Safe use of opioids national collaborative Learning session one Collaborative overview Carmela Petagna Senior Portfolio Manager Health Quality & Safety Commission
The Commission The Health Quality & Safety Commission was established in November 10 to build a culture of constant examination and improvement in the health and disability sector and reduce deaths, harm and waste from preventable errors.
The Commission The Commission works towards the New Zealand Triple Aim for quality and safety outcomes which means: improved quality, safety and experience of care improved health and equity for all populations better value for public health system resources.
Programmes
Collaborative methodology Collaborative teams Select topic Expert meetings Identify Change Concepts Pre-work A P S D LS 0 LS 1 LS 2 LS 3 Implement A P S D LS learning session The Breakthrough Series: IHI Collaborative Model for Achieving Breakthrough Improvement Support: emails / visits / reports / sponsors / meetings / assessments / conference calls
Collaborative structure National team DHB teams Local clinical lead Local improvement advisor (if available) Project lead Consumer Medical Nursing Pharmacy Anaesthesia Palliative care Pain management Other staff as appropriate Support, learning, implementation, measurement. The regional teams and individual DHBs will be supported by the: National collaborative clinical lead National medication safety clinical lead National project manager National improvement advisor Content specialists Expert faculty National steering group *Regional representation will come from local teams
Collaborative support National collaborative team Regional engagement Three national learning sessions Ongoing coaching and mentoring Improvement methodology Measure identification and analysis Meetings (conference calls/webex/video conference) Content specialists Support for international experts/partners
Achievements in six months Draft project charters completed by DHBs Teams formed at DHB level Preliminary data collection at DHB level Harms identified / scope agreed Initial measures identified Completion of regional learning session zeros Clinical leads identified Monthly teleconferences Learning session one executed two and three planned Expert faculty and steering groups formed Measures and intervention library from expert faculty Partnerships established with NHS & IHI Shared workspace created
Expectations from learning session Share stories and ideas Learn from experience of other DHBs Learn about quality improvement methodology Network with other DHBs and build relationships By the end of learning session one we will have a refined vision for: aim statement (S.M.A.R.T) scope of projects (to support reducing opioid-related harm) measures and data collection plan.
Pareto Chart of harm type selected by DHBs Data taken from charters received (n=18) 100 Number of DHBs 15 10 5 0 C1 9 Constipation 2 Discha rge 2 Nausea Respiratory Depression Prescribing Pt Experie nce Reduce ADE/Fentanyl C2 9 2 2 2 1 1 1 Percent.0 11.1 11.1 11.1 5.6 5.6 5.6 Cum %.0 61.1 72.2 83.3 88.9 94.4 100.0 2 1 1 1 80 0 Percent
Harm type by DHB Constipation Respiratory Depression Discharge Nausea patient experience of pain management Counties Manukau DHB Northland DHB Auckland DHB Hawkes Bay DHB Waitemata DHB Waikato DHB South Canterbury DHB Nelson Marlborough Southern DHB DHB Taranaki DHB Mercy Ascot Bay of Plenty DHB Lakes DHB Tairawhiti DHB Midcentral DHB Whanganui DHB West Coast DHB Prescribing Canterbury DHB to reduce adverse events related to fentanyl use Capital & Coast DHB
Safe use of opioids collaborative national dashboard ( DHBs) Harm at DHB level UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46 UCL=.46
UCL=.46 Baseline _
Graphs by harm type Constipation Nausea Prescribing UCL=.46 UCL=.46 UCL=.46 Baseline _ Baseline _ Baseline _ Respiratory Depression Discharge UCL=.46 UCL=.46 Baseline _ Baseline _
Collaborative aim To reduce opioid-related harm nationally by 25 percent across participating areas of district health board hospitals by April 16.