Reducing harm at a national level the scottish story
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Reducing Harm at a National Level:The Scottish Story1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs
November 4, 2013
São Paulo, Brazil
Derek Feeley
Carol Haraden
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“By what method?...
only the method counts”
W Edwards Deming
Emphasis on Method
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Our Change Theory
A clear and stretch goalA methodPredictive, iterative testing
3
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Where We Started:SPSP Outcome Aim Set (2008)
Mortality: 15% ReductionAdverse Events: 30% Reduction– Ventilator Associated Pneumonia: 0 or 300 days between– Central Line Bloodstream Infection: 0 or 300 days between– Blood Sugars within Range (ITU/HDU): 80% or > w/in range– MRSA Bloodstream Infection: 30% reduction– Crash Calls: 30% reduction
4
To be achieved across the nation by 2012Mortality aim amended to 20% by 2015
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Developments in Acute Care Hospitals5
Aims: To Further Improve the Safety of People in Acute Adult Healthcare
1. Reduce Harm95% of people in acute adult health care free from harms in the Scottish Patient Safety Index by 2015:
Cardiac ArrestCatheter Acquired Urinary Tract InfectionsPressure UlcersFalls
2. Reduce Hospital Associated MoralityReduce HSMR by 20% by 2015
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Further improve the safety of
people in Acute Adult Healthcare
Reduce Harm:95% of people in acute adult health care free from harms in SPSI:• Cardiac Arrest• CAUTI• Pressure Ulcers• Falls
Reduce HSMR by 20%
By December 2015
Strategic Priority
Pointof Care
Infrastructure
• Ensure safety and quality are organisational priorities
• Provide leadership & oversight to ensure delivery of programme
• Actively develop your safety culture• Essentials of Safety are
comprehensively implemented
• Reliable person centered response to deteriorating patients
• Reliable recognition & care delivery for patients with Sepsis
• Reliable care delivery for patients with Heart Failure
• Prevent avoidable Pressure Ulcers• Reduce SSI• Reliable risk assessment to prevent VTE• Prevent CAUTI• Reduce Falls• Safer Use of Medicines
• Develop & utilise local capacity & capability in QI
• Effective measurement systems• Programme Management• Effective Communications• Manage transitions of care
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Back to the start: What We Set Out to Improve
Acute Program: 5 workstreamsCritical CarePeri-operative CareGeneral Ward CareMedicines ManagementLeadership for Safety
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How do we improve?
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The Improvement Trilogy
Will
Ideas
Execution
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What We Know Works
Leadership is criticalClear Aim and PurposeStrong TeamThe Use of Data and MeasureTesting on a Small ScaleDeliberate Spread of Innovation
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Three Separate and Critical Competencies
1. Building successful prototypes2. Implementation of the successful prototype3. Spreading the change
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Skills to Support Improvement
Using DataDeveloping a ChangeTesting a ChangeImplementing a ChangeWorking With People
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Critical Care 13
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Care Bundles to Support
Peripheral Vascular Catheter (PVC) Bundle (HPS)Check to ensure the PVC in situ are still requiredRemove PVCs where there is extravasation or inflammationCheck PVC dressings are intactConsider removal of PVS in situ longer than 72 hoursPerform hand hygiene before and after all PVS procedures
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Peri-operative 15
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General Ward 16
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Medicines Management 17
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Leadership 18
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0,8
0,9
1,0
1,1
Oct-Dec2006
Apr-Jun2007
Oct-Dec2007
Apr-Jun2008
Oct-Dec2008
Apr-Jun2009
Oct-Dec2009
Apr-Jun2010
Oct-Dec2010
Apr-Jun2011
Oct-Dec2011
Apr-Jun2012
Sta
ndar
dise
d M
orta
lity
Rat
io
HSMR Scotland: January 2008 -September 2012
8497 less than expected deaths
12.4% reduction
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HSMR – Annual Rolling Averages20
0,8
0,9
0,9
1,0
1,0
1,1
1,1
1,2
1,2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
SM
R
Quarters
HSMR - Annual Rolling AveragesYear Ending Oct-Dec 2002 to Jul-Sep 2012
1.4% (Annualised Reduction)Oct-Dec 2002 to Jan-Mar 2010
4.0% (Annualised Reduction)Apr-Jun 2010 to Jul-Sep
Dec 2009:
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General ward C.Difficile rate (per thousand patient days)
