Shifting paradigms to build improvement
capacity in South Africa
Dr Dena van den Bergh, Chairperson BCA
Dr Michele Youngleson
Dr Kim Faure
LAUNCH - A call to a focused and collaborative approach
that leads to consistent and sustainable best practice “at
the bedside” and delivers tangible, real benefits
The Best Care Always Campaign....
• A unique collaborative national quality improvement campaign that
involves public and private sector working together to make a bigger
impact on patient care than we could each do alone.
• To join the campaign, must be willing to:
a)
b)
c)
d)
Implement evidence-based interventions at a faster pace;
Share information, experiences and successes with others;
Committed to measurement
Contribute to the advancement of the campaign as a whole
• Aim: to accelerate the implementation of evidence-based
practice and improve patient starting with:
─ Reducing healthcare-associated infections
─ Promoting antibiotic stewardship
Progress to further
patient safety and
improvement priorities
TOTAL No. of enrolled Hospitals = now 202 in 2011
•Clinix - 6
•LHC – 48
•Medi-Clinic - 52
•Netcare - 53
•NHN – 20
•Public Sector
•Gauteng- 14
•Western Cape - 9
•Free State , KZN, Limpopo
Participants
• Major private hospital groups
─ Clinix, Life Healthcare, Medi-Clinic, Netcare, NHN
─ Hospital Association of S Africa (HASA)
• NDOH and public sector
─ Endorsement by National Dept of Health
─ Public Sector Hospitals (Gauteng, West Cape, Free State, KZN)
• Professional community
─ FIDSSA, CCSSA, SASA, SpesNet, ICSSA, FPNL
SATS
• Partnership with Institute for Healthcare Improvement
5
Sponsors
•
•
•
•
•
•
•
•
Discovery Health – Platinum Founding
Janssen-Cilag - Gold Founding
Media sponsor – Medical Chronicle
HASA – public relations and administration
Adcock Ingram Critical Care
Astra-Zeneca
B.Braun
Fresenius Kabi
3M
Aspen ,
J&J
6
Health sector shift
•From me to we
•From competition to collaboration
•from secret to sharing
•private –public collaboration
•learning from private to public and public to private
•All BCA material is open source
Responsibility shift
•From it doesn’t happen here to
-knowing the facts
•From “we already do that” to
-acknowledging we may not
•from passive to
-active
•From overwhelm to
-high risk first then progressing
•From can’t do - to –
-if they can so can we
•Accept the inevitable to
-persistence
•From victim of limitations to
- building skills and taking on
the challenge
I’m sure glad the hole is not in
our end!
Culture shift
•from punishing to
•from blaming to
•from who (people) to
•From “spray and pray” to
•From helping to
-learning
-curious
-why (system)
-support
-capacitating (mentors)
QA and QI
•Quality assurance/audit to
-QA and QI
•Checklists as checking/ticklist to -checklists as
aids/support
•From writing more protocols
-to focused
interventions that
improve critical
elements one at
a time
Measurement shift
•From USA data to
•From numbers to
•From bar graphs to
•From data for centre to
-SA stats
-rates
-run charts (over time)
-frontline measures to
support staff
•From individual hospital to -measures across
systems
Methodology shift
•From spray and pray to PDSA
•Systems and measurement
•Psychology of change
•What and the how and the where
•Continuous Learning system
The BCA Quality Improvement approach
•
•
•
•
Not just protocol
Focus on the implementation gap
All learn all teach
Learning by doing
Leadership and Doctor engagement
•From “its up to clinicians/nurses” to
active
involvement
of leadership
and hospital
CEOs
• From ICC to EXCO
•Doctors and clinical leaders
•From sceptical and critical to “this might work” “it’s
worth trying” to more “how can we support you” and
even “I would like to initiate ...”
An invitation to stretch our boundaries
even further
“Nobody can go back and start a new beginning,
but anyone can start today and make a new
ending.”
Maria Robinson
Everyone in healthcare really has two jobs
when they come to work every day:
1. to do their work and
2. to improve it.
Healthcare-associated
infections are 2-3 x more
common in developing
countries
Allegranzi B. Burden of endemic health-care-associated infection in
developing countries: systematic review and meta-analysis. Lancet Dec
2010.
18
Allegranzi B. Burden of endemic health-care-associated
infection in developing countries: systematic review and metaanalysis. Lancet Dec 2010.
Number of HAI studies 1995-2008
19
SA Hospitals?
