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

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

Introducing Best Care.. Always! Dena van den Bergh

The BCA Quality Improvement approach Not just protocol Focus on the implementation gap All learn all teach Learning by doing

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

Framework for Leading Improvement

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; (Available on Will IdeasExecution

Next Steps Hospital visits (data) Learning sessions ─LS#1 May 25 Monthly mentoring meetings with quality champions More hospital visits

Learning Session #2 Carol R. Haraden, PhD Vice President, Institute for Healthcare Improvement (IHI) Lead: Safer Patients Initiative (UK) Lead: Scottish Patient Safety Alliance Executive lead: IHI Patient Safety Officer Executive Development Program Institute of Medicine Committee on Engineering Approaches to Improve Health Care Associate editor for the journal Quality and Safety in Health Care. October/November Breakout session for CEOs

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

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: 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 SiteMeta analysis Median /1000 device days TBH/ 1000 patient days VAP28ETA1- 3 CR BSI18CVP & B/C SSI /1000 surg opNO DATA

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 (per hospital) - 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) Fill in the scale – hand hygiene (each individual

The fundamentals of the Quality Improvement approach used in BCA

Changing View of Quality We are perfect! NO ACTION Get rid of the bad apples M&M Quality Assurance REACTION Incident reporting “Standards”

Patients get “recommended care” ~ 50% of the time. Adverse events occur in 10% of hospital patients. ─50% are preventable. ─7.5% of these patients die....the gap between evidence and practice 20 NEJM 2003; 348: Qual Safety in Health Care 2008;17:

Changing View of Quality We are perfect! NO ACTION Get rid of the bad apples System thinking M&M Quality Improvement Quality Assurance REACTIONPROACTIVE “Quality” Safe Effective Timely Equitable Patient-centred Efficient Improvement Science Incident reporting “Standards”Process Improvement

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

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

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

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

The power of the system 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 Step 7: Write down the name of a city that begins with your letter Step 4: Add your 2 digits together Step 5: Divide # from step 4 by 3 to get a 1 digit number 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 8: Go to the next Letter: A to B, B to C, C to D, etc. 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 Do you have a 2-digit Number? NO YES 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

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

Goal 90%

TimeOpportunitiesUsed Opportunities% 10:00-11: :15-12: :30-22: :30-23: :15-15: :20-16: :45-11: :45-12: :30-11: :30-12: :30-12: :30-13: :30-14: :30-15: :30-16: :00-15: :00-16: :00-13: :00-14: elsewhere in the hospital …

Forces in the system keeping hand washing rates where they are Time A B 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 Subject Matter Knowledge 4 fields of interaction - theories of systems - our theory of ‘knowledge’ - psychology of change - variation in measurement Improvement Knowledge

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

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

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

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

Improving many parts of the system at once PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT Bundle 1 Bundle 2 Unit 1 Unit 2 PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT

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

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

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

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

Flip a coin

JulyAugSepOct 5/713/87/95/10 5/79/98/10 6/712/915/10 11/715/919/10 25/720/10 27/721/10 25/10 ICU: Date of VAP infections 2010

Run Charts and Shewhart Charts Measuring change over time - simple yet rigorous tools to distinguish whether change in a system is due to normal variation or a significant change in the system. See the handout on runcharts

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

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

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

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

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

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

Number of infections against annual target Laurel SimmonsAssoc. Dir. for Quality Improvement Stockport NHS Foundation Trust Target - 6 for the year (Set for each Hospital for Each HAI by DOH)

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)

67 Bundle compliance

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)