You can’t fix it if no one thinks its broke!

A/Prof Bill ShearerAnaesthesia & Perioperative Medicine

Monash University, Medical Director Critical Care & Quality

Southern Health

Outline of presentation.

• A few stories about managing the detiorating patient

• Different ways of knowing & showing its “broke”

• Development of a system to monitor and improve the quality of care

• Our stories about how this system has helped

• The next instalments

In the beginning I knew it was broke because...

• I had very unhappy anaesthetists

• And despite some opinions that’s not their natural state:

– Acute Pain Service (APS) was providing basic ward care for some surgical patients

– APS was providing resuscitation for detiorating surgical patients

– Anaesthetic registrars were being asked to provide i.v. access – code for sick medical patients!

And along came…

• Ken Hillman & in my case Michael Buist

• And the Medical Emergency Team (MET)

• The original MET proponents had:

– Very little evidence

– Lots of foresight & conviction

– And they were brave & tough

• And we signed up:

– Enthusiastically

– At best “enlightened self-interest”

How did they get away with it..

• An idea whose time had come

– Because everyone had the same “feelings”

– Because they were convincing

– And they got immediate results that counted:

• Visible

• Better earlier patient rescue

• Earlier ICU involvement & relieved clinicians

• Some localized results suggesting improved outcomes for patients who became sicker in hospital

And everything was going along nicely until…

• They decided to gather evidence to prove they were doing good

• At about the same time I got a promotion

• Everyone knows about the MERIT study

• Everyone knows it didn't prove what we all wanted

• And everyone knows the technical explanations for that

But the real reason at least in our case was..

• The “control” hospital in our health service had reservations about MET & its local origins

• But no-one wanted people to think their hospital was “broke”

• So pseudo MET emerged

• And intensivists & anaesthetists became the surgeons best friends

• And first port of call for management of the detiorating patient.

And despite the lack of evidence

• The skeptics said “I told you so!”

• Then got on with establishing a real MET within months

• And the call criteria were standardised

• And the teams were the same

• And the intensivists & anaesthetists made very sure it continued to work

• And hospital management paid willingly

And everyone lived happily ever after?

• Well not really

• About this time I’d picked up another job

• Clinical Review Panels

– Multidisciplinary review of major adverse events

– All of Southern Health

– Modified root cause analysis methodology

– Made significant recommendations for improving the quality of health care

And along with a stack of other things we found…

• That MET looked a bit broke:

– Too many missed MET calls

– Worst at the most experienced hospital

– No clear explanations in individual cases

– Couldn’t classify all cases as “brain fade”

– Or “cognitive dysfunction” as we call it when our only response to an individual or team action is:

What the….

So we applied some special tools

• Aggregate Root Cause Analysis

– 14 cases where CRP identified a Missed MET

– Compared management to an ideal designed by an expert panel

– Intention is to identify themes not conduct a statistical analysis

• And we didn’t find much

• So we made pathetic recommendation:

– Study the problem further

– Collect more specific data

Study the problem further!

• We gained organizational support as well as external assistance from VMIA

• The Missed MET study:

– Multi campus, acute adult patients

– Point prevalence study

– Longitudinal study of missed MET on study wards

– Focus groups

– Human factors analysis

– Sociological analysis

• And we established very clear process & outcome measures which we collect monthly

And we found:

• Management of the detiorating patient is a bit broke

• But the usual suspects were not the significant problem

– Not willful bad behavior

– Not ignorance

– Not confused criteria

– Not previous bad experience with MET or peers

• We did find that local early responses to patients getting sicker could be improved

• Almost a tendency to wait till they were sick enough to “Call a MET”

The sociologists delivered!

• The problem that emerged in both the longitudinal study & the focus groups was very simple:

“WE DON’T DO IT THAT WAY HERE!”

