1. Making it happen Improving quality to improve productivity The Great Ormond Street Hospital for Children Experience Can it really be done?

2. © Great Ormond Street Key note Lord Howe  Aim to achieve best outcomes but using less  Pay freeze  Innovation and creativity  Aim to combine work of on care with levels of equity, excellence in clinical outcomes, free from micro management from above from a whole top down system – a system that progress of what we can do  Way forward is to have ideas flowing from the bottom up form innovation and creativity

3. © Great Ormond Street Some of the key changes  Structural change PCTs and replacement by GP consortia – align clinical decision making with funding  All foundation trusts and competition  Open health market to any willing provider – benefits of competition  Devolve power to the front line  Improve quality and release funds  Improve quality –patient empowerment clinical leadership and competition

4. © Great Ormond Street Key question to be answered Can we look at ways of delivering health care at lower cost and with increased productivity (or value) while we increase quality and safety? (4% per year)

5. Most health care today is sought, created, delivered and purchased at the level of the clinical micro- system. It is there that real gains in the quality, value, and safety of care can occur.  Integration of information  Measurement of outcomes  Interdependence of the care teams  Supportiveness of the larger system  Constancy of purpose  Connection to the community and client involvement  Investment in improvement – want to be better  Alignment of role and training with improvement methods More on micro-systems J J Mohr and P B Batalden: Improving safety on the front lines: the role of clinical micro-systems 2002;11;45-50 Qual. Saf. Health Care

6. © Great Ormond Street Is there evidence? “Does improving quality save money? Sometimes, but sometimes not, and mostly we do not know because the research is limited. There is a great potential for savings, but it depends what we mean by quality improvement, who makes the savings and when.”

7. © Great Ormond Street Spending more does not improve quality CMS data: Higher spending states have poorer quality Source: Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.

8. The GOSH strategy - aiming for high reliability and zero harm

9. High reliability means the patient gets exactly the treatment needed when it is needed and how it is wanted …..every time

10. No waits No waste Zero harm Working together GOSH transformation

11. © Great Ormond Street Increasing productivity needs a platform  Leadership  Knowledge - improvement methodology and skills  Information  Data  Understanding the problem  Resource to implement change  Redesign of services

12. © Great Ormond Street Zero Harm interventions Increase productivity and value by increasing safety

13. © Great Ormond Street Work program for Zero Harm Work Stream ProcessOutcome Critical CareVAP prevention bundle CVC bundles Daily Goals Reduction in VAPs Reduction in BSIs Improved communication WardsPaediatric Warning Systems Hand Hygiene Safety Briefings Recognition of deterioration Reduction in HAIs Improved communication Peri-opeativeOn-time Antibiotics Surgical Pause WHO Checklist and briefing Surgical Site Infections Reduction in surgical incidents Improved culture Medicines ManagementMedicines Reconciliation Dosage calculations Reduction in adverse drug events LeadershipWalkRounds Safety strategic priority Culture of Safety

14. Central Venous Line (CVL) Infections Relaunch of CVL Care Bundles Practical Annual IV Competency Update & 2% Chlorhexidine/70% Alcohol Skin Disinfection 2 % Chlorhexidine/70% Alcohol Hub Disinfection Introduction of annual IC audit programme

15. © Great Ormond Street Impact of decreasing infections  Each infection costs from £5000 - £10000  Decrease in line infections from 30 per month to less than 10 per month saves up to £200000 per month  Decreased length of stay  Decreased use of time  Improved patient experience  Ability to reinvest in other activities

16. © Great Ormond Street Cost of medication errors The direct cost of medication errors in NHS hospitals may be £200 - 400 million per year. The potential savings from reducing serious medication errors are therefore substantial. Improving medication Safety DoH 2004 Researchers conducting an AHRQ-funded study at Brigham and Women's Hospital and Massachusetts General Hospital found that, on average, ADEs increased the length of stay by as much as 4.6 days and increased costs up to $4,685 Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277(4):307-11.

17. © Great Ormond Street Medication error reduction PICU

18. PICU prescribing

19. CICU completed charts

20. CICU drug errors/prescription ratio

21. CICU drug error per patient ratio

22. © Great Ormond Street No waits and waste by eliminating variation  Improving productivity by decreasing flow failure  Decrease waiting in outpatients  Advance Access Programme  Decrease waits for procedures  MRI, interventional radiology etc  Decrease waste from variation

23. © Great Ormond Street Ways to improve productivity  Reduce length of stay  Expand capacity  Expand staff  Increase bed capacity and utilisation Or Increase flow by elimination of variation

24. © Great Ormond Street Can we understand variation?  Natural variation – must be actively managed  Clinical stress affecting patient safety  Stress by variation in professional abilities or teaching responsibilities affecting both safety and efficiency  Artificial variation – must be eliminated  Flow stress affecting efficiency

25. © Great Ormond Street Can our health care delivery system become a Toyota product line? What about Lean on its own? No Patients do not arrive at the same rate with the same acuity and providers are of unequal ability.

26. © Great Ormond Street GOSH Admissions By Date Program for Management of Variability in Health Care Delivery Boston University Health Policy Institute

27. © Great Ormond Street Admissions By Urgency and Date Program for Management of Variability in Health Care Delivery Boston University Health Policy Institute

28. © Great Ormond Street Discharges by Date: Non-holiday Weekdays

29. © Great Ormond Street Theatre Cases by Date: Non-holiday Weekdays Only Program for Management of Variability in Health Care Delivery Boston University Health Policy Institute

30. © Great Ormond Street Summary  While day case patients comprise majority of admissions, true inpatients have most impact  Substantial variability in elective admissions  Theatre cases comprise large majority  Wasted bed & theatre capacity  Improved scheduling of elective admissions, especially theatre cases, needed

31. © Great Ormond Street Recommendations 1. Central management of admissions 2. Establishment of a central ‘patient flow team’ 3. Central management of operationally-relevant information systems 4. Improve collection and reporting of flow data 5. Separate emergency and elective beds 6. Separate resources for day case and inpatients 7. Determine best management strategies for ‘high utiliser’ patients 8. Reconfigure wards into larger units

32. And how have we responded?

34. © Great Ormond Street

35. The gain – 14% in activity at no cost

36. © Great Ormond Street Cancellations

37. © Great Ormond Street Patients : Reduced waiting time and improved access to care Reduced mortality and medical errors Nurses: Reduced overtime Reduced workload Outcomes

38. © Great Ormond Street What do we need to do?  Decrease harm – adds value and decreases waste  Eliminate variation – redesign services to do more for less  Consider areas where you do not know how to solve the blocks in the system  Emergency room  Inpatient beds  Diagnostic procedures  Operating room  Outpatients