1. Senior Leadership and Direct Service Providers Team Up for Improving Patient Care November 6, 2006 Phil Hassen, Dr. Peter Norton, and Dr. Ward Flemons

2. Campaign To Continue Beyond December 2006 Moving forward with implementation, spread and measurement beyond December 2006 Phil Hassen, CEO Canadian Patient Safety Institute

3. Campaign Structure Partner Network Peer Support Network CAPHC Measurement Working Group & CMT Education & Resource Working Group Clinical Support Canadian ICU Collaborative ISMP Canada Operations Teams Other Canadian Faculty Communication Working Group Atlantic Node Ontario Node Western Node Campaign Support SHN National Steering Committee Secretariat - CPSI Patients CCHSA CIHI Quebe c Node IHI

4. Teams Continue to Enroll

5. Safer Healthcare Now! Enrollment by Province & Territory Province/TerritoryNumber of Teams New Brunswick23 Newfoundland13 Nova Scotia46 Prince Edward Island0 Quebec9 Ontario240 Alberta51 British Columbia98 Manitoba36 Northwest Territories1 Saskatchewan*17 Yukon1 Total535 As at November 2, 2006

6. Push Towards December 2006 Why? Measurement and reporting are integral to demonstrating at the local, nodal and national levels that it is possible to achieve and sustain improvements in the safety of patients within the Canadian health system. * 64.1% of enrolled organizations across Canada have submitted their data to the Central Measurement Team. Goal: Broaden the Campaign’s reach and impact later next year through the incorporation of new interventions that impact other healthcare settings in addition to acute care.

7. Pan-Canadian Survey Purpose: Determine how many teams intend to submit data by December 2006 Identify key challenges/barriers that maybe hindering teams Use the feedback to develop a targeted campaign of support strategies to assist teams Response rate - ~ 41% (156 respondents, representing 208 teams)

8. Pan-Canadian Survey Results Lack of time/resources for data collection 86.2% Lack of staff engagement 41.5% Lack of internal QI knowledge and technical skill to submit measurement forms 30.8% Other (e.g. insufficient population base, ongoing resource challenges) 29.8% Insufficient senior management/clinical leadership support 21.2% Top 5 barriers/challenges identified by teams:

9. Pan-Canadian Survey Results Workshops (e.g. hands on sessions with concurrent tools & data collection, spread strategies) 82.6% Tools to facilitate internal communication (e.g. aimed at Senior management, front line staff) 63.8% Teleconferences (e.g. spread strategies, including internal QI capability) 60.9% More information on the Community of Practice (e.g. sample concurrent data collection tools) 39.1% Facilitate access to the Safety Improvement Advisor 30.4% Top 5 Responses to: “which resources would you find helpful?

10. Phil Hassen Canadian Patient Safety Institute Suite 1414, 10235 – 101 Street Edmonton, AB T5J 3G1 (780) 409-8090 or 1.866.421.6933 For additional information please contact: Debbie Barnard, SHN Project Manager @ dbarnard@cpsi-icsp.ca www.patientsafetyinstitute.ca

11. A story – SSI in the Calgary Health Region Dr. Peter Norton University of Calgary

12. SSI – Calgary Health Region 3 adult urban acute care sites Antibiotic timing project not sustainable Focus on total joints to begin Correct timing tended to be 30% or less Process measures vs. outcome measure

14. 'If you cannot MEASURE it, you cannot IMPROVE it'. Lord Kelvin, International Electrotechnical Commission’s first President (1906)

15. How good is our health care system? What is the “Defect Rate”?

16. Key Numbers from the Canadian Adverse Events Study The overall AE rate found in the study was 7.5% [CI 5.7 - 9.3] – this means 1 in 13 adult hospital patients in year 2000 experienced an AE 2.8% of patients had one or more preventable AEs [CI 2.0 – 3.6] (i.e. 37.3% of AEs are preventable) Preventable AE rates were the same across the 3 hospital types An estimated total of 1.6% of people hospitalized in Canadian hospitals in 2000 had an AE and died [CI =0.9 to 2.2%] or approximately 16,000 per year [CI= 9250 to 23, 750] Assuming an average LOS of 3.5 days and 95% occupancy, then a 500 bed Canadian hospital would have an average of 100 preventable AEs per month

