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

• 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

• Patient Activated Consultant

Response

• Nobody Phoned!

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

Mean 1 = 24.8 Mean 2 = 20.3 Reduction from Baseline = 21%

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

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

Percentage mortality

This is a 21% reduction

Data source: ISD Scotland

Outcome Measures - Sepsis 30 Day Mortality (inpatients with Sepsis)

Baseline Median 1.98 Median 2 = 1.76 Reduction from Baseline = 11% Current Median 1.42 Reduction from Baseline = 28%

0.0 0.5 1.0 1.5 2.0 2.5 3.0

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

rate per 1000 discharges

This is a 28% reduction, which means that there are approximately 25 fewer cardiac arrests per month

Data source: SPSP returns

Signal of further reduction

Cardiac Arrest rate in 17 Scottish Hospitals

Baseline Median 1.00 Median 2 = 0.94 Reduction from Baseline = 6% Current Median 0.87 Reduction from Baseline = 13% 0.0 0.2 0.4 0.6 0.8 1.0 1.2

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

Hospital Standardised Mortality Ratio

This is a 13% reduction

Data source: ISD Scotland

HSMR for deaths within 30 days of hospital admission

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