The Challenges of Implementation
(Will, Ideas, Execution)
Dr Elizabeth Haxby
Royal Brompton and Harefield NHS Foundation Trust
Traditional Approach
•
Overwhelming number of issues to
be addressed
•
Large audits ie 100s of patients
telling us what we already knew
•
Time consuming committees
•
Profusion of policies – average 50
pages long
•
Assumption that policy = practice
•
Lack of Engagement
Design
Design
Design
Design
Approve
Conference Rooms
Real World
Implement
Trust wide VTE prophylaxis compliance
VTE Audit across the Trust (2009)
50%
47%
47%
45%
40%
Percentage
35%
30%
25%
20%
Sydney
20%
15%
10%
Fulham
7%
Harefield
5%
0%
7%
4%
April
0%
0%
May
0%
Jun
Jul
Aug
Reasons for Failure

Lack of clear goals or timeframes

Failure to frame the policy and provide context

Elements of the policy impractical

Failure to engage with the people who will implement the
policy

Feedback intermittent, not directed
New Approach
Surgical Site Infection
New Approach

Set context

Set clear aim and timeframe

Engage with front line staff

Listen to their concerns and ideas

Try small tests of change

Establish measures and feedback
SSI - cost to patients, cost to healthcare
•
Patients with a superficial infection had an extra LOS of 20 days (P<0.0000) and
cost an extra £9,735 (P<0.0098)
•
Patients with a deep or organ space infection had an extra LOS of 54.5 days
(P<0.0098) and cost an extra £40,726 (P<0.0098)
Infected
Difference in Median LOS
120000
100
100000
80
80000
Cost (£)
__
LOS__
120
Infected
Control
60
40
Control
Difference in Median Cost
60000
40000
20
20000
0
0
Superficial
Deep
Superficial
Deep
Driver diagram SSI prevention
Tribal
Non-alignment
Aims
Strategy
&
Tactics
Alignment
Language
Structure
Staff
Leadership
Multiple small changes




SSI data review at monthly CG day
Cross site multi disciplinary WIP
group
Care bundle measurement with
feedback to theatre staff
Changes to;










Theatre access
Hand hygiene / scrub up
Surgical prep
Dressings
Wound management
Vein harvest
Re-enforced antibiotic policy
Feedback to individual surgeons on
SSI with RCA and bundle
compliance for each patient
Board level reporting
Local CQUIN indicator
Small test of change
SSI Prevention Care Bundle
Conference Rooms
Approve
(if necessary)
Design
Test and
Modify
Test and
Modify
Real World
Test and
Modify
Implement
SSIs in CABG patients, detected primary admission and re-admission
ROYAL BROMPTON HOSPITAL
August 2009 - July 2010
Data from PATS as at 10/09/2010
25
20
15
RBH CABG July SSI rate = 0 per 100 operations
10
CQUIN target = 6.3
1
Tre
nd
line
National CABG SSI rate = 4.3
5
2
Ju
ne
ay
M
Ap
ri l
ar
ch
M
Fe
br
ua
ry
20
10
y
ua
r
ec
em
be
r
ov
em
be
r
ct
ob
er
O
be
r
ep
te
m
gu
st
20
09
0
The Challenge of Implementation

Clear Aim

Start small

Engage all the right people

Expect failure and respond
promptly

Measure

Don’t underestimate anyone

Give information / feedback
frequently

Seek additional drivers