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