National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

Methods for ImprovementMethods for ImprovementWhere are the Ideas?Where are the Ideas?

David I GozzardDavid I Gozzard

Quality Improvement FellowQuality Improvement Fellow

Health FoundationHealth Foundation

An International Movement of Movements?

The Entire UK Is EngagedThe Entire UK Is Engaged

3

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

EnglandEngland• Cause• To make the safety of patients

everyone’s highest priority

• Aim• No avoidable death and no avoidable

harm

• Interventions• Leadership for safety• Reducing harm from deterioration• Reducing harm in critical care• Reducing harm in perioperative care• Reducing harm from high risk

medicines

ScotlandScotland

• 5.5 million people• Scottish Patient

Safety Programme• 37 acute hospitals

• Critical care• Peri-op• Medicines• General ward• Leadership

• Aims• 15% reduction in

mortality• 30% reduction in

adverse events

6www.operationlife.dk

DenmarkDenmark• 5.5 million inhabitants• Health care is a public task• 5 regions that are responsible

for health care

Operation Life:• 38 hospital units

• Rapid Response Systems• AMI Bundle• Medication Reconciliation• Ventilator Bundle• Central Line Bundle• Surviving Sepsis Campaign

• Aims• Save 3000 lives during

campaign period All regions present at campaign

start Cover 75% of discharges

CanadaCanada • 33 million people• 10 interventions +

2 pilots• 1035 teams

enrolled• 80% of acute care

hospitals enrolled• All regional health

organizations outside of Quebec enrolled

Aim • Reduce adverse

events by 40-100% dependent upon intervention

www.saferhealthcarenow.ca

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd

http://kyodokodo.jp/

““PARTNERS for Patient SafetyPARTNERS for Patient Safety””National Campaign for Patient Safety in Japan

Japan

WalesWales

• 3 million people• 1000 Lives Campaign

• All Hospitals, Primary Care and Ambulance services

• Leadership• Critical Care/Rapid

response• Medicines• Healthcare associated

infection• Surgical care• General medical and

surgical care• Aims

• To save 1000 lives, and• Avoid 50,000 cases of harm

in 2 years from April 2008

www.1000livescampaign.wales.nhs.uk

• Deploy Rapid Response Teams…at the first sign of patient decline

• Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack

• Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

• Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps

• Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time

• Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

100,000 Lives 100,000 Lives CampaignCampaign

The PlatformReduce Surgical Complications – Adopt

“SCIP”Prevent Harm from High Alert

MedicationsPrevent MRSA InfectionsReduce Readmissions from Congestive

Heart FailurePrevent Pressure UlcersGet Boards on Board

5 Million Lives Campaign5 Million Lives Campaign

Reducing Surgical Reducing Surgical ComplicationsComplications

The Goal:

Reduce surgical complications by 25 percent by December 2008 by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)

Four Key Four Key InterventionsInterventions

Surgical Site Infection PreventionBeta Blockers for Patients on Beta

Blockers prior to AdmissionVenous Thromboembolism

ProphylaxisVentilator-Associated Pneumonia

Prevention

Reduce Surgical Site Reduce Surgical Site Infections Infections

1. Appropriate use of antibiotics2. Appropriate hair removal3. Postoperative glucose control (major

cardiac surgery patients cared for in an ICU)*

4. Perioperative normothermia (colorectal surgery patients)*

* These components of care are supported by clinical trials and experimental evidence in the specified populations; they may prove valuable for other surgical patients as well.

Beta BlockadeBeta Blockade

The American College of Cardiology / American Heart Association Task Force on Practice Guidelines: “Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications” (ACC/AHA Practice Guidelines. JACC. 2006; 47(11); 2342-2355).

In a study of 140 patients who received beta blockers preoperatively, eight patients had their beta blockers discontinued postoperatively and mortality was 50 percent, compared to mortality of 1.5 percent in the other 132 patients who had beta blockers continued (odds ratio 65.0, P<.001).

(Shammash JB, Trost JC, et al. Am Heart J. 2001;141(1):148-153)

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

Venous Thromboembolism Venous Thromboembolism Prophylaxis (VTE)Prophylaxis (VTE)

• Deep vein thrombosis (DVT) is estimated to occur in 10 to 40 percent of general surgical patients when prophylaxis is not provided.

• In a study cited by the American College of Chest Physicians (ACCP), autopsies of surgical patients who died within 30 days postoperatively revealed that 32 percent had had a PE and it was the cause of death for most (Lindblad B, Eriksson A, Bergqvist D. Br J Surg. 1991;78:849-852).

