HSCP Research Conference Friday 28 th February 2014 Dr. Philip Crowley, National Director QPS Safer Higher Quality Care for our Patients
Jan 05, 2016
HSCP Research ConferenceFriday 28th February 2014
Dr. Philip Crowley, National Director QPS
Safer Higher Quality Care for our Patients
Media coverage
€320k payout as hospital says sorry over death from dehydration
Healthcare System Failures
Where does improvement Happen?
Quality Improvement of Patient care
National
Group
Ward
Where Improvement Happens
Quality Improvement of Patient care
National
Group
Ward
ConditionsLeadershipPatient involvementClinical GovernanceEducation & Learning:- Measurement- QI Methods
ConditionsLeadershipPatient involvementClinical GovernanceEducation & Learning:- Measurement- QI Methods
A culture change – safety first
1. Individual relationship between HSCP and patient
2. Multidisciplinary Team / Ward
3. Hospital / organisation
Patient and H+SCP
Take ownership – accountable for the safety of care
Pivotal role in respecting and defending the dignity of every stage of life
Pivotal role in advocating for and on behalf of patients
What are the 3 biggest challenges that prevent me in delivering care – communicate out and up
MDT and Ward
Leadership role in drawing others into supporting change
Engaging Patients and staff you manage Safety Pause
MDT and Ward
Understanding what safety and quality means for your ward
Safer Better Healthcare Standards
Multidisciplinary team prompts
MDT and Ward
How well are you delivering Safe Quality Care QA+I tool, clinical audit
Clinical audit guidelines
Hospital / Organisation
Strong culture of Governance for Quality and Safety – be a champion for quality/question everything
Generate a culture of listening to your staff and patients Quality and Safety Walkrounds
Transparency Patients – open disclosure Measurement – Quality Profile
Checklists
Safe survey national policy and checklist Ward rounds principles for best practice and
checklist
Open disclosure
National Guidelines National Policy Guide for health and
social care staff Patient information
leaflet Staff support ‘assist me’
model
Quality Profile
Patient Experience
Staff Experience
Quality Improvement
Dashboard of Quality Indicators and Outcome Measures
0 0 0
1
0 0 0 0 0 0 0 0012
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Occ
ura
nce
s
Foreign Body left in Post Operatively
10
32
1
4
0 0
2 2
01
0246
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
In hospital fracture
25
20
20
6
03
0
7
00
5
10
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
In hospitals falls
3 4 210
26
1 1 3 2 4
01020
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Accidental Puncture or Laceration
23
1 12
0
2
4
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Transfusion Reaction
1
00.5
11.5
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Iatrogenic Pneumothorax
23
0
2
4
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Post Operative DVT / PE
1
0
0.5
1
1.5
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Wound Dehiscence
1
32
1 1
0
2
4
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Cardiac Arrest
21
0
2
4
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Post Operative Hip #
00.5
11.5
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Time to Hip # surgery
42 3
1
5
1 1 13
52 10
5
10
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Pressure Ulcers
0
1
2
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Mortality Indicators
00.5
11.5
Jan
Feb
Ma
rch
Ap
ril
Ma
yJu
ne
July
Au
gSe
pt
Oct
No
vD
ec
Medication Management
2
6 63 4
1 1
5
0
5
10
Jan
Feb
Mar
ch
Ap
ril
May
Jun
e
July
Au
g
Sep
t
Oct
No
v
Dec
Post Operative Sepsis
+
Employees & Patients: Likelihood to Recommend
16Press Ganey Associates
Em
plo
yee L
ikelih
ood
to
Reco
mm
en
d
Patient Likelihood to Recommend
How can we support you?
Quality and Patient Safety Division
Patients and StaffEngagement
Improvement Supporting and Assuring Quality
Improve the Safety of Patients
Listen to and empower patients
Listen to staff Foster development
and growth
Embrace Transparency through
Measurement(Indicators/Clinical Audit)
QI skills and knowledge
Areas for focus by QPS
Patient central
Patient Forums National Healthcare Charter Patient Safety Champions Measuring experience
Surveys Patient stories – from ward to board
Listening to Staff
Staff experience – seek and value feedback/ideas for improvement
Patient Safety Culture Survey/ Walk-rounds
Prioritise staff welfare
‘Walk in my shoes’
Elements of the National QI Programme
Each parallel element targets a different level of healthcare professional, maximising penetration of QI capability across the hospital system
Measurement
ASK FOR THE DATA
Data driven quality improvement Number of incidents plus trends
Ensuring preventable don’t keep reoccurringQuality Profile New quality indicators Patient experience and Staff experience Complaints…
Clinical audit Use data to generate light not heat
Berwick’s Challenge Abandon blame as a tool and trust the good will and
good intentions of staff Reassert the primacy of working with patients and
carers to achieve healthcare goals Use quantitative targets with caution – they should
never displace the primary goal of better care Recognise that transparency is essential and expect
and insist on it Give staff career-long help to learn, master and
apply modern methods for quality improvement Make sure pride and joy in work, not fear, infuse the
service
Oh! The places you’ll go..... And will you succeed?
Yes! You will, indeed! (98 and ¾ percent guaranteed.)
Kid, you’ll move mountains!Today is your day!Your mountain is waiting.So…get on your way!
Dr. Seuss
Thank You