Sustainabilityinqualityimprovement
Dr.FrancesMortimerMedicalDirector,CentreforSustainableHealthcare,Oxford
February2017
SustainabilityinQualityImprovementtrainingmaterials,developedbytheCentreforSustainableHealthcarewithgrantfundingfromNorthBristolNHSTrust.
Aims– youshouldbeableto:
1. Recognise sustainabilityasadomainofqualityinhealthcareanddiscussitsrelationshiptootherdomains.
2. Reviewtheenvironmental,socialandeconomicinputstoagivenhealthsystem,andidentifyrelevantcarbonhotspots.
3. ApplytheprinciplesofsustainableclinicalpracticeinthedesignofaQIintervention.
4. Identifyoutcomeandactivitymeasuresinordertoevaluateimpactonsustainability/sustainablevalue.
“Ourvisionofsustainablehealthandcare:Asustainablehealthandcaresystemworkswithintheavailableenvironmentalandsocialresourcesprotectingandimprovinghealthnowandforfuturegenerations.”
Sustainabilityasadomainofquality
SustainablePatient CentredEquitable
Efficient
Effective
Timely
Safe
Dr Donal O’DonoghueNational Clinical Director for
Kidney Care 2007-13
Seealso:Atkinson,S.etal.Defining QualityandQualityImprovement.Clin Medvol.10,no.6537-539(2010)
SettingQIgoalsIncludingsustainabilitywithinyourprojectaims(howwillthisaffectengagementwithcolleaguesandwiderstakeholders?)
Sustainable value in healthcare:
Academy of Medical Royal Colleges, 2016 (with CSH)
(goods – harms)
Informedbypatientvalues
outcomesValue =
environmental + social + financial costs(the “triple bottom line”)
SustainableQI
StudyingthesystemUnderstandingenvironmental andsocialresourceuseandimpacts
Carbonhotspots
Socialimpacts– onwhom?
👤 Patient👥 Staff👥 Carers👥 Dependants👥 Localcommunity👥 Distantcommunities(e.g.supplychainworkers)
Socialimpactsondistantcommunities
“Labourers insurgicalinstrumentmanufactureareoftenpaidlessthanUS$1perday,havepoorjobsecurity,havewoefullyinadequateprotectionofhealthandsafety,andmanyemployeesarechildren,someasyoungassevenyearsold.”BMAMedicalFair&EthicalTradeGroup
Socialsustainability• Basicneeds,includinghousingandenvironmentalhealth• Educationandskills• Employment• Equity• Humanrightsandgender• Poverty• Socialjustice• Demographicchange(ageing,migrationandmobility)• Socialmixingandcohesion• Identity,senseofplaceandculture• Empowerment,participationandaccess• HealthandSafety• Socialcapital*• Wellbeing,HappinessandQualityofLife
*definedas“networkstogetherwithsharednorms,valuesandunderstandingsthatfacilitateco-operationwithinoramonggroups”(OECD)
Source:Colantonio,A.&Dixon,T.(2009)MeasuringSociallySustainableUrbanRegenerationinEurope.OxfordInstituteforSustainableDevelopment(OISD)
DesigningyourQIinterventionApplyingtheprinciplesofsustainableclinicalpractice
Howwill80%carbonreductionbeachieved?
Sustainableclinicalpractice:principles
Reducecarbonwithoutreducing
health
Reduceactivity
Prevention
Selfcare
Leanpathways
Reducecarbonintensity
Lowcarbonalternatives
Sustainableestates
Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11
Outcomeneeded
Secondarydrivers
Primarydriver
Primarydriver
CENTRE forSUSTAINABLEHEALTHCARE
Sustainableclinicalpractice:principles
Reducecarbonwithoutreducing
health
Reduceactivity
Prevention
Selfcare
Leanpathways
Reducecarbonintensity
Lowcarbonalternatives
Sustainableestates
Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11
Outcomeneeded
Secondarydrivers
Primarydriver
Primarydriver
CENTRE forSUSTAINABLEHEALTHCARE
Sustainableclinicalpractice:principles
Reducecarbonwithoutreducing
health
Reduceactivity
Prevention
Selfcare
Leanpathways
Reducecarbonintensity
Lowcarbonalternatives
Sustainableestates
Mortimer-F.TheSustainable PhysicianClinicalMedicine2010,Vol10,No2:110–11
Sustainableclinicalpractice
Outcomeneeded
Secondarydrivers
Primarydriver
Primarydriver
Infrastructure&processCENTRE for
SUSTAINABLEHEALTHCARE
e.g.drypowderinhalers(1/20xcarbonofMDI)
Improvesustainabilityofrespiratoryinhalerprescribing
1.Preventavoidablerespiratorydisease
Reducesmoking Reviewreferral ratestosmokingcessationservice
Reducecold/mould exposure Investigatehousingimprovementreferral scheme
ReduceairpollutantexposureInputtolocaltransportpolicy
Ensurepatientsreceiveairqualityhealthadvice
2.Empowerpatientstoimprovediseasemanagement
Co-production
Ensureyearlycareplanning
Rescue packsforacuteexacerbations
Socialprescribing Singing/pulmonaryrehabreferral forms
3.Ensureleanprescribinganddispensingsystems
Leancommunications Introducepaperlessprescribing/repeat requests
Highvalueprescribing Introduceannualinhalerreviews
4.Switch tolowercarbonalternatives Preferential useofDPIvsMDI inhalers
Updateprescribingguidelines
Writearticle forlocalGPnewsletter
5.ImproveoperationalresourceuseInhalerrecycling Signpostrecyclingpoints
Waste,energy,travel Relevantactions
Leansystems…spottingwaste
• Outofdatestock• Singleuseitems• Cancellation• Packaging• Standby• Noncompliance• Waitingtime• Commutingtime• …canyouadd2moreeuphemismsforwaste?
