bc provincial perioperative improvement program · estimating the cost of serious injurious falls...

Proposal Presentation & Discussion

BC Provincial Perioperative Improvement Program

Panel Members

∗ Margi Bhalla, Director, Surgical Services, Ministry of Health – Provincial Surgical Advisory Committee Co-Chair

∗ Andy Hamilton, Medical Director, Surgical Services, Interior Health Authority – Provincial Surgical Advisory Committee Co-Chair

∗ Dermot Kelly, Director, Medical Administration & Surgical Services, Vancouver Coastal Health

∗ Felicia Laing, Project Manager, Quality & Patient Safety, Vancouver Coastal Health ∗ Peter Blair, Program Medical Director, Surgery, Fraser Health ∗ Susann Camus, NSQIP Quality Improvement Consultant, Fraser Health ∗ Adrian Leung, Executive Lead, Specialist Services Committee, British Columbia Medical

Association ∗ Marlies van Dijk, Director, Clinical Improvement, BC Patient Safety & Quality Council

Agenda

∗ Background and program proposal Margi & Andy – 5 minutes

∗ The Productive Operating Theatre ∗ Overview & Experiences Dermot & Felicia – 10 minutes

∗ Comprehensive Unit-Based Safety Program ∗ Overview & Experiences Peter & Susann – 10 minutes

∗ Coaching Team Marlies – 5 minutes

∗ Discussion & Questions All – 30 minutes

Background

∗ The Provincial Surgical Advisory Council (PSAC) was established in 2009 to inform the strategic direction of surgical services in BC

∗ Perioperative Improvement Sub-Group formed following release of BCMA’s ‘Enhancing Surgical Care in BC – Improving Perioperative Quality, Efficiency and Access’ ∗ Developed multi-year master plan for improvement in the perioperative

environment ∗ Provincial OR inventory and identification of provincial indicators underway ∗ Front-line initiatives to address common barriers to perioperative

improvement

Provincial Team &

Project Manager

Expert Trainer

Extended Site Team

Core Site Team

Core Site Team

Extended Site Team

Core Site Team

Exte

nded

Site

Team

Core Site Team

Extended Site Team

Proposed Provincial Program Overview

• Provincial coaching team – trained experts provide support to sites

• Sites – selected based on demonstration of patient safety oriented culture, readiness for project, clear plan to commit local resources, identified measurable goals

Proposed Provincial Program Overview

∗ Provide comprehensive support for sites to implement a quality improvement methodology

∗ Support could include: ∗ Module materials ∗ Provincial project management ∗ Funding clinical time ∗ QI methodology expert consultation (e.g., Maggie Morgan-Cooke, Dr. Liza Wick)

∗ 1-2 face-to-face meetings ∗ Coaching team site visits ∗ Coordinated peer support

Proposed Provincial Program Overview

∗ Provincial team will receive training and provide support to sites

∗ Could include representatives from program sites and from sites across the province using other improvement methods (e.g. LEAN) as well as others who are interested

∗ Method to be chosen by site, and could include: ∗ Productive Operating Theatre (TPOT) ∗ Comprehensive Unit-Based Safety Program (CUSP) ∗ “Building Local Expertise” Coaching Model ∗ LEAN or other QI methodologies

The Productive Operating Theatre Overview

∗ Toolkit ∗ 2 overview guides ∗ 11 modules ∗ Module materials:

∗ Handbooks & DVDs ∗ Planning & evaluation tools

∗ Primary concerns: Quality and efficiency

The Productive Operating Theatre Experience (Dermot & Felicia)

• Felicia and Dermot

RT2C Education

February 2013

VCH Lean Education

The Productive Ward Experience Releasing Time to Care Vancouver Coastal Health

NHS productive series

Modules: based on Lean thinking

• Leadership support • Foundational modules for sustaining improvements

Productive operating theatre Productive ward

• Set of modules designed to guide you through the processes • Efficiency guidelines to achieve significant and lasting

improvements, thereby allowing extra care time for patients • Tested and proven to be successful in many health care

settings: – Ontario, Manitoba, BC – US, CareOregon – UK, Sweden, European countries – Australia, New Zealand

Aim: to improve 4 key dimensions of quality

• Understand what is happening now • Display measures on a board • Use huddles on performance to drive improvement • Regularly update information

15

Releasing Time to Care/Productive Ward

Improvements

Process Action Change Shift report •From 45-60 min to 15 min per shift report

•Earlier vital signs assessments •On time patient readiness for meals •On time meds admin

67%

Wait time to DI •Wait time in hallway range 1 to 38 min •Porter now helps ready patient – no wait time

100%

Admission kits •Pre-assembled patient supplies •From 73.5 min to 4 min per week •Dedicated time admitting patient •Dedicated time getting handover report

95%

Meal trays •Delivery time changed to offset staff breaks •More time for patients to eat, food is warm

Interruptions •From 15.8 to 10.0 per hour •189 interruptions per shift reduced to 120 •General staff queries, patient status

37%

• Staff-led data collection and audits • Daily huddles around data board

Falls: Improvement actions and results Patient Safety & Reliability of

care

May Jun July Aug Sept Oct Nov Dec Jan2013 Feb Mar Apr May Jun Jul Aug Sep

2013# Falls (Safety Cross) 10 6 8 1 5 5 12 9 4 1 3 5 6 4 6 5 4

0

2

4

6

8

10

12

Number of patient falls

Trendline

Goal: To reduce falls by 50% by Dec 2013 to two falls per month.

