Health Care Safety at National Scale (PDF Presentation, 2008)
Health Care Safety at National Scale (PDF Presentation, 2008)
Health Care Safety at National Scale (PDF Presentation, 2008)
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<strong>Health</strong> <strong>Care</strong> <strong>Safety</strong> <strong>at</strong> N<strong>at</strong>ional <strong>Scale</strong><br />
Donald M. Berwick, MD, MPP, FRCP (London), KBE<br />
Institute for <strong>Health</strong>care Improvement<br />
Cambridge, MA, USA<br />
NHS Scotland <strong>2008</strong>: Better <strong>Health</strong>, Better <strong>Care</strong><br />
Glasgow, Scotland: 24 June <strong>2008</strong>
The Simple, Wrong Answer<br />
Blame<br />
Somebody
PARIS<br />
IN THE<br />
THE SPRING
PARIS<br />
IN THE<br />
THE SPRING
The First Law of Improvement<br />
“Every System Is<br />
Perfectly Designed<br />
to Achieve Exactly<br />
the Results It Gets”<br />
(Therefore, Although Not All Change Is<br />
Improvement, All Improvement Is Change)
Complex Cardiac Surgery:<br />
A Case Study of Playing with Fire<br />
• “Miraculous” mitral valvuloplasty<br />
• Transition home:<br />
– Extreme difficulty rising from bed<br />
– Lost five kilograms in 24 hours<br />
– “Lasix” to “furosamide” not understood<br />
– No instructions to discontinue Lasix<br />
– No inform<strong>at</strong>ion to primary care doctor<br />
– Surgeon: “I did my job; now it’s up to you.”<br />
The Cause: ?<br />
7
Complex Cardiac Surgery:<br />
A Case Study of Playing with Fire<br />
• “Miraculous” mitral valvuloplasty<br />
• Transition home:<br />
– Extreme difficulty rising from bed<br />
– Lost five kilograms in 24 hours<br />
– “Lasix” to “furosamide” not understood<br />
– No instructions to discontinue Lasix<br />
– No inform<strong>at</strong>ion to primary care doctor<br />
– Surgeon: “I did my job; now it’s up to you.”<br />
The Cause:<br />
Lasix doubled <strong>at</strong> discharge<br />
8
Choose One<br />
“Blame, Secrecy, and Injury”<br />
OR<br />
“Openness, Forgiveness, and<br />
<strong>Safety</strong>”
Leaders’ Tasks…<br />
• Will<br />
• Ideas<br />
• Execution
11<br />
The “100,000 Lives Campaign”
Campaign “Planks” –<br />
Six Changes Th<strong>at</strong> Save Lives<br />
• Deployment of Rapid Response Teams<br />
• Delivery of Reliable, Evidence-Based<br />
<strong>Care</strong> for Acute Myocardial Infarction<br />
• Medic<strong>at</strong>ion Reconcili<strong>at</strong>ion<br />
• Prevention of Central Line Infections<br />
• Prevention of Surgical Site Infections<br />
• Prevention of Ventil<strong>at</strong>or-Associ<strong>at</strong>ed<br />
Pneumonias<br />
12
Preventing Central Line Infections<br />
• Hand hygiene<br />
• Maximal barrier precautions<br />
• Chlorhexidine skin antisepsis<br />
• Appropri<strong>at</strong>e c<strong>at</strong>heter site and<br />
administr<strong>at</strong>ion system care<br />
• Daily review of line necessity and prompt<br />
removal of unnecessary lines<br />
14
Central Line Associ<strong>at</strong>ed Bloodstream Infections (CLABs)<br />
(from Rick Shannon, MD, West Penn Allegheny <strong>Health</strong> System)<br />
15
20<br />
15<br />
10<br />
5<br />
0<br />
Ventil<strong>at</strong>or-Associ<strong>at</strong>ed Pneumonia (VAP) R<strong>at</strong>e:<br />
Dominican Hospital, Santa Cruz<br />
17.5<br />
10.3<br />
Sed<strong>at</strong> ion Prot ocol<br />
7.1<br />
3.1<br />
