwork and collaboration.

The Improvement Guide, API AIM MEASURES TESTS Testing method

Aims Statements – some examples Surgery: Achieve 100% compliance with appropriate selection and timing of prophylactic antibiotic administration ICU: Reduce Central Line Infections in the ITU by 75% within 12 months Medication reconciliation: Medications reconciled with over 99% accuracy within 6 months Communication: Safety huddles occur daily on every ward 95% of days within 14 months Source: Institute for Healthcare Improvement

You can’t fatten a cow by weighing it…. How will we know a change is an improvement? Source: Institute for Healthcare Improvement

Measurement Tracking a few key measures over time is the single most powerful tool a team can use. (Required & Optional)

Why Test Changes? To increase the belief that the change will result in improvements in your setting To learn how to adapt the change to conditions in your setting To evaluate the costs and “side- effects” of changes To minimize resistance when spreading the change throughout the organisation “Negative results on the fish… Let’s try rubbing two sticks together.” Source: Institute for Healthcare Improvement

Testing using the PDSA Cycle for Learning and Improvement What changes are to be made? Next cycle? Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Carry out the plan Document problems and unexpected observations Begin analysis of the data Do PlanAct Complete the analysis of the data Compare data to predictions Summarize what was learned Study Source: Institute for Healthcare Improvement

Use the PDSA Cycle to: Answer the first two questions of the Model for Improvement Develop a change Test a change Implement a change “What tests can we complete by next Tuesday?”

This is different! The Cycles Build on Each Other… Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very small scale test Follow-up tests Wide-scale tests of change Implementation of change Source: Institute for Healthcare Improvement

Measurement and data collection during PDSA Cycles Collect useful data, not perfect data - the purpose of the data is learning, not evaluation Use a pencil and paper until the information system is ready Use sampling as part of the plan to collect the data Use qualitative data (feedback) rather than wait for quantitative Record what went wrong during the data collection

Keys and Barriers to Success Keys PDSA cycles Small, rapid cycle Seek usefulness not perfection -stickers Improve as fast as you test Multidisciplinary approach Early adopters ‘having made a difference’ Leadership Evidenced based Measurement over time Outcome & process measures Run charts - feedback Monthly review Barriers Resistance to change ‘ not invented here’ ‘already doing this’ ‘this week’s gimmick’ Culture & behaviour Educate, educate Clinician engagement Scepticism Resources Data collection Person dependence Sustainable process Source: McKinsey

In conclusion Safety and quality are big issues While they are system/organisation issues, everyone can make a difference Shifts in mindsets & capabilities are more important than specific tools But the model for improvement is a proven tool: start with the aim, choose measures, run rapid cycles Making change stick in a system requires addressing several dimensions simultaneously Source: McKinsey