Kupu Taurangi Hauora o Aotearoa 32nd Infection Prevention and Control Nurses College Conference Building Beyond The Commission s Role in IPC
NZ Health Quality & Safety Formally established under the NZ Public Health & Disability Act 2010 Triple Aim: Improved quality, safety and experience of care Improved health and equity for all populations Better value for public health resources Commission
Why establish a new national QI agency?
HQSC role and purpose To lead and coordinate work across the health and disability sector to: monitor and improve the quality and safety of health and disability services help providers across the health and disability sector to improve the quality and safety of health and disability services
Measurable improvement For every patient, at the individual, population and systems level Open for better care campaign wrapped around the improvement programmes Publicly reported quality & safety markers: visibility and priority at senior levels in DHBs Clinical leadership Multidisciplinary teamwork Consumer engagement
How the Commission adds value Shining the light on variation and key areas for improvement Being an intelligent commentator and advocate for change Lending a hand by making expert advice, guidance and tools available
Mix of programmes Strategic Long Term Improvement Approach Annual review of portfolio of programmes Continuous refreshing of improvement projects to keep pace with emerging trends, new knowledge and stakeholder expectations 7
HQSC Infection Prevention and Control Overarching IPC programme focus: Raising the strategic profile and importance of IPC Supporting clinical leadership Measuring and monitoring progress Capability building in quality improvement Current improvement projects: Surgical Site infection Improvement Programme (SSIIP) Hand Hygiene New Zealand (HHNZ) Previous improvement projects: Target CLAB Zero
What is an Improvement Project? Focus on a specific area or topic for improvement Known actions that if implemented will reduce harm Call to action for people to make change Builds leadership, re-usable networks and capability for improvement Uses a recognised improvement methodology Improvement can be measured National scale, accelerated pace Time limited, building sustainability Significant resource investment Quality and Safety Markers (QSMs) process and outcome measures 9
IPC: 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 Hand Hygiene delivery delivery delivery evaluation/ transition CLAB start-up delivery transition / evaluation transition/ BAU BAU BAU BAU BAU SSI (Ortho) scoping start-up delivery delivery delivery/ transition Med. Safety: Hospital emedicines Opioid Collaborative Perioperative Harm delivery delivery delivery / transition evaluation evaluation/ BAU BAU scoping start-up delivery delivery transition / evaluation scoping start-up delivery delivery transition / evaluation Falls scoping start-up delivery delivery transition / evaluation New Programme 1 scoping start-up delivery delivery New Programme 2 scoping start-up delivery
Pipeline of new improvement programmes Emerging priorities Refining of current prioritisation criteria Shorter list of 2-3 probable new programmes Further scoping of value proposition Pipeline of proposals collected during the year Long-list of feasible proposals for prioritisation 2-3 projects prioritised for implementation Implementation Project evaluation Transfer to the sector
Working list of proposed initiatives Potential Improvement Projects High Risk Meds Pressure injuries Deteriorating patient VTE Polypharmacy Catheter associated urinary tract infections Ventilator associated complications (VAC) Delay cases Patient identification Sepsis Transition points of care Blood products Caesarean Section SSIs PIV Infections
Informed by the Commission s Strategic IPC Governance Group, membership of which includes: Adrienne Morgan, IPC consultant, IPCNC private sector representative Arthur Morris, Clinical Microbiologist, Clinical Lead SSII Programme Don Mackie, Chief Medical Officer,Ministry of Health (ex officio) Geoff Cardwell, Consumer representative Jane Pryer, Senior Advisor - Healthcare Associated Infections & Communicable Diseases Jenny Parr, Assistant Director of Nursing & Director of IPC WDHB Jo Stodart, Charge Nurse Manager IPC Service SDHB, IPCNC DHB representative Joshua Freeman, Clinical Microbiologist ADHB, Clinical Lead HHNZ Lorraine Rees, Charge Nurse Manager IPC Service MCDHB, IPCNC DHB representative Mo Neville, Assistant Group Manager Quality and Patient Safety Waikato DHB Nick Kendall, Manager, Treatment Injury, ACC Richard Everts, Infectious Diseases Physician, ASID representative Sally Roberts, Infectious Diseases Physician and Clinical Microbiologist, Clinical Head of Microbiology ADHB, National Clinical Lead IPC Programme Trevor English, consultant (prev. GM Hospital Support and Laboratories at Canterbury DHB) HQSC : Gabrielle Nicholson; Karen Orsborn; Gillian Bohm; Deborah Jowitt; Rachel Hill
Target CLAB Zero All 20 DHBs IHI methodology: CLAB Collaborative ICU focus Spread to other clinical areas Standard of care
Reducing CLAB to <1/1000 central line days
Better for patients It s much better for patients if they are transferred from another ICU, we can see the insertion checklist and feel confident about leaving the line in place. Merilyn Beken, ICU Nurse Specialist, Auckland DHB
Hand Hygiene New Zealand WHO 5 moments for hand hygiene programme: Senior sponsorship POC hand gel Education/audit & feedback Champions/Clinical Leadership Patient participation
Figure 1. Trends in national aggregate and average hand hygiene performance: October 2012 to June 2015 Progress over time Trends in national aggregate and average hand hygiene performance: October 2012 to June 2015
Frontline ownership Waitemata DHB
DHB HH performance by moment Name Northern Region DHBs Midland Region DHBs Central Region DHBs South Island Region DHBs Correct moments Total moments Compliance rate Lower confidence interval Table 2. Hand hygiene performance by geographic region Upper confidence interval 12,037 15,171 79.3% 78.7% 80% 5,099 6,361 80.2% 79.2% 81.1% 7,691 9,635 79.8% 79% 80.6% 6,673 8,193 81.4% 80.6% 82.3%
Reaching 80 percent!