The response

• Standardised response to a patient getting sick

• Ventured into the vexed area of “pre-MET”

• Concentrated on first aid, escalation & local review & action

• Began a re-education program for local clinical area staff: VITALS

• Local Clinical Area Agreements trialed:

– Some standard responses required

– Limited ability to customise escalation & response

The response

• Trial of standard response & customisation

• Combined in a trial observation chart

• Same longitudinal study

• Results:

– No worse

– All trial wards trending to better outcomes

– Statistically significant improvement in missed METS in one area & unplanned ICU admissions in another

– Improvement in safety culture surveys in all trial areas

• But we were seeing continued significant improvement in our KPIs outside the trial wards

And just because we were on a roll

• We used the same wards to participate in a national observation chart trial

– “between the flags” leaning

– Able to incorporate our local area response & some customisation

– Undertook our own analysis of what works for us

– Using assessment tools & performance measures we developed along the way

So how did we know it was broke?

• Happy accident or a learning organisation in action?

– No doubt a combination of accident & willingness to learn at the start

– However a structure has evolved which supports learning & improvement:• Learning from the experience of others (can’t be glorified with the

title of EVIDENCE)

• Incident management & analysis system

• Measures of clinical performance

• Knowledge about improvement or learning methodologies

• We call such a system clinical governance

1. Reactive

– Adverse events, complaints, external reports etc.

2. Continuous:

– How we judge ourselves on a regular basis

– Usually called clinical indicators

– “Always look: Never Panic”

3. Focus:

– The clinical areas where we consider our current performance unacceptable

– Extreme Clinical Risks

4. Credentialing, Accreditation, etc.

5. Quality of Quality:

– Are we getting better/safer etc.

Quality & Safety Performance System.

Focus Clinical Performance Areas

• Extreme Clinical Risks:

– Usual criteria of frequency & hazard

– 5 organization wide extreme risks

– Each has a management committee:• Chaired by a member of Executive Management Team

• Identify internal & external best performance

• Identify current & target performance

• Identify learning

• Implement & monitor improvement plan

• Report monthly to Executive & Board using Target Zero format

Eliminate Harm!

• IHI 100,000 lives

• IHI 5 million lives

• Etc. etc.

• And my medical colleagues were seriously underwhelmed!– Its all just American….. ( chose your own offensive descriptor)

– Not relevant to us –we’re better

– Can’t be done

– Etc., etc.

Target Zero(A response to harm reduction which is culturally applicable in Australia.)

• This is our current performance

• And we’re not that much better

• Are you happy with this?

• Can we improve in small achievable steps

• A 50 % reduction in the rate of identified adverse events each year for 5 years– Yes we know we can’t keep it up for 5 years

– Yes we know it will get harder

– But it’s the right thing to do!(Professor Geert Hofstede is a source of much of the work on national culture)

Target Zero(Elimination of preventable harm in an incremental achievable fashion)

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Year Zero

Year One

Year Two

Year ThreeYear Four

The Problem.

Progressing to target for year one

Achieving target

Failure

Metacognition.Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry.

American Psychologist, 34, 906-911

• Metacognition is simply :

– thinking about how we think

• Metacognition comprises:

– Metacognitive Knowledge• person variables

– General knowledge about how humans think

– Specific knowledge about how you think

• task variables

• strategy variables

– Metacognitive Regulation• Planning cognitive activities

• Monitoring cognitive activities

• Checking the outcomes of those activities.

• Jennifer A. Livingston, Metacognition: An Overview. gse.buffalo.edu/fas/shuell/cep564/metacog.htm

Meta, Meta everywhere

• Meta-Memory

• Meta-Data

• Meta-regulation = Enforced self regulationJudith Healy & John Braithwaite, Designing safer health care through responsive regulation, Medical Journal of Australia,2006;184 (10): 56

• Meta-learning!

• Obviously someone should come up with

META-IMPROVEMENT

Meta-Improvement

• Improvement Knowledge– People & organisational variables

– Task variables

– Strategy variables

• Improvement Regulation– Planning improvement activities

– Monitoring improvement activities

– Checking the outcomes of those activities.

• And that sounds like every book or article or methodology for improvement / change management that any of us have ever read

But in management literature they came up with…

• Learning organisations:

– skilled at creating, acquiring, and transferring knowledge, and at modifying its behaviour to reflect new knowledge and insights.

• Five main activities:

– systematic problem solving,

– experimentation with new approaches,

– learning from their own experience and past history,

– learning from the experiences and best practices of others,

– transferring knowledge quickly and efficiently throughout the organization.

