introduction to quality improvement for theatres [read-only]€¦ · operating room checklist could...
TRANSCRIPT
change
change is hard
the world’s biggest change…
Changes we have seen in theatres
in the last couple of years…
• WHO Surgical Safety Checklist
• Reconfiguration of services
• Patients escort from TAU to reception
• Re-organisation of anaesthetic rooms
Surgical Patient Safety Incidents
No harm Low harm Moderate
harm
Severe
harm
Death
94,306 31,108 8331 1,206 296
Total: 135,247
Patients with a surgical site infection require on
average an additional hospital stay of 6.5 days
“This extraordinary coalition of United Kingdom’s
leading organisations for surgeons, anaesthesia
professionals and nurses has endorsed a seemingly
mundane but revolutionary idea: that a simple
operating room checklist could save lives in surgery
the same way that pilots’ checklists have saved lives in
aviation for the last half century.”
Atul Galwande
To energise you to go back and look at
your own work environment differently
AIM OF TODAY
change
??
What does it take to make
change happen?
Somebody challenging the current state of things...
the Sunday roast story
outpatients booking rulesNEW F UP
08:30 1
08:40 1
08:50 1
09:00 1
09:15 1
09:20 1
09:30 1
09:45 1
10:00 1
10:10 1
10:20 1
10:30 1
10:40 1
10:50 1
11:00 1
TOTAL 5 10
NEW F UP
08:30 1
08:40 1
08:50 1
09:00 1
09:15 1
09:30 2
09:45 1
10:00 1
10:10 1
10:15 1
10:20 1
10:30 1
10:40 1
11:00 1
TOTAL 6 9
?
The 5 WHYs analysis
The 5 WHYs example:The list did not start on time
The surgeon was late
They were marking and consenting
the patient
They had to wait for a bed space/room
to be available
There aren’t enough bed spaces or rooms
to mark and consent the patient in privacy
Because all the patients arrive
at the same time
WHY?
WHY?
WHY?
WHY?
WHY?
Renal list storyWHY?
Patients
aren’t
ready on
TAU
Problem:
late starts
WHY?
Blood results
not ready,
notes missing
WHY?
Patients have dialysis
on Sundays and
bloods are not taken
WHY?
Dialysis unit wasn’t
aware this was
important and
caused problems
What does it take to make
change happen?
Somebody seeing things differently….
Join all the dots with 4 straight lines and
without allowing your pen to leave the paper
Commodes are situated at the far end of the sluice room where
commodes and other stock items are randomly places in the sluice
How many steps in the process does it take to collect a
commode for a patient on the ward returning it back to the
sluice?
Waste Spotting!
Change?
Defects and
Rework
Motion
Over
production
Trans-portation
Over
processing
Waiting
Inventory
Equipment not returned
to the correct place so
the next person spends
time walking around the
department looking for
it
Waiting for a
member of the
team to arrive so
can do team brief
Repeatedly asking
patients the same
questions
Item not stocked in the
anaesthetic room, staff
walking to the main stock
room to collect item every
time required
Lost of copies of the
theatre list.
Excess stock with no
place to keep it,
potential for low use
items to go out of
date.
Duplication of
information at the
handover stages of
the patient journey
What does it take to make
change happen?
Somebody making it happen…
The Invisible
Bicycle Helmet
http://www.youtube.com/watch?feature=player_embedded&v=CMAhptqk-4Q
A local change idea
BeforeAnaesthetic Rooms. NGH Theatres
- Items overstocked, drawers full
- Key items out of stock.
- Out of date stock
- Items hard to find.
- Items left on the surface
The Stock
-125
-105
-85
-65
-45
-25
-5
15
35
55
Product
Nu
mb
er D
iffe
ren
ce
Difference Between Planned and Actual Stock Levels
-10
-5
0
5
10
15
20
25
30
35
40
Product
Nu
mb
er D
iffe
ren
ce
Mismatch between maximum stock needed and actual stock held.
Result:
- Staff frustration finding products not in stock.
- Theatre funding held in stock that would go out of date.
AfterAnaesthetic Rooms. NGH Theatres
- Items used together are kept together
- Clear coloured labelling system.
- New stock levels agreed
- Low usage cabinet introduced.
Colour Code
Category
Blue Intravenous
Yellow Warming
Red Invasive
Green Airway
Black Spinal/Epidural
White Miscellaneous
Staff Time to Find Temperature Probe in Anaesthethic Room
0
20
40
60
80
100
120
140
OD
P 5
OD
P 4
OD
P 3
OD
P 2
Student O
DP
Nurse
OD
P 1
Lead Practitioner
Anaesthetist
Anaesthetist
Support W
orker
OD
P 6
Nurse
Individual Member of Staff
Tim
e (s
eco
nd
s)
Before reorganisation
After Reorganisation
**
Measuring the Impact of the Change
• Somebody challenging the current state
of things…
• Somebody seeing things differently…
• Somebody making it happen…
What does it take to make
change happen?
change
??
