1. The big picture for improvement: Making systems more reliable Linking innovations in service delivery with new technologies Involving and engaging staff Hugh Rogers Associate, Service Transformation 30 th September 2005

2. NHSU Leadership Centre Modernisation Agency National Innovation Centre Delivering Quality & Value A No Wait system Primary care & LTCs HealthCare Associated Infection The NHS Institute for Innovation and Improvement

3. The Goal: towards reliable healthcare No needless delay –Treat me quickly and appropriately No waste –Use the resources we give you to greatest effect No feelings of helplessness –Treat me with respect and empower me No needless suffering –Give me effective treatments and relieve my pain No needless deaths –Protect me and heal me No inequity –Treat me fairly Adapted from ‘Crossing the Quality Chasm’, Institute of Medicine 2001

4. What is reliability? “The capacity to perform a given function under given conditions for a specified period of time” A reliable health care system is one that is designed to ensure that every patient consistently receives evidence- based, effective care every time he or she needs it. An important outcome of reliability would be patient and public confidence in the NHS “Reliability means keeping a promise” ( Don Berwick )

5. Measuring reliability ReliabilityApproach to achieving reliability 10 -1 Intent, vigilance, hard work 10 -2 Design Design informed by reliability science and human factors 10 -3 or more Design of Highly Reliable Organisations (HROs) Technical solutions (After Nolan & Weick)

6. Compare Reliability and Safety Safety Errors of commission special cause strategies reactive focused projects Reliability Errors of omission common cause strategies proactive creation of reliable systems When failure has high impact

7. Current Reliability Good people working hard will not be able to overcome the complexities of today’s systems of care to prevent errors Studies show that human beings make errors –Misreading errors 3 in 1000 –Omission in the absence of reminders 1 in 100 (BMJ March 18 2005 Tom Nolan) NCEPOD report on critical care (May 2005) shows: –27% of hospitals have no early warning system –44% of hospitals have no outreach service –66% of admissions to ICU were unstable for >12hrs (in hospital >24hrs) –25% were not reviewed by consultant intensivist in first 12 hrs –ICU care ‘less than good’ in 47% –Deficiencies may have contributed to death in 11%

8. 10 High Impact Changes

9. High Impact Changes # 3 #4 and #6 3.Manage variation in patient discharge thereby reducing length of stay 4.Manage variation in the patient admission process 6.Increase the reliability of therapeutic interventions through a “care bundle” approach

10. Principles of improved reliability Understand why LOS varies so much –Benchmarking can help –Variation partly due to variation in clinical care Establish what care processes need to be standardised to achieve more consistent LOS Put in place systems whereby this care becomes the default (care bundles) Establish failsafe mechanisms

11. TREATMENT AREAS OPERATING THEATRES DIAGNOSTICS WALK –IN CENTRE Delivering Quality & Value Systems & Operational Levels PATIENT PATHWAY OPERATIONAL LEVEL SYSTEM LEVEL

12. IMPROVING CLINICAL & SERVICE QUALITY WHILE CONTROLLING COSTS System level  Performance targets  Financial balance  Variation in Practice Operational level  Productivity & efficiency variation  Poor benchmarking Focus on improving and standardising core clinical processes Lean principles to reduce waste and apply best practice

13. Hip replacement Lower quartile – 10 days Upper quartile – 8 days Top 10 performance – 6.3 days If all trusts moved to perform like the top 10 the NHS would save £48.6 million p.a.

14. LOS for Fractured Neck of Femur Variation in LOS for different types of hospital Lower quartile – 19 days Upper quartile – 13 days Top 10 performance – 8 days Potential saving £81.4 million p.a.

15. Stroke Potential saving £74.3 million p.a.

16. Variation in LOS for Caesarian Section Potential saving £49.1 million

17. Initial focus for HRGs - episodes 50 HRGs account for 50% of all Finished Consultant Episodes Cumulative % FCEs by HRG 2003/04 for England 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1101201301401501601 HRG Source : HES % All FCEs

18. How can we improve flow? Ensure access to a bed –Smooth out elective flow Expedite simple discharges (across the week and within the day) –Set the discharge date at admission –Patient tracking to record what needs to be done Make optimum care the default –Standardise care bundles, build in reliability Maintain decision making throughout the week –Delegation of authority every day –Nurse led discharge Getting systems right to achieve discharge –Pharmacy, transport, external partners

19. Defining the optimal clinical process High volume, high variance clinical groups –Cost, LoS, Staff, Supplies etc. Study high and low performance Identify defining characteristics of high performing processes Field test principles Design and package for NHS Potential gain for the NHS with the top 50 HRGs: £1,500,000,000 (approx)

20. Win! Win! Win! Improving and standardising care processes: –Reduces LOS –Reduces staff stress –Improves clinical outcomes Readmissions HCAIs But also:

21. Hogarth’s take on clinical variation

22. Mortality vs Reference costs Source: ‘Pursuing Perfection’ programme No relationship between cost and mortality

23. Applying systems thinking to mortality

24. Some specific interventions Reliability in wards – observations – recognition – responsiveness [hospital at night -> hospital 24/7?] Critical Care Outreach services and ‘Crucial care’ rounds Eliminate medical outliers Eliminate unnecessary delay – access to specialist, higher level care, tests etc Hospital Infection: ‘Saving Lives’ change package High risk medications Decision, planning and diagnostics on admission

25. Blackburn Hospital May ‘04

26. Culture for improvement Changing culture Leadership strategies for openness and mindfulness Measurement demonstrating change is an improvement Staff capability – team working – communication up hierarchies

27. Measuring reliability in Luton Observations on wards improving New focus on responsiveness Testing colour banded EWS and response algorithms Looking at models of outreach / medical emergency teams Focus on increase uptake of ALERT training by doctors

28. The Potential for technology Frimley Park Portsmouth Sydney

29. 3 NHS Trusts, original Community of Practice 295 ‘lives saved’ since April 2004

30. High Impact Change # 6 Increase the reliability of therapeutic interventions through a “care bundle” approach Example for reducing ventilator associated pneumonia: –Elevating the head of the bed >30 o (Drakulovic 1999) –DVT prophylaxis (Cook et al 2001) –Peptic ulcer prophylaxis (Yang & Lewis 2003) –Managing sedation effectively with sedation Holds (Kress 2000) –Tight Control of Blood glucose 4.4-6.1 mils (Van den Berghe 2001) Can be applied to Surgical site infection Central line management Myocardial Infarction etc

31. West Middlesex Hospital

33. Reducing LOS at West Middlesex Guess when the new hospital opened? New Hospital Opened May 2003

34. Reducing Mortality at West Middlesex From 1.2 to 0.93 = ~25% New Hospital Opened May 2003

35. Financial Realism & transparent accountability Clinical purism & Opaque accountability Medicine, management, and modernisation; a “danse macabre”? Pieter Degeling et al BMJ 2003;326:649-652 Systematised conceptions of clinical work Nurse clinicians Nurse managers Medical clinicians General managers Medical managers Individualist conceptions of clinical work

36. Conclusion By increasing the reliability of clinical care we could: Save 10,000 Lives per year Save £1.5 billion per year The 10 High Impact Changes are just a start We can only achieve this by changing our organisations and educating our staff