17. Defect rate of 25%+ Health Quality Council of Saskatchewan, 2004

18. Ambulatory Care In 2004 Manitoba researchers lead by A. Katz used administrative data in a study They measured the proportion of eligible patients received 13 types of recommended care in the Winnipeg Health Region Only 37% of diabetics saw on ophthalmologist or optometrist the last year Only 35% of patients with a 30-day supply of anticoagulants who at least one blood clotting test in 45-days A. Katz, et. al. Using Administrative Data to Develop Indicators of Quality in Family Practice. Winnipeg: Manitoba Centre for Health Policy, 2004. http://www.umanitoba.ca/centres/mchp/reports/pdfs/quality_wo.pdf

19. What do the Citizens say? 2004 Commonwealth Fund International Health Policy Survey in Australia, Canada, New Zealand, the United Kingdom, and the United States Adults 1400 per country and 3061 in the UK Schoen C, et. al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood). 2004 Jul-Dec;Suppl Web Exclusives:W4-487-503.

20. Rank 1 is best, 5 is worst Australi a Canada New Zealand UKUS Patient Safety 2.54 15 Patient- Centerednes s 23154 Timeliness 25143 Efficiency 14235 Effectiveness 4.52.5 14.5 Equity 24315 Slide from Don Berwick August 2005

21. When you need care or treatment, how often does the doctor tell you about treatment choices and ask for your ideas/opinions?

22. In the past 2 years doctors ordered a medical test that you felt was unnecessary because the test had already been done

23. Went to ER for a condition that could have been treated by regular doctor or source of care if available

24. Last time you were sick or needed medical attention, how quickly can you get an appointment to see a doctor?

25. The Goal is Clinical Effectiveness "The best possible Health Care" An environment where all patients can consistently say: "I got exactly the care I was in need of exactly when I needed it!"

26. Clinical Effectiveness- Definition  Evaluating and improving health care delivery and enhancing patient outcomes through the collaborative application of best available clinical evidence  Identifying the most appropriate, ethical and cost-effective means of providing health care services

27. Compliance-Driven Quality Management Reactive in nature Designed to meet standards Clinicians often not engaged in process Clinician leadership not essential Indicators become the goal Difficult to sustain clinical improvement over time & across organization

28. Patient-Centered Clinical Effectiveness Proactive in nature Evidence-based foundation Clinicians actively engaged in process Clinician leadership critical to success Best and safest care as the goal, indicators as markers of success Sustainable improvement over time and across organization

29. Achieving Clinical Effectiveness “This time, like all times, is a very good one, if we but know what to do with it” - Ralph Waldo Emerson

31. Safer Healthcare Now! Implementation of six targeted and proven interventions in hospital based patient care Credible evidence that these six interventions can make a real difference in reducing avoidable adverse events and lead to reduced mortality and morbidity All are ‘low tech’

32. The Interventions Deployment of Rapid Response Teams Delivery of reliable, evidenced based care for acute myocardial infarctions Prevention of ADEs Prevention of central line infections Prevention of surgical site infections Prevention of ventilator- associated pneunomia

33. Eg. Surgical Site Infections Four specific activities –Don’t shave the skin but clip the hair –Make sure prophylactic antibiotics are given (and stopped) on time –Carefully monitor and control the blood sugar during the operation –Carefully monitor and control the body temperature during surgery

34. Key Campaign Principles “Some is not a number; soon is not a time.” Welcome anyone at any level. We do this together (i.e. we are forming ‘communities of practice’)

35. Some successes Several organizations with no VAP for six months Several pediatric hospitals with no CL infections for six months Early indications of reduced mortality in the ICUs of several hospitals

36. Why Participate in SHN? “To not participate is not an option, It is not about spending additional health care dollars, rather it is about our obligation to provide a safe clinical experience for the patients who walk through our doors and put their trust in us.” David Rowe, Senior Vice-President, Credit Valley Hospital, Ontario. “The SHN has provided us with leadership and coordination of the interventions. As well, there has been excellent information sharing and collaboration with those participating in the interventions within and across the nodes.” Kim Cook, Vice-President of Patient Services & Chief Nursing Officer, Headwaters Health Care Centre, Alberta.