Yourservice- sustainableclinicalpractice
Principle Opportunities?
1.Prevention
2.Patientempowermentandselfcare
3.Leansystems
4.Lowcarbonalternatives
Yourservice- sustainableresourceuseResourceuse Opportunities?
Energy
Travel(staff,patients)
Medicalsupplies
Non-medicalsupplies
Water
Waste
Prioritise
Opportunity Impact(1-3) Feasibility(1-3)
Measuringenvironmentalandsocialcosts/impacts
Sustainable value in healthcare:
Academy of Medical Royal Colleges, 2016 (with CSH)
(goods – harms)
Informedbypatientvalues
outcomesValue =
environmental + social + financial costs(the “triple bottom line”)
EnvironmentalCosts
Carbonfootprint- thesumofgreenhousegasemissionsreleasedinrelationtoanorganisation,productorservice,expressedascarbondioxideequivalents(CO2e).
Carbonfootprint:whatisincluded?(operationalboundaries)
Scope3:Indirectemissions
(other)
Scope2:Indirectemissions
(electricity)
Scope1:Direct emissions
• Supplychain• Travel• Wastedisposal
• Electricityuse
• Energygeneration• Vehicleemissions• HFCs,N2O,etc.
Topdowninput-output
Bottomupprocess-based
Emissionsfactorsappliedtocomponentsofaprocessorproduct,e.g.materials,energyuse
Emissionsfactorsappliedtospendindifferenteconomicsectors
Hybrid
Methods
Availablefromhttp://www.ukconversionfactorscarbonsmart.co.uk/
Greenhousegasemissionsfactors– UKGovt
Goodsandservicescarbonhotspots, NHSSustainableDevelopmentUnit(2013)
Care Pathways Guidance on Appraising Sustainability (SDU, 2015)
Carbonbyunitsofhealthcareactivity
Measuringenvironmentalcosts- exampleAprimarycareteamnoticedthatsomepatientswhowerereferredforhipandkneereplacementswerebeing
referredbacktotheGPsurgeryafterpre-operativeassessmentatthelocalhospital.Thiswasbecauseparameters,suchasbloodpressure,wereeitheroutsidethetargetrangeorwerenotcommunicatedproperly
inthereferralinformation.Anauditrevealedthat1in6patientsloopedthroughthesystem– 10/year.
Activity Outcome £’s CO2e Social
ExtraGPconsult [delaytosurgery]
£451 18kg2 Patient&carertime/stress
ExtraHospitalconsult [delaytosurgery]
£1121 23kg2 Patient&carertime/stress(parking…)
Total (for 10loops) £1570 410kg
1. UnitCostsofHealthandCare,PSSRU,December2015.Availableat:http://www.pssru.ac.uk/project-pages/unit-costs/2015/index.php2. CarbonHotspotsupdateforthehealthandcaresectorinEngland2015,SustainableDevelopmentUnit,January2016.
CharlieKenward,SevernGPST3SustainabilityScholar2014-15
Measuringsocialimpacts?
Patients Carers Community Supplychain Staff
Housing
Poverty
Health
Education
Employment
Safety/security
Satisfaction
Participation
Socialgradient
Canyouidentifyoutcomeandactivitymeasurestoevaluatesustainabilityimpactof…?
• Introducingone-stopservice,e.g.• Breastlumpassessment• Peripheralvasculardisease• Backpain
• Integratingpreventativeservices,e.g.• Vascularclinic– smokingcessationetc• Gallstonespathway- dietetics
• Overnight>daycasesurgery,e.g.• Laparoscopiccholecystectomy• Roboticprostatectomy
ThinkingsustainablywithinaQIproject
1. ApplysustainabilityapproachatthedifferentstagesofANYproject
2. Chooseaprojectareathatrelatescloselytosustainability,e.g.a. Prevention,patientempowerment,etc.b. Reducingpharmaceuticalwastec. Reducingover-investigation/over-treatment
http://sustainablehealthcare.org.ukfrances.mortimer@sustainablehealthcare.org.uk