Tips for Getting Tips for Getting StartedStarted

• Develop standard order sets for prophylaxis • Develop protocols for providing prophylaxis

automatically, based on surgical procedure• Provide education and training for staff on

the importance of VTE prophylaxis• Educate patients preoperatively about the

prophylaxis they will receive and steps they can take to reduce risk

Ventilator-Associated Ventilator-Associated PneumoniaPneumonia

• According to SCIP, “postoperative pneumonia occurs in 9 – 40% of patients and has an associated mortality of 30 - 45%”

• Hospital mortality of ventilated patients who develop VAP is 46 percent (Ibrahim EH, Tracy L, Hill C, et al. Chest. 2001;20(2):555-561)

• VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU (Rello J, Ollendorf DA, Oster G, et al. Chest. 2002;22(6):2115-2121)

Four Key ChangesFour Key Changes

Elevation of the head of the bed to between 30 and 45 degrees

Daily “Sedation Vacation” and daily assessment of readiness to extubate

Peptic ulcer disease (PUD) prophylaxis

Deep vein thrombosis (DVT) prophylaxis (unless contraindicated)

Reducing Harm from High-Reducing Harm from High-Alert MedicationsAlert Medications

The Goal:

Reduce harm from high-alert medications by 50% by December 2008

What Are High-Alert What Are High-Alert Medications?Medications?

High-alert medications are more likely to be associated with harm that is both more common and likely to be more serious:

• Anticoagulants• Insulin• Narcotics• Sedatives

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

Several studies have identified adverse drug events as the single most frequent source of health care mishaps, continually placing patients at risk of injury.

-Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Qual Saf Health Care. 2003;12:194-200.-Bates DW, Boyle DL, Vander Vliet VM, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199-205.-Bates DW, Cullen DJ, Laird NM, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34.-Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-317.

Warfarin and insulins caused: • One in every seven estimated adverse drug

events treated in emergency departments • More than a quarter of all estimated

hospitalizations In the elderly, insulin, warfarin, and digoxin were

implicated in:• One in every three estimated adverse drug

events treated in emergency departments• 41.5% of estimated hospitalizations

Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866.

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

Review of events in an adverse drug reaction database of 317 preventable ADEs, “…suggested that three high-priority preventable ADEs accounted for 50% of all reports:

(1) overdoses of anticoagulants or insufficient monitoring and adjustments (according to laboratory test values) were associated with hemorrhagic events,

(2) overdosing or failure to adjust for drug-drug interactions of opiate agonists was associated with somnolence and respiratory depression, and

(3) inappropriate dosing or insufficient monitoring of insulins was associated with hypoglycemia.”

Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R. Identifying clinically significant preventable adverse drug events through a hospital's database of adverse drug reaction reports. American Journal of Health-System Pharmacy. 59;18:1742-1749.

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

Prevent MRSA InfectionPrevent MRSA Infection

The Goal:

Reduce methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection by December 2008

Focus on “getting to zero”

MRSA Bloodstream Infections

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A Vision For The Future?MRSA in Denmark

Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88.

1960 1965 1970 1975 1980 1985 1990 1995

Or This?MRSA in the UK

What Does the Evidence Tell What Does the Evidence Tell Us? Us?

• Rational Interventions Should Target Modes of MRSA Transmission• Person-person via hands of health care

providers – by far the most important• Personal equipment (e.g., stethoscopes,

PDAs) and clothing• Environmental contamination• Airborne transmission• Carriers on the hospital staff

• Rare common-source outbreaks

Prevent Infection Prevent Infection andand ColonizationColonization

• Colonized patients comprise the reservoir for transmission (“colonization pressure”).

• High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin).

• Colonized patients have a high rate of MRSA infection.• Nearly 1/3 develop infection, often after discharge

• Colonization is long-lasting, and patients can transmit MRSA to patients in other health care settings (e.g., nursing homes), as well as to family members.

