the challenges of implementation (will, ideas, execution) dr elizabeth haxby royal brompton and...
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The Challenges of Implementation(Will, Ideas, Execution)
Dr Elizabeth HaxbyRoyal Brompton and Harefield NHS Foundation Trust
Traditional Approach
• Overwhelming number of issues to be addressed
• Large audits ie 100s of patients telling us what we already knew
• Time consuming committees
• Profusion of policies – average 50 pages long
• Assumption that policy = practice
• Lack of Engagement
Design Design Design Design Approve
Implement
Conference Rooms
Real World
Trust wide VTE prophylaxis compliance
VTE Audit across the Trust (2009)
47% 47%
20%
7%
0%
7%
0%0%4%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
April May J un J ul Aug
Perc
enta
ge
Sydney
Fulham
Harefield
Reasons for Failure
Lack of clear goals or timeframes
Failure to frame the policy and provide context
Elements of the policy impractical
Failure to engage with the people who will implement the policy
Feedback intermittent, not directed
New ApproachSurgical Site Infection
New Approach
Set context
Set clear aim and timeframe
Engage with front line staff
Listen to their concerns and ideas
Try small tests of change
Establish measures and feedback
SSI - cost to patients, cost to healthcare
0
20
40
60
80
100
120
Superficial Deep
LO
S__
Infected Control
0
20000
40000
60000
80000
100000
120000
Superficial Deep
Cost (£
)__
Infected Control
• Patients with a superficial infection had an extra LOS of 20 days (P<0.0000) and cost an extra £9,735 (P<0.0098)
• Patients with a deep or organ space infection had an extra LOS of 54.5 days (P<0.0098) and cost an extra £40,726 (P<0.0098)
Difference in Median LOS Difference in Median Cost
Driver diagram SSI prevention
TribalNon-alignment
AN
AE
ST
HE
TI
ST
S
SURGEONS
NURSES
MANE
GE
RS
EX
EC
s
PO
RT
ER
S
OD
As
Alignment
Staff
Structure
Strategy&
Tactics
Aims
Leadership
Language
Multiple small changes
SSI data review at monthly CG day Cross site multi disciplinary WIP
group Care bundle measurement with
feedback to theatre staff Changes to;
Theatre access Hand hygiene / scrub up Surgical prep Dressings Wound management Vein harvest
Re-enforced antibiotic policy Feedback to individual surgeons on
SSI with RCA and bundle compliance for each patient
Board level reporting Local CQUIN indicator
Small test of change
SSI Prevention Care Bundle
Design
Test and Modify
Test and Modify
Test and Modify
Approve(if necessary)
Conference Rooms
Real World
Implement
SS
I rat
e pe
r 10
0 op
erat
ions
Incidences of Surgical Site Infection All Categories (Superficial/Deep/Organ) Sternal and Donor WoundsSSIs in CABG patients, detected primary admission and re-admission
ROYAL BROMPTON HOSPITALAugust 2009 - July 2010
Data from PATS as at 10/09/2010
1
2
Trend lineCQUIN target = 6.3
National CABG SSI rate = 4.3
RBH CABG July SSI rate = 0 per 100 operations
Augus
t 200
9
Septe
mbe
r
Octo
ber
Novem
ber
Decem
ber
Janu
ary 2
010
Februa
ry
Mar
chApr
ilM
ayJu
ne July
0
5
10
15
20
25
The Challenge of Implementation Clear Aim
Start small
Engage all the right people
Expect failure and respond promptly
Measure
Don’t underestimate anyone
Give information / feedback frequently
Seek additional drivers