Transcript Slide 1

The big picture for improvement:
•Making systems more reliable
•Linking innovations in service delivery with new technologies
•Involving and engaging staff
Hugh Rogers
Associate, Service Transformation
30th September 2005
The NHS Institute
for Innovation and Improvement
• NHSU
Service
Transformation
• Leadership
Product &
Technology
Innovation
Centre
(NIC)
Agreed
• Modernisation Agency
programme
priorities
• National Innovation Centre
Leadership
Learning
•
•
•
•
Delivering Quality & Value
A No Wait system
Primary care & LTCs
HealthCare Associated Infection
The Goal: towards reliable healthcare
• No needless delay
– Treat me quickly and appropriately
• No waste
– Use the resources we give you to greatest effect
• No feelings of helplessness
– Treat me with respect and empower me
• No needless suffering
– Give me effective treatments and relieve my pain
• No needless deaths
– Protect me and heal me
• No inequity
– Treat me fairly
Adapted from ‘Crossing the Quality Chasm’, Institute of Medicine 2001
What is reliability?
• “The capacity to perform a given function under given
conditions for a specified period of time”
• A reliable health care system is one that is designed to
ensure that every patient consistently receives evidencebased, effective care every time he or she needs it.
• An important outcome of reliability would be patient and
public confidence in the NHS
“Reliability means keeping a promise”
(Don Berwick)
Measuring reliability
Reliability
Approach to achieving reliability
10-1
Intent, vigilance, hard work
10-2
Design informed by reliability science
and human factors
10-3 or
more
Design of Highly Reliable Organisations
(HROs)
Technical solutions
(After Nolan & Weick)
Compare Reliability and Safety
Reliability
Safety
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•
•
•
•
•
•
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Errors of omission
common cause strategies
proactive
creation of reliable systems
When failure
has high impact
Errors of commission
special cause strategies
reactive
focused projects
Current Reliability
• Good people working hard will not be able to overcome the
complexities of today’s systems of care to prevent errors
• Studies show that human beings make errors
– Misreading errors 3 in 1000
– Omission in the absence of reminders 1 in 100
(BMJ March 18 2005 Tom Nolan)
• NCEPOD report on critical care (May 2005) shows:
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–
–
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27% of hospitals have no early warning system
44% of hospitals have no outreach service
66% of admissions to ICU were unstable for >12hrs (in hospital >24hrs)
25% were not reviewed by consultant intensivist in first 12 hrs
ICU care ‘less than good’ in 47%
– Deficiencies may have contributed to death in 11%
10 High Impact Changes
High Impact Changes # 3 #4 and #6
3.
Manage variation in patient discharge thereby
reducing length of stay
4.
Manage variation in the patient admission
process
6.
Increase the reliability of therapeutic interventions
through a “care bundle” approach
Principles of improved reliability
• Understand why LOS varies so much
– Benchmarking can help
– Variation partly due to variation in clinical care
• Establish what care processes need to be
standardised to achieve more consistent
LOS
• Put in place systems whereby this care
becomes the default (care bundles)
• Establish failsafe mechanisms
Delivering Quality & Value
Systems & Operational Levels
OPERATIONAL LEVEL
PATIENT PATHWAY
PATIENT PATHWAY
PATIENT PATHWAY
OPERATING THEATRES
TREATMENT AREAS
DIAGNOSTICS
WALK –IN CENTRE
SYSTEM LEVEL
PATIENT PATHWAY
IMPROVING CLINICAL & SERVICE
QUALITY WHILE CONTROLLING COSTS
System level
 Performance targets
 Financial balance
 Variation in Practice
Focus on improving
and standardising
core clinical
processes
Operational level
 Productivity & efficiency
variation
 Poor benchmarking
Lean principles to
reduce waste and
apply best practice
Hip replacement
Lower quartile – 10 days
If all trusts
moved to perform like the top 10
Upper quartile – 8 days
the NHS
save £48.6
million
Topwould
10 performance
– 6.3
days p.a.
LOS for Fractured Neck of Femur
Variation in LOS for different types of hospital
Lower quartile – 19 days
Upper quartile – 13 days
Top 10 performance – 8 days
Potential saving £81.4 million p.a.
Stroke
Potential saving £74.3 million p.a.
Variation in LOS for Caesarian Section
Potential saving £49.1 million
Initial focus for HRGs - episodes
50 HRGs account for 50% of all Finished
Consultant Episodes
Cumulative % FCEs by HRG 2003/04 for England
100%
90%
80%
% All FCEs
70%
60%
50%
40%
30%
20%
10%
0%
1
101
201
301
HRG
Source : HES
401
501
601
How can we improve flow?
