Transcript SPSP Fellowship Project Charter - Healthcare Improvement Scotland

Patient Safety in Primary Care
Capacity Building Event
“Design and implement a Patient
Safety Programme in Primary
Care”
Roll out March 2013
Start with GP Practices, Community Nurses and
Pharmacy
Extend to rest of primary care….
Patient Safety in Primary Care
Programme - 3 Workstreams
• Safer Medicines
• Safe and reliable patient care across the
interface and at home
• Safety Culture and Leadership
•
•
•
•
Not all at once
Menu
Build over time
Organic spread
Current Activity
SIPC
Spread
•
•
•
•
•
•
•
• Dumfries and
Galloway
• Ayrshire and Arran
• Lanarkshire
Borders
Lothian
Tayside
Grampian
Highland
Forth Valley
Greater Glasgow &C
Innovation Adoption Curve
.
Build Will
•
•
•
•
•
•
•
“Houston we have a problem”
Correct Areas of focus
Safer care
Confidence in systems – less waste
Less things going wrong
Less stress
Improved interface working
Reduction in tests per patient
Tests per Patient
2.5
2
1.5
1
0.5
0
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Successful implementation needs..
• Build on the professionalism of front line
staff
• Prioritised within existing and adapted
GMS contract
• Alignment with GP Appraisal and
Revalidation
• Commitment of boards
Which way is your board looking…
Board Levers
•
•
•
•
•
•
•
Measurable high quality care
Reduce Admissions e.g 6% of admissions
Link to SPSP:
Med Rec – Warfarin – Pressure ulcers
Less adverse events - harm- complaints
Interface working
Reducing Falls/ UTIs/Pressure ulcers
Boards need…
• Executive buy in and championing
• Prioritise this programme
• Dedicated clinical leadership and QI
support
• Pharmacy support
• Build knowledge and skills
• Engagement with practices - PLT?
• Re focus
• Re energise
Support Available
•
•
•
•
Capacity Building
Tools
Experience
Resources - education / interventions to
build will
• IT
• Measurement
• Productive General Practice
Going back to your board…..
• How aware is your Board of the safety programme for
Primary Care?
• Current knowledge /skills/ infrastructure/experience to
support the the programme?
• What do you now need to do in your Board to prepare
for it?
• What support do you need?
Patient Safety in Primary Care
Capacity Building Event
Using data to improve
the reliability of care
Bruce Guthrie
Professor of Primary Care Medicine, University of Dundee
GP NHS Fife
With thanks to everyone in the Safety Improvement in
Primary Care Programme (SIPC), and The Health
Foundation for funding SIPC
Outline
• Getting started with data
• High-volume processes and sampling
– What are we trying to improve?
– How do you measure a nightmare?
• Reliability and bundles
– Examples from other contexts
– Examples from SIPC
• What to do in real life?
Getting started with data
• “Education, education, education”
Tony Blair 1997
• “It’s the economy, stupid”
Bill Clinton 1991
• No politician has yet said:
– “Data, data, data”
– “It’s the data, stupid”
Getting started with data
• My new practice fell apart over unreliable
results handling
• Warfarin sheets audit
No (%) of patients with
element recorded
Name and date of birth
Phone number
Diagnosis
Planned duration
Target INR
36 (100)
36 (100)
31 (86)
18 (50)
21 (59)
Data is people
• 68 year old woman on warfarin, diagnosis
and duration not recorded, target 2.5
– Warfarin for a pulmonary embolus shortly
after surgery for oesophageal cancer
– Should have stopped (and is now)…
No (%) of patients with
element recorded
Round 1
Name and date of
birth
Phone number
Diagnosis
Planned duration
Target INR
No (%) of patients with
element recorded
Round 2
36 (100)
36 (100)
36 (100)
31 (86)
18 (50)
21 (59)
36 (100)
36 (100)
27 (75)
36 (100)
Process volume
• Previous example is low volume, but the
rest of warfarin is higher volume
Criteria
Last INR within +/- 0.5 of target
Last INR within +/- 0.75 of target
% of patients (n=35)
71%
89%
Standard/comments
50% - MET
80% - MET
Last INR
<1.5
1.5-1.9
4-4.9
≥5
Number of weeks to ‘next test’
1
2
3
4
5
6
3%
19%
3%
0
Out of range are mostly
low which suggests we
are tending to undertreat
to target
26%
40%
6%
26%
0
3%
Testing much more than is
necessary given our good
levels of control
Process volume
• SIPC1 projects vary in volume
– Warfarin process is high volume
– DMARDs and heart failure low volume
• SIPC2 projects are all high volume
– Medicines reconciliation at discharge
– Outpatient letters
– Results handling
• Exciting and innovative improvement work
– “Solving some of the most important problems of
healthcare” (Health Foundation)
• Boring, boring, boring work…
Safety systems
• Learning from other industries
• Error doesn’t usually cause harm...
