Mid Staffordshire report

www.ihi.org

Outcome Aims

• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days

between• Central Line Bloodstream Infection: 0 or 300 days

between• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in

range• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction

Managing change.....In a nutshell?

• Have a compelling vision and aim high!• Be sure of your evidence base • Measure, measure, measure!

– The measures are backed by guidance that makes it easier to think through the on the ground requirement to deliver

• Grow knowledge in improvement and reliability science for you and your teams

• Develop a supportive learning community that are trying the same things in different ways and sharing their developments.

The “Quality Curve”

Shift and narrow the curve:What is the norm?Shift and narrow the curve:What is the norm?

Cut the tail:What is unacceptable?Cut the tail:What is unacceptable?

Extend the ambition: What is great? (What is possible?)Extend the ambition: What is great? (What is possible?)

11

22

33

17 years to apply 14% of research knowledge to patient care!

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

“Society’s huge investment in technological innovations that only modestly improve efficacy,

by consuming resources needed for improved delivery ofcare, may cost more lives than it saves.”

“Health, economic, and moral arguments make the case for spending less on technological advances and more

on improving systems for delivering care.”

Source: British Airways (NPSA adapted)

British Airways air safety reports, 1994-99Total reported events

Total events

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1994 1995 1996 1997 1998 1999

High/medium risk events

0

20

40

60

80

100

120

140

Number of reported events: high and medium risk

Sound impossible? – Here are some examples of success

Who they are: Largest Catholic and largest non-profit health system in the US, with 73 hospitals across 20 states and over 100,000 employees

Who they are: Largest Catholic and largest non-profit health system in the US, with 73 hospitals across 20 states and over 100,000 employees

Ascension Healthcare

Source: David B. Pryor MD – CMO, IHI Learning Lab, 12/08/2008

• Focused on 8 ‘Priorities for action’, all with clear measures

• Began with bottom up clinical engagement, by communicating harm and having staff identify goals and opportunities

• Adopted care bundle scoring approach (all or nothing)

• Launched 5 initiatives on ‘how we work together’ (organisational learning and cultural change)

• Provided additional support to poorer performing hospitals from highest performers

• Emphasised the business case for quality

• Focused on 8 ‘Priorities for action’, all with clear measures

• Began with bottom up clinical engagement, by communicating harm and having staff identify goals and opportunities

• Adopted care bundle scoring approach (all or nothing)

• Launched 5 initiatives on ‘how we work together’ (organisational learning and cultural change)

• Provided additional support to poorer performing hospitals from highest performers

• Emphasised the business case for quality

• 1500 fewer deaths in 2007/2008 (unadjusted preventable harm) vs. expected• > 20% reduction in mortality 2006-2008

– 60% reduction in VAP– 60% reduction in birth trauma

– 50% reduction in pressure ulcers

What they achievedWhat they achieved

System VAP rate per 1,000 vent days

01.02.03.0

Month

Jan

Ap

r

Jul

Oct

Jan

Ap

r

Jul

Oct

Jan

Ap

r

Jul

2006 2007 2008

Board actionsBoard actions

2005 Goal: No preventable injuries or death by July of 20082005 Goal: No preventable injuries or death by July of 2008

Primary Outcomes

• Develop and build a quality improvement and patient safety culture in our hospitals

• Build in long term sustainability and capability to drive this approach at all levels

Interventions• Critical Care

– Ventilator acquired pneumonia bundle, central line• Ward

– Early rescue , peripheral catheters, – Communication

• Medicines– Medicines reconciliation

• Theatres– Surgical pause– Infection prevention/control

• Leadership– Safety walkrounds– Executive leadership board patient safety profile

What is a Bundle?

• It is a set of evidence based steps that experts believe are critical 

• Having the steps joined provides a “forcing function.”

• Evidence based medicine Evidence based care delivery

Bundle Implementation

• The steps must all be completed to succeed

• The “all or none” feature is the source of the bundle’s power

• Pass/fail

Peripheral Vascular Catheter Bundle

• Is the PVC required / still in use

• No inflammation or extravasation

• Dressing intact, dated, timed and signed

• Reviewed/ Removed <72hrs

• Hand hygiene before and after

Systems and Processes

Making it easy to do the right thing

“Every system is designed to get the result it gets”

GRI VAP Prevention Bundle Sampled one day per week - varied day

Aim >95% Reliability by May 2009

30%

40%

50%

60%

70%

80%

90%

100%

Jun-

08

Aug-0

8

Oct-08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-09

Dec-0

9

All 4 components ofbundle

30° head up

Chlorhexidine used as part ofdaily mouth care

responsive to command; hadsedation hold; or describedexclusion

described weaning target ordescribed exclusion

AIM - how much by when

Daily Goals Sheet

Head-up redundancy

Script of questions to ask doctors

Re-testing at daily goals: handing script, using script, change daily goals sheet

DG sheet - reformatted,Prompts added

GRI VAP Prevention Bundle Reliability and VAP rate per 1000 ventilator days

Aim: > 95% reliability by March 2009

0

5

10

15

20

25

Aug-0

7

Oct-07

Dec-0

7

Feb-0

8

Apr-0

8

Jun-

08

Aug-0

8

Oct-08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-09

Dec-0

9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ventilator Associated Pneumoniarate per 1000 ventilator days

Median over first 6 months

Ventilator Associated Pneumoniacare bundle reliability (%)

AIM

DG sheet

Script of questions to ask Drs

Retesting at DG sheet; handling sript; change DG sheet

DG sheet change; prompts added

Last VAP 02/01/2009

GRI ICU Percentage had Daily Goals Setand Reviewed > 1 time

0%

20%

40%

60%

80%

100%

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep-0

9

Nov-0

9

Daily Goals Set and Reviewed > 1 time in the day Aim #1 >80% by March 2009, Aim #2 >95% by June 2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-

08

Aug-0

8

Oct-0

8

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-0

9

Dec-0

9

GRI ICU Monthly Average Length of Stay (days)

02468

10121416

Jan-

03

Jul-0

3

Jan-

04

Jul-0

4

Jan-

05

Jul-0

5

Jan-

06

Jul-0

6

Jan-

07

Jul-0

7

Jan-

08

Jul-0

8

Jan-

09

Jul-0

9

Jan-

10

Days

UCL

LCL

Process Avg

Daily Goals & VAP Prevention bundle start

Perioperative Care at Forth Valley:Better Processes

Percent Patients with Perioperative Briefings

Percent Patients with Perioperative Normothermia

Percent Eligible Patients with Perioperative Glucose Control

Percent On-Time Antibiotics

A shift upwards with a new median of 97.7% of the

antibiotics administered on-time

A shift upwards with a new median of 99.5% of the patients within the appropriate range

A shift upwards with a new median of 82.6% of

patients within range

A shift upwards with a new median of 99.6% of the

patients receiving briefings

The Story of NHS Forth Valley Fewer Deaths

A Shift Down

Percent Unadjusted Raw Mortality: A Shift Down

NHS Fife – 24 wards, peripheral vascular catheter bundle compliance

Can we apply the principles to other areas?

• Blood Culture Contamination?

• Sepsis?

• Comprehensive Geriatric Assessment?

Future Developments

• Paediatric

• Primary care

• Mental health

• Heart failure

• VTE

• Pressure ulcers

The Healthcare Quality Strategy for Scotland

• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.

• Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

• Focus on results

• Build capability quickly

• Rationalise measurement

• All improvement is local

• Build a guiding coalition in your context

• Patient voice

• Enjoy the work

Key messages