The Surgical Initiative concluded on March 31, 2014; the first system Hoshin to “graduate” to everyday work. Join us for an interactive discussion of the lessons learned over four years of transformational change.
💚 Punjabi Call Girls In Chandigarh 💯Lucky 🔝8868886958🔝Call Girl In Chandigarh
The Saskatchewan Surgical Initiative: Lessons Learned
1. 1
The Saskatchewan
Surgical Initiative:
Lessons Learned
Health Quality Summit, Saskatoon, May 7th 2014
Presenters: Donna Davis, Dr. Peter Barrett, Terry Blackmore
(Patient & Family Advisor) (Physician Leader) (A/Exec. Director, Saskatchewan Health)
2. 2
Where we were: March 31, 2010:
Backlog of 27,580
patients awaiting
surgery
1 in 5 waited > 1 year
for surgery
Pace of improvements
was very slow (no real
change in previous
year)
Patients deserved
better!
3. 3
The Environment
Sept. 2008 – “Releasing Time to Care” work
leads health leaders to Britain’s National
Health Service; see the 18-week wait time
work first-hand.
May 2009 – Best Brains exchange on
Managing Wait Times.
Change management principles.
IHI model for improvement.
5. 5
September 2009 – First Surgical Guiding Coalition and Executive
Sponsorship Group meeting held in Saskatoon
A biannual event
Shared ownership
Building the Team
6. 6
Guiding Coalition
RHA reps from across value stream, physicians, health provider
organizations, unions, academics, Ministry reps and patients.
Champions combining expertise, enthusiasm,
Started with 30; now approx. 90 people
7. 7
Executive Sponsorship Group
Leaders from Ministry, RHAs, HQC, provider orgs (SMA, SRNA,
SUN), physician leaders, patients
20-25 participants
Established the broad vision and objectives
Ongoing role included:
Breaking down barriers
Win hearts and minds in system – highly visible
Make it uncomfortable to maintain status quo
Demonstrate courage and commitment – stay the course
Create incentives; remove disincentives
Establish mandates and directives
Support physician leadership and engagement
Bring resources to the table; investments and disinvestments
9. 9
March 2010 – The Plan is Announced
Sooner, Safer, Smarter: A Plan to Transform the
Surgical Patient Experience
Developed collaboratively (Guiding Coalition and
Executive Sponsorship Group included over 80
individuals)
Clear, Publicly-Stated Goal: “No one will wait more than
3 months for surgery by March 31, 2014”
Incremental targets – 18 months, 12 months, 6
months…
Safety and quality remain priorities, not to be
jeopardized at the expense of “Sooner”
11. 11
What was different?
Emphasis on patient experience, quality, safety, access and
sustainability
Looking at every stage of the patient journey
Diagnostics
Laboratory
Diagnostics
Laboratory
Referral to
Specialist Home
Rehab
Health
Promotion
Prevention
Post-Op
Recovery/
Ward
Therapies
Primary
Care
Pre-Op
/ PAC
Surgery
12. 12
“Listening doesn’t mean you
have heard, and looking
doesn’t mean you have seen.”
Involving Patients and Families
14. 14
Lesson Learned: Patient Representation
“Nothing about me without me.”
The means may be debated, but the end goal is shared
by all: improve the experience of our surgical patients.
The most powerful motivator is a patient’s story.
Patient involvement must be meaningful.
Patient Safety is paramount.
Patients and Families included in Guiding Coalition and
Executive Sponsorship Group from the very beginning.
15. 15
SAFER
“Sooner, Safer, Smarter” should have been re-ordered.
Ministry established the Patient Safety Unit to dedicate resources
to safety initiatives.
Focus on Safety included:
Surgical Safety Checklist
Surgical Site Infection Bundle
Medication Reconciliation
Falls prevention
Stop the Line being piloted
Many Mistake-Proofing projects completed, more underway
The acceptable defect rate is ZERO. It is possible.
16. 16
SAFER – Results:
Surgical Volume and Checklist Compliance (Saskatchewan)
0
1,000
2,000
3,000
4,000
5,000
6,000
Apr-12
M
ay-12Jun-12Jul-12Aug-12Sep-12O
ct-12Nov-12
Dec-12Jan-13Feb-13M
ar-13Apr-13
M
ay-13Jun-13Jul-13Aug-13Sep-13O
ct-13Nov-13
Dec-13Jan-14Feb-14M
ar-14
Date
#ofSurgeries
Performed
0
10
20
30
40
50
60
70
80
90
100
ChecklistCompliance
(%)
# of surgeries performed
Checklist Compliance (%)
Data Source:
Saskatchewan
Health Quality
Council website
17. 17
SAFER: Good Catches!
Decision made to
perform a different
procedure following
Briefing.
Identified that a patient
was on Warfarin. The
procedure was
cancelled.
Identified abnormal
bloodwork at the
Briefing and surgery
was cancelled.
Identified that a
medication
administered pre-op
was not documented
on the anesthesia
record.
Identified incorrect
patient chart
brought into OR.
Found more than
one operative site
listed in the
documentation.
Identified that a patient
was positive for MRSA
but this was not
indicated in the chart.
Identified that
patient consent
was missing.
Identified that blood type
and screen had been
done but results not
ready.
Two procedures
scheduled; OR
slate only listed one.
Patient did not have
ID wristband.
Identified that
patient was allergic
to skin preparation
prior to surgery.
18. 18
“Insanity is doing the same
thing over and over again and
expecting different results”
– Albert Einstein
The Surgical Initiative asked “How can we work differently?”