• ... so should act on error and risk not harm
Safety systems
• “It appears to me that there were
significant flaws in the quality of
Occidental’s management of safety which
“Relying
the absence
any
affected theon
circumstances
of theof
events
of the disaster.
management
feedback
ofSenior
problems
as were
too easily satisfied that the Permit to Work
indicating
that operated
all wascorrectly,
well”
system was being
relying on the absence of any feedback of
problems as indicating that all was well.”
(Lord Cullen)
Data is people
• Letter comes in, a 64 year old woman just
diagnosed with terminal lung cancer in 2010
– “In retrospect, the lesion is visible on a previous CXR”
• Central Vision CXR report from 2005
– “Chest shows a well rounded opacity on the left side of the chest
which is strongly suspicious of bronchial lesion. Referral to the chest
physicians for further investigation is clearly appropriate.”
• A heartsink moment…
• …but not our fault
• What would stop it happening to us?
Data is people
• Home visit to a man with tenesmus in 2004
• Recently referred to colorectal with ?cancer
(appointment tomorrow)
• Had been seen with loose bowels 15
months ago
– Short history, normal examination inc PR, “do
some tests, come back if abnormal/persistent”
– FBC and stool culture normal, FOB positive
• Clinical care fine, results book failure
Data is people
Safety systems
• Remember Lord Cullen’s criticism of
Occidental management?
– “Relying on the absence of any feedback of
problems as indicating that all was well”
• ‘Usual’ feedback isn’t reliable
• Collecting data and measuring can be
• Health care is more dangerous to patients
than the oil industry is to employees
– But we harm people one at a time
Process volume
• SIPC topics
– High risk medicines - warfarin, DMARDs
– High risk conditions – heart failure
– Medicines reconciliation at discharge
– Outpatient letters
– Results handling
• Boring, boring, boring work…
• …but getting the paperwork wrong can kill
people
How to measure?
• Remember our warfarin audits?
– Data is all in the warfarin book
– Only 36 patients
– All the measures were easily countable
• Can’t always count everything every time
– Volume may be too high, but high volume is
an opportunity to sample
– Take 5 or 10 results and check if actions done
– Take 5 or 10 DC summaries or letters and
check medications reconciled/actions done
DMARD FBC in last 6 weeks
How to measure
• There’s no right answer to:
– How many to measure each time
– Complete audit vs small sample
– How often to sample
– Depends on the context
• Have to decide what to measure first…
Measures and bundles
• Quality measures are hard to define well
• Traditionally have usually been stand alone
– % of patients with HT with controlled BP
– % of patients on warfarin with INR in range
– % of patients over 75 receiving a flu jag
• Increasingly measures are ‘bundled’ in
various ways
– AKA composite measures
All or nothing measures
• ‘Care bundles’ are all or nothing measures
– The % of patients who achieve ALL individual
measures/get all appropriate care
• Appropriate when:
– Each element is important in its own right
– Patient outcome is improved by ALL
measured care being received (the whole is
greater than the sum of the parts)
– Each element should be necessary every time
Some examples
Diabetes data from 59 practices
Measure
% of patients achieving
GHB done
BP done
Cholesterol done
Smoking recorded
GHB≤7.4%
BP<140/80
Cholesterol≤5
Non smoker
Guthrie, B., A. Emslie-Smith, et al. (2009). Diabetic Medicine 26(12): 1269-1276.
