Improving Care turning the world blue

Euan M Wallace

CEO, Safer Care Victoria

Carl Wood Professor of Obstetrics and Gynaecology, Monash University

better healthcare

High quality healthcare is ……

Safe: Avoids harm to patients.

Effective: Provides evidence-based care based to all who could benefit, and not

to those not likely to benefit.

Patient-centred: Provides care that is respectful of and responsive to individual patient

preferences, needs, and values; ensuring the patient guides decisions.

Timely: Reduces waits and sometimes harmful delays.

Efficient: Avoids waste, including of equipment, supplies.

Equitable: Provides care that does not vary in quality because of personal

characteristics.

US National Academy of Medicine

Safe: Avoids harm to patients.

Effective: Provides evidence-based care based to all who could benefit, and not

to those not likely to benefit.

Patient-centred: Provides care that is respectful of and responsive to individual patient

preferences, needs, and values; ensuring the patient guides decisions.

Timely: Reduces waits and sometimes harmful delays.

Efficient: Avoids waste, including of equipment, supplies.

Equitable: Provides care that does not vary in quality because of personal

characteristics.

High quality healthcare is ……

US National Academy of Medicine

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Digital safetysolutions

EMR Nationalinterventions

Monitoring andreporting of patient

safety

Building a positivesafety culture

Expert

rating

What are the leading interventions to reduce patient harm?

OECD 2017

patient harm is 14th leading cause of global disease burden

(similar to TB or malaria)

medical error is 3rd most common cause of death in US

about 15% of total hospital activity and expenditure is on (avoidable) patient harm

in Canada this equates to 500,000 bed days or four large hospitals

Medical error and avoidable patient harm

Makary and Daniel, BMJ May 2016

Author Country Share of public hospital

spending

Brown (2002) New Zealand 32%

Rafter et al (2016) Ireland 4%

Etchells et al (2012) Canada 4.2%

Jackson (2009) Canada 14%

Health Policy Analysis (2013) Australia 16.5%

Ehsani et al (2006) Australia (Vic) 15.7%

Zsifkovits et al (2016) Europe 6%

Hoonhourt et al (2009) Netherlands 1.8%

most adverse events are preventable

patient harm is 14th leading cause of global disease burden

(similar to TB or malaria)

medical error is 3rd most common cause of death in US

about 15% of total hospital activity and expenditure is on (avoidable) patient harm

in Canada this equates to 500,000 bed days or four large hospitals

Medical error and avoidable patient harm

Makary and Daniel, BMJ May 2016

Author Country Share of public hospital

spending

Brown (2002) New Zealand 32%

Rafter et al (2016) Ireland 4%

Etchells et al (2012) Canada 4.2%

Jackson (2009) Canada 14%

Health Policy Analysis (2013) Australia 16.5%

Ehsani et al (2006) Australia (Vic) 15.7%

Zsifkovits et al (2016) Europe 6%

Hoonhourt et al (2009) Netherlands 1.8%

most adverse events are preventable

Issue 2017 2016 2015

Financial challenges 2.0 2.7 3.2

Governmental mandates 4.2 4.2 4.5

Personnel shortages 4.5 4.8 5.1

Patient safety and quality 4.9 4.6 4.2

Patient satisfaction 5.5 5.5 5.3

Physician-hospital relations 5.9 5.9 5.7

Access to care 5.9 5.8 6.2

Technology 7.0 7.2 7.1

Population health management 7.3 6.6 6.3

Reorganization 7.5 7.8 7.4

(ACHE Survey 2017)

Health service CEO priorities

Issue 2017 2016 2015

Financial challenges 2.0 2.7 3.2

Governmental mandates 4.2 4.2 4.5

Personnel shortages 4.5 4.8 5.1

Patient safety and quality 4.9 4.6 4.2

Patient satisfaction 5.5 5.5 5.3

Physician-hospital relations 5.9 5.9 5.7

Access to care 5.9 5.8 6.2

Technology 7.0 7.2 7.1

Population health management 7.3 6.6 6.3

Reorganization 7.5 7.8 7.4

(ACHE Survey 2017)

