So far but how good? 29 September 2009 Presenter: Mike Davidge LS3: So far but how good?

Content Some good news [5] What & why [5] What happens when its not [5] So how good are we [8] What to do [2] Content area preview [5] LS3: So far but how good?

Measured all patients and made changes Baseline with 10 patients A good news story % patients with peri-operative normothermia Brecon theatre Changes made: Changed to Bair hugger gowns Comprehensive warm up Changed thermometers 100% 80% % patients Measured all patients and made changes 60% Baseline with 10 patients 40% May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 LS3: So far but how good?

What is a reliable process? “Reliability is the ability of a person or system to perform and maintain its functions in routine circumstances, as well as hostile or unexpected circumstances” Wikipedia “Reliability is the extent of failure-free operation over time.” David Garvin – Harvard Business School “When I’m here it works, when I’m not it doesn’t” Healthcare professional LS3: So far but how good?

Why Reliable Design? Most processes deliver haphazard results Almost all studies that investigate the reliability of the application of clinical evidence conclude that it is 80% or worse Unreliable processes lead to variable outcomes 2 Studies in the US indicated up to 50% of patients received sub-optimal care LS3: So far but how good?

The cumulative effect of unreliable processes 23 step process What if all steps in process were 95% reliable? Out of 100 patients: 95 safely negotiate first step 90 safely negotiate first 2 steps (95%x95%) How many come through all 23 steps? 31 LS3: So far but how good?

What happens when we’re unreliable Turn to neighbour Tell them about an occasion when a process where you work broke down or went wrong Did it have a detrimental effect on patient care? Vote: Hands up if you could think of an example Keep them up if it affected patient care LS3: So far but how good?

How Hazardous Is Healthcare? LS3: So far but how good?

Very few whole Trust measures So how good are we? 411 Data series Very few whole Trust measures No Yes 47% 53% % with at least 6 data points No Yes % with last 6 data points at 95% or above 38% 15% LS3: So far but how good?

The First Law of Improvement “Every System Is Perfectly Designed to Achieve Exactly the Results It Gets” (Both reliable and unreliable processes don’t happen by accident, they are carefully planned) LS3: So far but how good?

Content Area breakouts: Leadership perspective Clearly describe your organisational outcome goals VAP, CLI, Mortality etc Understand the relationship between processes and outcomes Set process expectations for the teams eg all elements of the ventilator bundle will be done 95% of the time on eligible patients Demand data to show how reliable the process has become Set reasonable timescales Put your money where your mouth is If outcomes have not improved and process reliability is high provide resources to determine the “correctness of performance” of the processes LS3: So far but how good? 11

Content Area breakouts Focus on reliability Before lunch How to design a reliable process 2 case studies After lunch (clinical content areas only) Make a plan to design your next reliable process Prepare feedback for tomorrow’s planning session LS3: So far but how good?