95.4
95.0
93.6
96.2
55.3
38.7
75.0
82.9
Some examples
Measure
GHB done
BP done
Cholesterol done
Smoking recorded
GHB≤7.4%
BP<140/80
Cholesterol≤5
Non smoker
% of patients
achieving
95.4
95.0
93.6
96.2
55.3
38.7
75.0
82.9
% of all care
done (average of
the measures
95.0
51.4
Some examples
Measure
GHB done
BP done
Cholesterol done
Smoking recorded
GHB≤7.4%
BP<140/80
Cholesterol≤5
Non smoker
% of patients
achieving
95.4
95.0
93.6
96.2
55.3
38.7
75.0
82.9
% of patients
with all care
done
88.3
Could do better?
16.2
Ouch!
A SIPC1 example
• Heart failure bundle
– Prescribed licenced beta blocker
– Target or maximum tolerated BB dose
– NYHA status recorded in the last year
– Patient given education about deterioration
– Pneumococcal immunisation ever
• Each element necessary?
• Whole greater than the sum of the parts?
• Each element necessary every time?
A SIPC1 example
On BB
BB target
NYHA
Info about
deterioration
Pneumococcal
Composite =
got all
Yes
Yes
No
Yes
Yes
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
80%
60%
60%
40%
100%
20% Ouch!
All or nothing composites are brutal
or
Reliability is hard
Bundles and the Swiss
Cheese model
Result doesn’t arrive Test not tracked out
Test n
Result
not actioned
ot tracked
out
Patient not sure how to
get result
Missed diagnosis
HARMTest n
Missing result not noticed
ot tracked out
Patient not informed
Reason, James (1990). Human Error. Cambridge University Press.
Choosing measures?
• What are the individual measures?
– For Boards and practices to decide
– SIPC has a number of measures at various
stages of development; other examples
• Single measures or care bundle/all or
nothing approaches?
– Each element necessary?
– Whole greater than the sum of the parts?
– Each element necessary every time?
The SIPC approach
• Make every measure count
– 4-5 measures in total
– Measure what you need not just what you can
– Processes plausibly ‘tightly linked’ to outcomes
– Whole is plausibly more than the sum of its parts
– Room for improvement
– Suitable for repeated measurement in PDSAs
• Be flexible (change, drop, add)
• But there’s more to life than care bundles…
New political slogans?
• Data, data, data (David Cameron 2012)
• It is the data, stupid (Barack Obama 2012)
– Because data is people
– Because boring processes can kill people
when they are unreliable
– Because we can be better
• Good luck!
Patient Safety in Primary Care
Capacity Building Event
The Case for Quality Improvement
Jane Murkin
12th March 2012
Quality Improvement Hub
Session Aims
• Context of healthcare today and its relationship with
quality improvement
• Outlining the improvement approach, journey and
measurement plan
• Consider the application of improvement science and
methodologies in relation to Primary Care Patient Safety
Improvement
• Learning from others - collaboration – a network and
community
Quality Improvement Hub
Lets take a moment to……
• Thank you and celebrate your successes
• Building on work to date – acknowledge the need to
focus on demonstrable measurement for improvement
• Quality strategy – safe, effective & person centred care
• 20:20 vision – Sustainable high quality healthcare
• Focus – what has been achieved, where are our gaps,
priority areas for focus -testing, implementation and
improvement
• Achieving reliability : Communication, transitions, results
handling, medicines reconciliation
• Developing your local aims and your first pdsas,
Context
Quality Improvement Hub
Care is not safe –
Institute of Medicine report
“Between the care we have
and the care we could have,
lies not a gap, but a chasm”
Adverse Events
in Hospital
• 3.7% Harvard 1991
• 16.6% Australia 1995
• 10.8% London 2001
50% PREVENTABLE
3 million bed days in UK
£1 billion per annum in UK
• Acute hospitals 9.5% - HAI
• Primary Care 8.6%
(July 2007 HPS)
• Pre work SPSP
• SPSP Data – what are we learning in relation to harm
What we know about error and harm in
UK
• 11% of prescriptions flawed (Sandars & Esmail, 2001);
• GP prescribing: error in 7.5% of all items? (Garfield et al, 2009, UK);
• 76 errors per 1000 consultations (Rubin et al, 2003,UK);
• 1 in 25 hospital admissions attributed to medication issues
(Thompson, 2009)
• 191 SEA Reports – 25% harm + 50% near misses (McKay, Bradley,
Lough & Bowie, 2009);
• 500 random EPRs – 9.5% harm, c40% avoidable (de Wet & Bowie, 2009)
“Over the past 20 years there has been a growing awareness of the need
to improve quality across health care and general practice, driven by a
need to reduce inequalities in health care and the need to effectively
translate evidence into practice and by the changing expectations of
patients and carers. Activity to address this need has often been
variable.”
