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Appendices Error! Unknown document property name. The Breakthrough Series Method Key Elements of the Breakthrough Series Appendix 1 The following information has been gathered directly from the IHI web site www.ihi.com The Breakthrough Series is designed to help organisations close that gap by creating a structure in which interested organisations can easily learn from each other and from recognized experts in topic areas where they want to make improvements. A Breakthrough Series Collaborative is a short-term (6 - to 15-month) learning system that brings together a large number of teams from hospitals or other health and disability services to seek improvement in a focused topic area. Collaboratives range in size from 12 to 160 teams. This Collaborative would have 21 teams; one from each of the DHBs. Each team typically sends five of its members to attend Learning Sessions (three face-to-face meetings over the course of the Collaborative identified as LS on diagram 3.1), with additional members working on improvements in the local organisation. Some collaborative processes have found that an orientation session for teams before the Learning Sessions start is of great value. Teams in such Collaboratives have achieved dramatic results, including reducing waiting times by 50 percent, reducing worker absenteeism by 25 percent, reducing ICU costs by 25 percent, and reducing hospitalisations for patients with congestive heart failure by 50 percent. In addition, IHI has trained over 650 people in the Breakthrough Series methodology, thus spawning hundreds of Collaborative initiatives throughout the health care world.1 A final, follow-up Conference to better ensure sustainability of the improvement results achieved, is held approximately 7 months after the completion of the last learning session. After testing the Breakthrough Series model (Figure 1) in the first three Collaboratives, IHI had the key elements in place. These elements have remained fundamentally unchanged, even as the model has been continuously refined as hundreds of organisations around the world have participated in Collaboratives. Continued on next page 1 www.ihi.com Prepared by: Page 2 of 11 Appendices Error! Unknown document property name. Figure 1. Breakthrough Series Model Topic Selection IHI leaders identify a particular area or issue in health care that is ripe for improvement: existing knowledge is sound but not widely used, better results have been demonstrated in real-world settings, and current defect rates affect many patients somewhat, or at least a few patients profoundly. Faculty Recruitment: IHI identifies 5 to 15 experts in the relevant disciplines, including international subject matter experts as well as application experts, individual clinicians who have demonstrated breakthrough performance in their own practice. One expert is asked to chair the Collaborative and is responsible for establishing the vision of a new system of care, providing faculty leadership, and teaching and coaching the participating teams. Typically, chairs devote one or two days per week for the duration of the Collaborative. The chair and the expert faculty assist IHI in creating the specific content for the Collaborative, including appropriate aims, measurement strategies, and a list of evidence-based changes. An Improvement Advisor teaches and coaches teams on improvement methods and how to apply them in local settings. Continued on next page Prepared by: Page 3 of 11 Appendices Error! Unknown document property name. Enrolment of Participating Organisations and Teams Organisations elect to join a Collaborative through an application process, appointing multidisciplinary teams within the organisation charged to learn from the Collaborative process, conduct small-scale tests of change, and help successful changes become standard practices. Senior leaders from participating organisations are expected to guide, support, and encourage the improvement teams, and to bear responsibility for the sustainability of the teams’ effective changes. To help teams prepare for the start of the Collaborative, IHI conducts pre-work conference calls to clarify the Collaborative processes, roles, and expectations of organisation leaders and team members. IHI traditionally accepts all applicants who agree to commit to these expectations. Learning Sessions Traditional Learning Sessions are face-to-face meetings, usually three of which are conducted during a typical Collaborative, bringing together multidisciplinary teams from each organisation and the expert faculty to exchange ideas. At the first Learning Session, expert faculty present a vision for ideal care in the topic area and specific changes, called a Change Package, that when applied locally will improve significantly the system’s performance. Teams learn from an Improvement Advisor the Model for Improvement (described below) that enables teams to test these powerful change ideas locally, and then reflect, learn, and refine these tests. At the second and third Learning Sessions, team members learn even more from one another as they report on successes, barriers, and lessons learned in general sessions, workshops, storyboard presentations, and informal dialogue and exchange. Formal academic knowledge is bolstered by the practical voices of peers who can say, “I had the same problem; let me tell you how I solved it.” Action Periods During Action Periods between the Learning Sessions, teams test and implement changes in their local settings—and collect data to measure the impact of the changes. They submit monthly progress reports for the entire Collaborative to review, and are supported by conference calls, peer site visits, and Web-based discussions that enable them to share information and learn from national experts and other health care organisations. The aim is to build collaboration and support the organisations as they try out new ideas, even at a