Leading the Best Care...Always! Campaign Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh May 10th 2011 Cape Town

Agenda Welcome Introductions Best Care…... Always! (BCA) Fundamentals of the QI approach Measuring for BCA A framework for leading BCA LUNCH QI in action Next steps

The Burden of Healthcare-Associated Infection Prof Shaheen Mehtar UIPC, TBH & SUN Cape Town

Situation Analysis of LMI countries Rates of HAI are higher in LMI countries IPC programmes are poorly supported Little accountability by Health Care Workers Clinical commitment essential - Duty of Care

HAIs are at least 3 x more common in LMI countries Comparative data- HIC and LMIC Burden of endemic health care associated infection in developing countries: systematic review and meta analysis- B Allegranzi et al, Lancet, 2011, 377: 228-41 HAIs are at least 3 x more common in LMI countries

Crude HAI Infection Rate: TBH. Impact of an established IPC programme

Comparing TBH to meta-analysis Site Meta analysis Median /1000 device days TBH / 1000 patient days VAP 28 ETA 1- 3 CR BSI 18 CVP & B/C 0.5-1.3 SSI 1.2-23.6/1000 surg op NO DATA

Summary Surveillance shows a statistically significant decrease in HAI with device-related infection. Policies and SOPS are necessary for compliance by clinical staff Bundling is a highly specialised system of reducing HAI with zero tolerance Questions to be answered Who will ensure 2 people available for each procedure carried out? Who will do the data collection? Who will make sure that the same bundle is followed each and every time a procedure is carried out? How will this be enforced?

The BCA Quality Improvement approach All learn all teach Learning by doing Building a shared sense of the system and the approach to improvement Applicable across disciplines

The impact of Healthcare Associated Infections on the hospitals

The impact of HAIs on the hospitals Mortality and morbidity Lab and pharmacy costs Antibiotic use Bed occupancy Work load

The impact of HAIs on your hospital Fill in the column graphs peripheral vascular catheter-associated infection (PVCAI) central line-associated bloodstream infection (CLABSI) ventilator-associated pneumonia (VAP) catheter-associated urinary tract infection (CAUTI) surgical site infection (SSI)

The fundamentals of the Quality Improvement approach used in BCA

A brief history of systems improvement IHI Lean Overview Andy Brophy

Quality Improvement requires two Types of Knowledge Subject Matter Knowledge: Professional, content, evidence based knowledge. ‘What’ Subject Matter Knowledge Improvement Knowledge ‘How’ Improvement Knowledge (Deming): The interaction of the theories of systems, our ‘theory of knowledge’, variation in measurement, and psychology.

Improvement Improvement: develop effective changes that lead to an improvement. Subject Matter Knowledge ‘What’ ‘Where’ Improvement Knowledge ‘How’ Langley: Improvement Guide p76

Improvement Knowledge Subject Matter Knowledge Improvement Knowledge W.E. Deming (1900-1993) System of Profound Knowledge

Improvement Knowledge 4 fields of interaction - theories of systems - our ‘theory of knowledge’ psychology of change variation in measurement Subject Matter Knowledge Improvement Knowledge

Complex Dynamic Systems Step 1 – Everyone stand up Step 2 – Without speaking; pick two people but don’t say who they are or point at them (Keep it a secret) Step 3 - Move to be equidistant from both of the people Step 4 – Move one person and repeat

begins with your letter The power of the system NO Do you have a 2-digit Number? Step 1: Pick a number from 3 to 9 Step 2: Multiply your number by 9 Step 3: Add 12 to the number from step 2 YES Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I Step 4: Add your 2 digits together Step 5: Divide # from step 4 by 3 to get a 1 digit number Step 7: Write down the name of a city that begins with your letter Step 9: Write down the name of an animal (not bird, fish, or insect) that begins with your letter from Step 8 Step 10: Write down the color of your animal Step 8: Go to the next Letter: A to B, B to C, C to D, etc. Output: Color____________ Animal___________ City__________

Understanding Systems “Every system is perfectly designed to achieve the results it gets” Paul Batalden Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

Hand washing practice in the PICU from a Report of a participative observational study done during January and March 2006 Candice Bonaconsa and Minette Coetzee Child Nurse Practice Development Initiative Prof Andrew Argent, Red Cross Hospital

Calculating the % of hand washing How we did this: Actual x 100 = % Opportunity

Goal 90%

elsewhere in the hospital … Time Opportunities Used Opportunities % 10:00-11:00 12 2 16.7 11:15-12:15 11 18.2 21:30-22:30 14 3 21.4 22:30-23:30 7 1 14.3 14:15-15:15 9.1 15:20-16:20 42.9 10:45-11:45 28 5 17.9 11:45-12:45 10 20.0 10:30-11:30 15 11:30-12:30 8 37.5 6.7 12:30-13:30 10.0 13:30-14:30 40.0 14:30-15:30 12.5 15:30-16:30 4 0.0 14:00-15:00 19 5.3 15:00-16:00 9 12:00-13:00 16 6.3 13:00-14:00

Force Field Analysis The current situation The desired situation The situation if no action is taken Forces driving toward desired situation Forces resisting change ……

Forces in the system keeping hand washing rates where they are B Time Lewin K (1951) Field Theory in Social Science New York: Harper

Understanding Systems “Every system is perfectly designed to achieve the results it gets” Paul Batalden “All improvement needs a change Not all change is an improvement” Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

Improvement Knowledge 4 fields of interaction - theories of systems - our theory of ‘knowledge’ psychology of change variation in measurement Subject Matter Knowledge Improvement Knowledge

Theory of knowledge Our understanding of why things are the way they are.

