Safe – no needless deaths Effective – no needless pain or suffering Patient-Centered – no helplessness in those served or serving Timely – no unwanted waiting Efficient – no waste Equitable – for all The IHI’s blueprint for its work – the goals we aspire to – come from the Institute of Medicine’s landmark 2001 report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. In it, the IOM identified six urgently needed “Aims for Improvement” of health care in America. IHI has translated these goals into what we call the “No Needless” list: Safe – To reduce the harm done to patients by errors in care – defects which, according to the IOM, kill between 44,000 and 98,000 Americans each year in hospitals alone; Effective – To promise patients that they will receive care faithfully according to science, and that they will not be subjected to care that cannot help them; Patient-centered – To redesign care so as to restore dignity, self-esteem, and control to patients and families who too often feel helpless, forgotten, and unheard; Timely – To reduce the waiting and delays that pervade health care for both patients and those who give the care; Efficient – To recover a substantial portion of the money wasted in health care through administrative complexity, unnecessary procedures, and lack of coordination; Equitable – To close the racial and socio-economic gaps in health status, access, and outcomes. 2

Improvement and Support Team Patient Experience Collaboratives Patient Experience Healthcare Acquired Infections Taskforce E-Health

Safety

Why?

James Adams

How many people are harmed in our healthcare system?

Atul Gawande, “The Bell Curve” The New Yorker, December 6, 2004 “It used to be assumed that differences among hospitals or doctors in a particular specialty were generally insignificant. If you plotted a graph showing the results of all the centers treating cystic fibrosis—or any other disease, for that matter—people expected that the curve would look something like a shark fin, with most places clustered around the very best outcomes. But the evidence has begun to indicate otherwise. What you tend to find is a bell curve: a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle.”

Scottish Patient Safety Programme What? Scottish Patient Safety Programme

Outcome Aims Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction Harm from Anti-coagulation: 50% reduction in ADEs Surgical Site Infections: 50% reduction

Interventions Medicines Critical Care Ward Theatres Leadership Ventilator acquired pneumonia bundle, central line Ward Early rescue Communication Medicines Medicines reconciliation Theatres Surgical pause Infection prevention/control Leadership Safety walkrounds Executive leadership board patient safety profile

How?

The first law of improvement Every system is perfectly designed to achieve exactly the results it gets. Peter Senge The Fifth Dimension

The Improvement Guide, API

Looking for Harm

Board examples Leadership walkarounds Surgical briefings Handwashing Bedside cabinets Surgical briefings On theatre lists Four new staff Handwashing 100% Critical care bundles Runcharts