1. Leading the Best Care...Always! Campaign Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh June 25 th 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. Burden of HAI in LMI countries Prof Shaheen Mehtar UIPC, TBH & SUN Cape Town

4. Situation Analysis of LMI countries There is very little published data relating to HAI but it is recognised that the rates of HAI are higher in LMI countries IPC programmes are poorly supported and established without recognition or career paths for trained IPC practitioners There is little accountability by HCW which lead to inadequate clinical care Clinical commitment is essential under Duty of Care

5. 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: 228-41

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

7. ICU with highest IR: TBH

8. Comparing TBH to meta- analysis SiteMeta analysis Median /1000 device days TBH/ 1000 patient days VAP28ETA1- 3 CR BSI18CVP & B/C0.5-1.3 SSI1.2-23.6/1000 surg opNO DATA

9. Summary By carrying out surveillance a statistically significant decrease in HAI has been noted associated 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 that two people are 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 inforced?

10. 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

11. The impact of Healthcare Associated Infections on the hospitals

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

13. 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 track infection (CAUTI) - surgical site infection (SSI)

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

15. A brief history of systems improvement IHI Lean Overview Andy Brophy (MSc Lean Operations)

16. Quality Improvement requires two Types of Knowledge Subject Matter Knowledge Subject Matter Knowledge: Professional, content, evidence based knowledge. Improvement Knowledge (Deming): The interaction of the theories of systems, our ‘theory of knowledge’, variation in measurement, and psychology. Improvement Knowledge ‘What’ ‘How’

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

18. Improvement Knowledge Subject Matter Knowledge Improvement Knowledge W.E. Deming (1900-1993) System of Profound Knowledge

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

20. 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

21. The power of the system 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 Step 7: Write down the name of a city that begins with your letter Step 4: Add your 2 digits together Step 5: Divide # from step 4 by 3 to get a 1 digit number 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 8: Go to the next Letter: A to B, B to C, C to D, etc. 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 Do you have a 2-digit Number? NO YES Output: Color____________ Animal___________ City__________

22. 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.

23. 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

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

25. Goal 90%

26. Force Field Analysis 1.The current situation 2.The desired situation 3.The situation if no action is taken 4.Forces driving toward desired situation 5.Forces resisting change 6.……

28. Forces in the system keeping hand washing rates where they are Time A B 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 Subject Matter Knowledge 4 fields of interaction - theories of systems - our theory of ‘knowledge’ - psychology of change - variation in measurement Improvement Knowledge

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

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

33. GREAT IDEAS SYSTEM ANALYSIS to identify barriers to care DO STUDY ACT IMPLEMENT SUCCEED/ SUSTAIN PROBLEM PLAN Overcoming barriers at the frontline of care Quality Improvement Mentoring

34. Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement? What are we trying to accomplish? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT

35. Improving many parts of the system at once PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT Bundle 1 Bundle 2 Unit 1 Unit 2 PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT

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

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

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

39. Understanding Variation Walter Shewhart’s (1891-1967) – understanding variation through Statistical Process Control (SPC)

40. Flip a coin

41. JulyAugSepOct 5/713/87/95/10 5/79/98/10 6/712/915/10 11/715/919/10 25/720/10 27/721/10 25/10 ICU: VAP infections 2010

42. Run Charts and Shewhart Charts Measuring change over time - simple yet rigorous tools to distinguish whether change in a system is due to normal variation or a significant change in the system. See the handout on runcharts

43. 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

44. Reacting to Variation

45. Measuring for Best Care….Always!

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

47. 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

48. 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

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

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

51. Infection Rates Total number of infective cases per 1,000 device days: Total No. of VAP cases Ventilator days X 1,000 Numerator Denominator Good for aggregate data but high variation for units when events are rare (<10%)

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

53. Welsh Patient Safety Project

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

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

56. Date of infection # Days since last infection Days Be- tween Infecti on Sequence of Infections

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

58. Number of infections against annual target Laurel SimmonsAssoc. Dir. for Quality Improvement Stockport NHS Foundation Trust Target - 6 for the year (Set for each Hospital for Each HAI by DOH)

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

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

61. 61 Bundle compliance

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

63. Framework for Leading Improvement

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

65. Removing the Status Quo Making the future attractive 1.Set Direction: Mission, Vision & Strategy Setting Direction: Mission, Vision and Strategy PULL PUSH

66. Removing the Status Quo Make the status quo uncomfortable ─There are too many Healthcare Associated Infections (HAIs) 66

67. 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

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

69. 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; 2007. (Available on www.IHI.org)www.IHI.org) Will IdeasExecution

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

71. 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

72. Will, Ideas and Execution Engaging doctors

73. Will, Ideas and Execution Overcoming the implementation gap

74. Multidisciplinary teams

75. Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement? What are we trying to accomplish? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT

76. Accelerating change and improvement through networking and collaboration. Expert Meeting and Planning Group formed Learning session 1 Learning session 2 Repeated improvement cycles: Learning session 3 18 -24 months Mentoring and support

77. Resources BCA website bestcare.org.za IHI.org

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