Bundle Monitoring Model BuMM Integrating Professional Knowledge with Improvement Knowledge

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Bundle Monitoring Model (BuMM)Integrating
Professional Knowledge with Improvement Knowledge
ACHSE Best Practice in Aged Care 5th October 2007

• Helen Ganley MQIHC
• Clinical Governance Unit

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Acknowledgements

• Julia Poole, Terry Finnegan
• RNSH Aged Care and Rehabilitation
• Dierdre OMahony, Vicki Pope, Val Crowley
• Project Officers - Safer Systems Saving Lives
  Program
• Hornsby, Gosford, RNSH
• Sean Kelly, Jackie Hyslop
• Gosford Hospital ICU
• Melissa OBrien
• NSCCHS Wound Care Program Manager
• Vicki Fox
• NSCCHS Patient Safety Project Officer
• Chris Conn, Mary Cameron, Philip Hoyle
• Statistical thinkers extraordinaire

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Session Outline

• Problems
• Solution - Bundle Monitoring Model
• Professional knowledge
• Improvement knowledge
• Application of the model
• Infections, Leg Ulcers
• Falls, LOS, BSL
• Mortality
• Evaluation

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Problem 1 An Enormous Amount of Scientific
Knowledge remains Unused

• Failing to use scientifically proven
  interventions
• Is costly
• Can be harmful
• Leads to
• Overuse of unhelpful care
• Underuse of effective care

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Solution Care Bundles

• Care bundles are key evidence-based
  interventions which have a synergistic effect
  resulting in positive patient and organisational
  results
• Each intervention is supported by evidence that
  links it to one or more desirable endpoints

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Which Interventions to Bundle?

• Pareto Principle
• 80 20 rule
• Vital few rather than trivial many
• 3-5 scientifically grounded elements
• Executed in same space and time
• Add
• Change
• What gets measured gets managed

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Problem 2 Too Much/Too Little Measurement with
no Scientific Approach

• Unsure of what to measure, e.g.
• We have set up the project with "soft" outcomes,
  and your BuMM tool might help us to think about
  concrete measures GMCT network coordinator
• Measure everything that moves
• No scientific method for distinguishing between
  common cause and special cause variation

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Solution Our Scientific Method is Statistical
Process Control (SPC)
The control chart is the tool of choice to
appropriately display variation
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BuMM Aim

• Assist in maintaining / improving patient care,
  satisfaction and health outcomes
• Support clinical and corporate governance
• by..
• Requiring the uptake of evidence based
  interventions
• Counting, measuring and drawing appropriate
  statistical pictures
• Measuring only what matters

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ObjectiveIntegrate Complementary Bodies of
Knowledge
Professional Knowledge
Improvement Knowledge
Demings System of Profound Knowledge
Evidence-based interventions
PDSA
PDSA Plan, Do, Study, Act
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Professional Knowledge

• Subject specific, e.g
• Anatomy
• Wound care
• Discipline specific, e.g
• Physiotherapists
• Administrators
• Traditionally,
• healthcare improvement was achieved by increasing
  professional knowledge and applying it

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Improvement Knowledge

• Based on Demings System of Profound Knowledge
• Psychology
• Systems
• Theory of Knowledge
• Build knowledge and learning by developing a
  theory and taking action. Link both with
  prediction and measurement
• Prediction based on a theory is tested in a
  small-scale experiment, studying and measuring
  the effects to build knowledge and permit
  learning, i.e. PDSA
• Variation (statistical thinking and methods)

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Statistical Thinking

• A philosophy of learning and action based on the
  following fundamental principles
• all work occurs in a system of interconnected
  processes
• variation exists in all processes
• understanding and reducing variation are the keys
  to success

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Examples of Tools that Generate Knowledge for
Improvement
Degree of difficulty
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Summary PDSA Integrates PK and IK

• Professional Knowledge
• Evidence-based interventions
• Good Ideas
• Whats always worked before
• Structural issues
• Improvement Knowledge
• Improvement knowledge is executed using the PDSA
  cycle, the scientific method referred to as the
  pragmatic science of evidence-based healthcare.

