One small step for man … … The Model for Improvement ( keep it small and simple )

1. SSC COMPONENT QUB MEDICAL STUDENTS: FRIDAY, 17 FEBRUARY 2012 One small step for man … … The Model for Improvement (keep it small and simple)

2. TODAY YOU WILL: • Be able to outline the background to patient safety in health and • social care • Have a basic understanding of the person vs system approach • to error • Explain the Model for Improvement and be able to apply this • to a specific example

3. 1 in 10 = 551,000; 55,000, more likely 3 in 10 = 165,000 -

4. ‘Crossing the quality chasm’ (IOM, 2001) “Between the healthcare we have and the healthcare we could have lies not just a gap, but a chasm” • Why? Little reliability (80%) despite best intentions • Best-known science is not reliably applied (60%) • Widespread inefficiencies waste precious resources (20%) • Patients are being harmed at alarming rates (10%; 30-40%) • Failure to recognise, to rescue, to plan, to communicate • Variation in practice (ie inappropriate variation not determined by patient need) • So we work on… • Not the individual (blame, myopic view): ‘to err is human’ – • “we cannot change the human condition, but we can change the conditions under which humans work” (James Reason);but on • The system!

5. Patient level view Get in Get diagnosed Get treated Get out Get on Acute care SAFELY Systematic accurate diagnosis, early intervention, implementation of practices that are known to be safe and moving patients effectively along a care pathway* *Health Commission Report: Safe in the Knowledge, 2009

6. Vision - STEEEP • No needless deaths, harm or suffering • No delays • No waste • No feelings of helplessness S AFE T IMELY E EFFECTIVE E FFICIENT E QUITABLE P ATIENT CENTRED

7. Life is variation… • Variation is intrinsic in health care. It is the result of clinical variability (number of patients presenting with certain clinical conditions), flow variability (the ebb and flow of patients arriving throughout the day), and professional variability (the variation in skill levels and techniques among providers). • Some kinds of variability (so-called “random variability”) cannot be eliminated, or even reduced; they must be managed. This is true of patient variability. We cannot eliminate the many types of problems from which patients suffer, nor can we control when they arrive in the emergency department. • Other types of variability (“non-random”), on the other hand, are often driven by individual priorities, resulting, for example, in surgical schedules that are heavy on Wednesdays but light on Fridays due to surgeons’ preferences rather than actual demand. Non-random variability should not be managed; it should be eliminated.(Ref: IHI – Optimizing Patient Flow, 2003)

8. Could operation process improvement provide transformation in the NHS? Defining Domains of Quality Problems Overuse - Examples of include hysterectomies, cardiac catheterizations, tympanostomy, antibiotics, tranquilizers, sedatives, carotid endarterectomy, cardiac pacemakers, upper gastrointestinal endoscopy, and non-steroidal anti-inflammatory drugs Underuse - Example, providers routinely fail to administer a variety of evidence-based tests and treatments to heart attack victims and individuals with diabetes and congestive heart failure. Misuse - Medical errors represent the most common form of misuse within the health. Examples drug misuse, hospital-acquired infections, diagnostic, surgical errors, and incorrect use of medical equipment. Waste -unnecessary administrative activities is prevalent. In addition to driving up costs, waste can have a direct negative impact on service quality (e.g., waiting times), clinical quality, and access to care. Waste may also crowd out needed spending in other areas of health care.

9. Patient Safety Incident • Any unintended or unexpected incident/s that could or did lead to harm for one or more patients

10. Cost of Adverse Events • Patients and families • Healthcare staff -the second victims • Financial-additional hospital stays alone estimated to cost £2000m annually in UK

11. The perception… • If a professional is highly trained and tries hard enough he/she will not make errors • the punishment myth if we punish people when they make errors they will make fewer of them

12. The reality… • Human beings carrying out complex and risky procedures in our time pressurized healthcare organisations will make errors • 95% of errors that cause harm involve conscientious competent individuals trying hard to achieve a desired outcome –only 5% of harm is caused by incompetence or poorly intended care • We all make errors irrespective of how much training and experience we possess, or how motivated we are to do it right

13. We all make mistakes

14. How to think of error? • An individual failing • Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis • It will not solve the problem--it will probably in fact make it worse because it fails to address the problem • Professionals will hide errors • May destroy many staff (inadvertently (the second victim)

15. How to think of error? • A systems failure • This is the starting point for redesigning the system and reducing error “Every system is perfectly designed to get the results it gets” The First Rule of Improvement

17. SWISS CHEESE MODEL (James Reason - 1990)

18. Key Elements of Breakthrough Improvement • Will to do what it takes to change to a new system • Ideas on which to base the design of the new system • Execution of the ideas

20. Im “Improvement requires a will to improve, Ideas to test and execution of a plan” Frank Frederico, IHI, Doug Bonacum, Kaiser Permanante Health Exec., Jan 2010

21. 5 P’s Purpose What is the role of the team and what are you trying to achieve. Professionals Processes Patients • Who contributes to the service / care e.g.:- • Ancillary and General • Nursing • Doctors • AHPs Who is the service / care provided to / for. How are the services planned What are the current practices and procedures you use Patterns What do you know about how well your service performs e.g.:- Length of stay Pt satisfaction Staff Rotas Clinical Risk Complaints Team Meeting Have you sufficient information to identify areas for service improvement No Yes Review analysis gaps and measure as required Move to Stage 2 This model has been adapted from the Dartmouth Institute

