Leading the Best Care...Always!

Campaign

Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh

May 10th 2011

Cape Town

Agenda

• Welcome• Introductions• Best Care…... Always! (BCA)• A framework for leading BCA• Fundamentals of the QI approach• Measuring for BCA• LUNCH• QI in action• Next steps

Introducing Best Care.. Always!

Dena van den Bergh

The BCA Quality Improvement approach

• Not just protocol• Focus on the implementation gap• All learn all teach• Learning by doing

Accelerating change and improvement through networking and collaboration.

Expert Meeting and

Planning Group formed

Learning session

1

Learning session

2

Repeated improvement

cycles:

Repeated improvement

cycles:

Learning session

3

18 -24 months

Mentoring and support

Framework for Leading Improvement

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)

Will

Ideas Execution

Next Steps

• Hospital visits (data)• Learning sessions

─LS#1 May 25• Monthly mentoring meetings with quality

champions• More hospital visits

Learning Session #2

Carol R. Haraden, PhD • Vice President, Institute for Healthcare Improvement (IHI) • Lead: Safer Patients Initiative (UK)• Lead: Scottish Patient Safety Alliance • Executive lead: IHI Patient Safety Officer Executive Development Program • Institute of Medicine Committee on Engineering Approaches to Improve

Health Care• Associate editor for the journal Quality and Safety in Health Care.

October/November 2011+ Breakout session for CEOs

The Burden of Healthcare-Associated Infection

Prof Shaheen Mehtar

UIPC, TBH & SUN

Cape Town

Situation Analysis of LMI countries

• Rates of HAI are higher in LMI countries• IPC programmes are poorly supported• Little accountability by Health Care Workers• Clinical commitment essential - Duty of Care

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

HAIs are at least 3 x more common in LMI countries

Crude HAI Infection Rate: TBH. Impact of an established IPC programme

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42006 2007 2008 2009 2010

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

4.3

3.9 4.0

3.6

4.4

3.7

3.1

3.6

4.4

3.3

1.5

2.4

3.63.5

3.13.3

2.8 2.7

2.4

2.8

Crude Infection Rates

Infection Rates

Comparing TBH to meta-analysis

Site Meta analysisMedian/1000 device days

TBH / 1000 patient days

VAP 28 ETA 1- 3

CR BSI 18 CVP & B/C 0.5-1.3

SSI 1.2-23.6/1000 surg op

NO DATA

The impact of Healthcare Associated Infections on the

hospitals

The impact of HAIs on the hospitals

• Mortality and morbidity• Lab and pharmacy costs• Antibiotic use• Bed occupancy• Work load

The impact of HAIs on your hospital

• Fill in the column graphs (per hospital)- peripheral vascular catheter-associated infection

(PVCAI)- central line-associated bloodstream infection

(CLABSI)- ventilator-associated pneumonia (VAP)- catheter-associated urinary tract infection (CAUTI)- surgical site infection (SSI)

• Fill in the scale – hand hygiene (each individual

The fundamentals of the Quality Improvement

approach used in BCA

Changing View of Quality

We are perfect!

NO ACTION

Get rid of the bad apples

M&M

Quality Assurance

REACTION

Incident reporting

“Standards”

Patients get “recommended care” ~ 50% of the time.

Adverse events occur in 10% of hospital patients.─ 50% are preventable.─ 7.5% of these patients die.

...the gap between evidence and practice

20

NEJM 2003; 348:2635-2645

Qual Safety in Health Care 2008;17:216-223

Changing View of Quality

We are perfect!

NO ACTION

Get rid of the bad apples

System thinking

M&M

Quality Improvement

Quality Assurance

REACTION PROACTIVE

“Quality”Safe

EffectiveTimely

EquitablePatient-centred

Efficient

Improvement Science

Incident reporting

“Standards” Process Improvement

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’

Improvement

Improvement Knowledge

Subject Matter Knowledge

Improvement: develop effective changes that lead to an improvement.

Langley: Improvement Guide p76

‘Where’

‘How’

‘What’

Improvement Knowledge

Subject Matter Knowledge

Improvement Knowledge

W.E. Deming (1900-1993)

System of Profound Knowledge

Improvement Knowledge

Subject Matter Knowledge

4 fields of interaction - theories of systems - our ‘theory of knowledge’ - psychology of change- variation in measurement

Improvement Knowledge

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

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 thename 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 nameof 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__________

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 MedicineThe Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

Hand washing practice in the PICU

from a Report of a participative observational study done during

January and March 2006Candice Bonaconsa and Minette Coetzee

Child Nurse Practice Development Initiative

Prof Andrew Argent, Red Cross Hospital

Actual x 100 = %

Opportunity

How we did this:

Calculating the % of hand washing

Comparitive Table of Hand Washing - Bed Space

24%

38%

7%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Docters Nurses Other Visitors

Goal 90%

Time Opportunities Used Opportunities %10:00-11:00 12 2 16.711:15-12:15 11 2 18.221:30-22:30 14 3 21.422:30-23:30 7 1 14.314:15-15:15 11 1 9.115:20-16:20 7 3 42.910:45-11:45 28 5 17.911:45-12:45 10 2 20.010:30-11:30 15 3 20.011:30-12:30 8 3 37.511:30-12:30 15 1 6.712:30-13:30 10 1 10.013:30-14:30 5 2 40.014:30-15:30 8 1 12.515:30-16:30 4 0 0.014:00-15:00 19 1 5.315:00-16:00 9 0 0.012:00-13:00 16 1 6.313:00-14:00 10 0 0.0

elsewhere in the hospital …

Forces in the system keeping hand washing rates where they are

Time

A B

Lewin K (1951)Field Theory in Social ScienceNew York: Harper

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 MedicineThe Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

Improvement Knowledge

Subject Matter Knowledge

4 fields of interaction - theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement

Improvement Knowledge

Theory of knowledge

Our understanding of why things are the way they are.

