Hugh Rogers FRCS

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Can there be synergy between Quality Efficiency?

• Hugh Rogers FRCS
• Associate,
• NHS Institute for Innovation and Improvement
• Teaching PCTs conference
• 1-11-06

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DH view of system reform
Service Innovation
Quality
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LOS for Fractured Neck of Femur
Variation in LOS for different types of hospital
Lower quartile 19 days Upper quartile 13
days Top 10 performance 8 days
Potential saving 81.4 million p.a.
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NHS Indicators Quarter one 2006/7 Elective
admissions
National average 24
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Ward based staff typically spend less than 40 of
their time on direct patient care
100
First area of opportunity to remove wasteful
activities
24
11
5
10
5
3
3
2
37
31
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Paper work admin.
Time available
Motion
Direct patient care
Psycho- social care
Physical care
Hand- overs
Medicines Mgt. and prep (away from patient).
Discus- sion with other staff
Personal hygiene
Other
Patient flow
We should focus on improving effectiveness,
reliability and safety of direct patient care
activities as a second step
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Examples of waste
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Ward based staff typically spend less than 40 of
their time on direct patient care
100
If we reduce waste theres a huge opportunity to
increase direct care time
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5
10
5
3
3
2
31
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Paper work admin.
Time available
Motion
Direct patient care
Psycho- social care
Physical care
Hand- overs
Medicines Mgt. and prep (away from patient).
Discus- sion with other staff
Personal hygiene
Other
Patient flow
9
What is reliability?

• The capacity to perform a given function under
  given conditions for a specified period of time
• A reliable health care system is one that is
  designed to ensure that every patient
  consistently receives evidence-based, effective
  care every time he or she needs it.
• An important outcome of reliability would be
  patient and public confidence in healthcare

• Reliability means keeping a promise (Don
  Berwick)

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Compare Reliability and Safety

• Safety
• Errors of commission
• Special cause strategies
• Reactive
• Focused projects

• Reliability
• Errors of omission
• Common cause strategies
• Proactive
• Design of reliable systems

Overlap Failure has high impact
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A Major Study of Reliability in American Health
Care

• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)
• 439 indicators of clinical quality of care
• 30 acute and chronic conditions
• Medical records for 6712 patients
• Participants had received 54.9 of scientifically
  indicated care
• (Acute 53.5 Chronic 56.1 Preventative
  54.9)
• Conclusion The Defect Rate in technical quality
  of American health care is approximately
• 45

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Current Reliability

• Good people working hard will not be able to
  overcome the complexities of todays systems of
  care to prevent errors
• Studies show that human beings make errors
• Misreading errors 3 in 1000
• Omission in the absence of reminders 1 in 100
• (BMJ March 18 2005 Tom Nolan)
• NCEPOD report on critical care (May 2005) shows
• 66 of admissions to ICU were unstable for gt12hrs
  (in hospital gt24hrs)
• In ICU frequent deficiencies in care less than
  good in 47
• Deficiencies in care may have contributed to
  death in 11
• (National Confidential Enquiry into
  Perioperative Death)
• Consensus across many studies that
• Approx. 10 of patients suffer significant
  errors
• Half of these suffer harm

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Improvement Concepts Associated with 10-1
Performance (90 success) Described as intent,
vigilance, and hard work

• Common equipment, standard order sheets, written
  policies/procedures
• Personal check lists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training

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Improvement Concepts Associated with 10-2
Performance (99 success)

• Decision aids and reminders built into the system
• Desired action the default (based on scientific
  evidence)
• Redundant processes utilized
• Standardization of process based on clear
  specification and articulation

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6 Increase the reliability of therapeutic
interventions through a care bundle approach

• Example for reducing ventilator associated
  pneumonia
• Elevating the head of the bed gt30o (Drakulovic
  1999)
• DVT prophylaxis (Cook et al 2001)
• Peptic ulcer prophylaxis (Yang Lewis 2003)
• Managing sedation effectively with sedation Holds
  (Kress 2000)
• Tight Control of Blood glucose 4.4-6.1 mils (Van
  den Berghe 2001)
• Reducing variations in clinical care
• Can be applied to
• Surgical site infection
• Central line management
• etc etc

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Where else might reliability be relevant?

• Handovers?
• Medication safety?
• Bundles for
• Central lines
• Catheters
• Surgical site infection
• Ventilator associated pneumonia

• Wrong site / side surgery?
• Investigation at pre-assessment?
• Care on specific pathways
• high volume
• high risk
• Effective barrier nursing?

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Measuring reliability (All or none) in Luton
With good technology reliability can go higher
(Portsmouth)
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SAFETY CHANGE STRATEGIESLuton Dunstable
YES ICU admission NO
YES Comfort Care NO
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2
3
4
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Bradford mortality (HSMR)1996 - 2005
Data source Dr Foster
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Outcomes Bradford Teaching Hospitals Trust
Hospital antibiotic guidelines updated
Inappropriate end of life admission policy
Established steering group
Systematic Case note reviews
Warfarin prescribing chart
Medication errors training
MEWS
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Bradford mortality (HSMR)1996 - 2005
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Blackburn hospitalsMedical outliers vs Mortality
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West Middlesex Hospital designed for flow
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Reducing LOS at West MiddlesexGuess when the new
hospital opened?
New Hospital Opened May 2003
This is down to 6.3 now
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Keys to success

• Having clear goals
• Discovering what works for your own system by
  trial and error (PDSA)
• The importance of senior leadership (managerial
  and clinical)
• Engaging and involving clinicians
• Improvement skills

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Improvement capability is a significant issue
Source University of Warwick, 2006, clinical
systems improvement capability, sample of PCTS
and Trusts
.we need to close the capability gap we have
observed across the NHS system.enable
clinicians and managers alike to develop a
greater understanding of how service
information, financial data and clinical
indicators interrelate and can impact upon the
cost effectiveness of commissioning processes and
service delivery Delivering Quality and Value
Team, NHS Institute
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Improvement capabilityAcute trusts
PCTs
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Synergy for quality
Reliability
Quality care
Lean Flow
Safety Mortality