Healthcare quality lessons from the best small country in the world
Scotland and Canada
Scotland
5.5 Million people
Scottish Politics
Scottish Politics Devolution - 1997 Scottish National Party minority Government - 2007 Devolved powers Health Education Criminal justice Agriculture Transport
NHS Scotland 10.3 billion Integrated health and social care 14 territorial boards Special boards NHS Education for Scotland NHS Quality Improvement Scotland NHS Health Scotland NHS National Services Scotland National Waiting Times Centre Scottish Ambulance Service State Hospital
NHS Boards Responsible for individual and population health Acute hospitals - 15,000 beds in 37 hospitals Rural General Hospitals Community Hospitals Community Health Partnerships Primary healthcare and social care
NHS Scotland Leadership Board Chairs meet with Cabinet Secretary monthly Board Chief Execs meet with NHS Scotland Chief Exec monthly Medical Directors meet monthly Finance Directors meet monthly Nurse Directors meet monthly
All cause mortality: Males 0-64, 2001 Glasgow
Male alcohol-related deaths in Scotland
4 ways to deliver public services (LeGrand 2007)
The NHS No cannula in ambulance Nurse handwashing in A&E X-ray in an hour Admitted in two hours Medicines reconciliation Operated next day HDU recovery Stroke assessment
The NHS A&E consultant hand washing Ward information leaflet No surgical review in HDU Nutrition Water Milkshakes Wound sores National Clinical Lead and medical records!
Outcome Aims Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction
Primary Outcomes Develop and build a quality improvement and patient safety culture in our hospitals Build in long term sustainability and capability to drive this approach at all levels
Interventions Critical Care Ventilator acquired pneumonia bundle, central line Ward Early rescue Communication Medicines Medicines reconciliation Theatres Surgical pause Infection prevention/control Leadership Safety walkrounds Executive leadership board patient safety profile
The Improvement Guide, API
Rapid Cycle Change with PDSA What does this mean? Plan, Do, Study, Act Rapid cycle starts with e.g. One doctor, one nurse, one patient Moving to 1..3..5..All These changes happen in hours and days not weeks and months
Ventilator Care bundle Head of bed elevation 30 degrees Sedation vacation PUD prophylaxis DVT prophylaxis Multi Disciplinary Rounds Daily goals
Reality! Measurement of the ventilator bundle elements for 8 patients Head of Bed > 30 degrees = 35% Sedation Hold = 50% PUD prophylaxis = 85% DVT prophylaxis = 100% Bundle All or nothing concept 0% compliance to the ventilator bundle
Aim: Reduce VAP rates by 30% by Oct 2006 by implementing the VAP care bundle in Intensive care Measures Cycle 1e: Test sedation hold on all patients with completion of a ventilator bundle sticker Cycle 1a: Test sedation hold element of bundle on one patient with one nurse and one anaesthetist Cycle 1d: Test sedation hold guideline with exclusions five patients with five nurses and one anaesthetist Cycle 1c: Test sedation hold element of bundle on three patients with three nurses and one anaesthetist using feedback from first test Cycle 1b:Test repeated with another patient with different nurse and anesthetist Process Change: Testing the sedation hold element of the ventilator bundle with frontline staff
NHS Tayside Ninewells, ventilator associated pneumonia Implementation of daily goals TREND Oral hygiene element of VAP bundle implemented SHIFT
Number of Boards - Met Programme Goals Mortality: 15% reduction Adverse Events: 30% reduction 2 3 1 4 1 Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or >w/in range Staph aureus bacteraemias: 30% reduction Crash Calls: 30% reduction Harm from Anti-coagulation: 30% reduction in INRs> 6 Surgical Site Infections: 50% reduction in population of choice
7 1 6 10 7 11 4 4 1 Number of Boards - Statistically Significant Improvements Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days between Blood Sugars w/in Range (ITU/HDU): 80% or >w/in range Staph aureus bacteraemias: 30% reduction Crash Calls: 30% reduction Harm from Anti-coagulation: 30% reduction in INRs> 6 Surgical Site Infections: 50% reduction in population of choice
Forth Valley - mortality
100% Daily Goals Set and Reviewed > 1 time in the day Aim #1 >80% by March 2009, Aim #2 >95% by June 2009 GRI ICU Percentage had Daily Goals Set and Reviewed > 1 time 90% 80% 100% 70% 60% 50% 80% 60% 40% 30% 20% 40% 20% 10% 0% Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 0% Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Days GRI ICU Monthly Average Length of Stay (days) 16 14 12 10 8 6 4 2 0 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 UCL LCL Process Avg Daily Goals & VAP Prevention bundle start Jan-10
NHS Lothian Central line infection
A&A VAP rate
NHS Fife 24 wards, peripheral vascular catheter bundle compliance
NHS Highland Raigmore medical receiving unit
NHS Borders pilot ward c-diff
NHS Lanarkshire C.Diff in each hospital
D&G Early Warning Scoring
D&G Crash Call Rate
NHS Grampian theatre briefings
NHS Grampian DVT prophylaxis
NHS Orkney Hand hygiene
NHS Scotland Hand hygiene
Future Developments Paediatric Primary care Mental health Heart failure Pressure ulcers
Leadership Driver Diagram Develop the infrastructure to support quality and safety improvement Provide the leadership system to support the implementation of safety and quality outcomes in your NHS Board Provide oversight to programme Promote the position of safety and Quality in the organisation
Highest Performing Boards See extranet data regularly Discuss HSMR and question executive team about it Receive reports on extent of harm in hospital and see a plan to reduce it Board members on walkarounds Have safety and quality as first board agenda item
The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland s health care leaders NHS executives, QIS experts, clinical professionals, civil servants, and more all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care. Don Berwick, CEO and President, Institute for Healthcare Improvement
Patient Centred Healthcare Our new approach to achieving world-leading Healthcare Quality
Proposed New Quality Aims 1. To make NHS Scotland a world leader in healthcare quality improvement. 2. To do so in a way that is meaningful to all.
Key messages Focus on results Build capability quickly Rationalise measurement All improvement is local Build a guiding coalition in your context Patient voice Enjoy the work
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We look to Scotland for all our ideas of civilisation. Voltaire (Francois Marie Arouet, 1694 1778) jason.leitch@scotland.gsi.gov.uk