And so you can have a consultancy business…

• A really good learning organisation has :

Single loop learning

Double loop learning

Triple loop learning(Usually attributed to Argyris & Schon or to Bateman)

Triple loop Learning:attributed to Argyris

• http://www.thorsten.org/wiki/index.php?title=Triple_Loop_Learning

Have we got a

problem?

Are we fixing it as well as

possible?

Is this the best solution?

What haven’t we thought of?

A learning view of quality improvement.

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Year Zero

Year One

Year Two

Year ThreeYear Four

Single Loop Learning

Double Loop Learning

(Anything is better)

( More is better)

No idea at all!

( Better is More )

Triple Loop Learning

Consider DVT/ PE(A single loop learning success story)

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Year Zero

Year One

Year Two

Year ThreeYear Four

The Problem.

1. Ongoing measurement

2. No new actions or interventions

1. Org wide measurement of rate DVT/PE &

audit DVT prophylaxis

2. Standardised Risk assessment &

prophylaxis

3. Audits compliance

4. Case reviews of all in hospital DVT/PE

1. Continued measurement & auditing

compliance

2. National Medication Chart

3. SHIPP includes DVT/PE

4. Case reviews of all in hospital DVT/PE

2.1.3.1 Rate of preventable hospital acquired DVT/PE per 1,000 separations

Consider FallsA double loop learning success/failure

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Year Zero

Year One

Year Two

Year ThreeYear Four

The Problem. Steady decline in rate of falls but never of planned magnitude.Significant fluctuation in rate but difficult to attribute to any action of oursFocus on risk assessment, prevention strategies & assessment after fall has occurred.

Introduction of best practice prevention strategies& post falls Mx procedure.

No idea at all?

Falls

• What happened?– Recognise the problem exists

– Learning from our experience

– Learning from others

– Experimentation or ACTION

– Transferring the knowledge throughout the organisation

• So all the right things happened for a learning organisation

• But it didn’t work as well!– Is it metacognitive?

– Is it single double or triple loop learning?

2.1.2.1 Rate of falls resulting in serious injury (e.g. death, fracture or head trauma) per 1,000 bed days

Now Consider Detiorating patients

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Year Zero

Year One

Year Two

Year ThreeYear Four

The Problem. Performance always amber or greenDouble loop learning from the start:

Missed MET callsLocal responsesEducation of ward staff

Single Loop Learning:MET introducedCall criteria agreed

World Best Practice!

What’s happening ?

Detiorating Patient

• Definitely a learning organisation in action!

• Clearly moved to double loop learning very early:– MET criteria

– Actions of MET

– Missed MET

– Cultural barriers to using MET:• “That’s not how we do it”

• Definitely prepared to experiment

• Certainly metacognitive

• Seduced by success

• And now comes the really hard bit..

2.1.5.1 Rate of MET calls per 1,000 separations

2.1.5.2 Rate of MET calls not within 1 hour per 1000 separations

2.1.5.3 Cardiac arrests in-hospital per 1000 separations

2.1.5.4 Unplanned Admissions to ICU

So am I worried?

• Absolutely not!

• Because the Chair of the Board has demanded an explanation of:

– The slowing of improvement

– The increase in rate of MET calls

• Because the CE has demanded an explanation of all of the above & the increase in cardiac arrest rate

And that means they think its broke!

• And that means they’ll pay us to continue to improve the management of the detiorating patient

• And we wont give them a story about patient care

• We’ll give them a business case for improvement!

The “better is more” stage of improvement:

• Local early recognition & response – VITALS education

– Safety Check Lists for routine clinical interactions

– “Between the Flags” & observation charts

– Patient /carer initiated escalations

– Nursing Emergency Teams

• MET:

– Dose of MET

– Outcome of MET call

– Multiple MET calls

– Limitations on treatment

This is not an accident any more!

• Extreme clinical risks receive a lot of organisational attention:– The problem is defined and measured as part of

everyone’s routine

– The people who will improve performance & the organisation where it will occur is willing to consider how they contribute to the problem & the solution

– Clear goals and outcomes are set

– Experimentation is facilitated

– Improvement is monitored

– Success is studied as thoroughly as failure