21
0
0.5
1
1.5
2
2.5
Jan-
08Apr
-08
Jul-0
8Oct-
08Ja
n-09
Apr-0
9Ju
l-09
Oct-09
Jan-
10Apr
-10
Jul-1
0Oct-
10Ja
n-11
Apr-1
1Ju
l-11
Oct-11
1.15
0.12
90% reduction
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VAP Prevention Bundle Reliability(average Scottish ICUs)
22
VAP Prevention Bundle Reliability and VAP rate/1000 ventilated days
(average across Scottish ICUs)
50%
75%
100%
Feb-
08M
ay-0
8Aug
-08
Nov-0
8Fe
b-09
May
-09
Aug-0
9Nov
-09
Feb-
10M
ay-1
0Aug
-10
Nov-1
0Fe
b-11
May
-11
Aug-1
1Nov
-11
Feb-
12M
ay-1
2Aug
-12
Nov-1
2
0
6
12
18Better
Better
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Ventilator Acquired Pneumonia Rate23
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Surgical Safety Briefings24
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Scottish Amalgamated Hospital Post-Op Surgical Mortality
25
0,00
0,20
0,40
0,60
0,80
1,00
1,20
1,40
1,60
1,80
Apr
- J
un 1
981
Apr
- J
un 1
982
Apr
- J
un 1
983
Apr
- J
un 1
984
Apr
- J
un 1
985
Apr
- J
un 1
986
Apr
- J
un 1
987
Apr
- J
un 1
988
Apr
- J
un 1
989
Apr
- J
un 1
990
Apr
- J
un 1
991
Apr
- J
un 1
992
Apr
- J
un 1
993
Apr
- J
un 1
994
Apr
- J
un 1
995
Apr
- J
un 1
996
Apr
- J
un 1
997
Apr
- J
un 1
998
Apr
- J
un 1
999
Apr
- J
un 2
000
Apr
- J
un 2
001
Apr
- J
un 2
002
Apr
- J
un 2
003
Apr
- J
un 2
004
Apr
- J
un 2
005
Apr
- J
un 2
006
Apr
- J
un 2
007
Apr
- J
un 2
008*
Apr
- J
un 2
009*
Apr
- J
un 2
010*
Apr
- J
un 2
011*
,p
% M
orta
lity
on D
isch
arge
Quarter of Discharge
P' Chart for Surgical Mortality
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Scotland ICU Mortality Percentage26
0
5
10
15
20
25
30
jan
/…
ma
r…
ma
i…
jul/…
set/…
no
v…
jan
/…
ma
r…
ma
i…
jul/…
set/…
no
v…
jan
/…
ma
r…
ma
i…
jul/…
set/…
no
v…
jan
/…
ma
r…
ma
i…
jul/…
set/…
no
v…
jan
/…
ma
r…
ma
i…
jul/…
Intensive Care Unit Mortality %Units reporting via Extranet Average n = 16
National Average Annual…
14.6%
19.0% 18.3%
16.7%
14.3%
Overall reduction 25%
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Scotland Average Length of Stay27
0
1
2
3
4
5
6
7
jan
/08
ma
r/0
8
ma
i/0
8
jul/
08
set/
08
no
v/0
8
jan
/09
ma
r/0
9
ma
i/0
9
jul/
09
set/
09
no
v/0
9
jan
/10
ma
r/1
0
ma
i/1
0
jul/
10
set/
10
no
v/1
0
jan
/11
ma
r/1
1
ma
i/1
1
jul/
11
set/
11
no
v/1
1
jan
/12
ma
r/1
2
ma
i/1
2
jul/
12
Da
ys
ICU average length of stay15% reduction in median length of stay
average ICU los
median los
4.08 days
4.8 days
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ICU ALOS28
6.2 days
5.1 days
18% reduction(1.1 days)
Cost saving of £990,000
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How’d We Do? NHS Highland
Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in range Harm from Anti-coagulation: Reduction in INRs > 6All process measures will be > 95% reliable
AHO3
Adverse Events
Rate per 1000 pat ient days
.010.020.030.040.050.060.070.0
611
811
1011
1211
212
412
612
AHO3
Adverse Events
Rate per 1000 pat ient days
.010.020.030.040.050.060.070.0
611
811
1011
1211
212
412
612
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
711
911
1111
112
312
512
712
CCP2
VAP Prevention Bundle
Percent
80.0
85.0
90.0
95.0
100.0
711
911
1111
112
312
512
712
CCO1
VAP Rate
Rate per 1000 ventilated days
.02.04.06.08.0
10.0
611
811
1011
1211
212
412
612
CCO1
VAP Rate
Rate per 1000 ventilated days
.02.04.06.08.0
10.0
611
811
1011
1211
212
412
612
CCO2
Central Line Infection
Rate per 1000 pat ient days
.02.04.06.08.0
10.0
611
8 10 12 2 4 612
CCO2
Central Line Infection
Rate per 1000 pat ient days
.02.04.06.08.0
10.0
611
8 10 12 2 4 612
CCO6
Optimal Glucose Control
Percent
70.075.080.085.090.095.0
100.0
611
811
1011
1211
212
412
612
CCO6
Optimal Glucose Control
Percent
70.075.080.085.090.095.0
100.0
611
811
1011
1211
212
412
612
MMP3C Filtered
INR>6
Percent
0.00.10.20.30.40.50.6
711
911
1111
112
312
512
712
MMP3C Filtered
INR>6
Percent
0.00.10.20.30.40.50.6
711
911
1111
112
312
512
712
Process reliability achieves improved outcomes!697 days! 596 days!
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10 Interventions Now Embedded
10 Patient Safety
Essentials
Hand Washing
PVC Bundle
Surgical Brief & Pause
VAP Bundle
CVCInsertion
CVC Maintenance
General Ward Safety Brief
Early Warning Score
ICU Daily Goals
Leadership Walk rounds
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Missing Ingredients31
We needed a partner to help us with design and execution. We needed to overcome clinical (mainly medical) resistance.We needed to convince leaders and managers that this was not just “another initiative.” We needed to start somewhere.
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Solutions32
Improving the safety of patients
Quality of care &
patient safety above all else
Engage & empower
patients and carers
Foster staff development and growth
Embrace transparency unequivocally
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Remember…..33
“Health statistics represent people with the tears wiped off.”
Sir Austin Bradford Hill (1897-1991)