Recommended toolkit: Spread & Sustainability of Best Practices

1. Recommended toolkit: Spread & Sustainability of Best Practices Sujani Jayanetti September 9th, 2009 Safer Healthcare Now! Atlantic Node

2. Introduction • Patient safety is an international, national, and local issue • The range of adverse events that occur in healthcare facilities are astonishing. • Adverse events are unintentional unfavorable events that are due to healthcare management rather than the patient’s disease which may lead to extended hospital stay, disability, or even death (Baker et al. 2004).

3. Introduction • Adverse events may occur due to many reasons including; infections, medical errors, dangerous omission, incorrect procedures, incorrect diagnosis, and lack of effective team communication. • USA- Hospital Acquired Infections cause 90,000 deaths annually; costing $ 5 billion (Vincent 2006) • Canada- 70,000 adverse events (37%-51% are preventable) (Baker et al. 2004)

4. Introduction • Canadian Patient Safety Institute (CPSI)- 2003 • Safer Healthcare Now! (2005)- Based on 100,000 Lives Campaign in the US • Ten evidenced based interventions

5. SHN! Ten Evidence Based Interventions • 1. Deploy Rapid Response Teams/ Quick Response Teams (RRT/ QRT) • 2. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarctions (AMI) • 3. Prevent Adverse Drug Events (ADEs) • 4. Prevent Central Line Infections • 5. Prevent Surgical Site Infections (SSI) • 6. Prevent Ventilator-Associated Pneumonia • 7. Prevent harm from antibiotic resistant organisms • 8. Medication Reconciliation in long term care to reduce adverse drug events in long term care settings • 9. Prevent harm resulting from falls in long-term care settings • 10. Prevent Venous Thromboemoblism (VTE)

6. Why participate in spread of best practices • Patients’ and carers’ [service] expectations are increasing • Wide variation in outcomes and processes between practitioners and organizations is no longer acceptable • New technology is available to improve care and delivery processes • What worked in the past won’t necessarily work in the future • Shortages of resources, notably time, to invent own solutions • If your neighboring colleagues and organizations are improving by copying and re-inventing good practice, why aren’t you? Source: Fraser 2002, p. viii

7. Make it Happen!!! Source: Greenhalgh et al. 2004, p.593

8. IHI Spread Framework Source: Massoud et al. 2006; IHI n.d.

9. Sustainable Organizations • The IHI Get it Started Kit lists 6 properties that exist in organizations that have shown sustainability of interventions: • Supportive Management Structure • Structures to “Foolproof” Change • Robust, Transparent Feedback Systems • Shared Sense of the Systems to Be Improved • Culture of Improvement and a Deeply Engaged Staff • Formal Capacity-Building Programs Source: 5 Million Lives Campaign 2008

10. Focus Group • May 22, 2009 • WebEx • 6 Participants • Atlantic Provinces: Nova Scotia, New Brunswick, Newfoundland • Aim: To understand the barriers and success factors to spread and sustainability of best practices in Atlantic Node SHN!

11. Focus Group- Emerging themes • Necessity for a culture change towards patient safety • Need for proper leadership & champions • Need for clinician involvement • Necessity for adequate communication • The need for monitoring, measuring, and providing feedback of interventions • The need for more resources (staffing, measurement resources, training) • The false perception that patient safety alone is a good enough incentive

12. Survey • Created using themes from focus group • 34 questions • Sent to 53 key stakeholders in Atlantic Canada: NB, NL, NS, & PEI • 45% response rate

13. Survey Results- Respondents

14. Survey Results- Culture • Majority responded- Organizational structure supports patient safety and quality improvement work • Two third responded - quality improvement is nonnegotiable • Two third responded- has a history of sustaining quality improvement work • 54% responded- structures in place to sustain and hardwire quality improvement work.