distance. Continued on next page Prepared by: Page 4 of 11 Appendices Error! Unknown document property name. The Model for Improvement To apply changes in their local settings, Collaborative participants learn an approach for organizing and carrying out their improvement work, called the Model for Improvement (Figure 3). This model, developed by Associates in Process Improvement (The Improvement Guide, Jossey-Bass, 1996), identifies four key elements of successful process improvement: specific and measurable aims, measures of improvement that are tracked over time, key changes that will result in the desired improvement, and a series of testing “cycles” during which teams learn how to apply key change ideas to their own organisations. Figure 3. Model for Improvement Continued on next page Prepared by: Page 5 of 11 Appendices Error! Unknown document property name. The Model for Improvement The Model for Improvement requires Collaborative teams to ask three questions: What are we trying to accomplish? (Aim) Here, participants determine which specific outcomes they are trying to change through their work. How will we know that a change is an improvement? (Measures) Here, team members identify appropriate measures to track their success. What changes can we make that will result in improvement? (Changes) Here, teams identify key changes that they will actually test. Key changes are then implemented in a cyclical fashion: teams thoroughly plan to test the change, taking into account cultural and organisational characteristics; they do the work to make the change in their standard procedures, tracking their progress using quantitative measures; they closely study the results of their work for insight on how to do better; and they act to make the successful changes permanent or to adjust the changes that need more work. This process continues serially over time and refinement is added with each cycle; these are known as “Plan-Do-Study-Act” (PDSA) cycles of learning (Figure 4). Figure 4. Multiple PDSA Cycles Summative Congresses and Publications: Once the Collaborative is complete, the work is documented and teams present their results and lessons learned to individuals from non-participating organisations at national and international conferences and meetings. Measurement and Evaluation Collaboratives involve regular measurement and assessment. All teams are required to maintain run charts tracking their system measures over time and key faculty members review each team’s monthly report to assess the overall progress of the Collaborative. Prepared by: Page 6 of 11 Appendices Error! Unknown document property name. Appendix 2 International Infection control programmes CANADA Programme: Hand Washing Public Service Campaign Programme Description: The College of Registered Nurses of Manitoba’s hand washing campaign, “Frequent hand washing is your best defense against illness and disease”. http://www.crnm.mb.ca/handwashing.php CANADA Programme: Handwashing: Public Education Campaign Programme Description: Objectives of the program are: • Educate the general population on proper hand hygiene • Support stakeholder and healthcare provider patient-education efforts • Educate the public on their role in helping to control infectious disease • Create a framework of accepted infectious disease control through healthcare promotion and support beneficial behaviour change http://www.health.gov.on.ca/english/public/program/pubhealth/handwashing/ handwashing_mn.html CANADA Programme: Clean Hands for Life Programme Description: The Clean Hands for Life campaign is an ongoing effort to improve awareness about the importance of hand hygiene in protecting patients, residents, visitors and staff from nosocomial infection. www.vch.ca/news/docs/2005_10_13_infection_prevention_campaign.pdf AUSTRALIA Programme Description: A standardized tool for measuring hand hygiene compliance was developed as part of the Debug Infection Prevention Program at Austin Health in Melbourne, Australia. This standardized Hand Hygiene Compliance Tool (HHCT) was an integral part of the culture change program that encouraged the increased use of bedside alcohol-chlorhexidine hand rubs. This program was associated with a sustained improvement in hand hygiene among Health Care Workers and a reduction in the rate of Methicillin Resistant Staphylococcus Aureus (MRSA) infections. The DeBug Infection Prevention Program is based on the Hand Hygiene model implemented at the University of Geneva Hospital. http://www.debug.net.au/index.html Programme: DeBug Infection Prevention Program Continued on next page Prepared by: Page 7 of 11 Appendices Error! Unknown document property name. SWITZERLAND Programme: Programme Description: Cross-transmission of microorganisms by healthcare workers' hands is the Hopisafe.ch – a main route of the spread of nosocomial infections. Hand hygiene can prevent New Program to cross infection in hospitals but compliance with recommended instructions is Prevent poor, usually below 50%. Infection in We promoted hand hygiene by implementing a hospital-wide program with Hospitals special emphasis on bedside alcohol-based hand disinfection. The campaign produced a sustained improvement in compliance with a reduction of nosocomial infections and MRSA transmission. http://www.hopisafe.ch/next.html UNITED KINGDOM Programme: Clean Your Hands Campaign UNITED KINGDOM Programme: Wipe it out Programme Description: The “cleanyourhands” campaign aims to minimize the risk to patient safety of low compliance with hand hygiene by National Health Service (NHS) staff through a national strategy of improvement. The NPSA has developed and produced the “cleanyourhands” campaign toolkit in light of pilot evaluation findings and is currently implementing the campaign across the NHS acute sector. The campaign involves the following: • Placing disinfectant hand rubs near to where staff have patient contact • Displaying posters and promotional materials where they will influence