EVIDENCE-BASED SOLUTION The Implementation Gap PROBLEM EVIDENCE-BASED SOLUTION PLAN “typical” attempts to change IMPLEMENT FAIL

SYSTEM ANALYSIS to identify barriers to care Overcoming barriers at the frontline of care SYSTEM ANALYSIS to identify barriers to care PROBLEM GREAT IDEAS Quality Improvement Mentoring PLAN IMPLEMENT SUCCEED/ SUSTAIN DO STUDY ACT

Model for Improvement What are we trying to accomplish? PLAN DO STUDY ACT What can we change that will result in an improvement? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT How will we know that a change is an improvement?

Improving many parts of the system at once PLAN DO STUDY ACT Unit 2 PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT Unit 1 Bundle 1 Bundle 2

Improvement Knowledge 4 fields of interaction - theories of systems our theory of ‘knowledge’ psychology of change variation in measurement Subject Matter Knowledge Improvement Knowledge

Psychology of Change Population Early Majority Late Majority Early Adopters Innovators Traditionalists Source: E. Rogers. Diffusion of Innovation

Improvement Knowledge 4 fields of interaction - theories of systems - our theory of ‘knowledge’ psychology of change variation in measurement Subject Matter Knowledge Improvement Knowledge

Understanding Variation Walter Shewhart’s (1891-1967) – understanding variation through Statistical Process Control (SPC)

Flip a coin

ICU: VAP infections 2010 July Aug Sep Oct 5/7 13/8 7/9 5/10 9/9 8/10 6/7 12/9 15/10 11/7 15/9 19/10 25/7 20/10 27/7 21/10 25/10

Measurement Common mistakes Using bar graphs rather than run charts Not enough data points (12 at least to understand normal variation) Not making allowances for normal variation when interpreting data Not measuring trends over a long enough period - cut off at year end or financial year end

Reacting to Variation We are going to try to address what it does mean

Measuring for Best Care….Always!

Measurement Builds will Assesses impact Drives improvement Keeps the project alive Sustains the gains

Measurement Data must be visually appealing and accessible Owned and used at the frontline of care Routinely reviewed at monthly management meetings An active, encouraging feedback loop from management to frontline staff

Measurement Leaders need to know i) what measures are being used for incidence of HAIs bundle compliance (implementation of bundles) ii) how data is being presented iii) how to interpret the data respond to the data

Measurement for BCA Outcome measures (HAIs) Process measures (bundle compliance) Balancing measures Morbidity and mortality reviews

Outcome measures the incidence of HAIs impact of changes made

Infection Rates Total number of infective cases per 1,000 device days: Numerator Total No. of VAP cases Ventilator days X 1,000 Denominator Good for aggregate data but high variation for units when events are rare (<10%)

Welsh Safety Calendar I Developed by Annette Bartley, Welsh 1000 Lives Campaign

Welsh Patient Safety Project

Measuring rare events Events that occur < 10% of the time

Measuring rare events – days between events Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana

Sequence of Infections Date of infection # Days since last infection Days Be-tween Infection Sequence of Infections

Measuring rare events and time-between measures. James Benneyan IHI I

Number of infections against annual target for the year (Set for each Hospital for Each HAI by DOH) Laurel SimmonsAssoc. Dir. for Quality Improvement Stockport NHS Foundation Trust

Dashboard of measures Eastern sub-district HIV/AIDS Improvement project report March 2009

Process measures Bundle compliance drives the improvement Target must be set at 95% for each bundle element and therefore the whole bundle (reliability theory)

Bundle compliance 61 61

A Framework for Leading Best Care….Always!

Framework for Leading Improvement

Leading BCA Dr Hannes Loots Regional Clinical Manager Western Cape Region Medi-Clinic Southern Africa (9 mins)

Setting Direction: Mission, Vision and Strategy 1.Set Direction: Mission, Vision & Strategy Setting Direction: Mission, Vision and Strategy Removing the Status Quo Making the future attractive PUSH PULL

Removing the Status Quo Make the status quo uncomfortable There are too many Healthcare Associated Infections (HAIs)

Look to the Future Making the future state attractive No more unnecessary deaths and suffering from HAI Best practice shows it is possible to reduce HAI between 20 – 80% There are evidence based protocols and practices to do this We will be part of a national and international campaign

IHI Whitepaper 2008 Seven Leadership Leverage Points for Organizational-Level Improvement in Healthcare pg 4

3,4,5: Will, Ideas and Execution Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)

Will, Ideas and Execution Why are we spending our time and energy on this project?

Will, Ideas and Execution Leaders play a significant role in building and maintaining will Clear, desirable aims Making it doable start small allocate time and resources remove obstacles bring in the right people/teams culture of learning vs blame and shame Keep the project alive demonstrate interest monthly review of data

Will, Ideas and Execution Engaging doctors

Will, Ideas and Execution Overcoming the implementation gap

Multidisciplinary teams

Model for Improvement What are we trying to accomplish? PLAN DO STUDY ACT What can we change that will result in an improvement? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT How will we know that a change is an improvement?

Repeated improvement cycles: Expert Meeting and Planning Group formed Accelerating change and improvement through networking and collaboration. Learning session 2 Repeated improvement cycles: Learning session 3 18 -24 months Expert Meeting and Planning Group formed Learning session 1 Mentoring and support

Resources BCA www.bestcare.org.za IHI www.ihi.org

Handouts Getting Started Kits – including peripheral line Presentation handout Framework for leading improvement Run chart article