Hand Hygiene 2015/16 HHNZ website being maintained Database being upgraded by Hand Hygiene Australia (HHA) Reporting maintained and enhanced National coordinator role Communications on-going
Working regionally The Commission working with the sector to support the development of regional IPC networks First round of meetings Dec 2014/Feb 2015 in Northern, Midland, Central and Southern regions Focused on what would be needed to sustain practice improvement as the hand hygiene programme is transitioned from being centrally led by the Commission, to being regionally supported
Approaches to improvement and results to date
SSIIP progress to date All 20 DHBs engaged in the orthopaedic workstream of the programme Canterbury and Auckland DHBs delivering the SSIIP in partnership with HQSC ICNet-based national data warehouse supports data collection, analysis and reporting (local and national reports quality and safety markers) Three of five DHBs (Auckland; Canterbury; Southern) engaged in cardiac workstream of the programme
SSII Programme SG members: Dr Sally Roberts, Clinical Head of Microbiology, ADHB Dr Arthur Morris, Clinical Microbiologist, ADHB Mr Imran Ramanathan, Cardiothoracic Surgeon, ADHB and NZ Representative on the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Mr Richard Lander, Orthopaedic Surgeon, MidCentral DHB, Executive Director for Surgical Affairs, Royal Australasian College of Surgery (RACS), representing the Surgical College (replaced Dr Allan Panting NMDHB March 2015) Mr Kelly Vince, Orthopaedic Surgeon, Northland DHB Claire Underwood, IPC Clinical Nurse Specialist, Hutt Valley DHB Marie Russell, Perioperative Nurse, Grace Hospital, representing from the NZNO Perioperative Nurses College Dr Andrew McWilliams, Anaesthetist, Canterbury DHB, representing the Australia and New Zealand College of Anaesthetists (ANZCA) *Lisa Maxwell, IPC Clinical Nurse Specialist, Waikato DHB, on SSIIP Expert Faculty
Improvement approach A range of improvement methodologies: the right tool for the right job Continuous quality improvement shift from initial Lean Six Sigma approach to a more inclusive approach that uses a mixture of methodologies including the IHI Model for Improvement (PDSA cycles)and Frontline Ownership
Local Barriers to Engagement Some similar to other IPC initiatives: ensuring senior executives actively involved overcoming resistance to working together in a multidisciplinary way creating local ownership of improvement Issues particular to SSIIP: time involved in manual inputting of data translating IT needs into action
QSMs: Process Markers QSMs for SSIIP confirmed in consultation with the sector as: Antibiotic prophylaxis given on time (0-60 minutes before knife to skin) Correct dose of recommended antibiotic Alcohol-based skin preparation either chlorhexidine or povidone iodine
QSM Compliance over time QSM March-June 2013 October- December 2013 January- March 2014 October- December 2014 On time 91% 90% 92% 95% Dose >=2g cefazolin Alcohol based skin preparation Post-op duration <24hrs 51% 68% 78% 90% 94% 96% 98% 98% 61% 84% 76% 83%
On time antibiotic prophylaxis
Correct dose of antibiotic
Use of alcohol-based skin prep
Outcome measure: Hip and knee SSI rates Mar 2013-Dec 2014
SSIIP 2015/16 Maintaining engagement in all 20 DHBs More in the consumer space Appointment of a new QI Advisor to support local and regional work Automated data collection and reporting a priority for sustainability Improved reporting both local and regional Frontline ownership? a
Looking forward Continue to raise the profile of IPC Focus on connectedness - facilitate the sharing of good practice from islands of excellence to a more integrated network Put resources towards QI capability building with an IPC focus Consult, share, work in partnership across the sector to improve patient outcomes
Acknowledgments All the work being done by IPC nurses, hand hygiene champions, surgical teams and SSI champions, & others that support their efforts to improve patient safety & reduce HAIs Clinical Lead for IPC programme Dr Sally Roberts SallyRob@adhb.govt.nz Clinical Lead for SSII programme Dr Arthur Morris ArthurM@adhb.govt.nz Clinical Lead for thand Hygiene Programme Dr Josh Freeman JoshuaF@adhb.govt.nz