The Implementation Gap

PLAN

IMPLEMENT

FAIL

PROBLEM

EVIDENCE-BASED SOLUTION

“typical” attempts to change

GREAT IDEAS

SYSTEM ANALYSIS to identify barriers to care

DO

STUDY

ACTIMPLEMENT

SUCCEED/ SUSTAIN

PROBLEM

PLAN

Overcoming barriers at the frontline of care

QualityImprovementMentoring

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

Improving many parts of the system at once

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

Bundle 1 Bundle 2Unit 1 Unit 2

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

Improvement Knowledge

Subject Matter Knowledge

4 fields of interaction- theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement

Improvement Knowledge

Psychology of Change

Population

Innovators

Source: E. Rogers. Diffusion of Innovation

Early Adopters

Early Majority Late Majority

Traditionalists

Improvement Knowledge

Subject Matter Knowledge

4 fields of interaction - theories of systems - our theory of ‘knowledge’- psychology of change- variation in measurement

Improvement Knowledge

Understanding Variation

• Walter Shewhart’s (1891-1967) – understanding variation through Statistical Process Control (SPC)

Flip a coin

1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

2

4

6

8

10

12

# heads up in 10 flips of a coin

Consecutive turns

# h

ead

s u

p

July Aug Sep Oct

5/7 13/8 7/9 5/10

5/7 9/9 8/10

6/7 12/9 15/10

11/7 15/9 19/10

25/7 20/10

27/7 21/10

25/10

ICU: Date of VAP infections 2010

MeasurementCommon 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

Reacting to Variation

Measuring forBest Care….Always!

Measurement

• Builds will• Assesses impact• Drives improvement• Keeps the project alive• Sustains the gains

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

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

Measurement for BCA

• Outcome measures (HAIs)• Process measures (bundle compliance)• Balancing measures• Morbidity and mortality reviews

Outcome measures

• the incidence of HAIs• impact of changes made

Infection Rates

• Total number of infective cases per 1,000 device days:

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Good for aggregate data but high variation for units when events are rare (<10%)

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09Jul-0

9

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10Jul-1

0

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

5.57

3.85

5.66

4.21

7.17

4.955.22

2.01 2.10 2.01

3.222.93

3.36

2.58

3.12

2.46

3.48

2.90 2.98

2.082.33

2.17

1.57

2.05

1.67

0.570.85

CLABSI - Infection Rates Per 1000 Central Line DaysLife Healthcare Group - Oct 2008 to Sept 2010

CLABSI-Rate Mean

Upper control limit Lower control limit

Step change after implementation of reporting system and training on BCA in all acute hospitals

Step change after cross functional workshops in ICU's to implement bundle compliance improvement ac-tions and to increase the involvement of Unit Managers in the process

57

Welsh Safety Calendar

IDeveloped by Annette Bartley, Welsh 1000 Lives Campaign

Measuring rare events

Events that occur < 10% of the time

Measuring rare events –days between events

Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana

Date of infection

# Days since last infection

Days Be-tweenInfection

Sequence of Infections

IMeasuring rare events and time-between measures. James Benneyan IHI

Number of infections against annual target

Laurel SimmonsAssoc. Dir. for Quality ImprovementStockport NHS Foundation Trust

Target - 6for the year

(Set for eachHospital forEach HAIby DOH)

Dashboard of measures

Eastern sub-district HIV/AIDS Improvement project reportMarch 2009

Process measures

• Bundle compliance drives the improvement• Target must be set at 95% for each bundle

element and therefore the whole bundle (reliability theory)

Mar

-09

Apr-

09

May

-09

Jun-

09

Jul-0

9

Aug-

09

Sep-

09

Oct

-09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar

-10

Apr-

10

May

-10

Jun-

10

Jul-1

0

Aug-

10

-

2.00

4.00

6.00

8.00

10.00

12.00

14.00

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11.97 12.00 12.66

12.35 11.83 11.82

8.28

12.96

9.78 9.94

6.70

9.06 8.58

10.01

9.17

7.16

5.63

8.61

69%

82%

77%

71%

86%88%

91% 91% 91%89% 89%

92%88%

93% 93% 92% 93%

80%

Ventilator Associated Pneumonias- Bundle Compliance and Infection Rate

Mar 09 - Aug 10

Infection Rate VAP

67

Bundle compliance

A Framework for Leading Best Care….Always!

Framework for Leading Improvement

Leading BCA

Dr Hannes LootsRegional Clinical ManagerWestern Cape RegionMedi-Clinic Southern Africa

(9 mins)