─9.7% HAI point prevalence
─28.6% in ICU
Private + Public Hospitals in Gauteng
Prof A Duse. SA-HISC study (unpublished)
20
HAI Impact
• On the patient &
family
• On staff
• On the hospital
• Financial
21
Film
Partnering to Heal - computer-based,
interactive learning tool about infection
control practice and culture of safety.
http://www.hhs.gov/ash/initiatives/hai/trainin
g/
22
CLABSI
CAUTI
+ Antibiotic Stewardship
Peripheral line infection
SSI
VAP
202 Hospitals enrolled
at least 1 intervention
24
Closing the “Know-Do” gap
25
Accelerating change and improvement
through networking and collaboration.
18 - 24 months
Repeated
improvement
cycles:
Expert
Meeting and
Planning
Group formed
Learning
session
1
Repeated
improvement
cycles:
Learning
session
2
Mentoring and support
© Institute for Healthcare Improvement
Learning
session
3
Project review exercise
• Learning sessions ran May – November 2010
• Learning sessions were followed by
implementation periods driven by the Plan, Do,
Study, Act (PDSA) method.
• No external on-site mentoring was possible
• Implementation at each hospital was the
responsibility of the respective teams
• No formal reports or centralized data collection
were undertaken.
• Unexpected interruption six months into the
project with no further external support available
from BCA
Hospital presentations
Teatime
What Is a Bundle?
•
A group of 4-5 evidence-based best practices that each
individually improve care, and when done together result in
much better outcomes.
 The science behind the bundle is so well established that it
should be considered standard of care.
 Compliance can be measured: yes/no answers.

Measuring
rare events and time-between measures.
I
James Benneyan IHI
BCA focus areas for improvement
6 infection prevention bundles
• VAP (ventilator associated pneumonia)
• CLABSI (central line associated bloodstream infection)
• PVC
• SSI (surgical site infections)
• CAUTI (catheter associated urinary tract infections)
(Peripheral vascular catheter associated infection)
• Hand Hygiene
Getting started
•
•
•
One infection prevention bundle
One unit
Follow the sequence from piloting
to spread
The Sequence for Improvement and
Spread
Spread
Scale up
Sustain
Implement
Pilot
Robert Lloyd
Mapping the Challenge
Exercise
On the table provided:
1. Identify the high risk units
2. Identify which bundles would apply to each unit
3. Select a priority unit and bundle to start with
Mapping the Challenge
ICU,
High
care or
ward
Unit 1
Unit 2
Unit 3
Unit 4
Ventilators
Central
lines
Peripheral
lines
Surgical
Sites
Urinary
Catheters
Hand
hygiene
The challenge at your facility
ICU
Ventilato
rs
Central
lines
Periph
eral
lines
Surgica
l Sites
Urinary
Catheter
s
Hand
Hygiene
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Theatre
High Care
Medical
Ward
Surgical
Ward
X
X
X
Emergency
X
X
X
X
Unit
Exercise: i) Mark the procedures relevant to each of your
ICU, high care units and/or wards with an ‘X’.
ii) Prioritise the area of most concern in each
unit and circle the appropriate ‘X’ in that unit
The challenge at your facility
ICU
Ventilato
rs
Central
lines
Periph
eral
lines
Surgica
l Sites
Urinary
Catheter
s
Hand
Hygiene
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Theatre
High Care
Medical
Ward
X
Surgical
Ward
Emergency
Unit
X
X
X
X
Exercise: i) Mark the procedures relevant to each of your
ICU, high care units and/or wards with an ‘X’.
ii) Prioritise the area of most concern in each
unit and circle the appropriate ‘X’ in that unit
Choosing your bundle and unit
Importance - impact
• size of the problem
• size of the impact
• leadership preference
Start where you’ll get the best results
• the most support
Start small, scale up or spread when ready
ICU
Ventilat
ors
Centr
al
lines
Periph Surgic
eral
al
lines
Sites
Urinary
Cathete
rs
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Theatre
High Care
Medical
Ward
X
Surgical
Ward
Emergency
Unit
X
X
X
X
X
X
X
Mapping exercise
ICU
Ventilat
ors
Centr
al
lines
Periph Surgic
eral
al
lines
Sites
Urinary
Cathete
rs
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Theatre
High Care
Medical
Ward
X
Surgical
Ward
Emergency
Unit
X
X
X
X
X
X
X
Breakout sessions
1. Bundle Content
• HAI Definitions
• Elements of the bundle
2. CEOs - Leading BCA
Bundle Content Session
• SSI – Sarie van der Westhuizen / Rita Pretorius (Mediclinic
Gynaecological Hospital)
• CAUTI – Annamarie Crumplin and Patricia January (Mediclinic
Highveld)
• CLABSI – Margaret Lidhovo (Mediclinic Morningside)
• HAND HYGIENE – Karen Swart (Netcare infection control)
• VAP – Amanda Jansen van Vuuren (Mediclinic Vereeniging)
• Surveillance
control)
definitions – Lesley Devenish (Netcare infection
Setting an Aim
What do we want to achieve?
