IHI s 25 th Annual National Forum Orlando, Florida Lessons in Quality Improvement from Around the World Wim Schellekens, MD Implementation of Evidence-Based Safety Guidelines Instruct: Motivate: Train: Facilitate: Inspire: knowledge sense of urgency what and how make it possible the heart = the patient Again and again and again.. Is this enough??? NO!!!?? 1
Avoidable harm to patients in : 1500-2000 preventable death in hospitals each year 5,7% of patients in hospitals: harm 50% in the surgery pathway: avoidable! Evidence-based interventions in the surgery process save lives: Infection prevention guidelines Safe Surgery Checklists ( SURPASS ) Crew Resource Management (CRM) SURPASS study: (NEJM 2010; 363: 1928-37) Surgical pathway: checklist on each step in the pathway (6): admission, preoperative, operative, recovery, postoperative, discharge Implementation in 6 hospitals: 6-9 months, 3820 patients, 4387 interventions Control group: 5 hospitals: 2664 patients, 3058 interventions Results: - Number of complications per 100 patients: 27,3 16,7 - Proportion of patients with 1 or more complications: 15,4% 10,6% - In-hospial mortality: 1,5% 0,8% Results in control-group hospitals: unchanged!!!! EVIDENCE-BASED!! 2
Crew Resource Management: Root-cause of incidents: 70% is the human factor In education focus on: individual knowledge + technical skills CRM: focus on team performance = culture intervention Condition: non-facultative 2-day training + 1 year implementation + refresh training Results in a large ICU (UMC-Nijmegen): 3 year study, 7500 patients, in publish - reduced complication rate - reduced SMR (standardized mortality rate) National Patiënt Safety Award IGZ, 2013 Go to Session C25 on Tuesday, 01.30 PM (prof. Hans vd Hoeven, dr. Marck Haerkens)!! EVIDENCE-BASED!! Implementation: All doctors, all hospitals know the guidelines, know the evidence All doctors, alle hospitals know the importance for the patiënt But: Compliance is still low: 20-60% Still wrong side surgery, still huge variation in complications, etc. Still a culture of resistance Dutch Healthcare Inspectorate (superision body of the government) 2011: National supervisory standards for surgery: non-facultative anymore 3
Dutch Healthcare Inspectorate in 2012: Unannounced visits to 21/90 hospital-or: observation, interviews, patiënt records Infection prevention, SURPASS, dubble-check medication, propofol Results: 4 OR: satisfactory 11 OR: substandard within 8 weeks on standard, audit, report 6 OR: serious shortcomings within 8 weeks on standard, revisit If not: results become public (reputation!!!) and if necessary: close the OR What happened in the hospitals? Crisis in each hospital: crisisteam: retrain, remotivate, re-inspire, refacilitate + address peers + sanctions! All hospitals on standard after 8 weeks! 2013: again 20 unannounced visits! major impact Implementation of Evidence-Based Safety Guidelines Instruct: Motivate: Train: Facilitate: Inspire: knowledge Is this enough??? NO!!! We need to add: sense of urgency what and how make it possible the heart = the patient = Foundation Peers address their peers, leaders address professionals and emplyees Sanctions: warning 1 week 1 month you don t want to work here + 4
Balance: Intrinsic motivation Extrinsic pressure Accepting the non-acceptable will kill your culture and in due time also your patients (Schellekens) You work safe, or you don t work here (Shell, Rein Willems, CEO) Who stops being good, stops being better (Cromwell) Wim Schellekens, MD E-mail: w.schellekens@tiscali.nl Mobile: +31 6 21154552 Twitter: @Wim_Schellekens Linked-In 5