20. 20
SMARTER – Continuous Improvement
Surgical Initiative the first system-wide project to benefit
from Lean methodology:
Standardized process
Visible targets and results
Replicating results
21. 21
SMARTER - Appropriateness
Appropriateness work is underway.
Appropriateness is conceptually tied to “clinical variation”.
Unexplained variation implies a quality problem.
Working to understand variation and reduce clinical variation in 4
clinical groups (Variation and Appropriateness Working Groups)
“Variation is the breeding ground for error.”
Dr. Richard Shannon
Quality Summit, April 2011
22. 22
Dr. Brent James – Intermountain, Utah
1. Well-documented, massive, variation in practices
(beyond the level where it is even remotely possible that all patients are receiving good care)
2. High rates of inappropriate care (2 - 32% of all care delivered, depending on specific
condition examined)
3. Unacceptable rates of preventable care-associated patient injury and death
4. A striking inability to "do what we know works"
5. Huge amounts of waste ( >50%, by best recent measures), spiraling prices, and limited
access
SMARTER - Appropriateness
23. 23
SMARTER – Clinical Pathways
Pathways promote timely and appropriate care aligned with the
patient’s preference.
Clinical pathways implemented:
1. Hip/knee
2. Spine
3. Pelvic floor
4. Prostate
5. Bariatric Surgery
Acute Stroke Care and Lower Extremity Wound Care pathways
are in development
24. 24
“Only those that provide the
care can improve the care.”
- Don Berwick, IHI, Orlando; Dec 7, 2011
25. 25
Lesson Learned – Physician Engagement
Critical to engage physicians in improvement work.
We’re learning how to do a better job of physician
engagement.
Accurate, meaningful data is persuasive.
27. 27
Laurel Trujillo, M.D., Medical Director of Quality
Palo Alto Medical Foundation
Create a dataset about costs for common problem
Present data to MDs with goal of triggering conversation
Allow group to define their own practice standard
Communicate standard to all
Provide follow-up data to track changes
Lesson Learned – Physician Engagement
28. 28
Lesson Learned – Shared Vision
Committed, consistent leadership:
Drive it
No other option
Provide the tools and resources
But, those closest to the work must fix it
Own it
Drive it
Celebrate the successes
Learn from the failures
31. 31
SOONER
RHAs implemented many improvements – OR allocation, case
cart standardization, better patient flow, better communication,
better relationships.
Pooled referrals and the Specialist Directory have helped level the
workload amongst specialists, allowing patients to accept the first
available appointment if they choose.
Third party service delivery offered additional surgical capacity.
Mid size regions are offering surgery as close to home as
possible.
Additional perioperative nurse training.
32. 32
Lesson Learned: Importance of Leadership
Executive Sponsorship Group & Guiding Coalition
Committed leadership – senior leaders, physicians
and front-line
Common vision – Think and Act as One
Patient and family involvement in decision-making
Bold, clear goals
Transparent results, shared widely
33. 33
Lesson Learned: Transition Planning
Keep it Visible
Consultations across the system on:
Design of future governance;
Ensuring continuous improvement; and
How to engagement system partners.
Provincial Surgical Oversight Team established
Patients, physician leaders and system administration involved
Will monitor results and report to Provincial Leadership Team
34. 34
Results for the Health System
More than shortening wait times
System wide culture shift to patient-centred care and
continuous improvement
Simultaneously improved quality, safety and efficiency
Serve the patient as a whole person – consider the entire
patient journey
Visible incremental targets and measures
35. 35
Results for the Health System
Strengthened partnerships and relationships
Patient advisors have become the norm
Province wide approach to safety and continuous
improvement
Willingness to share results and learn from each other as well
as high performing organizations
Introduction of speakers
Outline:
Context and background
Governance structure
The Plan
Impact of Patient Advisors
Necessity of engaging physicians
Results
Lessons learned throughout the four year initiative.
TERRY…
With any large scale change initiative there must be a sense of urgency
Our burning platform: Create a better system for our patients. Despite efforts, there had been no real change in previous 6 years.
TERRY…
TERRY…
Minister Don McMorris announced the plan, with Dr. Peter Barrett participating in the announcement as the physician lead.
Objectives:
Shorten wait time for surgery
Better patient experience
Safer, higher quality of care
Support for good health
Patient and family-centred providers.
TERRY…
Looked at entire patient journey
TERRY…
The “Driver Diagram” was a useful tool because it showed visually how the work fit together
Should have led out with SAFER.
DONNA…
DONNA…
DONNA…
DONNA…
DONNA…
Safety initiatives grouped together within the Ministry for the first time.
Four examples of safety initiatives under the Surgical Initiative
Other work includes Stop the Line (which requires cultural change to enforce that it’s everyone’s responsiblity to speak up if there’s a safety issue.
Senior Leaders are being trained in how to conduct Mistake Proofing Projects. It’s important to first identify where mistakes can happen, and then work to fix the processes that allow mistakes to occur. Blame is never placed on an individual – it’s the process that needs to be fixed.
The system shouldn’t tolerate any rate of defects greater than zero.
- Share your story. What is at stake? Safety is paramount.
DONNA…
In the 24 months shown, surgical volumes increased fairly steadily, nearly doubling (from 2,822 in April 2012 to 5,118 in March 2014).
At the same time, Surgical Checklist Compliance increased from 80% to 97% today.
Goal is 100%, so there is still room for improvement.
DONNA…
Real Saskatchewan examples of how the Surgical Safety Checklist has protected patients from harm.
From patient’s perspective, safety is the most important factor.
PETER…
PETER…
PETER…
PETER…
PETER…
PETER…
TERRY…
4,380 patients waiting >3 months for surgery compared to 15,353 when the initiative began.