(Quality improvement in general practice – Kings Fund 2010)
• Quality and Outcomes Framework (QOF) has undoubtedly improved the
quality of care for a number of important conditions managed within
general practice
• However how safe and reliable are our systems & processes
• Co design - Involving patients and public in improving quality and safety
Converting research to care
Original research
18%
Negative
results
variable
Dickersin, 1987
Submission
46%
0.5 year
Kumar, 1992
Koren, 1989
Acceptance
17
years
to apply 14% of
Negative
0.6 year
results
research Publication
knowledge
17:14
to 35%
patient care! 0.3 year
Kumar, 1992
Poyer, 1982
Balas, 1995
Lack of
numbers
Expert
opinion
Bibliographic databases
50%
Poynard, 1985
Inconsistent
indexing
6. 0 - 13.0 years Antman, 1992
Reviews, guidelines, textbook
9.3 years
Patient Care
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
How safe are clinical systems?
Primary research into the reliability of systems within 7 NHS
organisations and ideas for improvement
( Health Foundation May 2010)
Reliability in healthcare – This is not simply a matter of putting in
place proper guidelines and expecting practitioners to follow
them. It involves identifying in advance the points at which those
mistakes can happen, the different elements that contribute to
those mistakes and the systems that practitioners should follow
in order to ensure pt safety
In aviation 75% of accidents are
caused
by human factors…
…what’s the figure in healthcare?
Complex Systems
Probability of performing perfectly:
Probability of success, each element:
# of steps
0.95
0.99
0.999
0.9999
1
0.95
0.99
0.999
0.9999
25
0.28
0.78
0.975
0.997
40
0.12
0.66
0.96
0.995
100
0.006
0.37
0.90
0.99
from R Resar, Institute for Healthcare
Improvement
Sources of variation in a system
Process
Staff
motivation
skills
illness
shifts
holiday
training
unclear
disease
guidelines
race education
differ
sex
complications
anaesthetics
GP
machines not
the same
supplies
rooms not
the same
Kit
Patients
age motivation
transcription
transport
applications
Discharged!
80% is under our
control
Information
62
So, how is our business changing?
Demography – 25 % increase over 75 ( nxt 10yrs)
Finance – Falling public expenditure
Technology
Inequality
Epidemiology/ Morbidity- Shift long term care and
complex needs
Expectations growing/ Quality
Mutuality
Why Quality Improvement?
Context in relation to Healthcare
•
•
•
•
•
•
•
•
What is the problem?
Unacceptable variation in our systems
Delays - for patients and staff
Unpredictable process and outcomes
Waste
Preventable harm
Chaos and complexity
Innovation is recognised by leading commercial
organisations as being essential for success
• We have innovative approaches within healthcare, but these
are not systematically applied
• The current rate of improvement is not likely to achieve the
change we want and need
Measurement for
Improvement
Process and value
stream mapping
Future State
Measurement
of
Improvement
Current
State
30 - 70% of work doesn’t
add value
Up to 50% of process
steps involve a ‘hand-off’,
leading to error, duplication
or delay
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Establish value in the
eyes of your
patients/service users
Map the total
Customer/Provider
value stream
Make value flow
with no
interruptions
Pull what you want
when you want it
Search for
perfection with
no waste
Developing an Aim Statement
Team name:
Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)
You should review your Aim Statement frequently to make sure
it is consistent and that everyone involved with the initiative
has a common understanding of what is to achieved.