staff and patients • Involving patients in improving hand hygiene http://www.npsa.nhs.uk/cleanyourhands Programme Description: The Royal College of Nursing, with support from its partners, Nursing Standard, Kimberly Clark and the Infection Control Nurses' Association, has mounted the Wipe it out campaign. The campaign aims to provide healthcare staff, employers, patients and visitors with resources to promote better and safer practice around MRSA and healthcare-associated infections (HCAIs). http://www.rcn.org.uk/resources/mrsa/ Continued on next page Prepared by: Page 8 of 11 Appendices Error! Unknown document property name. UNITED STATES Programme: Clean Hands Save Lives! UNITED STATES Programme: Infection: Don't Pass It On Programme Description: The Clean Hands Coalition (CHC) is a unified alliance of public and private partners working together to create and support coordinated, sustained initiatives to significantly improve health and save lives through clean hands. The CHC is facilitated by the Centers for Disease Control and Prevention (CDC). According to the Centers for Disease Control and Prevention, handwashing is the single most important action that one can take to prevent the onset of illness. The need for all individuals, as a public health imperative to routinely wash their hands everyday, transcends all ages and demographic categories. The Clean Hands Coalition has initiated grassroots education efforts to improve food safety and public health by making hand washing an integral part of the day. http://www.cdc.gov/cleanhands/ or http://www.cleanhandscoalition.org/ Programme Description: Infection: Don’t Pass It On is a VA public health campaign established through collaboration between the Office of Public Health and Environmental Hazards, National Center for Patient Safety, Employee Education System, Infectious Diseases Program Office, and VA experts in infection control. The goal of the campaign is to involve staff, patients and visitors in taking basic steps to preventing infection, whether occurring daily, seasonally, or during infectious disease emergencies (natural or man-made). http://www.publichealth.va.gov/InfectionDontPassItOn/Default.htm Continued on next page Prepared by: Page 9 of 11 Appendices Error! Unknown document property name. INTERNATIONAL Programme Provider: World Health Organization Program: Clean Care is Safer Care Programme Description: The World Alliance for Patient Safety was launched in October, 2004, the result of approval by the Fifty-seventh World Health Assembly (May, 2004) to create an international alliance to improve patient safety as a global initiative. The Global Patient Safety Challenge, a core element of the Alliance, creates an environment where safety of care brings together the expertise of leading specialists in the fields of hand hygiene and the safety of injections, surgical procedures, blood use and the care environment. The topic chosen for the first Global Patient Safety Challenge is healthcareassociated infection (HCAI), and a key action within the challenge is to promote hand hygiene in healthcare globally as well as at the country level through the campaign ‘Clean Care is Safer Care”. Hand hygiene, a very simple action, reduces infections and enhances patient safety across all settings, from advanced healthcare systems in industrialized countries to local dispensaries in developing countries. In order to provide healthcare workers, hospital administrators and health authorities with the best scientific evidence and recommendations to improve practices and reduce HCAIs, WHO has developed Guidelines on Hand Hygiene in Health Care (Advanced Draft), to be issued as a final version in 2007. http://www.who.int/patientsafety/events/06/newdelhi_inauguration/en/index INTERNATIONAL Programme Description: Growing interest and concern about control of infectious disease in the domestic setting has led an international group of experts to form the International International Scientific Forum on Home Hygiene (IFH). Through its Scientific Forum on Hand international initiatives the IFH is working to raise awareness of the fundamental role that home hygiene plays in preventing infectious disease, Hygiene (IFH) and to promote understanding of good hygiene practice in situations where infection risk exists including food hygiene, general hygiene, personal hygiene and the care of the sick and other «at risk» groups. The IFH is also seeking to promote research into areas of home hygiene which are currently not well understood and facilitate debate and consensus on issues relating to home hygiene. http://www.ifh-homehygiene.org/2003/2mission/2ifh00.asp Programme Provider: Prepared by: Page 10 of 11 Appendices Error! Unknown document property name. Appendix 3 International Healthcare-Associated Infection Surveillance Year Name Country Mandatory /Voluntary /State No of hospitals (if known) Type of Infection Data Collected Ventilatorassoc pneumonia (VAP) USA 1970 NNIS Voluntary Belgium 1991 National Programme for the Surveillance of Hospital Infections Voluntary UK 1996 Nosocomial Infection National Surveillance Scheme Voluntary Finland 1997 Finnish Hospital Infection Program Germany 1997 Holland BSI SSI ICUspecific MROs UTI Other VAP BSI 315 SSI 100+ Voluntary 4 Krankenhaus Infektions Surveillance System Voluntary 100+ 1996 Preventie van Ziekenhuisinfecties door Surveillance Voluntary 93 Australia 2003 Hospital Infection Standardised Surveillance Voluntary as part of pilot 10 Canada 1995 Canadian Nosocomial Infection Surveillance Program Unknown 34 (MRSA) 110 (VRE) NSW 2003 Mandatory 37 Illinois 2003 Mandatory Florida 2004 Mandatory Not yet specified Missouri 2004 Mandatory Pennsylvania 2004 Mandatory from 1/7/04 California 2004 Mandatory from a date yet to be determined MRSA VAP BSI Neonatal Bonemarrow transplant patients UTI Prepared by: RSV, Rotavirus MRSA VRE Page 11 of 11 Critical incidents related to reprocessing Occupational body fluid exposures Appendices