Measuring Safety Improvement - IHI

1 9/18/20121 Measuring Safety Improvement National Healthcare Group, SINL earning OutcomesoUnderstand the concept of system-level measures in patient Safety and quality Improvement workoExplain the importance of measurement in improvementoIdentify three kinds of measures: process, outcome and balance measuresoState the difference between project-level measures and PDSA-level measures9/18/20122 Institute of Healthcare QualityMacro-view Health System using Whole System Measures National Healthcare Group, SINWhat are System-level measures ? oBalanced set of measures which are not disease-specific or condition-specificoEvaluate performance on quality and valueoServe as input for quality Improvement planning9/18/20123 National Healthcare Group, SINWhy balanced set of System-level measures?

2 OProvides leaders and stakeholders with dataoShows performance of the health care system over timeoAllows the organization to see how it is performing relative to its strategic plans for improvementoServes as input to strategic quality Improvement planning National Healthcare Group, SINL evels of Measures within the Healthcare SystemTier 1 Board & CEOTier 2Sr VPs & VPsTier 3 Business Process Quality Management (BPQM)Tier 4 DepartmentsMacrosystemMesosystemMicrosys tem 2008 Institute for Healthcare Improvement /R Lloyd & R ScovilleThe Big Dots9/18/20124 National Healthcare Group, SINTier 1 Board & CEOTier 2Sr VPs & VPsTier 3 Business Process Quality Management (BPQM)Tier 4 DepartmentsBig dot measures / composite measuresSubscale measuresIndividual measuresExample: Cascading System of Measures T1: % Inpatient Mortality T2: hospital acquired Infection Rate T3: % compliance with bundlesT4: VAP bundleCentral Line bundlePressure Ulcer bundleHand Hygiene bundle National Healthcare Group, SINBig Dot Approaches Themed Categories(Patient Credo) - Heal Me- Don t Hurt Me- Be Nice To MeClinical Categories(McLeod Health, S.)

3 Carolina)- Complications- Readmissions- Mortality Strategic Categories - Patient Safety - Patient Flow- Mission Excellence- Financial Stewardship9/18/20125 National Healthcare Group, SINE xample: Big Dot connecting with Little DotsBig DotLittle DotsHospital Standardized Mortality RatioInfectionsMedication ErrorsFallsEmergency DepartmentWait TimesTime to Lab resultsTime to DI resultsAwaiting for discharge patientsMarginVolumesBed turnsSick timeSource: National Healthcare Group, SINE xample : Potential Measures for Improvement in the EDTopicOutcomeMeasuresProcess Measures BalanceMeasuresImprove waiting time and patient satisfaction in the EDTotal Length of Stay in the EDPatient Satisfaction ScoresTime to registrationPatient/staffcomments on flow% patient receiving discharge materialsAvailability of antibioticsVolumes% Leavingwithout being seenStaff satisfactionFinancials 2008 Institute for Healthcare Improvement /R Lloyd & R Scoville9/18/20126 National Healthcare Group, SINE xample: System approach to reduce infections What Changes Can We Make?

4 Understanding the System for reducing hospital acquired Infections National Healthcare Group, SINE xample: System measures to reduce infections How Will We Know We Are Improving? Understanding the System for reducing hospital acquired Infections with Measures9/18/20127 National Healthcare Group, SINS ingapore Story National Healthcare Group, SINU nderstanding the System for reducing Adverse Events To decrease Adverse Event (AE) Rate for Inpatients at hospital A from 11% to less than 5% by 2013 OUTCOME MEASURE AE per 100 inpatient episodesReduce Medication Errors by 50% Voluntary Electronic ReportingOpen & Fair Incident Reporting Policy Patient Safety Leadership Walkabouts Communication and Awareness How will we know we are improvingNumber of Patient Safety BriefingsNumber of eHOR raisedNumber of Patient Safety Leadership Walk-aboutsPercentage of raised issues raisedPercentage of patients achieving therapeutic INR within 5 days from Warfarin TitrationPercentage of medication errors prevented through medication reconciliationPercentage of reduction of potential Adverse Drug EventsNumber of Root Cause Analysis Number of Failure Mode Effect