How good?
By when?
69
Quality Improvement Hub
• Improvement comes from the application of knowledge
• Five fundamental principles of improvement:
1. Knowing why you need to improve
2. Having a feedback mechanism to tell you if the
improvement is happening
3. Developing an effective change that will result in
improvement
4. Testing a change prior to implementation
5. Knowing when and how to make the change
permanent – implementation
The Quality
Pioneers
Walter Shewhart
W. Edwards
Deming
(1900 - 1993)
72
(1891 – 1967)
Joseph Juran
(1904 - 2008)
The Primary Drivers of
Improvement
Having the Will (desire) to change the current state to one that is better
Will
Developing
Ideas that will
contribute to
making
processes and
outcome better
QI
Ideas
Execution
Having the
capacity to apply
CQI theories,
tools and
techniques that
enable the
Execution of the
ideas
The Quality Measurement Journey
AIM
(Why are you measuring?)
Concept
Measure
Operational Definitions
Data Collection Plan
Data Collection
Analysis
ACTION
Source: Lloyd, R. Quality Health Care. Jones and Bartlett Publishers, Inc., 2004: 62-64.
74
A Model for
Learning and
Change
When you
combine
the 3
questions
with the…
…the Model
for
Improvement.
PDSA cycle,
you get…
The Improvement Guide, API, 2009.
The basics
•
•
•
•
Aims
Measures
Changes
Testing
What are yours in relation to reliable and safe
systems for primary care interfaces and
transitions ?
4 Key measurement questions
1.Do you know how good you are?
2.Do you know where you stand relative to the best?
3.Do you know where the variation exists?
4.Do you know your rate of improvement over time?
IHI President and CEO Maureen Bisognano
1
Developing an Aim Statement
Team name:
Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)
You should review your Aim Statement frequently to make sure
it is consistent and that everyone involved with the initiative
has a common understanding of what is to achieved.
How good?
By when?
78
MODEL FOR IMPROVEMENT
A P
S D
Exercise
CYCLE:____DATE:____
Objective for this PDSA Cycle
PLAN:
QUESTIONS:
At your table individually or
with your
Colleague spend 5 minutes
drafting your aim and your
first PDSA
Something you will commit to
do next Monday!
PREDICTIONS:
PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE
PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE
PDSA
Worksheet
DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ACT:
ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
Closing the Gap
Between best practice and
common practice:
is based on the ability of
health care providers and
their organizations to rapidly
spread innovations and new
ideas.
80
Challenges in Spreading New Ideas
• Characteristics of the innovation itself
• Willingness or ability of those making the
adoption to try new ideas
• Characteristics of the culture and
infrastructure of the organization to
support change
81
Expectations will always exceed
capacity.
The service must always be
changing, growing and
improving…”.
“
Aneurin Bevan, 1948
Quality Improvement Hub
What will it take to improve quality ?
•
•
•
•
•
•
•
•
•
•
•
•
Winning the hearts and minds of the staff
A clear, defined and executable aim. Communication
Linked with the overall strategy of the organization- Leadership
Tempo-momentum monthly reviews for on track status, quarterly by chief
executives
Transparency- visibility
Focus- less is more
Change at the local level
Integration
Making it daily work
Creating capability and capacity
Measurement that has meaning
Understanding context and culture
Patient Safety in Primary Care
Capacity Building Event
Breakout Rooms
1. Shuna (upstairs) – Warfarin
2. Bara & Jurra (upstairs) – Human Factors
3. Argyll (next door) – Near Patient Testing
Questions for Consideration
1. How aware is your board of the Safety
Programme in Primary Care?
2. What is the current infrastructure to support
the implementation of the programme?
3. What do you need to do in your board to
prepare for it?
Patient Safety in Primary Care
Capacity Building Event
Patient Safety in Primary Care
Capacity Building Event
Patient Safety in Primary Care
Capacity Building Event