Introduction. Singapore. Singapore and its Quality and Patient Safety Position 11/9/2012. National Healthcare Group, SIN

Transcription

1 Introduction Singapore and its Quality and Patient Safety Position Singapore 1

2 Singapore 2004: Top 5 Key Risk Factors High Body Mass (11.1%; 45,000) Physical Inactivity (3.8%; 15,000) Cigarette Smoking (7.4%; 28,000) High Blood Pressure (7.3%; 28,000) High Blood Cholesterol (6.6%; 25,000) Singapore Resident Population Age Profile 2008 Actual vs 2050 Projection June 2008 Actual Year 2050 Projection Source: Singapore Statistics Department Monthly Digest of Statistics Singapore July 2009 Source: United Nations Population Division 2

3 Healthcare Spending is increasing o Singapore GDP from 4% to 8% o S$4 billion to S$8 billion a year over next five years o Healthcare will cost more o Our system is complex and the cost drivers are numerous. 3

4 We could Innovate, Redesign, Reduce Waste Redefining Singapore Healthcare Cost to Cost Effectiveness Aim is Health, not Healthcare Making It Happen Bottom-line to Value Episodic ( snapshot ) to Longitudinal, Whole System approach to measuring and managing quality Enablers: Manpower, IT, Research & Innovation Singapore Ministry of Health, December

5 Value from Patient s Perspective DIAGNOSIS Good clinical outcomes Cost-effective Respect & Dignity Convenience TREATMENT & ADVICE What are patients willing to pay for? What do Patients really want? Cure Me Heal Me Don t hurt me Respect me as a person Don t make me waste my money 5

6 IOM Six Primary Aims Safe Equitable Efficient Patient s View Timely Effective Patient - Centred - Institute Of Medicine Report, IOM Six Primary Aims Safe Hippocrates -do no harm Effective Based on sound knowledge Patient-Centered Respectful, responsive to individual preferences, needs and values Timely Unnecessary waits should be reduced Efficient Many steps to get the job done; waste Equitable Should not vary in quality because of patient characteristics, such as ethnicity, or geographic location 6

7 The Patient s Journey 1 Patient asks for primary care Institute National of Healthcare Group, Quality SIN SIN Setting Aims 7

8 Learning Outcomes o Understand the system perspectives in relation to Healthcare Improvement Work o State the importance of developing an AIM statement at the beginning of Improvement Work o Identify the fundamental elements of an effective AIM statement The Deming System of Profound Knowledge All managers need to have a System of Profound Knowledge, consisting of four parts: Appreciation of a system: understanding the overall processes involving suppliers, producers, and customers (or recipients) of goods and services; Knowledge of variation: the range and causes of variation in quality, and use of statistical sampling in measurements; Theory of knowledge: the concepts explaining knowledge and the limits of what can be known; Knowledge of psychology: concepts of human nature. 8

9 Appreciation of a System Improvement requires us to understand where things fit Making sense of what is happening, where, who and how we get what we get 9

10 Systems: Leverage for Improvement Events (crisis, anecdotes, incidents, problems) Trends and Patterns (time-series charts) Leverage for Improvement System Structure (pattern of interrelationship among key components of the system: hierarchy, policy processes, and perceptions) Systems Perspective of Healthcare Inputs Care Processes Outputs Patients Staff Supplies Equipment Facilities Diagnose Treat Explain Teach Monitor Document Clinical outcomes Harm rate Patient satisfaction Cost per case 10

11 The Central Law of Improvement Every system is perfectly designed to achieve the results that it achieves. The central law reframes performance from a matter of effort to a matter of design. Donald M Berwick -BMJ : , 9 March The Patient s Journey 1 Patient asks for primary care 2 Investigate primary care 3 Treatment Outpatient 7 Step-down Care Community 4 Diagnosis & decision about care 6 Rehabilitation 5 Treatment hospital 11

12 Who else needs to be involved Questions we need to ask What are the Public Health Policy Directions and Strategic Priorities? Strategic Intent Strategic Direction Service Priorities Define Health Who else thinks Breast Cancer Expanding Health How do you Implement know National Outcomes this for is specific a problem? Cervical Cancer Screening there is a problem? Screening Framework conditions, while as defined by Ministry maintaining our cost Colorectal Cancer of Health Too many problems? Can I solve this Asthma problem Which a. to Implementing start first? a. Implement in the next few months or end-to-end clinical Integrated Care weeks or do I have Chronic to wait Obstructive pathways Pathways (ICP) for major structural Pulmonary and Disease Is the problem that have been culture change? (COPD) worth developed solving? Diabetes b. Transforming the b. Develop Centers Congestive Can Cardiac I solve this Primary myself? Care of Excellence in Failure Do I need help? sector Chronic Diseases Hypertension management Stroke 12