Aim
•
•
•
•
•
Helps leaders think through all aspects of the project
Helps select the correct processes for improvement
Select the right team
Keeps activities focused
Empowers individuals to make changes
What reduction in HAIs is possible?
1. Adult Ventilator Associated Pneumonia
Average 45% reduction.
With every bundle element every time – Zero cases for over long
periods of time (pg 7 Getting Stared Kit)
2. Central Line Associated Blood Stream Infections
Nearly eliminate CLABSI (pg 7&8 Getting Started Kit)
3. Peripheral Line Associated Infections
4. Surgical Site Infections
(incidence in clean cases 2-3% USA) 40 – 60 % infections
are preventable (pg 6 Getting Started Kit)
5. Catheter Associated Urinary Tract Infection
Reductions of 46% - 81% have been achieved (pg 6 Getting Started Kit)
Define an Aim for your HAI
Statement of where you want to go you don’t need to know how to get there yet
• must have a number
• must have a time frame
• must stretch you
- not achievable in the current system
- requires change
• benchmark against what has been
achieved elsewhere
Aim
To reduce ………… (VAP, CLA-BSI, PLI, SSI, CAUTI)
By ……………. amount
By implementing the whole ………bundle
to every patient every time
By May 2013 (in 18 months)
Traditional approach to
improvement
PROBLEM
EVIDENCE BASED SOLUTION
PLAN
“traditional”
attempts to
change
I
IMPLEMENT
FAIL
Closing the “Know-Do” gap
54
Overcoming the Implementation
Gap
SYSTEM ANALYSIS to
identify barriers to care
PROBLEM
GREAT IDEAS
PLAN
IMPLEMENT
I
SUCCEED/
SUSTAIN
ACT
DO
STUDY
Rapid Cycle Change
What are we trying to
accomplish?
PLAN
DO
ACT
What can we change that
will result in an
improvement?
STUDY
PLAN
DO
ACT
DO
ACT
PLAN
STUDY
PLAN
STUDY
DO
ACT
How will we know that a
change is an improvement?
STUDY
Film – Maru
• What is he trying to achieve?
• How will he know if he has succeeded?
• How many changes did he try?
Model for Improvement
What are we trying
to accomplish?
What can we
change that will
result in an
improvement?
Aim
How will we
know that a
change is an
improvement?
Change
Measurement
PLAN
DO
ACT
STUDY
The Plan, Do, Study, Act Cycle
A scientific approach to improvement
PDSA starts with a theory and tests the theory
Act
Plan
Study
Do
Improvement Guide, Chapter 1, p. 24, 25
Film – Making a garden
• What problem did the women experience?
• What was their theory about the cause of the problem?
• How could a small test of change have helped?
Where small tests of change
would have been helpful
• Endotrachael tubes in the ICU
• Peripheral line insertion trays for anaethetists
The theatre sisters had decided to try this …….
Chlorhexidine skin prep for peripheral IV lines….. a great
idea!
62
The problems identified:
The pack:
• No trolley space, has to be balanced on the patient
The gloves:
• Aneasthetist are mostly Male - gloves are far to small for their hands
• numerous complaints
- “I cannot put them on without them ripping to shreds”
– gloves discarded into a box for the nurses to use in non sterile procedures.
• results - using non sterile gloves,
or surgical gloves which triples the cost
The bag:
• The red bag is also saved for other waste disposal.
63
PDSA:
team work and small tests of change
How many doctors would have needed to test the
packs to discover these problems?
What could have been saved with small tests of
change?
- money
- frustration
- enthusiasm for change
- time to create something effective and efficient
64
The Plan-Do-Study-Act Cycle
A small bite of the elephant in 4 steps
Improvement Guide, Chapter 5, p. 97
The Plan-Do-Study-Act Cycle
A: Clippers
ordered.
Another
PDSA with 6
other
surgeons
planned
S: Was some
resistance as
predicted.
Lack of
supplies
unexpected
barrier.
Improvement Guide, Chapter 5, p. 97
P: Ask one
doctor to use
clippers
instead of
razor with 1
patient
D: Dr. M used
clippers on 2
patients. Was
pleased. Told
staff not to put
razor on his cart
again!