-Risk assessment on admission

-Families pamphlet on fall prevention -Motion-sensored lights in all rooms

-Yconnectors with each bed alarm -Safety checks qshift

-Regional rollout Falls Prevention Program

Falls: projected cost-avoidance

•The three target wards could reach a cost avoidance of $

802,134 by reducing their falls by 50 %

• 560 Bed Days could be

prevented due to an extended length of stay (LOS)

•Assumption (1,2): Total extended LOS for serious falls 34 days;

Extended LOS for minor falls 5 days

Projection Analysis

What if we are reaching the goal of reducing falls by 50%?

Patient Safety & Reliability of

care

1 CIHI, National Trauma Registry Analytic Bulletin Hospital Costs of Trauma Admissions in Canada, 2000/2001.

2 Estimating the Cost of Serious Injurious Falls in a Canadian Acute Care Hospital Zecevic A., et al.. Canadian Journal of Aging Volume 31, Number 2 (2012), p. 139-147.

2012 Reduced by 50 % Number of minor falls per year (30% RH; 54% SGH) ) 88 44 Number of moderate and severe harm falls (10% RH; 5% SGH) 20 10 Costs (minor harm); $ 11,254 per case1 $ 990,348 $ 495,174 Costs (moderate and severe harm); $ 30,696 per case2 $ 613,920 $ 306,960

Total $ 1,604,268 $ 802,134

Cost Avoidance $ 802,134 Bed Days minor falls1 440 220 Bed Days moderate and severe harm falls2 680 340

Total Bed Days 1120 560 Bed Days Avoided 560

Patient experience – 3S Richmond

19

Patient Experience

92.9%

71.4%

85.7%

75.0%

87.7%

71.4%

77.4%

47.6%

0% 20% 40% 60% 80% 100%

In general, during your hospital stay, did you feel treatedwith respect and dignity?

Were you well informed of your condition or treatmentapproach by your attending health care team?

Did you notice that the staff wash or disinfect their handsprior and after caring?

Do you feel confident with your current discharge plan andsupport outside the hospital?

Acute Care Patient Experience 2012 - % positive score (October 2011 - March 2012)

3 South Patient Feedback - % of positive responses (Dec 2012-Jan 2013)

Patient experience – Squamish

20

Patient Experience

100.0%

96.6%

89.7%

96.4%

100.0%

0 20 40 60 80 100

During this hospital attendance/stay did you feel you were treatedwith dignity and respect?

Did you have good opportunity to participate in the decisions thatapplied to your care?

Did the doctors, nurses or other staff give your family or someoneclose to you all the information needed to help you during your stay

or treatment?

Did a member of staff explain the purpose of the medicines youwere to take at home in a way you could understand?

Were you provided with the equipment you needed to go homewith?

Acute Care Patient Experience 2012 SGH Patient Feedback

Staff unplanned absence- Squamish

Background • Staff well being has been shown to

impact absence rate

• Identified high rate of unplanned on the unit

• Safety cross was used to bring awareness to the unit.

21

Staff Well-Being

0

2

4

6

8

10

12

14

Nov2012

Dec Jan2013

Feb Mar April May Jun2013

Num

ber o

f Unp

lann

ed A

bsen

ces

Unplanned absences – Day shift

“This is the first time in my 30 years of nursing where I've seen frontline staff get involved with any quality improvement. I really believe that this will work and will be sustainable.”

22

“Since our unit has a lot of issues, and we know its potential, it inspired a lot of conversations [..].It made us more vocal and involved, and gave us a platform to speak with Allied Health.”. - Staff Nurse

Comprehensive Unit-based Safety Program (CUSP) at Royal

Columbian Hospital

Dr. Peter Blair, RCH Surgeon Champion & FH Surgery Medical Director

Susann Camus, NSQIP Quality Improvement Consultant

October 28, 2013

Purpose of CUSP

• Strategic framework for improving patient safety

• Integrates communication, teamwork, and leadership to create and support a culture of patient safety

• Provides frontline staff with the tools and resources to improve quality

October 28, 2013 CUSP at Royal Columbian Hospital 24

CUSP’s Beginnings • First applied in more than 100 Intensive Care Units in

Michigan in 2003 • 5 evidence-based procedures recommended by CDC to

reduce Central Line Associated Site Infections (CLABSI): hand hygiene, full-barrier precautions, Chlorhexidine gluconate skin cleansing, avoiding femoral site, minimizing use of Foley catheters

