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

2. 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

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

4. 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

5. 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:
HAIs are at least 3 x more common in LMI countries

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

7. 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
SSI
/1000 surg op
NO DATA

8. 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?

9. 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

10. The impact of Healthcare Associated Infections on the hospitals

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

12. 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)

13. The fundamentals of the Quality Improvement approach used in BCA

14. A brief history of systems improvement
IHI Lean Overview Andy Brophy

15. 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.

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

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

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

19. 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

20. 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__________

21. 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.

22. 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

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

24. Goal 90%

25. 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

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

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

29. 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.

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

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

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

33. 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

34. 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?

35. 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

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

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

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

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

40. Flip a coin

41. 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

42. 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

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

44. Measuring for Best Care….Always!

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

46. 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

47. 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

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

49. Outcome measures
the incidence of HAIs
impact of changes made

50. 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%)

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

52. Welsh Patient Safety Project

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

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

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

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

57. 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

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

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

60. Bundle
compliance 61 61

61. A Framework for Leading Best Care….Always!

62. Framework for Leading Improvement

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

64. 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

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

66. 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

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

68. 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

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

70. 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

71. Will, Ideas and Execution
Engaging doctors

72. Will, Ideas and Execution
Overcoming the implementation gap

73. Multidisciplinary teams

74. 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?

75. 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
months
Expert Meeting and Planning Group formed
Learning session 1
Mentoring and support

76. Resources
BCA
IHI

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