Improvement Science and Quality; Scotland s Journey. Prof Jason Leitch Clinical Director The Quality Unit, Scottish Government

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1 Improvement Science and Quality; Scotland s Journey Prof Jason Leitch Clinical Director The Quality Unit, Scottish Government

2 Improvement Science Jason Leitch Clinical Director The Quality Unit, Scottish

3 Expectations will always exceed capacity. The service must always be changing, growing and improving. Aneurin Bevan, 1948

4 Jim s pathway Retired Joiner Married to Mary 2 children and 6 grandchildren Keen bowler Interested in politics Enjoys gardening and his allotment Susanne Forrest, NES, 2012

5 Jim s pathway Admitted via A&E with chest pain The fact that he has a diagnosis of dementia is not established. Limited information is requested /obtained from Mary and his wider family. Jim is admitted to the medical receiving ward for further tests. Jim becomes very anxious and disorientated in the new environment he is then moved to three different wards His community mental health nurse is not contacted. Staff understanding and tolerance of dementia is poor. Jim gets quite agitated staff identify him as at risk of wandering and aggression. Susanne Forrest, NES, 2012

6 Jim s pathway Jim is commenced on psychotropic medication to calm him down. The sedative effects lead to Jim having reduced mobility and being at risk of falls, increased incontinence, disturbed sleep pattern and being less able to take meals and drinks. Jim is catheterised due to increased incontinence this leads to a urinary tract infection. Jim develops delirium, leading to increased dependency and confusion. Jim suffers a number of falls; while no serious injuries are sustained, he is now covered in bruises and continues to lose weight. The staff have now put Jim on one to one observation level to manage risk. After a 35 day stay, Jim is transferred to a care home as the staff and Mary feel he will no longer be able to be supported at home. Susanne Forrest, NES, 2012

7 5 million people 12 billion 14 Health Boards 8 Support Boards Integrated delivery Moving towards social care integration

8 Public Finances Fall in Government expenditure

9 Health Budget

10 Population of Scotland

11 Source: Human Mortality Database Life Expectancy Trends Scotland & other Western European Countries,

12 All Cause Mortality Males 15-44

13 Cirrhosis mortality males 15-44

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15 Evidence based discovery Evidence based delivery 17 years to get 14% of evidence into practice

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17 Strategic Objectives

18 "Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. 1941, William A. Foster

19 Aims: To deliver the highest quality healthcare services to the people of Scotland For NHSScotland to be recognised as worldleading in the quality of healthcare it provides

20 The Healthcare Quality Strategy for Scotland Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

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22 Implementing at scale. can it be done?

23 By what method? W. Edwards Deming

24 quality improvement The combined and unceasing efforts of everyone professionals, patients and their families, researchers, payers, planners, administrators, educators to make changes that will lead to better patient outcome, better system performance, and better professional development. Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

25 The Typical Approach: Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; Available: p26

26 The Quality Improvement Approach:

27 Subject Matter Knowledge Successful Change Improvement Knowledge

28 Our change theory A clear and stretch goal A method Predictive, iterative testing

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30 NEJM 2009;360:491-9

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32 8 hospitals 5809 beds 160 theatres

33 46% reduction in surgical site infection 47% reduction in mortality

34 NHSScotland Surgical Safety Briefings

35 NHSScotland Surgical Mortality 23% reduction from median

36 Smoothed SMR Hospital Standardised Mortality Ratios (Seasonally Adjusted) Scotland: Oct-Dec 2002 to Jan-Mar % average yearly reduction average yearly reduction (Oct 2002 to Jan 2010) 4.2% Quarters (Apr 2010 to Mar 2012)

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39 At some level all of the challenges we face are reliability challenges

40 But every time I learn something new, it pushes something old out of my brain...

41 Normalisation of Deviance

42 VERY UNSAFE SPACE Systemic Migration to Boundaries INDIVIDUAL BENEFITS Driving 80 mph the illegalillegal space (for almost all of us!) Driving 60 mph- the Illegalnormal space The posted speed limit is 50 mphthe legal space Life Pressures Belief Perceived vulnerability Systems. PERFORMANCE

43 VERY UNSAFE SPACE Systemic Migration to Boundaries INDIVIDUAL BENEFITS Life Pressures Only wash hands on audit days Handwashing when patient has MRSA Handwashing every patient, every time Perceived vulnerability Belief Systems. PERFORMANCE

44 Hazard - Castle Bridge Human Factors Want photos at castle Bridge perfect, but dangerous Remedy?

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46 PARIS IN THE THE SPRING

47 Definition of Reliability for Health Care: Failure free operation over time David Garvin Harvard Business School

48 Example: in a 10 day period, your friend picks you up for work 6 days on time Reliability = # of total intended actions = 6/10 = 60% # of actions taken Defect Rate= 100% - 60%= 40%

49 High reliability organisations?

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52 The Reliability Gap Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on outcomes tends to exaggerate the reliability within healthcare giving clinicians a false sense of security Permissive clinical autonomy creates and allows wide performance margins

53 Healthcare processes

54 Jim s pathway When Jim is admitted Full Information about Jim s dementia and how he currently copes was obtained from Mary and other family members. This is Me document completed and Butterfly Scheme discussed with family. Jim s community mental health nurse was contacted and visited Jim and his family in hospital and also provided the staff with advice about how to support him. Jim was admitted to the assessment ward for further tests but no further ward moves occurred. Butterfly displayed. Susanne Forrest, NES, 2012

55 Jim s pathway Staff in the ward had a good understanding and management of dementia and delirium. Mary and other family members stayed with Jim to support him and help out with his care. Staff work in partnership with Mary, other family members, and Jim s community mental health nurse to support Jim to maintain his optimal abilities Jim was discharged home after three days Susanne Forrest, NES, 2012

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57 @jasonleitch