22. Identified areas for improvement Identify themes Theme3 Theme 4 Theme 5 Theme 1 Theme 2 • Prioritises themes (Consider) • What matters most to patients and staff • Time and effort • Corporate Objectives Yes No Clearly identified area for improvement Move to Stage 3 Review analysis as requiredr

23. The Model for Improvement Thethreefundamentalquestions forimprovement What are we trying toachieve? Constructing a clear aim statement How will we know that achange is an improvement? Choosing right measures and planning how you will collect right information Coming up with ideas on how to improve current state: evidence, hunches,other people etc. What changes can we make that will result in the improvements we seek ? Act Plan The fourthquestion:how to make changes - testing Study Do Langley, Nolan et al 1996

24. FORM THE TEAM • Leadership Support • System Leadership • Clinical Technical Expertise • Day to day leadership

25. SET AIMS • Agreed by Improvement Team • Time specific • Measurable HOW MUCH, BY WHEN?

26. ESTABLISH MEASURES How do we know a change is an improvement? • Process measures • Outcome measures • Balancing measures

27. Why we measure

28. 1. Decide Aim The Seven steps to Measurement are: Step 1 - Decide your aim Step 2 - Choose your measures Step 3 – Define your measures Step 4 - Collect your baseline data Step 5 - Analyse and present your data Step 6 - Meet to decide what it is telling you Step 7 - Repeat steps 4-6 each month or more frequently 2. Choose measures 3. Define measures 6. Review Measures 4. Collect data 7. Repeat Steps 4-6 5. Analyse + present In God we Trust, all others bring Data … …

29. MEASURES contd. • PROCESS: (Losing weight) • Number of visits to gym each week, • Number of walks per week, • Number of calories lost per day/week • PROCESS:(Ventiliator acquired pneumonia bundle) • Elevation of head of bed between 30 and 45 degrees • Daily awakening: “sedation vacation” • Daily assessment of readiness for weaning • DVT prophylaxis (unless contraindicated) • Stress bleeding (peptic ulcer) prophylaxis

30. MEASURES contd. • Outcome: • Number of pounds lost per month • OUTCOME: • Reduction in Ventilator acquired pneumonia rate • OUTCOME: • Reduction in deaths each year from stroke

31. S + P = 0

32. MEASURES contd. • BALANCING: • Reduction in hours of sleep • BALANCING: • Increasing Re-Admission rates • BALANCING: • Increase in Waiting times in A&E

33. SELECT CHANGES • An understanding of processes and systems of work • Challenge boundaries • Adapting known good ideas • Re-arrange order of steps • Smooth work flow

34. TEST CHANGES • Plan • Objective • Questions and predictions • (why?) • Plan to carry out the cycle • Plan for data collection • Act • What changes are to • be made? • Next cycle? • Study • Complete analysis of data • Compare data to predictions • Summarise what was learned • Do • Carry out the plan • Document problems and • unexpected observations • begin analysis of data

36. Multiple PDSA Cycles Directed Toward a Single Aim • AIM Concept D Concept C Concept A Concept B

37. TIPS • Do not be tempted or • pressurised into implementing • or spreading until you have • achieved a reliable process • that is fit for purpose and • your are happy with • Collate your PDSA cycles • and when you spread so • they can understand what • processes, predictions, and • tests they went through that • lead to share them with • other areas change

38. IMPLEMENTING CHANGE • From PDSA to SDSA • Only implement what you know is an improvement • Communication • Consider impact on people • Consider infrastructure

39. Tips for Improving Sustainability • Be clear about the benefit to stakeholders • Winning hearts and minds, “what's in it for me?” • Pay attention to ongoing training and education needs • See how you can contribute to building the improvement into the structure of your organisation and make it the new standard • Build in ongoing measurement • Work towards making sustainability mainstream • Is it someone's responsibility? Has resource been allocated? • Celebrate, renew and set the bar higher

41. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996 • Achieving Safe and Reliable Healthcare; strategies and solutions. M Leonard, A Frankel, T Simmonds • Improving the Reliability of Healthcare. Institute for Healthcare Improvement Innovation Series 2004 White Paper. Available free at www.ihi.org • Quality by Design: A Clinical Microsystems Approach. E Nelson, P Batalden, M Godfrey • To Err is Human: Building a Safer health System” Kohn LT • Clinical Microsystems Website: Dartmouth Institute: http://cms.dartmouth.edu/ • National Patient Safety Agency website: www.npsa.nhs.uk • Patient Safety First campaign – www.patientsafetyfirst.nhs.uk • 1000 Lives Welsh Patient Safety Campaign – www.wales.nhs.uk • Scottish Patient Safety Programme: http://patientsafety.etellect.co.uk/programme • Institute for Healthcare Improvement: www.ihi.org

42. CONTACT DETAILS: Janet Haines-Wood, Regional Patient Safety Advisor, HSC Safety Forum janet.haines-wood@setrust.hscni.net Tel: 02892665181, Ext 4819 Levette Lamb, Regional Patients Safety Advisor, HSC Safety Forum levette.lamb@setrust.hscni.net Tel: 02892665181, Ext 4817 HSC Safety Forum Website: http://www.publichealth.hscni.net/directorate-nursing-and-allied-health-professions /hsc-safety-forum