How lessons from automotive industry informed a healthcare organisation s approach to patient safety. Simon Ball Queen Elizabeth Hospital Birmingham
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1 How lessons from automotive industry informed a healthcare organisation s approach to patient safety Simon Ball Queen Elizabeth Hospital Birmingham
2
3 An underpinning Philosophy?
4 Aggregating Marginal Gain?
5 Eliminating marginal deficit Local BMW engine factory 99.9% perfect leaving plant Should be 100 Real interest % trouble free at 5 years
6 Eliminating marginal deficit Local BMW engine factory 99.9% perfect leaving plant Should be 100 Real interest % trouble free at 5 years Bolts on engine head line up Different take on errors
7 Eliminating marginal deficit Local BMW engine factory 99.9% perfect leaving plant Should be 100 Real interest % trouble free at 5 years Bolts on engine head line up Different take on errors
8 Important errors
9 Important errors
10 Unimportant errors?
11 Eliminating marginal deficit
12
13 How to use electronic records to improve patient safety
14 Reducing clinical errors Strategic Aim Minimise errors Strategic Enabler Purpose built IT systems Clinical decision support at the point of care Front line error reduction Convert data to information Inform Clinicians Management Patients Alter behaviour
15 Point of Care Decision Support
16 Point of Care Decision Support Examples from the prescribing system Interruption
17 Point of care CDS for prescribing ecarrots Helping doctors to do things right Passive decision support On the menu (non-interruptive) esticks Making doctors do the right things Active decision support In your face (interruptive)
18 How do you avoid alert fatigue in prescribing Order sentences Corollary ordering Role based alerting Seniority based alerting Speciality based alerting Location based alerting Use data to focus the decision support
19 Virtuous circles of information
20 Virtuous circles of information
21
22 Does it work? Response to password messages lvlcat 2 100% Count of msgid 90% 80% 70% % 50% 40% state Carried on Backed off 30% 20% % 0% Contraindication Dose Interaction Dose/Freq Presc Admin qtype catname
23 Medication errors Does it work? National comparators 90 National UHB Administration Dispensing Prescribing Monitoring
24 Providing information that influences behavior Omissions in drug prescribing
25 Instantaneous feedback to cardiothoracic consultants on peri-op prescribing practice Anti-platelet Statin Beta blocked perioperatively ACE inhibitor onward
26 Instantaneous feedback to cardiothoracic consultants on peri-op prescribing practice 30 Anti-platelet Statin 20 Beta blocked perioperatively ACE inhibitor onward
27 3 Year CABG survival Post Intervention Pre Intervention
28 Providing information that influences behavior Omissions in drug administration
29 Converting information into data into changing behaviour
30 Clinical Dashboard Turning data into information
31 RCA Led by Chief Executive
32 Ward management
33 Individual management
34 QED UNIT E2DU - EAST 2 DAY UNIT ENDO QEH EGDU Renal Surgery Renal Assesment Diabetic/Dermatology N4DU WWG East 4C Planned Investigation Unit Chemotherapy Day Unit E5DU - E5B DAY UNIT RDU SD3 QCCU WW5 Emergency Admissions Unit WW2 SB1 ELB EGB Surgical Assessment Unit E1 Day Unit Bournville Admissions Bay North 3 Critical Care WellcomeBuilding Critical Care SA3 Young Persons Unit Neuro Critical Care SB3 EGA E3LU - E3 LIVER UNIT WW4 SB4 SC2 W3LU - W3 LIVER UNIT SA5 ELA E2B WW1 SCCU E5 Selly Oak Critical Care SD1 E4A SS7 E2A E4B E1A SS2 SC3 Acute Renal Care SPSB - PLASTIC SURGERY/ SS6 SA1 SS3 E3A SS5 C2 Assessment SS8 SD4 W01 - Bournville SS4 SC4 W02 - Harborne W03 - Edgbaston BMT Managing management August 2009 Dashboard use by senior nurse Missed Doses 40% % 50 0 Patient Feedback Ward Area Correlation R 2 >0.9 p <0.01
35 Benefits translation? 16.2% Rosser D, Cowley N, Ray D, Nightingale PG, Jones T, Moore J, Coleman JJ. Quality improvement programme, focusing on error reduction: a single center naturalistic study. J R Soc Med Sh Rep 2012;00:0.
36 Providing information that influences behavior Feedback on prescribing performance
37 VTE prophylaxis VTE assessment within the process of admission Recommendation for VTE prophylaxis
38 Improving Safety VTE risk assessments VTE assessment integrated within the admission process Prescription of prophylaxis If guidance not followed Daily warning generated Reminder led to 4% increase in for surgical patients 14% increase for medical patients
39 Junior Doctor Performance indicators Accurate VTE assessment Prescribing for VTE prophylaxis Accurate dementia assessment Attempting to prescribe contraindicated drug Attempted warfarin prescription if INR>5 Prescription warning e.g. sedatives Use of structured prescribing for antimicrobials Type-in prescribing
40 Individual Accountability Doctors Early feedback using composite score Invited to clinic if outlier Recommendations on how to improve Recognise good performance Feedback on monitoring systems
41 VTE prophylaxis VTE assessment within the process of admission Recommendation for VTE prophylaxis Automated proposal of prophylaxis Prescription of prophylaxis
42 Automated proposal of VTE prophylaxis PICS automated proposal went live (Feb 2014)
43 The Power of Information Information enables accountability enables leadership enables clinicians to beneficially alter behaviour enables clinicians to improve systems In order to do this it must be timely credible relevant
44 Lessons from sport & industry Performance is everything High performance is in addressing the margins Get the system right then Don t be shy about individuals variation in performance but Don t be simplistic about the reasons for those variations
45 Acknowledgements Dame Julie Moore Dr Dave Rosser Dr Jamie Coleman Dr Tanya Pankhurst Prof D Pagano Dr Ian Woolhouse Dr Zoe Wryko Wolfson Computer Labs Ian Clark Deb Mckee Health Informatics Daniel Ray
46 Let your communication be: Yea or Nay, for whatsoever is more than these cometh of evil Matthew 5:37
47 Queen Elizabeth Hospital Birmingham
48 NHS number & intelligent design Clinical care The NHS Number makes important contributions to clinical care because it: is the only National Unique Patient Identifier supports safer practice identification practices helps create a complete record, linking every episode of care across organisations. systems.hscic.gov.uk/nhsnumber/staff/benefits
49 NHS number & intelligent design The Magical Number Seven, Plus or Minus Two: Some Limits on Our Capacity for Processing Information G A Miller Psychological Reviews 1956
50 NHS number & intelligent design The Magical Number Seven, Plus or Minus Two: Some Limits on Our Capacity for Processing Information G A Miller Psychological Reviews digit NHS number An invitation to work around?
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