one small step for man … … the model for improvement ( keep it small and simple )
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SSC COMPONENT QUB MEDICAL STUDENTS: FRIDAY, 17 FEBRUARY 2012. One small step for man … … The Model for Improvement ( keep it small and simple ). TODAY YOU WILL: Be able to outline the background to patient safety in health and social care - PowerPoint PPT PresentationTRANSCRIPT
One small step for man … … One small step for man … …
The Model for ImprovementThe Model for Improvement((keep it small and simple))
SSC COMPONENTQUB MEDICAL STUDENTS:
FRIDAY, 17 FEBRUARY 2012
TODAY YOU WILL:TODAY YOU WILL:
Be able to outline the background to patient safety in health and social care
Have a basic understanding of the person vs system approach to error
Explain the Model for Improvement and be able to apply this to a specific example
1 in 10 = 551,000; 55,000, more likely 3 in 10 = 165,000 -
“Between the healthcare we have and the healthcare we could have lies not just a gap, but a chasm”
Why? Little reliability (80%) despite best intentions◦ Best-known science is not reliably applied (60%)◦ Widespread inefficiencies waste precious resources (20%)◦ Patients are being harmed at alarming rates (10%; 30-40%)◦ Failure to recognise, to rescue, to plan, to communicate◦ Variation in practice (ie inappropriate variation not determined
by patient need)
So we work on…◦ Not the individual (blame, myopic view): ‘to err is human’ –
◦ “we cannot change the human condition, but we can change the conditions under which humans work” (James Reason); but
on◦ The system!
Get diagnosed Get treated Get out Get on
Systematic accurate diagnosis, early intervention, implementation of practices that are known to be safe and moving patients effectively along a care pathway*
Acute care
SAFELY
Get in
*Health Commission Report: Safe in the Knowledge, 2009
•No needless deaths, harm or suffering•No delays•No waste•No feelings of helplessness
S AFET IMELYE EFFECTIVEE FFICIENTE QUITABLEP ATIENT CENTRED
Variation is intrinsic in health care. It is the result of clinical variability (number of patients presenting with certain clinical conditions), flow variability (the ebb and flow of patients arriving throughout the day), and professional variability (the variation in skill levels and techniques among providers).
Some kinds of variability (so-called “random variability”) cannot be eliminated, or even reduced; they must be managed. This is true of patient variability. We cannot eliminate the many types of problems from which patients suffer, nor can we control when they arrive in the emergency department.
Other types of variability (“non-random”), on the other hand, are often driven by individual priorities, resulting, for example, in surgical schedules that are heavy on Wednesdays but light on Fridays due to surgeons’ preferences rather than actual demand. Non-random variability should not be managed; it should be eliminated. (Ref: IHI – Optimizing Patient Flow, 2003)
Defining Domains of Quality Problems
Overuse - Examples of include hysterectomies, cardiac catheterizations, tympanostomy, antibiotics, tranquilizers, sedatives, carotid endarterectomy, cardiac pacemakers, upper gastrointestinal endoscopy, and non-steroidal anti-inflammatory drugs
Underuse - Example, providers routinely fail to administer a variety of evidence-based tests and treatments to heart attack victims and individuals with diabetes and congestive heart failure.
Misuse - Medical errors represent the most common form of misuse within the health. Examples drug misuse, hospital-acquired infections, diagnostic, surgical errors, and incorrect use of medical equipment.
Waste -unnecessary administrative activities is prevalent. In addition to driving up costs, waste can have a direct negative impact on service quality (e.g., waiting times), clinical quality, and access to care.
Waste may also crowd out needed spending in other areas of health care.
Patient Safety Incident
• Any unintended or unexpected incident/s that could or did lead to harm for one or more patients
• Patients and families• Healthcare staff -the second victims• Financial-additional hospital stays
alone estimated to cost £2000m annually in UK
If a professional is highly trained and tries hard enough he/she will not make errors
the punishment myth if we punish people when they make errors they will make fewer of them
Human beings carrying out complex and risky procedures in our time pressurized healthcare organisations will make errors
95% of errors that cause harm involve conscientious competent individuals trying hard to achieve a desired outcome –only 5% of harm is caused by incompetence or poorly intended care
We all make errors irrespective of how much training and experience we possess, or how motivated we are to do it right
An individual failing◦Only the minority of cases amount from
negligence or misconduct; so it’s the “wrong” diagnosis
◦It will not solve the problem--it will probably in fact make it worse because it fails to address the problem
◦Professionals will hide errors◦May destroy many staff (inadvertently (the
second victim)
A systems failure◦ This is the starting point for redesigning the
system and reducing error
“Every system is perfectly designed to
get the results it gets”
The First Rule of Improvement
SWISS CHEESE MODELSWISS CHEESE MODEL(James Reason - 1990)
Will to do what it takes to change to a new system
Ideas on which to base the design of the new system
Execution of the ideas
Im
“Improvement requires a will to improve, Ideas to test and execution of a plan”
Frank Frederico, IHI, Doug Bonacum, KaiserPermanante Health Exec., Jan 2010
5 P’s
PurposeWhat is the role of the team and what are you trying to achieve.
•Who contributes to the service / care e.g.:- •Ancillary and General•Nursing•Doctors •AHPs
How are the services planned
What are the current practices and procedures you use
Who is the service / care provided to / for.
Have you sufficient information to identify areas for service improvement
Review analysis gaps and measure as required
Processes Patients
Move to Stage 2
This model has been adapted from the Dartmouth Institute
Professionals
What do you know about how well your service performs
e.g.:- Length of stay Pt satisfaction Staff Rotas Clinical Risk Complaints Team Meeting
Patterns
No Yes
Identified areas for improvement
Identify themes
Theme 1 Theme 2 Theme 4Theme 3 Theme 5
Prioritises themes (Consider)1. What matters most to patients and staff2. Time and effort3. Corporate Objectives
Review analysis as requiredr
No
Move to Stage 3
YesClearly identified area for improvement
Coming up with ideas on how to improve current
state: evidence, hunches,other people etc.
