Carrie Marr

Chief Executive CLINICAL EXCELLENCE COMMISSION

5 August 2016

Emergency Care Institute

Our Quality and Safety Focus in NSW

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CAUTI Human Factors

Socio -Technical Framework for Healthcare

• Senior leadership • Clinical Leadership • Reliable processes of care • Process improvement • Psychological Safety • Effective teamwork • Just and accountable culture • Person and Family Centred Care

GENERATIVE Organization wired for safety and

improvement

PROACTIVE Playing offense - thinking ahead,

anticipating, solving problems

SYSTEMATIC Systems in place to manage hazards

REACTIVE Playing defense – reacting to events

UNMINDFUL No awareness of safety culture

Safety is a process of enquiry

Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2012. www.health.org.uk/publications/the-measurement-and-monitoring-of-safety

Has care been safe

in the past?

Are our clinical systems &

processes reliable?

Is care safe today?

Will care be safer in the future?

Are we responding & learning

& improving?

Highly Reliable Organisations (HRO) Guiding Principles

Openness about failures Emphasis on learning Obligation to act Accountability Just culture Appropriate prioritisation of action Teamwork Leadership

Safety II

• A balanced approach to quality assurance and quality improvement

• Specific and measurable reliable processes for improving care – measurement of reliable application of improvement bundles

• Supporting staff through education and training in quality improvement

• Developing cultural competence in which leaders and staff focus on better care through clinical leadership, teamwork and engagement at all levels

Safety II

• A commitment to listen, learning and partnering with patients, carers and our communities – assuring their full participation in design, redesign, assessment and governance

• Systematic, transparent measurement and reporting of improvement – Quality Boards

• Moving from pockets of innovation to system wide improvement – at scale..

• What is best done State wide and locally? – The Boards responsibility for quality and safety?

• Developing learning systems- learning what is and is not working to help implementation become more successful

• The resources, expertise and architecture to enable the delivery of Safety II – learning from best practice

NSW Patient Safety Alliance

Adult Older Person Paediatric Maternity

& Neonate Mental Health Community

Phase 1 Phase 2

Patient Safety Essentials: Hand Hygiene Safety Huddles Leadership Team Culture

LHD/SHN Safety Priorities: Medicines Safety Falls VAP VTE CAUTI Pressure Injury SEPSIS BTF

CEC Organisational Structure – Functional

CHIEF EXECUTIVE Executive Support Unit

CORPORATE SERVICES

• Strategy • Performance • Corporate Governance • Audit • Workforce / HR • Finance • Corporate services • Communications • Briefs / Ministerials

INFORMATION MANAGEMENT

• IT Strategy • Analytics • Biostatistics • TRIM Records

Management

ORGANISATIONAL DEVELOPMENT

• Organisational Diagnostics

• Cultural competence • Diagnostic Error • Human Factors • Person Centred Care • End of Life Care • Clinical Handover and

Escalation • Team Effectiveness

and Culture

QUALITY IMPROVEMENT HUB

• Incident Management • RCA Committees • Special Committees • QI Academy • Patient Safety

Academy • Improvement

Support Team

CLINICAL GOVERNANCE & ASSURANCE

• Clinical Governance • HAI • QARS • Databases • Bloodwatch • External Reviews • National Q&S

Standards

STRATEGIC PARTNERSHIPS; KNOWLEDGE EXCHANGE

• Evaluation • Research • Publications • Strategic Partnerships • Evidence Analysis

ADULT/OLDER PERSONS PATIENT SAFETY PROGRAMS

PAEDIATRIC , MATERNITY & NEONATAL PATIENT SAFETY

ADULT; OLDER PERSON; AND PAEDIATRIC PATIENT SAFETY PROGRAMS

• Essentials of Safety • Evidence based change packages • Improvement collaboratives • Improvement coaches

Factors used by leading QI organisations to deliver improved outcomes

Build Infrastructure & Capacity

Quality program organisation Education

Leadership development

Priorities maintained during crises Stability of general management and

program management Choosing tools to support staff in their “day job”

of improvement

Program logistics Measurement systems Information systems

Culture: • Will and commitment • Measurement • Evidence based learning • Learning organisation

Ref: Staines 2009

6 Essential Capabilities to Creating High-Performing Organisations

(KP) • Leadership and the ability of leaders to identify the “vital

few breakthrough opportunities” • A systems approach • Measurement capability at all levels • The culture of a learning organisation (with an infrastructure

to harvest best practices for sharing and learning to create potential for spreading practices with the greatest impact)

• Team engagement from the bottom up • A strong internal capability to improve

Bosignano, M & Kennedy, C (2012) Pursing the Triple Aim

Key Learnings

• Moved from counting error to measuring harm and reliability

• Learn from others – “the best at getting better” • Aggregated data does not show the same outcome as

local data • Data for improvement not judgement • Shift from spray and pray to ruthless attention to the

microsystem - where change happens

Experts Senior

Leaders & Boards

Change Agents

(Middle

Managers, project leads)

Everyone

Staff

Teams

Continuum of PI Knowledge and Skills

Deep Knowledge

Many People Few People

What Skills Do We Need?

Source: Kaiser Permanente, 2008

Shared Knowledge

A key operating assumption of building capacity is that different groups of people will have different levels of need for QI knowledge and skill – what will you need people to have?

Our approach will be to make sure that each group receives the knowledge and skill sets they need when they need them and in the appropriate amounts.

Considerations • Do we know how good we are? • Do we know where our waste, unwarranted

variation and harm is? • Do we know how we compare compared to

the best in class? • Do we know what our rate of improvement is

over time?

Our leadership challenge • Our organisational strategy for improving

patient safety and our internal capability to improve?

• Our organisation-wide approach for creating a positive safety culture?

• Ensuring that safety can be better measured and monitored across the organisation?

carrie.marr@health.nsw.gov.au @carriemarr