4.5<br />
Respir<strong>at</strong> ory<br />
Prot ocols<br />
0.7<br />
3.8 4.2<br />
IHI Collabor<strong>at</strong> ive<br />
& Vent Bundle<br />
1.7<br />
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005<br />
•Developed and Implemented Aspir<strong>at</strong>ion Precautions<br />
•Implemented revisions to sed<strong>at</strong>ion use Sed<strong>at</strong>ion Protocol<br />
•Standardized Ventil<strong>at</strong>or <strong>Care</strong> in the Unit Respir<strong>at</strong>ory Protocols<br />
0<br />
VAP/ 1000<br />
Vent Days<br />
NNIS<br />
Mean
Observed minus Expected R<strong>at</strong>e per 100 Discharges<br />
Apr-03<br />
May-03<br />
Jun-03<br />
Jul-03<br />
Aug-03<br />
Sep-03<br />
Oct-03<br />
Nov-03<br />
Dec-03<br />
Jan-04<br />
Feb-04<br />
Mar-04<br />
Apr-04<br />
May-04<br />
Jun-04<br />
Jul-04<br />
Aug-04<br />
Sep-04<br />
Oct-04<br />
Nov-04<br />
Dec-04<br />
Jan-05<br />
Feb-05<br />
Mar-05<br />
Apr-05<br />
May-05<br />
Jun-05<br />
Jul-05<br />
Aug-05<br />
Sep-05<br />
Oct-05<br />
Nov-05<br />
Dec-05<br />
Ascension <strong>Health</strong> Mortality Reduction<br />
-0.3000<br />
<strong>Care</strong>Science Observed minus Expected Mortality R<strong>at</strong>e per 100 Discharges<br />
Ascension <strong>Health</strong> System<br />
-0.4000<br />
Baseline<br />
-0.5000<br />
-0.6000<br />
-0.7000<br />
-0.8000<br />
1,038 Mortalities<br />
Avoided (Year 2)<br />
374 Mortalities<br />
Avoided<br />
(9 mos. of Year 3)<br />
1,412 Mortalities<br />
Avoided Since<br />
Baseline Period<br />
-0.9000<br />
Actual Monthly Difference p-bar (Center Line for Difference) LCL UCL<br />
17
Does Improving <strong>Safety</strong> Save Money?<br />
18<br />
103 ICUs Working on Central Line Infections:<br />
•82% Reduction in Mean R<strong>at</strong>e<br />
•1,578 Lives Saved<br />
•81,020 Hospital Days Saved<br />
•Over $165,000,000 in Costs Averted
“<strong>Safety</strong> is not a goal; it is a<br />
continually emerging, dynamic<br />
property of a system.”<br />
– James Reason
20<br />
The “5 Million Lives Campaign”
The Campaign “Planks” –<br />
Six Changes Th<strong>at</strong> Save Lives<br />
• Deployment of Rapid Response Teams<br />
• Delivery of Reliable, Evidence-Based<br />
<strong>Care</strong> for Acute Myocardial Infarction<br />
• Medic<strong>at</strong>ion Reconcili<strong>at</strong>ion<br />
• Prevention of Central Line Infections<br />
• Prevention of Surgical Site Infections<br />
• Prevention of Ventil<strong>at</strong>or-Associ<strong>at</strong>ed<br />
Pneumonias<br />
21
Six Additional Planks<br />
• Prevent Pressure Ulcers<br />
• Reduce Methicillin-Resistant Staphylococcus<br />
Aureus (MRSA) Infection<br />
• Prevent Harm from High-Alert Medic<strong>at</strong>ions<br />
• Reduce Surgical Complic<strong>at</strong>ions (the Surgical<br />
<strong>Care</strong> Improvement Project (SCIP))<br />
• Deliver Reliable, Evidence-Based <strong>Care</strong> for<br />
Congestive Heart Failure<br />
• Get Boards on Board<br />
22
Safer P<strong>at</strong>ients Initi<strong>at</strong>ive 2: Aims<br />
VARIABLE<br />
Mortality<br />
Ventil<strong>at</strong>or-Associ<strong>at</strong>ed Pneumonia<br />
Central Line Bloodstream Infection<br />
Blood Sugar Control<br />
MRSA Bloodstream Infection<br />
Crash Calls<br />
Harm from Anticoagul<strong>at</strong>ion<br />
Surgical Site Infections<br />
Process Reliability<br />
