Transforming Care at the Bedside Using reliable techniques to improve patient safety and patient’s experience of care Annette Bartley RGN BA(hon) MSc MPH Head of Modernisation NHS North Wales (Central)

Facts Increased Technology Better treatment options Outcomes improving So WHY are patients consistently complaining about the NHS Everyone of us can tell a story What is going wrong?

The Context In the last 20 years the average length of stay in hospitals has declined significantly Nurses are spending an average of between 24%-35% or even less of their time in direct patient care 13-28% of their time in patient care documentation Korst 2003, Pabst 1996, Smeltzer 1996, Upeniecks 1998 Total time ALL health care workers spent in direct patient care and assessments on a med-surg unit is a median of 1.7 hours in a 12 hour period IOM, Keeping Patients Safe, 2004

(IOM Committee on Quality). Background to TCAB Issues with recruitment and retention of nurses in US Patient satisfaction deceasing Patient Safety As many as 90,000 people die annually from mistakes – an error rate unacceptable in any other industry. There are more deaths due to medical errors than deaths from accidents, breast cancer, or AIDS (IOM Committee on Quality). Relevant healthcare clinical research can take as long as 17 years to find its way into common practice, Isaacson said. Many national agencies such as AHRQ is seeking ways to accelerate the adoption and spread of innovations in healthcare through a "user-driven" strategy. It takes more than publication of research, synthesis of evidence, and changes in guidelines and performance measures, she said. Real change happens when a compelling message meets users’ needs and is supported by a sustained infrastructure.

TCAB USA Three Phases Local data collection Phase 1-three hospitals Phase 2 10 hospitals Phase 3 spread AONE & IHI Local data collection Run Chart-Time series analysis Data compared ‘within’ hospitals rather than ‘between’ Research evaluation (UCSF)

TCAB core themes Transformational Leadership Teamwork &Vitality Patient and Family centred care Value-added Care (Lean element) Safety &Reliability

TCAB-aims Increase the amount of time nurses spend in value-added/direct care to 70 % Reduce hospital acquired pressure ulcers by 50% Reduce the number of in patient falls by 50% Increase the patients satisfaction with their experience of care to >95%(ie pt –reporting excellent care) Increase staff satisfaction to >95%

Transform Care at the Bedside in the two development sites by Content Area Drivers Interventions Transformational Leadership Establish, oversee and communicate system levels aims for improvement Align measures, strategy & projects and leadership learning system Channel leadership attention to quality improvement and safety Build the right team Align Quality projects to Finance. Engage Physicians in improving care at all levels Build improvement capability Value-Added Care Increase the percentage of time spent in direct/value-added care to 70% by: Eliminating waste & Improve work flow processes for admissions, hand-offs an discharge Improving work environment through physical space re-design Enhancing efficiency with technology Reducing duplication & time spent in documentation Transform Care at the Bedside in the two development sites by 2010 Safety & Reliability Reduce the adverse events rate in pilot wards Prevent Falls by implementing falls bundle Prevent Pressure Ulcers by implementing Skin bundle Support and involve patients and families Ensure patients physical comfort Optimise care transitions to home or elsewhere Create Patient- Centred Healing Environments Provide Emotional & Spiritual Support Ensure Patients rights to privacy & dignity is maintained Patient Centred Care Empower ward managers to create care teams with the authority to act and transform care Build capability of front line staff and mid level managers in Innovation and Improvement Utilise clinical micro system model & tools Enhance physical environment for staff &prevent staff injuries Optimise communication across the care team Develop staff and match roles to responsibility Teamwork & vitality

Improvement Methodology Innovation/ Prototype testing Ideas Generation ‘The Deep Dive’ / ‘Snorkel’/ Paddle The IHI Model for Improvement PDSA Lean methodology Learning from Industry

Collaborative Care Patient Progression Tollgate 1 Tollgate 2 Tollgate 3 Tollgate 4 Tollgate 5 Are we progressing care? Are we progressing care? Are we progressing care? Are we progressing care? Are we progressing care? PT Care PT Care PT Care PT Care PT Care Patient Admission Patient Discharge PT Care NO NO NO NO NO Problem Solve Problem Solve Problem Solve Problem Solve Problem Solve Collaborative Care Value Stream Metrics Copyright 2006 © All Rights Reserved. Patent Pending.