15. Survey Results- How important is patient safety work to:

16. Survey Results- Within your organization there are patient safety champions among:

17. Survey Results- Education & Training • 54% of direct care providers see a positive change • 33% of the time physician champions involved in SHN! interventions • 50% agreed roles and responsibilities are clearly defined; 25% some progress is being made • 95% agreed there needs to be more training continued education

18. Survey Results- Communication • 58% responded patient and family perspectives guides quality work; additional 12% said these perspectives were used • Need to be considered since they are clients and contributes to system and behavioural change. • Staff surveys used third of the time; ½ of the organizations use leadership walkabouts

19. Survey Results- Monitoring and Improvement measures • 75% of respondents use measurements • 42% reported quality improvement data are displayed in easy to read charts and posted in clinical areas • Only 54% understand what the results of the collected data mean

20. Survey Results- Incentives • 96% reported the intrinsic value in providing safer care and was a good incentive to get staff on board • Critical element to improving care • However, insufficient for change in behaviour • Rewards and recognition necessary • Note: Calgary Health Region found physician buy in difficult without financial incentives (Baker et al. 2008)

21. Survey Result- Resources

22. Eleven Recommendations • Steering Committee for SHN! interventions • Develop and use a formal improvement spread plan • Monitoring, measuring, and feedback • Closer integration, engagement, communication among healthcare providers • Physician champions for all SHN! interventions

23. Eleven Recommendations • Champions not only at the frontline, but also senior leaders • Staff and healthcare provider input is needed • Training and education • Safety Competency Framework by CPSI • Recognition and rewarding achievers • Compiling and sharing how patient and family perspectives are brought to organizational and provincial decision tables

24. Take home message: • The whole organization from the Board of Directors to the point of service teams and individuals must be aligned in their efforts towards patient safety improvement and great outcomes. There is a need to take a holistic approach in strengthening all components of the system to maximize patient safety outcomes. • A chain is only as strong as its weakest link!

25. Tips &Tools • New Idea Scorecard • Adoption Exercise • Project Charter • Team Charter • PDSA Cycles • Quality Improvement and Change Implementation • Quality Tools • Improvement Tracker • Dr. Jan Davies as a consultant • Walkabouts • Patient Safety Rounds • Physician Quality Officers • Spread planner • Spread Check List • Checklist for Readiness to Spread

26. Questions

27. Acknowledgement • Theresa Fillatre: • Theresa.Fillatre@cdha.nshealth.ca • Dannie Currie: • curried@cbdha.nshealth.ca • Pauline MacDonald • Focus Group Participants • Survey Respondents

28. References • Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J. Etchells, E., Ghali, W. A., Majumdar, S.R., O’Beirne, M., Palacios-Derflingher, L., Reid, R.J., Sheps, S., Tamblyn, R. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. JAMC, 170(11), 1678-1686. • Baker, G. R., MacIntosh-Murray, A., Porcellato, C., Dionne, L., Stelmacovich, K., & Born, K. (2008). High Performing Healthcare Systems Delivering Quality by Design. Toronto: Longwoods Publishing Corporation. • Fraser, S. W. (2002). Accelerating the Spread of Good Practice. A Workbook for Health Care. United Kingdom: Kingsham Press. • Greenhalgh, T., Robert, G., MacFarlene, F., Bate, P., Kyriakidou, O. (2004). Diffusion of Innovation in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), 581-629. • IHI. (nd). Case for Improvement. Retrieved on July 4, 2009, from http://www.ihi.org/IHI/Topics/Improvement/SpreadingChanges/SpreadCaseforImprovement.htm.

29. References • Massoud, M.R., Nielsen, G.A., Nolan, T., Schall, M.W., Sevin, C. (2006). A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. Retrieved on July 21, 2009, from http://www.ihi.org/NR/rdonlyres/661BCB93-1FED-4ADB-86FE-4DDD84445AFD/0/AFrameworkforSpreadWhitePaper2006.pdf • 5 Million Lives Campaign. (2008). Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement. Retrieved on July 21, 2009, from http://www.saferhealthcarenow.ca/EN/Interventions/RRT/Documents/RRT%20Getting%20Started%20Kit.pdf. • Vincent, C. (2006). Patient Safety. Toronto: Elsevier Limited.