• Ensure access to a bed
Admit
Presents
at A&E
– Smooth out elective flow
A&E
time
Length of stay
Numbers
discharged
• Expedite simple discharges (across the week and within the day)
– Set the discharge date at admission
– Patient tracking to record what needs to be done
• Make optimum care the default
– Standardise care bundles, build in reliability
• Maintain decision making throughout the week
Medical patients
Length of stay by days - April to July 2002
– Delegation of authority every day
• Getting systems right to achieve discharge
– Pharmacy, transport, external partners
Number of patients
– Nurse led discharge
Note: average LOS = 7.24 days
250
200
150
100
50
0
0
3
6
9
12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Length of stay (days)
Defining the optimal clinical process
• High volume, high variance clinical groups
– Cost, LoS, Staff, Supplies etc.
• Study high and low performance
• Identify defining characteristics of high performing
processes
• Field test principles
• Design and package for NHS
Potential gain for the NHS with the top 50 HRGs:
£1,500,000,000
(approx)
Win! Win! Win!
Improving and standardising care
processes:
– Reduces LOS
– Reduces staff stress
– Improves clinical outcomes
• Readmissions
• HCAIs
But also:
Hogarth’s take on clinical variation
Mortality vs Reference costs
Hospital standardised mortality rates by reference costs
140
130
120
HSMR 2002
110
100
90
80
70
60
50
50
60
70
80
90
100
110
120
Reference costs 2002
‘Pursuingbetween
Perfection’cost
programme
NoSource:
relationship
and mortality
130
UCL
Median
Weekly deaths
LCL
31/03/2004
29/02/2004
31/01/2004
31/12/2003
30/11/2003
31/10/2003
30/09/2003
31/08/2003
31/07/2003
30/06/2003
31/05/2003
30/04/2003
31/03/2003
28/02/2003
31/01/2003
31/12/2002
30/11/2002
31/10/2002
30/09/2002
31/08/2002
31/07/2002
30/06/2002
31/05/2002
30/04/2002
31/03/2002
28/02/2002
31/01/2002
31/12/2001
Applying systems thinking to mortality
50
45
40
35
30
25
20
15
10
5
0
Some specific interventions
• Reliability in wards – observations – recognition –
responsiveness [hospital at night -> hospital 24/7?]
• Critical Care Outreach services and ‘Crucial care’ rounds
• Eliminate medical outliers
• Eliminate unnecessary delay – access to specialist, higher
level care, tests etc
• Hospital Infection: ‘Saving Lives’ change package
• High risk medications
• Decision, planning and diagnostics on admission
Blackburn Hospital
May ‘04
Culture for improvement
Changing culture
• Leadership strategies for openness and
mindfulness
• Measurement demonstrating change is an
improvement
• Staff capability – team working –
communication up hierarchies
Measuring reliability in Luton
Mortality Project Improvement All observations 'complete'from monthly case
note reviews
20.00
20 sets of notes reviewed each month
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Jan-04
Feb-04
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
• Observations on wards improving
• New focus on responsiveness
• Testing colour banded EWS and response algorithms
• Looking at models of outreach / medical emergency teams
• Focus on increase uptake of ALERT training by doctors
The Potential for technology
• Frimley Park
• Portsmouth
• Sydney
3 NHS Trusts, original Community of Practice
295 ‘lives saved’ since April 2004
3 NHS Trusts (Pursuing Perfection), trends of annual HSMRs
115
110
HSMR (95% CIs)
105
100
95
90
85
80
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
High Impact Change # 6
Increase the reliability of therapeutic interventions
through a “care bundle” approach
• Example for reducing ventilator associated pneumonia:
– Elevating the head of the bed >30o (Drakulovic 1999)
– DVT prophylaxis (Cook et al 2001)
– Peptic ulcer prophylaxis (Yang & Lewis 2003)
– Managing sedation effectively with sedation Holds (Kress 2000)
– Tight Control of Blood glucose 4.4-6.1 mils (Van den Berghe 2001)
• Can be applied to
• Surgical site infection
• Central line management
• Myocardial Infarction
• etc etc
West Middlesex Hospital
West Middlesex Hospital
Reducing LOS at West Middlesex
Guess when the new hospital opened?
New Hospital
Opened
May 2003
Reducing Mortality at West Middlesex
From 1.2 to 0.93 = ~25%
1.4
1.2
1
0.8
New Hospital
Opened
May 2003
HSMR
0.6
0.4
0.2
0
2002 - 03
2003 - 04
2004-05
2005 ytd
Conclusion
By increasing the reliability of clinical care
we could:
• Save 10,000 Lives per year
• Save £1.5 billion per year
• The 10 High Impact Changes are just a
start
• We can only achieve this by changing our
organisations and educating our staff