October 2012
Ros Gray
Head of Safety in Healthcare
WE WILL COVER
• National context to safety in healthcare
• National aims – and specifics related to
smoking in pregnancy as an example
• Use of Improvement Methodology
• Launch of the SPSP Maternal Quality
Improvement Collaborative
381
The number of women experiencing severe morbidity
reported in the 7th SCASMM report (published 2011).
71%
The proportion of women reported to have received optimal
management of severe obstetric haemmorhage
“...everyone in healthcare really has
two jobs when they come to work
every day: to do their work and to
improve it.”
What is ‘‘quality improvement’’ and how can it transform healthcare?
Batalden,P; Davidoff.F Qual Saf Health Care. 2007 February; 16(1): 2–3
6 Dimensions of Quality
Institute of Medicine’s
THE HEALTHCARE QUALITY
STRATEGY FOR SCOTLAND
• Person-Centred - Mutually beneficial partnerships between
patients, their families, and those delivering healthcare services
which respect individual needs and values, and which demonstrate
compassion, continuity, clear communication, and shared decision
making.
• Clinically Effective - The most appropriate treatments,
interventions, support, and services will be provided at the right time
to everyone who will benefit, and wasteful or harmful variation will
be eradicated.
• Safe - There will be no avoidable injury or harm to patients from
healthcare they receive, and an appropriate clean and safe
environment will be provided for the delivery of healthcare services
at all times.
BE BOLD
“Bringing excellence to scale”
Don Berwick
B
NEXT…
• Primary care safety
• Mental health safety
• Sepsis / Venous thrombo-embolism
• Medicines reconciliation
•Maternal safety
Subject Matter Knowledge: Specialist knowledge and skills required to be a
good clinician
Improvement
Subject Matter
Knowledge
Profound Knowledge
Profound Knowledge: The interaction of the theories of
systems, variation, epistemology and psychology.
ALL IMPROVEMENT IS LOCAL
Clinicians working in
partnership with patients
BUT...
Societal context
Political and policy context
Organisational context
Team context
Clinicians
working in
partnership with
patients
QI IS... A COMPLEX SOCIAL INTERVENTION
Quality Improvement can be described as a
complex intervention that involves a number of
inter-related components: training in specific
improvement methods and approaches, the
creation of improvement teams, data feedback,
tailored facilitation and support.
Lilford 2003
NEW TOOLS ...
RELENTLESS MEASUREMENT
“In God we trust…
All others bring data.”
W. Edwards Deming
http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme
WORKSTREAMS &INTERVENTIONS
CONSIDERING ….HOW WILL WE ORGANISE
OURSELVES FOR THE NEXT COLLABORATIVE?
•
Critical Care
– Ventilator acquired pneumonia bundle, catheter related infection
•
General Ward
– Early rescue
– Communication
•
Medicines Management
– Medicines reconciliation
– High risk medicines
•
Perioperative
– Surgical pause; briefings
– Infection prevention/control
•
Leadership
– Executive safety walk rounds
– Executive leadership; board patient safety profile
R
OUR EXAMPLES ARE THERE
C. Diff in Lothian
NHSSCOTLAND HSMR TO MARCH 2012 – ↓10.6%
Standardised Mortality Ratio (SMR)
Regression line
Standardised Mortality Ratio
1.5
1.0
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- JanJun Sep Dec Mar
Jun Sep Dec Mar
Jun Sep Dec Mar
Jun Sep Dec Mar
Mar
Jun Sep Dec
Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011 2011 2011 2011 2012p
Dec-11
Oct-11
Aug-11
85
Jun-11
Apr-11
Feb-11
Dec-10
Oct-10
Aug-10
Jun-10
Apr-10
Feb-10
Dec-09
Oct-09
Aug-09
Jun-09
Apr-09
Feb-09
Dec-08
80
Oct-08
Aug-08
Jun-08
VAP BUNDLE COMPLIANCE
7% improvement
100
95
90
92%
85%
75
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
O
ct
-1
1
VAP RATE
(PER THOUSAND VENTILATOR DAYS)
20
18
16
14
12
10
8
6
4
2
0
61% reduction
9.11
3.54
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
O
ct
-1
1
CENTRAL LINE BUNDLE COMPLIANCE
100
95
90
5% improvement
89%
94%
85
80
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
O
ct
-1
1
CENTRAL LINE INFECTION
RATE
(PER THOUSAND LINE DAYS)
4
3.5
3
1.5
2.8
70% reduction
2.5
2
0.84
1
0.5
0
IT ISN’T MAGIC !