What changes can we make that willWhat changes can we make that willresult in the improvements we seek ?result in the improvements we seek ?
What are we trying toWhat are we trying toachieve?achieve?
Constructing a clear aim statement
How will we know that aHow will we know that achange is an improvement?change is an improvement?
Choosing right measures and planning how you
will collect right information
Act Plan
Study Do
The fourthquestion:
how to make changes -
testing
Thethree
fundamental
questions for
improvement
Langley, Nolan et al 1996
The Model for Improvement
Leadership SupportLeadership Support
System Leadership
Clinical Technical Expertise
Day to day leadership
Agreed by Improvement Team
Time specific
Measurable
Process measures
Outcome measures
Balancing measures
How do we know a change is an improvement?How do we know a change is an improvement?
Research Judgement Improvement
Purpose To discover new knowledge
To compare others, to rank To bring new knowledge into daily practice
Tests One large trial Public reporting quarterly or with 12 month running averages
Many sequential, observable tests
Data Gather as much data as possible, just in case
Reports structure, processes or outcomes
Small tests of significant changes, accelerates the rate of improvement
Duration Can require large numbers of patients and long periods of time to obtain results
Ongoing data collection and quarterly public reporting
Short iterative cycles in a limited number of subjects, followed by spread
1. Decide Aim
2. Choose measures
3. Define measures
4. Collect data
5. Analyse
+ present
6. ReviewMeasur
es
The Seven steps to Measurement are:
Step 1 - Decide your aim
Step 2 - Choose your measures
Step 3 – Define your measures
Step 4 - Collect your baseline data
Step 5 - Analyse and present your data
Step 6 - Meet to decide what it is telling you
Step 7 - Repeat steps 4-6 each month or more frequently
7. RepeatSteps 4-
6
In God we Trust, all others bring Data … …
PROCESS: (Ventiliator acquired pneumonia bundle)
• Elevation of head of bed between 30 and 45 degrees• Daily awakening: “sedation vacation”• Daily assessment of readiness for weaning• DVT prophylaxis (unless contraindicated)• Stress bleeding (peptic ulcer) prophylaxis
MEASURES contd.
PROCESS: (Losing weight)
• Number of visits to gym each week,• Number of walks per week,• Number of calories lost per day/week
OUTCOME:
• Reduction in Ventilator acquired pneumonia rate
OUTCOME:
• Reduction in deaths each year from stroke
Outcome:
• Number of pounds lost per month
MEASURES contd.
S + P = 0S + P = 0
BALANCING:
• Increasing Re-Admission rates
BALANCING:
• Increase in Waiting times in A&E
BALANCING:
• Reduction in hours of sleep
MEASURES contd.
An understanding of processes and systems of work
Challenge boundaries
Adapting known good ideas
Re-arrange order of steps
Smooth work flow
Act
• What changes are to be made?• Next cycle?
Study
• Complete analysis of data• Compare data to predictions• Summarise what was learned
Do
• Carry out the plan• Document problems and unexpected observations• begin analysis of data
Plan
• Objective• Questions and predictions (why?)• Plan to carry out the cycle• Plan for data collection
AIM
Concept B
Concept C
Concept A
Concept D
Multiple PDSA Cycles Directed Toward a
Single Aim
Collate your PDSA cycles
and when you spread so
they can understand what
processes, predictions, and
tests they went through that
lead to share them with
o
ther areas change
Do not be tempted or
pressurised into implementing
or spreading until you have
achieved a reliable process
that is fit fo
r purpose and
your are happy with
TIPS TIPS
• From PDSA to SDSA
• Only implement what you know is an improvement
• Communication
• Consider impact on people
• Consider infrastructure
Be clear about the benefit to stakeholders◦ Winning hearts and minds, “what's in it for me?”
Pay attention to ongoing training and education needs
See how you can contribute to building the improvement into the structure of your organisation and make it the new standard
Build in ongoing measurement Work towards making sustainability mainstream
◦ Is it someone's responsibility? Has resource been allocated?
Celebrate, renew and set the bar higher
Tips for Improving Sustainability
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996
Achieving Safe and Reliable Healthcare; strategies and solutions. M Leonard, A Frankel, T Simmonds
Improving the Reliability of Healthcare. Institute for Healthcare Improvement Innovation Series 2004 White Paper. Available free at www.ihi.org
Quality by Design: A Clinical Microsystems Approach. E Nelson, P Batalden, M Godfrey
To Err is Human: Building a Safer health System” Kohn LT
Clinical Microsystems Website: Dartmouth Institute: http://cms.dartmouth.edu/
National Patient Safety Agency website: www.npsa.nhs.uk
Patient Safety First campaign – www.patientsafetyfirst.nhs.uk
1000 Lives Welsh Patient Safety Campaign – www.wales.nhs.uk
Scottish Patient Safety Programme: http://patientsafety.etellect.co.uk/programme
Institute for Healthcare Improvement: www.ihi.org
CONTACT DETAILS:
Janet Haines-Wood, Regional Patient Safety Advisor, HSC Safety [email protected]: 02892665181, Ext 4819
Levette Lamb, Regional Patients Safety Advisor, HSC Safety [email protected]: 02892665181, Ext 4817
HSC Safety Forum Website:http://www.publichealth.hscni.net/directorate-nursing-and-allied-health-professions /hsc-safety-forum