World-Wide Sites Replicating TCAB Sweden & the Netherlands England, Ireland, Scotland & Wales Singapore New Zealand

Time in Direct Patient Care – 8 South Surgical Pilot

A model for improvement... What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements we seek ? Aims The three fundamental questions for improvement Measurement Ideas, evidence, hunches, other people etc. Act Plan Study Do The fourth question: how to make changes Langley, Nolan et al 1996

Health Care Processes Desired - variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom - variation Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Terry Borman, MD Mayo Health System 14

“Reliability is failure free operation over time “Reliability is failure free operation over time.” David Garvin Harvard Business School 15

Whose job is it? This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done

What are we trying to accomplish? Reduce Pressure Ulcer Incidence by 50% Preventing pressure ulcers isn't difficult! It just requires attention to the details and re-establishing good habits.  Use rounding/bundles to implement new habits and ways of thinking can and will ultimately impact outcomes.

Process Eyes Make the process for preventing Pressure Ulcers (&Falls) visible to ALL Measure it -so we can ‘see’ if it is adhered to and effective Make it easy for others to do the right thing (simple checklists, reminders) The right process with high % compliance WILL influence outcomes

Care bundles A “care bundle” is a collection of interventions (usually three to five) that may be applied to the management of a particular condition. It is distinct in several ways from just any checklist about patients’ care. The elements in a bundle are best practices based on evidence, and all clinicians should know them. In routine clinical practice, these elements may not always all be done in the same way, making patient care vary. So a bundle aims to tie them together into a cohesive unit that must be adhered to for every patient, every time. All the tasks are necessary and must all occur in a specified period and place. Successfully completing a bundle is clear cut, and compliance is measured in an “all or none” approach, as its proponents argue that better outcomes are achieved when interventions are executed together rather than individually.

Using bundles to improve reliability Bundles demand “all or none” thinking and measurement. Bundles facilitate identifying failures. Failures are actively used to redesign the process. Teamwork & communication improve

ALL OR NONE-COMPOSITE MEASURE Compliance (6 or non-compliant) Y/N Risk assessment on admission 2. Communication of risk status-Verbal & Visual Cue 3. Surface- x 4. Keep patients turning- care round 5. Skin Inspection-care round 6. Nutritional assessment- care round ALL OR NONE-COMPOSITE MEASURE

TLC Rounds Created more time-less bell calls Pressure areas checked Position changed Pain assessment Nutrition-check (fluids encouraged where appropriate) Obstacles & Call bells –Call don’t fall Personal Hygiene Emotional support

New Jersey Hospital Association Exemplars of success New Jersey Hospital Association Educational programs, e-mail information distribution list, monthly conference calls with experts 70% reduction in pressure ulcer incidence and 30% reduction in prevalence “No ulcers” Nutrition and fluid status Observation of skin Up and walking or turn and position Lift (don’t drag) skin Clean skin and continence care Elevate heels Risk assessment Support surfaces for pressure redistribution

Exemplars of success Ascension Health SKIN bundle Nurses throughout the organization created and implemented care methods under the SKIN bundle Reduced pressure ulcer incidence to about 1.4 per 1,000 patient days system-wide Six hospitals had no pressure ulcers for 1 year Almost all that did occur were Stage I or II SKIN bundle Surface selection Keep turning Incontinence management Nutrition

Design in Implementing the Ventilator Bundle                                                                             RT built into 1 hour scheduled vent checks as a) Integrate daily goals with MDR to identify defects as a Feedback on compliance Education Baseline 25

Steps to reliable care Do the acid test? Segment your population Design an articulated process goal, Agree a clear outcome goal connected to the process with some good medical evidence. In addition you have now set up a theoretical design using the prevent, identify, mitigate and with the knowledge of failures how to redesign design your first test of change Determine the tempo of change you will “dance to” 26

Safety is No 1 Safety Walk-rounds Safety first agenda item in every meeting Safety Briefings at shift handover SBAR (Situation/ Background/ Assessment / Recommendations ) MEWs reporting Transfer/Discharge C-DIFF & MRSA Admission/Discharge nurse Admission Trio

THANK-YOU Questions? Contact details: Annette Bartley annette.bartley@cd-tr.wales.nhs.uk