• Results: Reduced CLABSI rates by 67% within 3 months • Saved more than 1,500 lives and $200 million in the

first 18 months • Expanded to other settings & more types of

preventable infections. October 28, 2013 CUSP at Royal Columbian Hospital 25

Five Steps: Using CUSP to Reduce SSIs

1. Staff educated on the science of safety 2. Staff complete patient safety culture assessment 3. Senior hospital executive partners with unit to improve communications and educate leadership 4. Staff learn from unit defects 5. Staff use tools such as checklists to improve teamwork, communication, collaboration October 28, 2013 CUSP at Royal Columbian Hospital 26

Learning from Defects Defect = any clinical or operational event or situation that you would not want to happen again. 1) What happened? 2) Why did it happen? 3) What did you do to reduce the risk? 4) How do you know that risks were reduced?

October 28, 2013 CUSP at Royal Columbian Hospital 27

Two Questions 1. Ask staff two questions:

a) How is the next patient going to get an SSI on this unit? b) How can we prevent this from happening?

October 28, 2013 CUSP at Royal Columbian Hospital 28

SSI Bundle & Results 1) Standardization of skin prep and use of

chlorhexidine wash cloths 2) Mechanical bowel prep with oral antibiotics 3) Patient warming 4) Enhanced sterile technique 5) Antibiotic timing and dosage 33% reduction in SSIs $168,000 - $280,000 cost savings per year at 1 site Source: Wick et al., 2012 Implementation of a Surgical Comprehensive Unit-Based Program to Reduce Surgical Site Infections, JACS 2012:215(2), Aug 2012. October 28, 2013 CUSP at Royal Columbian Hospital 29

CUSP Participating Sites

• Ronald Reagan UCLA Medical Centre, Los Angeles

• New York Hospital of Queens, Flushing • Mills Peninsula Health Services,

Burlingame • Saint Elizabeth Medical Centre, Utica • The Ottawa Hospital, Ottawa • Royal Columbian Hospital, New

Westminster October 28, 2013 CUSP at Royal Columbian Hospital 30

CUSP at RCH 1. Safety Attitudes Questionnaire showed ample

room for improvement in RCH safety culture 2. RCH was invited to join CUSP 3. Steering Team assembled 4. Defects were identified and prioritized through

safety assessments

October 28, 2013 CUSP at Royal Columbian Hospital 31

Results of 1st Safety Assessment

October 28, 2013 CUSP at Royal Columbian Hospital 32

OR Traffic Audit

• 8 cases observed over 614 minutes • Average case was 77 minutes (35-134

min) • Doors swung open 354 times, or 44.25

times per case (18-101 times) • Doors were open 19% of the time,

disrupting air flow in the OR

October 28, 2013 CUSP at Royal Columbian Hospital 33

Normothermia Initiative

Reviewed charts of PACU surgical patients, recorded their temperature (pre, intra, post op) and type of procedure after 2 days in April 2013, 5 hours per day:

October 28, 2013 CUSP at Royal Columbian Hospital 34

Results of 2nd Safety Assessment

October 28, 2013 CUSP at Royal Columbian Hospital 35

Next Steps for RCH

• Document CUSP process, share tools • Confirm executive support & commitment • Get team on a regular meeting schedule

(e.g. every two weeks) • Identify potential quick win (scrubs

storage?) • Post notes, SSI rates, all documentation

every month, and prominently for OR October 28, 2013 CUSP at Royal Columbian Hospital 36

Surgical Provincial Coaching Team

Safety Climate – 14 BC Hospitals 75 surgical units - 2012

Perceptions of Local Management 14 Hospitals – 75 BC surgical units - 2012

Risk of Failure

Potential Problem • 6 months after project lose

the improvements • Long term sustainability

• Leaders behave the same as

before project

• Systemic changes not made

End Goal • Improvements held • Improvement sustained

• Leaders are on the units

doing walk rounds and using visual display boards and participate in huddles

• Identification and change in systems/tactics

Training and Commitment

• Coaching Team Training (2 face to face meetings and monthly webex training over 24 months)

• Expert Led – tentative: Allan Frankel, Ontario Coach Support and others

• Identify are of need! (using local data) • Co-create a local plan which aims at improvement at a system

wide level/organizational goals • Attendance to at least 2 site visits (other Transformation sites)

over the duration of 2 years

Who can Join?

• Up to two people from each site that is participating

• Total up to 20 people

Discussion & Questions

Next Steps

For more information on the Provincial Perioperative Improvement Program, please contact:

Margi Bhalla 250 952 1040

munjeet.bhalla@gov.bc.ca

Andy Hamilton 250 870 4778

andy.hamilton@interiorhealth.ca