5 AnalysisNumber of Medication Safety ProjectsAnalysis of Reported IncidencesRisk Analysis / FMEAP atient Safety and Improvement ProjectsInpatient Anticoagulation Service for Warfarin TitrationMedication ReconciliationDedicated ICU PharmacistWhat changes can we make? Primary DriversWhat?Secondary Drivers How?Process RedesignSafety CultureLearning From Errors9/18/20128 National Healthcare Group, SINU nderstanding the System for reducing Adverse Events OUTCOME MEASURE AE per 100 inpatient episodesHow will we know we are improvingWhat changes can we make? Primary DriversWhat?Secondary Drivers How?To decrease Adverse Event (AE) Rate for Inpatients at hospital A from 11% to less than 5% by 2013 Reduce Medication Errors by 50% Percentage of patients achieving therapeutic INR within 5 days from Warfarin TitrationInpatient Anticoagulation Service for Warfarin TitrationProcess Redesign National Healthcare Group, SIN 2008 Institute for Healthcare Improvement /R LloydThree Types of MeasuresoOutcome Measures: Voice of the customer or patient.

6 How is the system performing? What is the result?oProcess Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?oBalance Measures: Looking at a system from different directions/dimensions. What happened to the system as we improve the outcome and process measures? (eg unanticipated consequences, other factors influencing outcome)9/18/20129 National Healthcare Group, SINE xample: Warfarin ManagementOutcome % of patients achieve therapeutic range (INR 2-4) within 5 days of Warfarin initiationProcessNumber of days to achieve therapeutic rangeBalance% of patients with INR > 4% of patients with INR < 2 National Healthcare Group, SIN9/18/201210 National Healthcare Group, SINE xample.

7 Diabetes Care MeasuresOutcome % of patients with HbA1c < 7% of patients with BP <= 130/80% of patients with LDL < 100 Process% of patients with >= 1 LDL% of patients with >= 9 HbA1c% of patients with foot exam% of patients with eye exam% of patients with micro-albumin screenBalanceAnnual cost per patientCycle timeAverage Length of Day Staff satisfactionPatient satisfaction National Healthcare Group, SINP roject Measure : To reduce the percentage of diabetic patients in polyclinic H with HbA1c greater than 9% from 15% to 10% within 6 months Example: Diabetes Care Measures9/18/201211 National Healthcare Group, SINP roject Measure and PDSA Cycle MeasuresAchieving AimData for Project MeasureAdapting changes during PDSA Cycles Data for PDSA Measures National Healthcare Group, SINT esting andrefining ideasBrightidea!

8 Developing Improvement with PDSAsImplementing newprocedures & systems- sustaining changeChanges that result in improvement9/18/201212 National Healthcare Group, SINP roject Measure and PDSA Cycle MeasuresProject Measure : To reduce the percentage of diabetic patients in polyclinic H with HbA1c greater than 9% from 15% to 10% within 6 months National Healthcare Group, SINH ealthcare Associated InfectionAdverse EventsPatient Satisfaction Percentage of Emergency Percutaneous Coronary Intervention within 90 minutes of arrivalPercentage of extraction of Cataract with / without implantHealth Screening 30-day readmission rate after Acute Myocardial InfarctionAverage length of stay for Acute Stroke Activity: Which are Measures? 9/18/201213 The Measurement Imperative"Not everything that countscan be counted, and noteverything that can be countedcounts"- Albert Einstein - If you can t measure it, youcan t manage it - W Edwards Deming -AcknowledgementsMaterials for program sourced from:oThe Improvement Guide : A Practical Approach to Enhancing Organizational Performance by Gerald J.

9 Langley et aloThe Healthcare Quality Book: Vision, Strategy & Tools by Scott B. Ransom et aloToward Optimized Practice [Online information; retrieved on 24/08/12.] oEnhancing Clinical Practice Improvement : A Tribute, 2008 (National Healthcare Group, Singapore)oAdding Years of Healthy Life , 2010 (National Healthcare Group, Singapore) oMinistry Of Health, Statement of Priorities, FY 2011 SingaporeoModel for Improvement by Carol Haraden (Institute for Healthcare Improvement ) adapted from Flickr/LumaxArt National Healthcare Group, SIN