Improving many parts of the bundle/system
simultaneously
PLA
N
PLA
N
STU
DY
PLA
N
STU
DY
PLA
N
DO
ACT
STU
DY
Element 1
STU
DY
Element 2
STU
DY
PLA
N
DO
ACT
DO
ACT
STU
DY
PLA
N
STU
DY
PLA
N
DO
ACT
DO
ACT
STU
DY
Element 3
PLA
N
DO
ACT
STU
DY
PLA
N
DO
ACT
DO
ACT
DO
ACT
PLA
N
DO
STU
DY
DO
ACT
STU
DY
Element 4
STU
DY
PLA
N
ACT
PLA
N
DO
ACT
Progress Snapshot – PDSA Cycles
Special
Needs
Notice
TRST
Research
Research
Cycles
Blaylock
Develop
Blaylock
Feb 18-21
2008
Bed
Avail.
Tool
Dec 12-16
2007
Bed
Avail.
Tool
Dec 3-4
2007
Nov 26-30
2007
Nov 19-23
2007
Patient
Pamphlet
PCC
Tool
Allied
Referral
Poster
Feb 2008
Discharge
Package
Checklist
Feb 2008
Discharge
Package
Checklist
Nov 12-16
2007
Implement
Risk Screening
Feb 10
to Mar
5 2008
Jan 28
to Feb
10 2008
Jan. 28
to Feb
26 2008
Feb 19
-26
2008
Feb 1519 2008
Test
Blaylock
Jan 28
to Mar
4 2008
Bed
Avail
Question
Jan 10
2008
Communication
Source: Paula Raggiunti, Wave 6 IHI IA Program
CCC
Rehab
Decision
Tree
Referral
Feb 26
to Mar
4 2008
Discharge
Package
Checklist
Jan 28
to Feb
15 2008
Discharge
Lunchtime
Closing the “Know-Do” gap
70
Traditional approach to
improvement
PROBLEM
EVIDENCE BASED SOLUTION
PLAN
“traditional”
attempts to
change
I
IMPLEMENT
FAIL
Model for Improvement
What are we trying
to accomplish?
What can we
change that will
result in an
improvement?
Aim
How will we
know that a
change is an
improvement?
Change
Measurement
PLAN
DO
ACT
STUDY
Overcoming the Implementation
Gap
SYSTEM ANALYSIS to
identify barriers to care
PROBLEM
GREAT IDEAS
PLAN
IMPLEMENT
I
SUCCEED/
SUSTAIN
ACT
DO
STUDY
Rapid Cycle Change
What are we trying to
accomplish?
PLAN
DO
ACT
What can we change that
will result in an
improvement?
STUDY
PLAN
DO
ACT
DO
ACT
PLAN
STUDY
PLAN
STUDY
DO
ACT
How will we know that a
change is an improvement?
STUDY
Model for Improvement
What are we trying
to accomplish?
What can we
change that will
result in an
improvement?
AIM
How will we
know that a
change is an
improvement?
CHANGE
MEASUREMENT
PLAN
DO
ACT
STUDY
Different aims and different data
Research data
- new knowledge
DATA FOR
IMPROVEMENT
Data for
routine
monitoring
76
Measurement
Outcome measure
Are we getting closer
to our target?
Measurement
Process measure
(Bundle compliance)
Did we use
the whole bundle
in every patient
every time?
Measurement
Measuring the impact of a change
Was the change
an improvement?
Ventilator Associated Pneumonias- Bundle Compliance and Infection Rate
Mar 09 - Aug 10
14.00
100%
12.66
12.00
11.97 12.00
82%
12.35
91%
12.96
91% 91%
88%
86%
11.83 11.82
93%
92%
89%
89%
93%
92%
93%
88%
90%
80%80%
77%
10.00
71%
69%
9.78
10.01
9.94
9.17
9.06
8.61
60%
8.58
8.28
8.00
70%
7.16
50%
6.70
6.00
5.63
VAP
40%
30%
4.00
20%
2.00
10%
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
0%
Mar-09
-
Infection Rate
80
Outcome measures
How many infections did we have? – the numerator
Is this better than before?
I
# infections – the numerator
When is it a hospital acquired infection?
- definitions
Is it our infection?