THE MODEL FOR IMPROVEMENT
1 Gerald J. Langley, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, and Lloyd P. Provost, 1996 The Improvement Guide, San Francisco: JosseyBass
PDSA CYCLES
• Encourages
change
• Drives a focus on
data
• Repeated, small,
rapid tests of
change
27
MATERNITY CARE QUALITY
IMPROVEMENT
COLLABORATIVE
To improve outcomes and reduce inequalities
in outcomes by providing a safe, high quality
care experience for all women, babies and
families across maternity care settings in
Scotland.
OUTCOMES
• To reduce the number of avoidable
adverse events in women and babies by
30% by 2015
• Increase the percentage of women
satisfied with their experience of
maternity care to > 95%.
SUB AIMS BY 2015- HOW MUCH,
BY WHEN?
•
Reduce the avoidable proportion of
stillbirths and neonatal mortality by
15%
•
Reduce severe PPH by 30%
•
Reduce the incidence of non medically
indicated elective deliveries prior to 39
weeks gestation by 30%
•
To offer all women CO monitoring at
the booking for antenatal care
appointment
•
To refer 90% of women who have
raised CO levels or who are smokers to
smoking cessation services.
•
To provide a tailored package of care to
all women who continue to smoke
during pregnancy
SOCIAL AND LIFESTYLE FACTORS
2009 ISD data
• 25% of babies are born into the areas of highest
deprivation in Scotland- 15000 per year
• 32% of pregnant women from these most
deprived areas reported smoking at booking
• Drug abuse very poorly recorded – 592 women
discharged from maternity hospitals recorded as
drug users
• 11% of women who die during pregnancy are
substance misusers
CMACE 2007
MATERNAL SMOKING
• 18.1% of pregnant
women reported
smoking at booking
• 32% in the most deprived
• 6% in least deprived
• Affects all aspects of
pregnancy and beyond:
conception, miscarriage,
congenital anomalies,
growth restriction,
stillbirth, cot death
ISD 2009
SUBSTANCE MISUSE
Substance misuse
Miscarriages, ectopic pregnancies, fetal
abnormalities, pre term rupture of membranes,
medical problems, venous thrombosis,
medication, IUGR, abnormal fetal heart rate,
emergency caesarean section, prematurity,
stillbirth, neonatal death, admission to NICU,
postnatal depression, death
HARD TO REACH WOMEN
• 20% of women who died in most recent
confidential enquiry either first booked for
antenatal care after 20 weeks gestation,
missed over four routine antenatal
appointments, or
• did not seek care at all
CMACE Saving Mothers Lives 2007
OUR OPPORTUNITY…
half-opened door into a future full
of interest, intriguing beyond my power to describe ”
“ I look through a
William Mayo
1931
WHY IS CULTURE IMPORTANT ?
Organisations with a positive safety culture
are more likely to learn openly and
effectively from failure and adapt their
working practices appropriately.
WHAT IS ‘SAFETY CLIMATE’?
The measurable, surface components
that provide a “snapshot” of the
underlying safety culture.
Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a
review of surveys. Qual Saf Health Care 2005;14:364e66.
OUR PRACTICE SAFETY CLIMATE
Much of the value of these types of surveys
lies in raising the profile of patient
safety and promoting conversations, ....
that’s when the improvements come
through
The Health Foundation, 2011
BE BOLD
“Bringing excellence to scale”
Don Berwick
11th Annual Report - 2016
?
The number of women experiencing severe morbidity
reported in the 11th SCASMM report (published 2016).
?%
The proportion of women reported to have received optimal
management of severe obstetric haemmorhage
“EACH OF YOU ... ALL OF US”
“ The key is collective
impact !”
“ working together means
that you should never
worry alone.”
Thank You
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What is ``quality improvement`