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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 • • • • • • • • 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: – – – – – 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