GOAL<br />
15% Reduction<br />
“Zero” or 300 Days Between<br />
“Zero” or 300 Days Between<br />
>80% within Range<br />
50% Reduction<br />
30% Reduction<br />
50% Reduction in ADE’s<br />
50% Reduction for Clean Surgeries<br />
95% or Better for All Measures
Safer P<strong>at</strong>ients<br />
Initi<strong>at</strong>ive 2 Aim<br />
Driver Diagram<br />
.<br />
Improve<br />
healthcare safety<br />
on an<br />
organis<strong>at</strong>ion-wide<br />
basis by reducing:<br />
1. Mortality by 15%<br />
2. Adverse events<br />
by 30%<br />
Primary Drivers<br />
Leadership<br />
System for <strong>Safety</strong><br />
<strong>Care</strong> of Critically<br />
Ill P<strong>at</strong>ients<br />
Perioper<strong>at</strong>ive<br />
<strong>Care</strong> Management<br />
<strong>Care</strong> of General<br />
Ward P<strong>at</strong>ients<br />
Secondary Drivers<br />
<strong>Safety</strong> as a Str<strong>at</strong>egic Priority<br />
Sustainable Infrastructure<br />
Engaged and Committed Leadership<br />
Ventil<strong>at</strong>or Associ<strong>at</strong>ed Pneumonia<br />
(Reduce to 0 or 300 Days Between)<br />
Central Line Bloodstream Infections<br />
(Reduce to 0 or 300 Days Between)<br />
Blood sugars within Range (80% or >)<br />
Surgical Site Infections - clean<br />
(Reduce by 50%)<br />
Crash Call R<strong>at</strong>es<br />
(Reduce by 30%)<br />
MRSA Bloodstream Infections<br />
(Reduce by 50%)<br />
Key<br />
Process<br />
Measures<br />
Reliable<br />
<strong>at</strong> 10 -2<br />
(defects<br />
in parts<br />
per 100)<br />
Medicines<br />
Management<br />
Anticoagulant Adverse Drug Events<br />
(Reduce by 50%)
Calls to Outreach Team and Cardiac<br />
Arrest R<strong>at</strong>e: Luton and Dunstable<br />
Sustaining<br />
33%<br />
reduction in<br />
cardiac<br />
arrestsincreasing<br />
accuracy in<br />
d<strong>at</strong>a<br />
collection
Cases Between Surgical Site Infections:<br />
Torbay Hospital
Ventil<strong>at</strong>or-Associ<strong>at</strong>ed Pneumonia:<br />
North Bristol, Cardiff and Vale<br />
Compliance<br />
with Ventil<strong>at</strong>or<br />
Bundle<br />
VAP R<strong>at</strong>e
Individual Value<br />
2/28/2005<br />
3/20/2005<br />
4/20/2005<br />
5/20/2005<br />
6/30/2005<br />
A<br />
7/30/2005<br />
8/23/2005<br />
9/29/2005<br />
10/20/2005<br />
11/20/2005<br />
12/20/2005<br />
1/20/2006<br />
2/16/2006<br />
3/16/2006<br />
4/16/2006<br />
5/16/2006<br />
6/16/2006<br />
7/16/2006<br />
8/16/2006<br />
9/16/2006<br />
10/16/2006<br />
11/16/2006<br />
12/16/2006<br />
1/16/2007<br />
2/16/2007<br />
3/16/2007<br />
4/16/2007<br />
5/16/2007<br />
Luton and Dunstable: Overall<br />
Impact on Adverse Events<br />
Adverse events<br />
Special Cause Flag<br />
150<br />
100<br />
50<br />
0<br />
HMSR<br />
-50<br />
From 11%<br />
worse to<br />
10% better<br />
Period
Scottish Phase I SPI Site: Tayside
The Scottish P<strong>at</strong>ient <strong>Safety</strong> Programme (SPSP)
The Vision of the Scottish P<strong>at</strong>ient<br />
<strong>Safety</strong> Alliance<br />
To transform the safety of acute<br />
care in Scotland, thereby<br />
improving care and radically<br />
reducing needless de<strong>at</strong>h and<br />
harm.
Popul<strong>at</strong>ion:<br />
5 Million People
An Agenda for Action<br />
1. Declare p<strong>at</strong>ient injuries an<br />
enemy, and establish safety<br />
improvement as a shared goal.