Five Key InterventionsFive Key Interventions

Hand hygiene Decontamination of the

environment and equipment Active surveillance cultures (ASCs) Contact precautions for infected

and colonized patients Compliance with Central Venous

Catheter and Ventilator Bundles

Tips: Hand HygieneTips: Hand Hygiene• Single most important intervention,

especially after and before patient contact• Compliance rates of 40-50% no longer are

acceptable• Hold staff accountable • Encourage patients and families to remind

caregivers to practice hand hygiene• Alcohol hand rubs have made hand hygiene

much easier• Rapidly kill bacteria (except Clostridium difficile

spores)• Surprisingly gentle on hands• Not a substitute for soap and water when hands

are grossly soiled

Tips: Decontamination of Tips: Decontamination of Environment and EquipmentEnvironment and Equipment

• Use dedicated equipment for colonized/infected patients• For general patient care, use alcohol wipes for

stethoscopes and other personal equipment when leaving the bedside

• Put environmental services personnel on the team

• Clean and disinfect the environment carefully, especially “high touch” areas• Use an environmental cleaning checklist• Trust and verify

Tips: Active SurveillanceTips: Active Surveillance• Perform active surveillance cultures (ASCs)

to detect colonized patients on admission• Necessity of ASCs per se in controlling MRSA is

controversial• But “knowledge is power” – clinical cultures miss many

colonized patients and vastly underestimate the magnitude of the problem

• ASCs on admission, followed by testing weekly and/or at discharge, is necessary to document the extent of transmission and the success of control measures

• Successful programs combine ASCs with reliable implementation of other interventions

• Controversy regarding ASCs for high-risk areas (ICUs) vs. entire hospital

• Flag colonized patients when discharged

Reduce Re-admissions from Reduce Re-admissions from Congestive Heart Failure Congestive Heart Failure

(CHF)(CHF)

The Goal:

Reduce the 30-day re-admission rate of patients discharged with the diagnosis of CHF by 50% by December 2008

What Is “Congestive Heart What Is “Congestive Heart Failure?”Failure?”

• A clinical syndrome resulting from a structural or functional cardiac disorder that impairs the ability of the heart (the ventricles) to fill with or eject blood• Characterized by

• Shortness of breath (dyspnea) and fatigue (exercise intolerance)

• Fluid retention – trouble lying flat, swelling (edema) of dependent parts of the body (especially the legs)

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

• Measuring left ventricular systolic (LVS) function is a critical step in determining who needs specific treatment (left ventricular ejection fraction (LVEF) < 40%)

• Numerous clinical trials demonstrate that drugs that help the ventricles pump more effectively reduce symptoms, readmissions, and mortality• Angiotensin-converting enzyme (ACE) inhibitors • Angiotensin receptor blockers (ARBs)• Beta blockers

• Patients with atrial fibrillation (AF) tend to form blood clots in the heart and are at increased risk for stroke• Anticoagulation reduces the risk of strokeACC/AHA Guideline, Circulation 2005;112:154-235

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

• CHF patients have a higher risk of hospitalization and mortality due to pneumonia • Influenza and pneumococcal immunizations both are

effective in reducing the risk of pneumonia, hospitalizations, and mortality (ACIP recommended)

• Smoking is a risk factor for poor outcomes in CHF• Smoking cessation programs initiated in the hospital

can help patients quit smoking, as least in the short term

• Discharge planning, including a good “hand off,” probably reduces short-term re-hospitalizations and puts the patient and ambulatory providers on the right track for better longer-term outcomes

Seven Key Seven Key InterventionsInterventions

Left ventricular systolic (LVS) heart function assessment (CMS,JCAHO,ACC,AHA)

ACE inhibitor or ARB at discharge for CHF patients with systolic dysfunction (LVEF<40) (CMS,JCAHO,ACC,AHA)

Anticoagulant at discharge for CHF patients with chronic/recurrent atrial fibrillation (ACC,AHA)

Seven Key Seven Key InterventionsInterventions

Influenza immunization (ACIP) Pneumococcal immunization (ACIP) Smoking cessation counseling

(CMS,JCAHO,ACC,AHA) Discharge instructions that address all of

the following: activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen (CMS,JCAHO,ACC,AHA)

Hospital performance on all interventions is sub-par (54% on the discharge component, 2005 CMS data)

Other Interventions to Other Interventions to ConsiderConsider

• Beta blocker therapy for patients who have minimal or no evidence of fluid overload or volume depletion (AHA,ACC)• Well supported by randomized controlled trials• If started at discharge (as recommended by

AHA Get With The Guidelines-HF):• Insures patient is started on therapy and hastens

attainment of therapeutic levels• Requires close monitoring and follow-up post-

discharge

• Discharge “contract” • Statin for patients with/at risk for coronary

artery disease• Spironolactone

(certain high risk patients)

Prevent Pressure Prevent Pressure UlcersUlcers

The Goal:

Reduce the incidence of hospital-acquired pressure ulcers by December 2008

Focus on “getting to zero”

