1 The Saskatchewan Surgical Initiative: Lessons Learned Health Quality Summit, Saskatoon, May 7 th 2014 Presenters: Donna Davis, Dr. Peter Barrett, Terry Blackmore (Patient & Family Advisor) (Physician Leader) (A/Exec. Director, Saskatchewan Health)
Nov 15, 2014
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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)
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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!
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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.
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The Environment
October 2009:Patient First Review released;Speech from the Throne
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September 2009 – First Surgical Guiding Coalition and Executive Sponsorship Group meeting held in Saskatoon
A biannual event Shared ownership
Building the Team
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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
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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
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March 2010 – The Plan is Announced
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March 2010 – The Plan is AnnouncedSooner, 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”
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What was different? Emphasis on patient experience, quality, safety, access and
sustainability Looking at every stage of the patient journey
DiagnosticsLaboratory
DiagnosticsLaboratory
Referral to Specialist Home
Rehab
Health Promotion Prevention
Post-OpRecovery/Ward
TherapiesPrimary
CarePre-Op / PAC
Surgery
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“Listening doesn’t mean you have heard, and looking
doesn’t mean you have seen.”
Involving Patients and Families
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Patient advisors
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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.
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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.
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SAFER – Results:Surgical Volume and Checklist Compliance (Saskatchewan)
0
1,000
2,000
3,000
4,000
5,000
6,000
Apr-1
2
May
-12
Jun-
12
Jul-1
2
Aug-1
2
Sep-1
2
Oct-12
Nov-12
Dec-12
Jan-
13
Feb-1
3
Mar
-13
Apr-1
3
May
-13
Jun-
13
Jul-1
3
Aug-1
3
Sep-1
3
Oct-13
Nov-13
Dec-13
Jan-
14
Feb-1
4
Mar
-14
Date
# o
f S
urg
erie
s P
erfo
rmed
0
10
20
30
40
50
60
70
80
90
100
Ch
eckl
ist
Co
mp
lian
ce
(%)
# of surgeries performed
Checklist Compliance (%)
Data Source: Saskatchewan Health Quality Council website
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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.
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“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?”
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Don't ask “What's the matter”; ask “What matters to you?”
- IHI Conference
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SMARTER – Continuous Improvement
Surgical Initiative the first system-wide project to benefit from Lean methodology:Standardized processVisible targets and resultsReplicating results
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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
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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
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SMARTER – Clinical Pathways
Pathways promote timely and appropriate care aligned with the patient’s preference.
Clinical pathways implemented:1. Hip/knee2. Spine3. Pelvic floor4. Prostate5. Bariatric Surgery
Acute Stroke Care and Lower Extremity Wound Care pathways are in development
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“Only those that provide the care can improve the care.”
- Don Berwick, IHI, Orlando; Dec 7, 2011
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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.
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Laurel Trujillo, M.D., Medical Director of QualityPalo 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
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Lesson Learned – Shared Vision
Committed, consistent leadership: Drive itNo other optionProvide the tools and resources
But, those closest to the work must fix itOwn itDrive itCelebrate the successesLearn from the failures
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01
00
00
20
00
03
00
00
Saskatchewan: All Specialties: Number Waiting by Time Already Waited
Month End Dates (Data Source: 30Mar2014 refresh of the SK Surgical Patient Registry)
Nu
mb
er
of C
ase
s W
aiti
ng
at M
on
th E
nd
28Feb2005 28Feb2006 28Feb2007 29Feb2008 28Feb2009 28Feb2010 28Feb2011 29Feb2012 28Feb2013 28Feb2014
28,679 28,923
27,229 26,67127,756 27,799
25,345
21,843
19,544
15,776
18,85218,012
16,79315,766 15,978 16,003
12,950
9,291
7,868
4,380
13,57012,420
11,10310,456 10,387 10,075
7,686
4,645 3,920
1,691
8,0926,874
5,5995,051 4,678 4,150
2,763
1,060 947 319
4,5583,852
2,823 2,526 2,002 1,706 872
275 165 80
Wait Time Colour Key (% change from: 28Feb2010 to 28Feb2014, 31Mar2010 to 28Feb2014)
All (-43%, -43%) > 3 mth (-73%, -71%) > 6 mth (-83%, -83%) > 12 mth (-92%, -92%) > 18 mth (-95%, -95%)
Change from
Mar 31 2010 to
Feb. 28 2014:
- 43 % (total)
- 71 % (>3 month)
- 83 % (>6 month)
- 92 % (>12 month)
- 95 % (>18 month)
Initiative Begins
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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.
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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
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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
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Results for the Health System
More than shortening wait timesSystem wide culture shift to patient-centred care and continuous improvementSimultaneously improved quality, safety and efficiencyServe the patient as a whole person – consider the entire patient journeyVisible incremental targets and measures
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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
Questions?Contact Me:
Terry BlackmoreA/Executive Director, Saskatchewan Health
www.qualitysummit.ca
#QS14