the pathway of care Calum McGregor National Clinical Lead for Acute - PowerPoint PPT Presentation

People Make Change! Improving outcomes and experience across the pathway of care Calum McGregor National Clinical Lead for Acute Care with Healthcare Improvement Scotland

Glasgow Transport Museum

People Make Change – Learn and design better systems 1. Share SPSP approach to whole system improvement 2. Examples from the deteriorating patient workstream – applying QI methods and developing culture of improvement 3. Focus on patient journey and co-production

SEPSIS IN SCOTLAND 2012 • 25% of patients with severe sepsis receiving IV antibiotics within an hour • http://www.stag.scot.nhs.uk/SEPSIS/ Main.html

BARRIERS to quality across the pathway of care • Poorly designed systems • A culture not receptive to quality improvement • Unwanted variation • Silo working with poor communciation • Patient/carer voice not being heard

Poorly Designed Systems

“The Aggregation of Marginal Gains”

Poorly Designed Systems / Opportunities to Improve • Antibiotics not in department • Patient going to X-ray prior to antibiotics and fluids • Triage system not robust enough to prioritise sick patients • Nursing staff not informed of STAT antibiotic prescription • MEWS added incorrectly • Not applicable section on form • Medical Students…. • Lack of awareness • WE’RE TOO BUSY!

AIM and STRATEGY • To reduce mortality and harm for people in acute hospitals by reliable recognition and response to acutely unwell patients • Outcome Measures: • HSMR • Sepsis Mortality Rate • Cardiac Arrest Rate

METHOD for improvement Deming WE 1994 ‘The New Economics: For Industry, Government, Education’ MIT Press: Massachusetts p41

National Improvement

National Improvement

NEWS 2 – Lessons from Highland

Where to focus? – Local Improvement

Understand Own Systems • The measurement and monitoring of safety. Vincent et al. 2013

Make it easy for staff to do the right thing

Reduce Unwanted Variation

Progress: Local Process and Outcome Sepsis Mortality Rate

Pride in Work

Resilience Engineering • “Learning from what went well” • Safety 1 v Safety 2

Save of the Month! • MDT Review • Establish what went well • Aim to increase reliability of desirable “thing” • Apply model for improvement to test plan (PDSA)

Give power to patients / Carers

Shared Decision Making Anticipatory care planning • 29% of inpatients in last year of life Clark D et al. Imminence of death among hospital inpatients. Palliative Medicine.2014, 28 (6). 474-479.

Treatment Escalation Planning

Cede Power to Patients Help patients make informed decisions

Cede Power to Patients • Patient Activated Consultant • Nobody Phoned! Response • Consultant Response to Activation by Patient (CRAP) • ? Failed test • "Felt safe." "Wasn't worried and could tell staff were busy." "No need." "Staff explained there would be a wait" • Flatten hierarchy and show willing

Focus on Patient Journey

Primary Care / Scottish Ambulance Service • Pre-Alerting in NHS Lanarkshire, GG and C, Highland and Grampian Martin Carberry, and John Harden BMJ Qual Improv Report 2016;5:u212670.w5049

Improve Patient Journey

Outcome Measures - Sepsis 30 Day Mortality (inpatients with Sepsis) 35.0 Mean 1 = 24.8 30.0 Mean 2 = 20.3 Reduction from Percentage mortality Baseline = 21% 25.0 20.0 15.0 10.0 This is a 21% reduction 5.0 0.0 Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Data source: ISD Scotland

Cardiac Arrest rate in 17 Scottish Hospitals 3.0 Median 2 = 1.76 Current Median 1.42 Reduction from Reduction from 2.5 Baseline = 11% Baseline = 28% Baseline Median 1.98 rate per 1000 discharges 2.0 1.5 This is a 28% reduction, 1.0 which means that there are Signal of approximately 25 fewer 0.5 further cardiac arrests per month reduction 0.0 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17 Dec-17 Feb-18 Apr-18 Jun-18 Aug-18 Data source: SPSP returns

HSMR for deaths within 30 days of hospital admission Current Median 0.87 1.2 Median 2 = 0.94 Reduction from Baseline Median 1.00 Reduction from Hospital Standardised Mortality Ratio Baseline = 13% Baseline = 6% 1.0 0.8 This is a 13% 0.6 reduction 0.4 0.2 0.0 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Sep 18p Data source: ISD Scotland

Summary Can improve - requires whole system and local level QI input Make it easier to do the right thing for patients Learn and design better systems