leading the best care...always! campaign

Leading the Best Care...Always!

Campaign

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

June 25th Cape Town

Agenda

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

Burden of HAI in LMI countries

Prof Shaheen MehtarUIPC, TBH & SUN

Cape Town

Situation Analysis of LMI countries

• There is very little published data relating to HAI but it is recognised that the rates of HAI are higher in LMI countries

• IPC programmes are poorly supported and established without recognition or career paths for trained IPC practitioners

• There is little accountability by HCW which lead to inadequate clinical care

• Clinical commitment is essential under 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

Crude HAI IR: 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

4.33.9 4.0

3.6

4.4

3.7

3.1

3.6

4.4

3.3

1.5

2.4

3.6 3.5

3.13.3

2.8 2.72.4

2.8

Crude Infection Rates

Infection Rates

2006 2007 2008 2009 20100

10

20

30

40

50

60

18.56 18.88

13.38 14.2

18.0318.5 17.7

10.413.6

11

43.3

40

30.1

25.5

21.11

25.6

49.6

36.3

42.3

22

ICU crude HAI rates 2006-2010

NNU burns Surg Resp

/100

0 IP

day

s

ICU with highest IR: TBH

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

Summary• By carrying out surveillance a statistically significant

decrease in HAI has been noted associated with device related infection.

• Policies and SOPS are necessary for compliance by clinical staff

• Bundling is a highly specialised system of reducing HAI with zero tolerance

• Questions to be answered─ Who will ensure that two people are available for each

procedure carried out?─ Who will do the data collection?─ Who will make sure that the same bundle is followed each

and every time a procedure is carried out?─ How will this be inforced?

The BCA Quality Improvement approach

• All learn all teach• Learning by doing• Building a shared sense of the

system and the approach to improvement

• Applicable across disciplines

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 - peripheral vascular catheter associated infection (PVCAI)

- central line associated bloodstream infection (CLABSI)

- ventilator associated pneumonia (VAP)- catheter associated urinary track infection (CAUTI)

- surgical site infection (SSI)

The fundamentals of the Quality Improvement

approach used in BCA

A brief history of systems improvement

IHI Lean Overview Andy Brophy (MSc Lean Operations)

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%

Force Field Analysis

1. The current situation2. The desired situation3. The situation if no action is taken4. Forces driving toward desired situation5. Forces resisting change6. ……

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 changeNot 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

# he

ads

up

July Aug Sep Oct5/7 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: 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

MeasurementLeaders need to know i) what measures are being used for

─ incidence of HAIs─ bundle compliance (implementation of

bundles)ii) how data is being presentediii) 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%)

Welsh Safety Calendar

IDeveloped by Annette Bartley, Welsh 1000 Lives Campaign

Welsh Patient Safety Project

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

61

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)

Removing the Status Quo

Making the future attractive

1.Set Direction: Mission, Vision & Strategy

Setting Direction: Mission, Vision and Strategy

PULLPUSH

Removing the Status Quo

• Make the status quo uncomfortable

─There are too many Healthcare Associated Infections (HAIs)

66

Look to the Future

• Making the future state attractive

─ No more unnecessary deaths and suffering from HAIBest practice shows it is possible to reduce HAI

between 20 – 80%There are evidence based protocols and practices

to do thisWe will be part of a national and international

campaign

67

IHI Whitepaper 2008 Seven Leadership Leverage Points for Organizational-Level Improvement in Healthcare pg 4

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

Will, Ideas and Execution

• Why are we spending our time and energy on this project?

Will, Ideas and Execution• Leaders play a significant role in building and

maintaining will─ Clear, desirable aims─ Making it doable

start smallallocate time and resourcesremove obstaclesbring in the right people/teams culture of learning vs blame and shame

─ Keep the project alivedemonstrate interestmonthly review of data

Will, Ideas and Execution

• Engaging doctors

Will, Ideas and Execution• Overcoming the implementation gap

Multidisciplinary teams

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

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

Resources

• BCA website bestcare.org.za• IHI.org

Handouts

• Getting Started Kits – including peripheral line• Presentation handout• Framework for leading improvement • Run chart article