‘We must redesign services.
Decisions about service redesign must
be clinically led and clinicians must be
prepared to challenge the way services -
including their own service – are
organised.’
Hospitals on the Edge – The time for action
Royal College of Physicians, 13th September 2012
When system improvement is needed, there are
different options we can choose from…
Focus on blame Focus on shared learning
Focus on individuals Focus on teams
Emphasis on symptoms Emphasis on diagnosis
External pressure Internal drive
Top down Bottom up
‘One offs’ Continuous Improvement
VS
System Levels
Patients who need some help and care
Teams helping patients -microsystem
Support structures to help the teams be effective –mesosystem
Corporate functions to help the support structures be effective -macrosystem
Directorate Admin and Clerical structures, kit and
equipment, training and education
Estates, IT, Human Resources, Finance, Executive Team
What is a Clinical Microsystem?
“The Place where Patients,
Families and Clinical
Teams meet.
It’s where everything
happens with, for and to
the patient and family.”
Just like a patient…
To improve a patient’s health status
A clinician:
• Assesses
• Diagnoses
• Treats
• Follows-up
based on biomedical science, patient preferences, and their outcomes.
Just like a patient…
To improve a microsystem’s “health” status
An interdisciplinary group:
• Assesses
• Diagnoses
• Treats
• Follows-up
based on improvement scienceand performance feedback.
The methodology uses 3 main approaches
1. Finding ways to do better at meeting each patient’s
needs.
2. Making the work experience for every staff person
meaningful and enjoyable.
3. Increasing each person’s ability to improve his/her
own work and contribute to the betterment of the
system.
Microsystem Improvement
Assessment
Diagnose
Treat -‘PDSA’ & ‘SDSA’
What is the purpose of this team?
What do staff think?What do patients think?
What does the data tell us?Define the high-level process
Microsystem Improvement
Assessment
Diagnose
Treat -‘PDSA’ & ‘SDSA’
Define themes, Set aimsDeeply understand a processExplore the reasons for what
we think are the issues
Microsystem Improvement
Assessment
Diagnose
Treat -‘PDSA’ & ‘SDSA’
Plan – Do – Study – ActPlan a small test of changeAgree balanced measures
Is the change an improvement?
What do staff involved
in improvement work think?
a story told by your colleagues…
What were your initial feelings?
“I must say initially I did just think:
‘oh, this is just more work for us
to do on top of…’ We haven’t got
enough hours in the day...”
“When I first when I must
all this before’…”
“When I first when I must
say I did sort of sit there
and think: ‘oh, I’ve heard
all this before’…”
Why did you start the work?
“I think we are all just very aware that for
things to change, we all have to get
involved. We can’t just sit there and say:
’this needs to be done…’
We have realised that nothing actually gets
done unless we actually get involved…”
“We got to the point, when you
to get involved…”
“We got to the point, when you
can’t just carry on and let other
people just decide for us. If we
want something doing, we’ve got
to get involved…”
How does it feel now?
“We do a superhuman effort to meet; because I think what
the team really see is that it’s not a waste of time, that we
are actually moving forward. It might only be small steps,
but you can see the enthusiasm that we’ve got as a team…”
“We know it’s taking a long time, we appreciate that, but
we all know now that it is a positive move; that the backing
is going to be there; that at last somebody’s listening to us.
I think it just makes you feel better to come to work…”
“At last things have started to improve, we
can now see that we are driving forward and
feeling more positive”
What was important?
“Data is extremely important, if we
haven’t got data, we can’t prove where
we are, what we actually need, what we
get, it just underpins everything…”
“Team is very dedicated. They go above and
beyond and desire to improve is great.”
“Clinical leadership is crucial, we
medical director.”
“Clinical leadership is crucial, we
need consultant backing and the
support and the ear of the
medical director.”
What was important?
“It’s not all about throwing money
and getting more staff, it’s not
always the answer and that’s not
always what we are asking for, it’s
just streamlining the processes,
the education and some of the
staff to support the capacity issues
we’ve got…. but nothing’s ever
going to improve unless we get
this external support…”
Where next?
http://www.sheffieldmca.org.uk/
• Information about
microsystems work
in Sheffield
• Case studies
• Principles of
microsystems
approach
• 2 days
Introduction to QI
course
http://www.youtube.com/watch?v=S_6y1CieJHo
The story of
Jonny the Bagger