Health service CEO priorities

Scheduled flight Barcelona to Dusseldorf, 24th March 2015

Dep 09.01 GMT, GMT 09.41

Within hours of crash BEA team (7 people) were on site

3 days after the crash the co-pilot’s home was visited

Within 1 week the flight recorder had been recovered

2 wks after the crash the pilot’s medical history was known

Within 2 months (May) all airlines had changed policy

13th May 2016 final BEA Report issued

Germanwings flight 9525

Aviation security changes

Flight / event Response

Palestinian hijackers (1970) introduction of metal detectors at checking

Pan-Am 103 (1988) improved baggage security (5% to 100% screening)

airport security staff independent of carrier

9/11 (2001) categorisation of airports (capability framework)

reinforced, locked cockpit doors

increased armed air marshalls

no sharp objects (tweezers, scissors, knives, box-cutters), plastic cutlery

enhanced ID checks (multiple photo ID, pre-screening, risk profiling)

Richard Reid AA63 (2001) no shoes, belts, jackets off, pat down, scanning

2006 thwarted attack (UK) 100mL liquid limit

Germanwings 9525 (2015) minimum 2 persons in cockpit at all times

Thwarted attack (2017) no carry-on laptops from some origin ports

Umar Farouk Abdulmutallab ???????????

selection of health service inquiries ……..

hospital /

service report year $

patient

needs

registration &

credentialling culture leadership governance complaints

outcome

monitoring incidents

Bristol Kennedy 2001 ✗ ✗ ✗ ✗ ✗ ✗ ✗

King Edward Douglas 2001 ✗ ✗ ✗ ✗ ✗ ✗ ✗

Campbelltown Walker 2004 ✗ ✗ ✗ ✗ ✗ ✗

Bundaberg Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗

Rockhampton Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗

Hervey Bay Davies 2005 ✗ ✗ ✗ ✗ ✗ ✗ ✗

14 NHS (Eng) Keogh 2013 ✗ ✗ ✗ ✗ ✗ ✗

Mid Staffs Francis 2013 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗

Furness, UK Kirkup 2015 ✗ ✗ ✗ ✗ ✗ ✗ ✗

Bacchus Marsh Wallace 2015 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗

Victoria Duckett 2016 ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗

To err is human, to forgive divine Alexander Pope

Errare humanum est,

sed in errare perseverare diabolicum. Lucius Annaeus Seneca

Manuel Domínguez Sánchez

To err is human, to cover-up is unforgivable,

to fail to learn is inexcusable. Sir Liam Donaldson

high performing hospitals…..

have specific and quantified goals for improving care

use systematic, transparent measurement and reporting of progress

use an established method of quality improvement (in a sustained manner)

have clinical leadership, teamwork and engagement at all levels

have a culture in which patient care quality and safety are valued

continually reduce fear in the workforce

use the workforce to design and re-design work and processes

have a commitment to listening and learning from patients and carers

Improving quality in the English NHS. King’s Fund 2016

high performing hospitals…..

have specific and quantified goals for improving care

use systematic, transparent measurement and reporting of progress

use an established method of quality improvement (in a sustained manner)

have clinical leadership, teamwork and engagement at all levels

have a culture in which patient care quality and safety are valued

continually reduce fear in the workforce

use the workforce to design and re-design work and processes

have a commitment to listening and learning from patients and carers

Improving quality in the English NHS. King’s Fund 2016

Patient outcomes mortality rates

readmission rates

hospital acquired complications (falls, HAIs, PE, pressure injury)

medication errors

Wellbeing outcomes patient satisfaction

quality of life

patient mood

depressive symptoms

symptom burden at end of life

positive workplace and organisational culture

Mapping a safety culture in Victorian public healthcare

(VMIA 2012)

