Patient safety- what works?

4th June 2009

See safety folder on web site http://homepage.mac.com/johnovr/FileSharing2.html

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John Øvretveit,Director of Research, Professor of health innovation and

implementation, Karolinska Medical Management Centre Sweden and Professor of Health Management, Faculty of Medicine, Bergen University

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Once upon a time…

In a parallel universe…

Not so far from here…..

Dr Anna Johansson,

Director of Internal Medicine, Shockholm sjukhus.

Unusually,

called Jon Tviet over

Director of research, Katolinksa Medical School. (You know that look when…)

Wanted to know, “We’ve got to improve patient safety…

– quickly, cheaply, saving the most suffering, and costs”

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Don’t complicate things – what works…?Proven safety solutions recommended or mandated by authoritative bodies

(See SDO safety folder on web site)

Do you use any of these? AHRQ 2001 – The first 11 “Nike no-brainers” – just do it!

NQF top 30

IHI 100k and 5m lives solutions (& country versions)

WHO list

Joint commission safety goals

ACHS etc & …You pays your money…t

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Clinical safety practices: changes for common problemsTwo of 11 AHRQ 2001 “just do its” (others in the 680p report)

Ø Antibiotic-impregnated central venous catheters to prevent infection

Ø Pressure relieving bedding materials to prevent pressure ulcers.

Inappropriate prescribing for people over 65

Information on medications for patient transfers (NCH (2000))

Every patient, every time, every place as appropriate?

What’s the cheapest?

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Katolinska Sjukhus toilets – quick/low cost video cams & poster

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Katolinska Sjukhus

Good cost/effectiveness – direct communication with patients

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We will do these 2 because these are a problem for us

1 Infection rates: Antibiotic prophylaxis

2 Failure to rescue (arrests, emergency admit to ICU): critical care outreach team

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How do you know these work?Evidence: see Øvretveit, 2004, 2007, 2009 reviews

of research for WHO and SKL

2) Antibiotic prophylaxis

Clinical trial standardised full implementation and excluded other explanations : intervention to physiology – “mechanical” causal pathways

Critical care outreach team

Less sure: social intervention to social system – people are unpredictable, especially when together…

Not fully implemented, long pathway, but makes sense!10

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You have not convinced me, but to sell to my colleagues:

Would it work here?

How much would it cost?

and what’s effective for implementation?

Little research on this

Effective implementation to get the changes?

Which contexts necessary or help and hinder?

Probable that supportive context more important than you or implementation strategy

Come with me to see the CEO, to get this…

But keep it simple…11

Sven Angstrom: the Dr Darth Viking of Shockholm sjukus & the Local Context King

Look at this research Dr Darth….

Jon, do you have a cat…

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Can you grow pineapples in Shockholm?

Seed Gardener/planting & nurture Climate / soil

The point is, choose plants you see growing in similar environments – and change which aspects of climate you can

Can Darth change the micro or macro climate?

Anna, supported by Darth

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Say again Jon?

Environment + Evidence +Implementation = Quality

Supportive infrastructure + Proven change

+ Effective implementation = Higher

quality

Anna needs help with the context bit…that’s Darth’s department…

Later… back at the Katolinska Research Centre …Jon calls together the research group

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Jon enthuses the research team - we can make a difference…

Fantastic opportunity – no research on this:

1)Before/After complex changes: effective?

2)Implementation strategies: effective for getting the before/after change?

3)Supportive contexts: group, departmental, organisational, external - what is necessary to help the implementation?

4) Also, not just evaluation & implementation research Eg patients view about how to involve them in improving safety

(choose 2 – quickest and lowest cost?)

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Other points about safety – post modernist writer in residence

Intervention is not separate from context

Many influences on result variables you study

Intervention is one, and it interacts with context

Research “draws a boundary” between the intervention and context To assess how influential intervention is on outcomes vs other

influences

Don’t confuse your model with reality

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Research points - 2

Theory informed evaluation – models of intervention in context: next is one example

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1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Theory informed evaluation – safety interventions evolve in context

Actions: planning and preparations

Result: agreed care goals, three shared centres and joint management

Planning Innovation Further development actionsEstablished

Actions to develop coordinated client/patient care planning system & other systems & procedures >>>>>>>>>>>>

Context factors help and hinder implementation at different timesGovernment policy helps planning

Intermediate results: coordination structures and changes in personnel behaviour

1996 2000 2004 2008

Results : Consequences for personnel

Results: Consequences for clients

Hindrances for us researchers:

More silos than in health organisations

Academic departments, disciplines

Ownership and branding wars confuse terminology Makes communication between disciples for MD and

MM research more difficult

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Johns safety research wish list

Incidence and solutions to AEs outside of hospitals PHC, Nursing homes

The “in-betweens” – transitions and entire episode of care

Costs of adverse event, Cost of 50% solution, Saving (MMC “saving suffering campaign” )

Second victim impact and costs

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Other points about safety research – 3 – address the 4 challenges

Data validity

Attribution

Generalisation

Use and ultility

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Summary

What works to reduce AEs – rigorous research in one setting

Where works best? Which implementation and context; context insensitive/ robust?

Why it works? explain pathways of influence & intermediate and ultimate effects

Helps others decide if and how to implement – will it work in my service?

How strong evidence needs to be before acting? Proportionate to cost and ease of implementation and risk of harm

compared to alternatives (eg no action)

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What works?

High certainty: If implemented fully, will reduce Aes in most situations

Don’t know costs or how best to implement in different situations

Probable In some situations

Possible/promising No research, little testing experience

Does not work Research high certainty in some situations, probably, possibly

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What does not work?

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“be more careful”

Patient safety - what works?

Evidence from elsewhere about Efficacy in rigorous study situation

Effectiveness of implementation actions, in a context

Find and adapt this evidence to your service

Look for implementation research into similar changes To find which context factors help and hinder

Use iterative testing with feedback on small scale to develop the intervention locally and spread

More at http://homepage.mac.com/johnovr/FileSharing2.html .

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Researchers may need guidance…

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Questions to you …1)How to collaborate to make the needed

research practicaland the practical research needed?

2) This was new or surprising, for me…Reviews of research download from safety folder on web

site

http://homepage.mac.com/johnovr/FileSharing2.html

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