We would like to thank Pfizer and Boehringer Ingelheim for the non-promotional Educational Grants that made the free nature of this event possible

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• We would like to thank Pfizer and Boehringer
  Ingelheim for the non-promotional Educational
  Grants that made the free nature of this event
  possible

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Next Seminar ½ day on June 1, 2009

• Quality by Design
• Achieving strategic outcomes in health care
  through
• Clinical Microsystem
• Development
• Marjorie Godfrey, MS, RN
• The Dartmouth Institute for Health Policy and
  Clinical
• Practice Director, The Clinical Microsystem
  Resource
• Group

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Belfast May 2009
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James Adams
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How many people are harmed in our healthcare
system?
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Global Trigger Tool Reviews
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NHS Scotland

• 10.3 billion
• Integrated health and social care
• 14 territorial boards
• Special boards
• NHS Quality Improvement Scotland
• NHS Education for Scotland
• NHS Health Scotland
• NHS National Services Scotland
• Scottish Ambulance Service
• State Hospital

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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

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All cause mortality Males 0-64, 2001
Glasgow
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The wrong skills
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Current Improvement methods in healthcare are
highly dependent on vigilance and hard work
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The focus on outcomes tends to exaggerate the
reliability within healthcare giving clinicians a
false sense of security
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Permissive clinical autonomy creates and allows
wide performance margins
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The use of deliberate designs to articulated
reliability goals seldom occurs
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New skills

• Human factors
• Reliable design
• Evidence based care delivery
• Improvement science

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Eras of quality

• 1) The 1990s Evidence based medicine

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Parachute use to prevent death and major trauma
related to gravitational challenge systematic
review of randomised controlled trialsGordon C S
Smith, Jill P Pell. BMJ 20033271459-1461

• Aim To determine whether parachutes are
  effective in preventing major trauma related to
  gravitational challenge.
• Design Systematic review of randomised
  controlled trials
• Results Our search strategy did not find any
  randomised controlled trials of the parachute.

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Parachute use to prevent death and major trauma
related to gravitational challenge systematic
review of randomised controlled trialsGordon C S
Smith, Jill P Pell. BMJ 20033271459-1461

• Conclusion As with many interventions intended
  to prevent ill health, the effectiveness of
  parachutes has not been subjected to rigorous
  evaluation by using randomised controlled trials.
  Advocates of evidence based medicine have
  criticised the adoption of interventions
  evaluated by using only observational data. We
  think that everyone might benefit if the most
  radical protagonists of evidence based medicine
  organised and participated in a double blind,
  randomised, placebo controlled, crossover trial
  of the parachute

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Eras of quality

• 2) The 2000s Add evidence based care delivery

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The Leaders Role
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What Will it Take?

• Winning the hearts and minds of the staff
• Focusing on improvement not targets
• Leadership
• Integration into daily work
• Tying it all together
• Creating infrastructure
• Creating capability and capacity
• Measurement that has meaning

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A Project
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Moving a Big Dot
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Sound impossible? Here are some examples of
success
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Ascension Healthcare
Who they are Largest Catholic and largest
non-profit health system in the US, with 73
hospitals across 20 states and over 100,000
employees
2005 Goal No preventable injuries or death by
July of 2008
What they achieved
Board actions

• Focused on 8 Priorities for action, all with
  clear measures
• Began with bottom up clinical engagement, by
  communicating harm and having staff identify
  goals and opportunities
• Adopted care bundle scoring approach (all or
  nothing)
• Launched 5 initiatives on how we work together
  (organisational learning and cultural change)
• Provided additional support to poorer performing
  hospitals from highest performers
• Emphasised the business case for quality

• 1500 fewer deaths in 2007/2008 (unadjusted
  preventable harm) vs. expected
• gt 20 reduction in mortality 2006-2008
• 60 reduction in VAP
• 60 reduction in birth trauma
• 50 reduction in pressure ulcers

Source David B. Pryor MD CMO, IHI Learning
Lab, 12/08/2008
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• The Patient Safety Programme has captured the
  imagination of a wide range of staff. I believe
  it is beginning to have a major impact on
  organisational culture and is so perfectly
  aligned to our vision and values. It is proving
  to be one of the most professionally satisfying
  areas of work that most of us have ever done at
  senior exec level and it is already the day job
  rather than a programme or initiative.
• NHS Board Chief Exec

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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 gt w/in
  range
• MRSA Bloodstream Infection 30 reduction
• Crash Calls 30 reduction

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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

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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

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Boards Endorse Safety as Key Strategic
Priority Deliver the programme Build a
Sustainable Infrastructure for Improvement
Align SPSP with national improvement
programmes and measures
Primary Drivers
Secondary Drivers
Scottish Patient Safety Alliance (SPSA) Driver
Diagram
National leaders openly endorse SPSP aims,
failure is not an option for execs - Time and
space given for improvement (not a target) -Royal
Colleges serve in official capacity -Safety is an
element of all programmes
Scottish Government Sets PSA as Strategic
Priority
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-National Board development strategy -Ownership
of agreed upon set of outcomes and measures
-Quality and safety comprises 25 of
agenda --Development of infrastructure that
supports improvement and measurement -Clear
improvement aims in strategic plan
Improve Safety of Healthcare Services in
Scotland
-Segment hospitals , customize
approach -In-country support for Boards -Spread
strategy community hosp., primary care -One Team
-Everyone in the tent
-One Team -Develop experts in imp. methods and
coaching -In-country measurement system, culture
survey -Safety work migrates to appropriate
agency -Training programmes developed in
Scotland - Work with IST, QIS and HES to develop
unified improvement approach
-Align aims and measures with national programmes
-Develop a portfolio and execution model -Build
connection to safety in national work -Define
within clinical governance framework
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Driver 5
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Alignment

• Policy
• Programmes
• People
• Methodologies
• Aims
• Measures
• Education

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What does real alignment look like?

• Vision
• Values

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NHS Highland VAP Bundle Compliance
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NHS Highland VAP Rate
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NHS Grampian Percent Compliance with Hand
Washing in ICU
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NHS Grampian Percent Compliance with Peripheral
Line Bundle
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NHS Grampian Compliance with Ward Safety
Briefings
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NHS Grampian Percent Compliance with Theatre
Briefings
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NHS Fife - Percent Compliance with Early Warning
Score
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NHS Fife Crash Call Rate
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NHS Lothian C.Diff. Rate
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NHS GGC ICU Mortality, Glasgow Royal Infirmary
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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 Scotlands
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

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Key Components Self-Assessment
How prepared is your organisation? How prepared
are the people who work within your organisation?

• Will
• Ideas
• Execution

• Low Medium High
• Low Medium High
• Low Medium High

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BEST
BEST
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Jean Boal
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jason.leitch_at_scotland.gsi.gov.uk

• It is not necessary to change. Survival is not
  mandatory
• W. Edwards Deming