- transferred in
I
Overcoming Numerator Issues –
diagnosing the HAI
Checklists for
Diagnosing the
HA Infection
used by the
team
User-friendly outcome measures
Outcome measures that only need a
numerator
I
Safety Calendar
Welsh 1000 lives campaign
I
Developed by Annette Bartley
Welsh Patient Safety Project
Fill in the Welsh Calendar to show the infections
September
Dates of
infection
(CAUTI)
1/9/11
4/9/11
6/9/11
8/9/11
12/9/11
13/9/11
13/9/11
28/9/11
28/9/11
29/9/11
Welsh safety Calendar
Christian Barnard Hospital
Measuring HAI
The concept of
‘days between’ infections
Month 1
Month 2
KEY
No incident
New incident
More than
1 incident
Month 3
Numerator only
91
Days between infection
September
Dates of
infection
(CAUTI)
Days
between
infection
1/9/11
4/9/11
3
6/9/11
2
8/9/11
2
12/9/11
4
13/9/11
1
13/9/11
0
28/9/11
15
28/9/11
0
29/9/11
1
Plot ‘Days between infection’ on the
graph
September
Days
Dates of
infection
(CAUTI)
between
infection
1/9/11
?
4/9/11
3
6/9/11
2
8/9/11
2
12/9/11
4
13/9/11
1
13/9/11
0
28/9/11
15
28/9/11
0
29/9/11
1
Days
Between
Infection
Sequence of Infections
# Days since
last infection
Date of
infection
Measuring
rare events and time-between measures.
I
James Benneyan IHI
Outcome measures with a
numerator and denominator
Ratios
Percentage:
SSI / number of cases (Caesarian Sections)
Rate:
CLABSI / 1000 central line-days
97
Overcoming Denominator Issues
At the same time
every day the
Unit manager
counts devices
in use in the ward
Process measures
Bundle
compliance
99
Process measures
• Overall compliance with the whole bundle
– reliability
– how any patients got the whole
bundle every time?
• Compliance with individual bundle
elements
100
Measuring bundle compliance
Adapted from a tool created by Dominical Hospital (Santa Cruz, CA) (IHI VAP
HowtoGuide V6)
101
Measuring bundle compliance
Adapted from a tool created by Dominical Hospital (Santa Cruz, CA) (IHI VAP
HowtoGuide V6)
102
Individual bundle elements
Know where your problem areas are
103
District Hospital
VAP bundle compliance August 2011
120%
120
100
97.2
88.89
60
40
100%
72.6
80
53.6
38.9
20
0
% Compliance
Percentage compliance
VAP Compliance July 2011
80%
60%
40%
20%
0%
HOB 30
degrees
Bundle elements
Sedation
Vacation
DVT
PUD
prophylaxis prophylaxis
Bundle items
104
Oral
hygiene
Run chart for individual bundle
elements
Compliance with VAP bundle elements
100
80
60
40
20
0
2011
JUL
AUG
SEP
HOB 30 degrees
OCT
NOV
Sedation vacation
DEC
2012
JAN
FEB
DVT prophylaxis
MAR
APR
MAY
PUD prophylaxis
JUN
JUL
Oral Hygiene
105
Measuring bundle compliance
No. receiving ALL 5 components of vent bundle
= reliability of bundle compliance
No. on ventilators for the day of the sample
106
Total bundle compliance
Need to reach
and sustain
95%
compliance
Knowing if you are becoming more reliable
107
The data cycle
Collect
Collate
Display
Activity
Analyse
interpret
Act on data
Share
Report
Outcome measure
(e.g. number of infections per unit, days between infection, infection rate per
1000 device days, etc.).
Select Outcome Measures:
1. Welsh Safety Cross
Collate
Collect
2. Days between infections
3. Infection Rate/1000 device days
Display
Activity
4. Other:
Numerator:
Denominator:
Analyse
interpret
Act
Share
Report
Process measures
UNIT:
Collate
Collect
BUNDLE:
Process Measures:
Display
Activity
1. Compliance with individual bundle
elements
2. Overall Compliance with Bundle
Analyse
interpret
Act
Share
Report
PDSA
• Planning measurement systems using the
model for improvement and PDSA
Problem:
Aim of this change:
The Change:
ACT:
Abandon
Adapt
PLAN:
(Who, what,
where,when,
how)
Adopt
STUDY:
Prediction:
DO:
Measurement
for this
change
Accelerating change and improvement
through networking and collaboration.
18 - 24 months
Repeated
improvement
cycles:
Expert
Meeting and
Planning
Group formed
Learning
session
1
Repeated
improvement
cycles:
Learning
session
2
Mentoring and support
© Institute for Healthcare Improvement
Learning
session
3
Feedback forms please