37. Organizational Leadership & Accountability W. Ward Flemons MD FRCPC FACP Vice-President Quality, Safety & Health Information

38. Strategy for Quality Quality Assurance Quality Improvement  Structures  Processes Every system is perfectly designed to produce the results that it gets. If you want improved results you must redesign the system. Paul Batalden / Don Berwick

42. Quality Management Cycle

43. Safer Healthcare Clinical Process Improvement  Designing for Higher Reliability

44. Improved AMI Care Clinical Process Improvement  Designing for Higher Reliability

45. Reliability – Improving Performance Measured as the inverse of failure rate  10 -1, 10 -2, 10 -3, 10 -4, 10 -5, 10 -6  Example: Reliability of administering prophylactic antibiotics in surgery Nolan T, Resar R, Haraden C, Griffin F. 2004 Improving the Reliability of Health Care. IHI Innovation Series White Paper Three Step Model 1. Prevent failure a breakdown in operations or functions 2. Identify and mitigate failure identify failure and intercept before harm or mitigate harm 3. Redesign processes based on the critical failures that are detected

46. Three Step Model Prevent Failure  10 -1 Performance starts with an intent to follow a uniform process or guideline basic standardization – common equipment / order sheets / guideline memory aids (e.g. checklists) feedback mechanisms (e.g. compliance with standards) awareness raising and training Identify & Mitigate Failure  10 -2 Performance (error proofing) building decision aids into the system creating redundancy / using defaults designing protocol into the usual workflow process strategies to identify failures to use the process ‘Identification Trigger’ design mitigation strategies Redesign  10 -3 Performance analysis of failures to use the standard care protocols where is it failing and why? (failure modes and causes) cycle of continuous quality improvement real time measures of performance & accountability

47. Do Healthcare Organizations need a QI Strategy?

48. Where does QI fit into the agenda? Should be strategic (it’s core business)  Not off the side of someone’s desk  Executive & Board Accountability Needs to be resourced Needs to have strong leadership  Understanding of the concepts  Top-down QI doesn’t work  Bottom-up QI can have some short-term success  Model of engagement Sharp end (Direct Care Providers)  MULTIDISCIPLINARY! Blunt end (Management)

49. To improve quality document continuous improvement (process steps) (outcomes) eliminate inappropriate variation Brent James

50. QUALITY IMPROVEMENT STRATEGY PERFORMANCE MEASUREMENT BUDGETING (PBMA) INDICATORS

51. QUALITY IMPROVEMENT STRATEGY PERFORMANCE MEASUREMENT BUDGETING (PBMA) INDICATORS STRATEGIC PERFORMANCE MEASUREMENT

52. Improving Quality Clinical Process Improvement  Designing for Higher Reliability What Clinical Outcomes?  Gap analysis (low hanging fruit) Solid evidence about what could (should) happen What is currently happening? What Clinical Processes?  Solid evidence about impact on outcomes Who Decides?  Clinicians who understand evidence based care  Management who sign the cheques

53. Improving Processes  Outcomes Medication Reconciliation Acute Myocardial Infarction Surgical Site Infection Ventilator Associated Pneumonia Central Line Infection Structures  Outcomes Rapid Repsonse Teams Setting Priorities

54. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo From:: Associates in Process Improvement

55. QI Projects - Accountability Executive Sponsor – CEO / VP Medical / VP Acute Care / Exec Director Planning & Evaluation  Can send a strong message of the importance of this project to the organization  Follow outcome and process measures Administrative Sponsor  Direct accountability for the results of this care  Director / Chief of Cardiology Project (Team) Lead  Understanding of QI / Change Management  Understanding of the clinical context  Leadership skills Project members  Reps from all disciplines that are involved in the processes

56. Example – Improved Care for AMI Executive Sponsor  CEO / VP Medical & VP Acute Care Adminstrative Sponsor  Chief of Medicine / Cardiology  Director of Medicine Project Lead  PCM / APCM of Cardiology unit / CCU Project Team members  MDs – Internist / Cardiologist / Emerg  Nursing – Emerg / Medicine  Pharmacist  Unit Clerk  EMT  Discharge Coordinator  Patient Educator

57. Example – Improved Care for AMI What are you trying to accomplish?  Reduce AMI 30 day mortality by _____ %  Improve the reliability of 6 clinical processes How will you know that a change is an improvement?  30 day mortality Define & collect data for the numerator/denominator  Reliability of (Percentage of patients receiving) Components - Delivering each of the 6 components of care Composite – delivering all components What changes can you make that will result in improvement?  Change package  AMI Getting Started Kit

58. Accountability – Measures over Time

60. 1 st Test Cycle 2 nd Test Cycle

61. VAP – outcome & process measures

62. Getting Focused Accountability Place the measures in the Corporate Scorecard Commit to an improvement target (be bold) Put into Performance Agreements  CEO  Board  VPs  CEO  Directors / Dept Heads  VPs

63. Organizational Risks Understanding (or lack thereof)  How to implement a QI agenda  QI tools  Time commitments (People / Organization) Expectation of quick wins Viewed as ‘flavour of the month’ Leadership (or lack thereof)  Executive  Quality Improvement