An Agenda for Action<br />
2. Cease blame as a remedy.<br />
Substitute science and<br />
redesign.
An Agenda for Action<br />
3. Assess where you are starting.
An Agenda for Action<br />
4. Cre<strong>at</strong>e and join collabor<strong>at</strong>ives to<br />
pursue “Shared Aims” together.
Proposed Shared Aims<br />
• Infection Control<br />
90% Reduction in….<br />
– Ventil<strong>at</strong>or-Associ<strong>at</strong>ed Pneumonias<br />
– Surgical Site Infections<br />
– Indwelling Venous C<strong>at</strong>heter Bacteremias<br />
• Blood Product Use and <strong>Safety</strong><br />
90% Reduction in….<br />
– Unnecessary Blood Product Use<br />
– Blood Product-Rel<strong>at</strong>ed Complic<strong>at</strong>ions
Proposed Shared Aims<br />
• Dangerous Medic<strong>at</strong>ions<br />
90% Reduction in….<br />
– Anticoagul<strong>at</strong>ion Complic<strong>at</strong>ions<br />
– Insulin-Rel<strong>at</strong>ed Injuries<br />
– Sed<strong>at</strong>ive- and Narcotic-Rel<strong>at</strong>ed Injuries<br />
• Surgical Complic<strong>at</strong>ions<br />
50% Reduction in….<br />
– Surgical Complic<strong>at</strong>ion R<strong>at</strong>es
An Agenda for Action<br />
5. Establish knowledge exchange,<br />
and increase peer-to-peer<br />
learning.
An Agenda for Action<br />
6. Engage professional<br />
development. Establish a<br />
“<strong>Health</strong> <strong>Care</strong> Improvement<br />
Fellowship.”
Linked Improvements<br />
(B<strong>at</strong>alden and Davidoff)<br />
Better Outcomes for<br />
P<strong>at</strong>ients and<br />
Popul<strong>at</strong>ions<br />
Better<br />
Professional<br />
Development<br />
EVERYONE<br />
Better<br />
System<br />
Performance<br />
41
We Need Professionals Who…<br />
• Embrace System Improvement Aims<br />
• Are Experts on the Sciences of <strong>Safety</strong>, Quality,<br />
Systems, and Learning, such as….<br />
– Reliability<br />
– Cooper<strong>at</strong>ion<br />
– P<strong>at</strong>ient-Centered <strong>Care</strong><br />
– Measurement and Vari<strong>at</strong>ion<br />
– Quality Improvement Methods<br />
– Error, <strong>Safety</strong>, and Human Factors<br />
– Systems Thinking<br />
42
We Need Professionals Who…<br />
• Embrace System Improvement Aims<br />
• Are Experts on the Sciences of <strong>Safety</strong>, Quality,<br />
Systems, and Learning, such as….<br />
– Reliability<br />
– Cooper<strong>at</strong>ion<br />
– P<strong>at</strong>ient-Centered <strong>Care</strong><br />
– Measurement and Vari<strong>at</strong>ion<br />
– Quality Improvement Methods<br />
– Error, <strong>Safety</strong>, and Human Factors<br />
– Systems Thinking<br />
THE “IHI<br />
OPEN SCHOOL<br />
OF HEALTH<br />
PROFESSIONS”<br />
43
http://www.ihi.org/IHI/Programs/IHIOpenSchool/<br />
IHIOpenSchoolfor<strong>Health</strong>Professions.htm
An Agenda for Action<br />
7. Reflect, review, learn, and<br />
celebr<strong>at</strong>e – often and carefully.
An Agenda for Action<br />
1. Declare p<strong>at</strong>ient injuries an enemy, and<br />
establish p<strong>at</strong>ient safety as a shared goal.<br />
2. Cease blame. Substitute science.<br />
3. Assess where you are starting.<br />
4. Cre<strong>at</strong>e and join collabor<strong>at</strong>ives to pursue<br />
“Shared Aims” together.<br />
5. Establish knowledge exchange, and increase<br />
peer-to-peer learning.<br />
6. Engage professional development. “<strong>Health</strong><br />
<strong>Care</strong> Improvement Fellowship.”<br />
7. Review, reflect, learn, and celebr<strong>at</strong>e, often.
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