PLAN
ACT
STUDY
DO
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Baby BuMM
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A What are the Program Goals / Aims related
to Safety? Effectiveness? Appropriateness? Eff
iciency? Access? Continuity of care
? Information management? Accreditation? Competenc
e organisation, team, individual?
B Accountability and Improvement Did the
program achieve its goals/aims? What clinical
governance structures are in place to learn about
(PDSA cycle) systems and make effective
decisions?
BuMM
C Variation How do we analyse, interpret and
address variation?
D IMPACT - Health Outcomes Clinical endpoints
/ patient requirements Functional status
E IMPACT - Balancing Measures Monitoring these
measures ensures that changes to improve one part
of the system arent causing new problems in
other parts of the system, e.g. adverse events
F IMPACT Patient / Carer / Staff Satisfaction
with Care
G IMPACT - Efficiency/Cost Outcomes Hard costs
and soft costs
H1 PROCESS - Perfect Process Proportion of
patients receiving the entire care
bundle Objective No credit is given for patients
receiving partial care Numerator the number of
patients who actually received ALL ELIGIBLE CARE
(every intervention) Denominator the number of
patients eligible to receive at least one of the
elements of care
H2 PROCESS - Composite Compliance Proportion of
all care that was given Objective Credit is
given for patients receiving incomplete
care Performance on the provision of SEVERAL
INTERVENTIONS Numerator Sum of all numerators
for each of the elements of care across the
population to give a composite measure (all the
care that was given) Denominator Sum all
denominators for each element of care to give a
composite denominator
H3 PROCESS - Intervention Compliance Proportion
of the provision of EACH ELEMENT OF CARE reported
separately Objective Stratify the data to focus
areas of improvement Numerator total number of
patients for whom the item was present in the
medical record Denominator total number of
patients in the daily sample
I Attribution, Causation and Contributory Factors
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BuMM Poses Generic Questions

• What is the aim / goal of the bundle?
• What is the impact on
• Other systems?
• Satisfaction?
• Cost?
• How often do we provide evidence-based
  interventions?
• What are the attribution / causation /
  contributory factors that affect performance?
• How do we analyse, interpret and address
  variation?
• What clinical governance structures are in place
  to learn and make decisions about program
  performance / risk and reliability?

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Objective Measure Only what Matters

• Health Outcomes
• Satisfaction
• Efficiency
• Cost
• Safety
• Balancing Measures
• Quality Index

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Measure Only what Matters Infection Morbidity
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Measure Only What Matters Clinical Endpoint
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Measure Only What Matters Patient Safety
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Measure Only What Matters Process Capability of
Physiological System
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Measure Only What Matters Length of Stay
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Measuring Process May be Preferable to Measuring
Outcomes

• Outcome
• May not be immediately known
• Can be influenced or perceived to be influenced
  by difference in co-morbidity
• Not frequent enough to provide large enough
  sample
• May be biased due to confounding variables such
  as type of hospital

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Measure Only What Matters Process

• Composite Compliance
• Patient gets several interventions
• Proportion of all care that was given
• Aggregate measure
• Hides a multitude of sins
• Cannot identify the cause of poor performance

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Monitoring Composite Compliance Leg Ulcer Bundle
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Is Near Enough good Enough?

• Example Infection Prevention system 80
  compliance
• Which of these 5 perioperative interventions
  would you like omitted?
• Instruments sterilised?
• Prophylactic antibiotics?
• Sterile gloves / gowns?
• Bed / theatre decontaminated between patients?
• Clinician handwashing?

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Measure Only What Matters Perfect Process

• Patient gets ALL eligible care
• No credit for partial care
• A more sensitive scale for assessing improvements
• Fosters a system perspective to look at the whole
  patient journey not just parts
• Forces one to identify the difficult systems
  issues
• Closely reflects the interests and likely desires
  of patients

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Monitoring the Perfect Process Leg Ulcer Bundle
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Measure Only What Matters

• Singleton Interventions
• Provision of each element of care in the bundle

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Monitoring Singleton Interventions Leg Ulcer
Management
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Monitoring Bundle Interventions SSI Prevention
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Measure Only What Matters Attribution,
Causation, Relationships
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Evaluating and Actioning Results

• Evaluate performance (mean and variance) against
• Targets
• Customer expectations
• Process capability
• Address special cause variation
• Address common cause variation
• Search / eliminate common causes associated with
  all data points, i.e.
• Stratify
• Disaggregate
• Experiment
• Or
• Expand specifications
• Live with a certain level of defects

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Evaluation

• Early adopters
• Deployment Plan
• External Interest
• NSW Falls Program
• NSW Therapeutic Advisory Group
• Clinical Excellence Commission

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Achievement Predict and Manage Risk, Improve
Systems and Solve Problems

• In order to function effectively and efficiently,
  health care organisations must maintain
  statistical control of their core processes.
• Control charts
• assist learning about inherent risk by predicting
  system capability and reliability
• Direct efforts to
• Improvement by identifying common cause variation
• Problem solving by identifying assignable causes
  (special cause variation)

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Conclusion

• Simple roadmap
• Amenable to a staggered implementation
• Generic measurement model populated by users
• Lead and lag indicators
• Requires evidence-based care
• Utilises rigorous yet simple statistical methods
• make informed decisions in the face of
  uncertainty
• Is fully supported with a suite of tools
  resources
• Perfect process is what the patient requires
• Improvement becomes mainstream as opposed to
  project-based

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hganley_at_nsccahs.health.nsw.gov.au