1 in 4 Victorian hospital staff would not attend their own hospital for care

Oppositional

cautious

controlling

flexible

hierachical

reasoned

resistant

Generative

curious

encouraging

experimental

forceful

inquiring

nurturing

Defensive

cautious

conforming

controlling

directive

hierarchical

resistant

Uniform

appreciative

considered

controlling

competitive

flexible

hierarchical

✔ ✗

✗ ✗

psychological safety

low

high

cognitiv

e d

ivers

ity

high

low

40% vs 15%

33% vs 10%

24% vs 5%

(Alison Reynolds and David Lewis, HBR 2018)

organizational attributes

setting culture

deciding not only how to act but …

how NOT to act

disrupt

unhelpful behaviours

strengthen and sustain

psychological safety commit to new routines

focus on the team, performance will follow

Failing to create a generative team leads to ….

lack of deep understanding

fewer creative options

diminished commitment to act

increased anxiety and resistance

reduced morale and wellbeing

Successful teams

blend of different problem-solving behaviours

enjoy collaboration

look for problems to solve

maintain discipline

break rules

invent

meet mistakes with curiosity

share responsibility for outcomes

(Alison Reynolds and David Lewis, HBR 2018)

open

lack of fear

The three eras of healthcare: from heroism to

professionalism Don Berwick

Era 1: the age of heroism

Era 2: the age of accountability

- using measurement to drive compliance

- doesn’t work

- creates professional anger and community distrust

- leads to loss of information and “gaming”

- remains the dominant era

Era 3: the age of professionalism

culture

(intrinsic motivation)

compliance

(external measurement)

oppositional generative

defensive uniform

oppositional generative

defensive uniform

oppositional generative

defensive uniform

reaching era 3: the age of professionalism

release the workforce from eras 1 and 2 (backdown from metrics a little)

stop excessive measurement

know your own outcomes (strengths and weaknesses)

share data openly

set ambitious outcome (quality) targets

focus on improvement science

increase patient authority and engagement

culture

(intrinsic motivation)

compliance

(external measurement)

oppositional generative

defensive uniform

high performing hospitals…..

have specific and quantified goals for improving care

use systematic, transparent measurement and reporting of progress

use an established method of quality improvement (in a sustained manner)

have clinical leadership, teamwork and engagement at all levels

have a culture in which patient care quality and safety are valued

continually reduce fear in the workforce

use the workforce to design and re-design work and processes

have a commitment to listening and learning from patients and carers

Improving quality in the English NHS. King’s Fund 2016

high performing hospitals…..

have specific and quantified goals for improving care

use systematic, transparent measurement and reporting of progress

use an established method of quality improvement (in a sustained manner)

have clinical leadership, teamwork and engagement at all levels

have a culture in which patient care quality and safety are valued

continually reduce fear in the workforce

use the workforce to design and re-design work and processes

have a commitment to listening and learning from patients and carers

Improving quality in the English NHS. King’s Fund 2016

better healthcare

better healthcare how good am I today (relative to others)?

how good do I want to be?

how will I know?

2nd Atlas of Variation, ACSQHC

educational tool for individual surgeons

high level overview of mortality

provides insights into care deficiences

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2012-13 2013-14 2014-15 2015-16 2016-17

No.

death

s (

VA

ED

)

year (VASM 2016-17 Report)

15% potentially avoidable

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

Goethe

Using data to improve

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CLA

BS

I (p

er

1000 c

entr

al lin

e d

ays)

aggregate hospitals

Year

Using data to improve

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CLA

BS

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1000 c

entr

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e d

ays)

aggregate hospitals

Year

Benchmarking Perinatal Care

2013-14

2014-15 2015-16

Casey Hospital

2016-17

Safer Care Victoria work ahead

Safety minimum measure set – shades of blue

improved incident reporting

better learning from error (sentinel events, complaints, litigation)

Culture structured leadership programs

speaking up for safety learning

enhanced clinician engagement

Improvement programs Perineal tears (with WHA)

Maternity bundle

Sepsis

ED partnership

Specialist clinic partnership

Tonsillectomy

Delirium

Five building blocks for patient safety

Committed leadership to lay the right culture.

Clear policies. Every practitioner must know and understand best practices, including on

reporting and learning from medical error.

Data driven improvements, allowing continuous adjustments to care.

Competent and compassionate workforce, in sufficient numbers.

Consumers and families involved and respected.

Dr Tedros Adhanom Ghebreyesus

Director-General, World Health Organization, London 2018