Learning Session One
21 st October 2009
Supporting NHS Wales to Deliver World Class Healthcare

Driver Diagrams and Care Bundles
Chris Hancock
Critical Care Specialist
Supporting NHS Wales to Deliver World Class Healthcare

Slide 3
WCCIP

Slide 4
ABC of Critical Care Medicine
• Arrive
• Blame
• Criticise
• Delegate
• Exit

WCCIP 2006-08
• All Welsh ICUs participated
• Ventilator Care Bundle
• Central Line Care Bundle
Slide 5

I Chart of Vent Bundle
100.00%
_
X=97.82%
6
90.00%
80.00% 1
1
Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-07
National Aggregate CVC Bundle Compliance
I Chart of CVC bundle
6 6 5 _
X=97.11%
90.00%
3
3
1 1
60.00%
5
30.00%
1
Jun-06
1
Aug-06
6
6
Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-07
I Chart of CVCI bundle
Slide 6
102.00%
UCL=103.43%
96.00% _
X=94.71%
90.00%
Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-07
LCL=85.99%

2.5
2.0
1.5
1.0
0.5
0.0
Helics defined CVC Infection rate by month of line insertion,
Wales: 09/2007 - 05/2009*
Source : W HAIP
Infection Rate (per 1000 catheter days)***
Mean Average
UCL
LCL
Slide 7

Reliability of Healthcare
How often during your episode of healthcare should you receive the agreed optimum care and treatment?
• Sometimes
• Most of the time
• Always
Slide 8

A Major Study of “Reliability” in
American Health Care…
The Defect Rate in technical quality of
American health care is approximately:
45%
McGlynn, et al: The quality of health care delivered to adults in the United States.
NEJM 2003; 348: 2635-2645 (June 26, 2003)
Slide 9

In the UK
• Retrospective case note review of 1006 admissions to a large NHS hospital.
• Adverse events - 8.7%, of these:
• Disability > 6 months – 15%
• Contributed to death – 10%
• Adverse events are common, serious and potentially preventable
(Sari, Sheldon, Cracknell et al, Qual Saf Health Care
2007;16:434–439.)
Slide 10

Slide 11

Instead of Considering the Entire
Patient Pathway why not Concentrate on the Points Where These Adverse
Events Occur?
Slide 12

Slide 13
What Does the Evidence Tell us
Should be Done Reliably at These
Points?

If We Do These Processes Reliably
What is the Expected Outcome for the
Patient?
Slide 14

Slide 15
Hence the Driver Diagram

Driver Diagrams Do:
• Establish the expected outcome
• Identify the critical points within the system
• Set out the relevant evidence based interventions
Slide 16

Driver Diagrams Don’t:
• Describe the whole pathway or all the necessary interventions
• Limit clinical or professional judgement
• Prevent or discourage innovation
Slide 17

Care Bundles Are:
• A small collection of evidence based interventions
• That are essential to the completion of a small part of overall process
• Carried out within a defined time period
• On every occasion unless there is a good reason for not doing so.
• They are all or nothing in nature
Slide 18

Welsh Ventilator Care Bundle
• Daily sedation rest
• Elevation of the head of the bed.
• DVT prophylaxis
• Peptic ulcer prophylaxis
Slide 19

DVT Prophylaxis
GU Prophylaxis
Head Elevation - 30 °
Sedation Hold
Slide 20
Variance Tracking
Yes No Clinical Exclusion
√
√
√ Signed
√

I Chart of Vent Bundle
100.00%
_
X=97.82%
6
90.00%
80.00% 1
Jun-06
1
Aug-06 Oct-06
We already do that!
Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07
I Chart of CVC bundle
Dec-07 Feb-07
6 6 5 _
X=97.11%
90.00%
3
3
1 1
60.00%
5
30.00%
1
Jun-06
1
Aug-06
6
6
Oct-06 Dec-06 Feb-07 Apr-07 Jun-07
I Chart of CVCI bundle
Slide 21
102.00%
Aug-07 Oct-07 Dec-07 Feb-07
UCL=103.43%
96.00% _
X=94.71%
90.00%
Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-07
LCL=85.99%

As it represents a reduction in errors of omission, compliance with the care bundle is a good proxy for reliability of that process.
Slide 22

A simple idea but it has many repercussions – as long as ownership is shared and is of both the intervention and the data analysis
Slide 23

Slide 24

Slide 25
Thank You.
Happy Bundling!