13 If we can agree on the destination, we can then talk about how we get there. Let s put a Man on the Moon -John F. Kennedy - Call for Action! Adverse Event (AE) Prevalence Study (2002) o Adverse Drug Event (ADE) as one of the major contributors to the overall AE rate in 3 acute hospitals o Accounted for 19% of all AEs o Associated with 2% of hospitalisation episode 13

14 Driver Diagram IPSG 1 - Identify patient correctly IPSG 2 - Improve Effective Communication International Patient Safety Goals IPSG 3 - Improve safety of high alert medications IPSG 4 - Ensure correct site, correct patient, correct procedure surgery IPSG 5 - Reduce risk of healthcare associated infections AIM Culture & Learning Medication Safety To Decrease Adverse Event Rate for Inpatients Teamwork & at Hospital A Communications from 11% to less than 5% by 2013 Medication Errors Hospital Acquired Infections IPSG 6 - Reduce risk of patient harm from falls Improvement Programme Training Status Improvement Projects & Stages Patient Safety Priority for Improvement o Medication Error Reporting o Medication Reconciliation Total No. of ehor Raised Patient Safety Climate Survey SBAR Training for Staff Root Causes Related to Teamwork & Communications Reported medication Error Incidence Medication Reconciliation Inpatient Anticoagulation Service for Warfarin Titration o Warfarin Titration Time to Therapeutic Range MRSA Prevalence VAP Rate for all ICUs Central Line related blood infection rates Catheter related UTI rates Procedural Adverse Events Adverse Events Surgical Site Infection Improving Surgical Outcomes (POSSUM) Procedural AEs per 1000 patient days Adverse Events in Mortality Cases reviewed by CRP AEs per 1000 patient days for CRP reviewed cases 14

15 Driver Diagram: Do No Harm Primary Drivers Evidence-based care Effective teamwork Prevention Leadership Secondary Drivers Acute myocardial infarction Congestive heart failure Community acquired pneumonia Surgical care improvement Establish reliable techniques for handoffs Adopt multidisciplinary huddles Standardise team response drills, simulation Prevent ADEs through medication reconciliation Prevent HAIs (hand hygiene, MRSA screening) Eliminate falls and pressure ulcers Establish community partnerships Conduct safety briefings Establish safety aims and goals Engage the Board Adopt a proactive approach to errors and harm Medication Safety Collaboratives Smart Pumps Over Anti- Coagulation Base-line Study Inpatient Warfarin Titration NHG Standardized Medication Safety Taxonomy System Analysis Tool Pre-mixed Intravenous Potassium Patient Safety Climate Survey Medication Reconciliation IHI Trigger Tool and Clinical Review Program Electronic Inpatient Medication Record Patient Safety Leadership Walkabout Dedicated ICU Pharmacist 15

16 Coaching Model for Improvement Model of Improvement o What are we trying to accomplish? o How will we know that a change is an improvement? ACT PLAN o What change can we make that will result in improvement? STUDY DO 16

17 Guide-Post for Setting Aims HOW GOOD BY WHEN FOR WHOM What are we trying to accomplish? Develop Aim Statement using SMART Technique - unambiguous, clear, specific, numerical, measurable, time-frame Relates to the System Focuses what needs to be accomplished Meets Management Expectation Guides the Team and Project Medication Safety 3 Culture of Safety Increase voluntary electronic hospital occurrence reporting 2 Warfarin Titration Ensure safe use of warfarin and reduce patient harm associated with its use 1 1 Medication Errors Reduce Medication Errors through Medication Reconciliation 17

18 Examples of effective AIM statements o Reduce potential medication errors by 30% through medication reconciliation for newly admitted patients in the next 6 months o Reduce time of Warfarin titration to therapeutic INR from 90% within 11 days to 90% within 5 days for newly hospitalized patients o Increase rate of voluntary electronic hospital occurrence reporting from a monthly mean of 100to200permonthbythe1 st quarterof2008 Our first step into major change What will you do, your first 100 days? 18

19 Exercise Read and Reflect o Work together in small groups o Choose a topic of common interest and relevance to the group o Develop a strong, clear aim statement to guide improvement work on this topic o Discuss how you would set the goal in this aim statement 19

20 Acknowledgements Materials for program sourced from: o The Improvement Guide : A Practical Approach to Enhancing Organizational Performance by Gerald J. Langley et al o The Healthcare Quality Book: Vision, Strategy & Tools by Scott B. Ransom et al o Toward Optimized Practice [ Online information; retrieved on 24/08/12.] o o Enhancing Clinical Practice Improvement: A Tribute, 2008 (National Healthcare Group, Singapore) o Adding Years of Healthy Life, 2010 ( National Healthcare Group, Singapore) o Ministry Of Health, Statement of Priorities, FY 2011 Singapore o Model for Improvement by Carol Haraden( Institute for Healthcare Improvement) o Visuals adapted from Flickr/LumaxArt Questions? 20