The Challenges of Implementation (Will, Ideas, Execution) Dr Elizabeth Haxby Royal Brompton and Harefield NHS Foundation Trust

Traditional Approach Overwhelming number of issues to be addressed Large audits ie 100s of patients telling us what we already knew Time consuming committees Profusion of policies – average 50 pages long Assumption that policy = practice Lack of Engagement

Design Approve Implement Conference Rooms Real World

Trust wide VTE prophylaxis compliance

Reasons for Failure  Lack of clear goals or timeframes  Failure to frame the policy and provide context  Elements of the policy impractical  Failure to engage with the people who will implement the policy  Feedback intermittent, not directed

New Approach Surgical Site Infection

New Approach  Set context  Set clear aim and timeframe  Engage with front line staff  Listen to their concerns and ideas  Try small tests of change  Establish measures and feedback

SSI - cost to patients, cost to healthcare Patients with a superficial infection had an extra LOS of 20 days (P<0.0000) and cost an extra £9,735 (P<0.0098) Patients with a deep or organ space infection had an extra LOS of 54.5 days (P<0.0098) and cost an extra £40,726 (P<0.0098) Difference in Median LOSDifference in Median Cost

Driver diagram SSI prevention

Tribal Non-alignment ANAESTHETISTSANAESTHETISTS SURGEONSSURGEONS NURSESNURSES MANEGERSMANEGERS EXECsEXECs PORTERSPORTERS ODAsODAs

Alignment Staff Structure Strategy & Tactics Aims Leadership Language

Multiple small changes SSI data review at monthly CG day Cross site multi disciplinary WIP group Care bundle measurement with feedback to theatre staff Changes to; Theatre access Hand hygiene / scrub up Surgical prep Dressings Wound management Vein harvest Re-enforced antibiotic policy Feedback to individual surgeons on SSI with RCA and bundle compliance for each patient Board level reporting Local CQUIN indicator

Small test of change

SSI Prevention Care Bundle

Design Test and Modify Test and Modify Test and Modify Approve (if necessary) Conference Rooms Real World Implement

The Challenge of Implementation Clear Aim Start small Engage all the right people Expect failure and respond promptly Measure Don’t underestimate anyone Give information / feedback frequently Seek additional drivers