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

• Risk is predictable• age immobility, incontinence, poor nutrition, sensory

problems, circulation problems, dehydration and poor nutrition

• Skin integrity can deteriorate in hours• frequent assessment prevents minor problems from

becoming major ulcers

• Wet skin is more vulnerable to skin disruption and ulceration• But dry skin is a risk factor as well

• Continual pressure, especially over bony prominences, increases risk

• Pressure-relieving surfaces work

Reddy et al., JAMA 2006;296:974-84

Six Key Six Key InterventionsInterventions

Conduct a pressure ulcer admission risk assessment for all patients

Reassess risk for all patients dailyFor all patients identified as being at risk

for pressure ulcers: Inspect skin daily Manage moisture: keep the patient dry;

moisturize dry skin Optimize nutrition and hydration Minimize pressure: ensure that patients are

turned every two hours; use pressure-relieving surfaces

Conduct a Pressure Ulcer Conduct a Pressure Ulcer Admission Risk Assessment; Admission Risk Assessment;

Reassess DailyReassess Daily

• Use visual cues in admission documentation for completion of skin and risk assessment

• Standardize risk assessment tool/check list across the institution• Incorporate action steps linked to risk

• Use multiple methods to visually identify patients at risk• Stickers on chart, visual cues on door and bed

• Post compliance rates to motivate staff• Improve processes to ensure risk

assessment is conducted within 4 hours of admission and daily

• Assess surgical patients

Inspect Skin DailyInspect Skin Daily

• Required for high-risk patients• Skin integrity can deteriorate in a

matter of hours• Always look at sacrum, back,

buttocks, heels, and elbows every time the patient is assessed

Manage Manage MoistureMoisture

• Cleanse skin at time of soiling and at routine intervals• Watch for excessive moisture due to

perspiration and wounds• Use gentle cleansing agent

• Use moisturizers for dry, fragile skin• Provide under-pads that wick moisture

away from skin• Keep kit of needed supplies at bedside for

at-risk incontinent patients

Optimize Optimize Nutrition/HydrationNutrition/Hydration

• Respect patient’s dietary preferences

• Involve dietician, use supplements as needed

• Monitor hydration• Offer water (when appropriate)

whenever patient is turned

Minimize PressureMinimize Pressure• Turn/reposition patient at least every 2 hours

• Use alerts and cues to remind staff to turn patient• Protect skin when turning patient (use lift devices or

“drawsheet,” heal and elbow protectors, sleeves and stockings; do not “drag”)

• Use pillows and cushions strategically• Use static and/or dynamic pressure-relieving

support surfaces• Static surfaces include well-designed mattresses,

mattress overlays filled with water, air, gel, foam, or a combination of these

• Dynamic surfaces include devices that vary pressure beneath the patient, reducing duration of pressure at any given skin site

Engage Leadership and Engage Leadership and GovernanceGovernance

The Goal: Boards in all hospitals will spend at

least 25% of their meeting time on quality and safety issues

Full Board will have a conversation with at least one patient (or family member of a patient) who sustained serious harm at their institution within the last year

What Does the Evidence Tell What Does the Evidence Tell Us?Us?

• Outcomes are better in hospitals where:• The Board spends >25% of its time on quality

and safety• The Board receives a formal quality

measurement report• There is a high level of interaction between the

Board and medical staff on quality strategy• Senior executive compensation is based in part

on quality and safety performance• The CEO is identified as the person with the

greatest impact on QI, especially when so identified by the QI Executive

Vaughn T, Koepke M, Kroch et. al. J of Patient Safety 2:2-9

Six Things That Boards Can Six Things That Boards Can DoDo

Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement (e.g., reduction in unnecessary mortality or harm)

Select and review progress towards safer care as the first agenda item at every Board meeting• Get data on harms and hear stories; put a

“human face” on data Establish and monitor a small number of

organization-wide “role up” measures that are updated continually and are transparent to the entire organization and its customers

Six Things That Boards Can Six Things That Boards Can DoDo

Commit to establish and maintain an environment that is respectful, fair, and just for all who experience pain and loss from avoidable harm• Patients, their families, and staff at the sharp

end of error Develop the capability of the Board

• Learn how the “best in the world” Boards work with executive and MD leaders to reduce harm

• Set an expectation for similar levels of education/training for all staff

Oversee the effective execution of a plan to achieve the Board’s aims to reduce harm, including executive team accountability for clear quality improvement targets