Metodologías y enfoques de implementación y mejora de la calidad en el IHI

Metodologías y enfoques de implementación y mejora de la calidad en el IHI País Vasco / Euskadi 3/11/11 Pedro Delgado Executive Director Institute for Healthcare Improvement

Los Roques

I. IHI (10) II. Metodologías y enfoques III. La Ciencia de la Implementación? IV. El futuro (10) Joe, Marie, Jason, Nana, Pierre, Kedar, Carol, Don

Por qué existimos? Entre la atención de salud que tenemos y la atención que podríamos tener no hay sólo una brecha, hay un abismo. - Institute of Medicine, Atravesando el Abismo de la Calidad, 2001

Saber...hacer: el Know-Do gap

Las Brechas son el resultado de sistemas y procesos no diseñados de acuerdo a la necesidad** Todo sistema está perfectamente diseñado para lograr exactamente los resultados que logra -Paul Batalden, MD

Rediseño de procesos

IHI está aquí para Ser fuente de energía y optimismo Mejorar la vida de los pacientes, la salud de las comunidades y la alegría de los recursos humanos del sector salud Acelerar la mejora de la atención sanitaria convirtiendo ideas innovadoras en resultados prácticos, que sean realmente significativos para los pacientes Cerrar the Quality Gap lo antes posible

Nuestro Blueprint: atención que debe ser Segura Oportuna Eficaz Centrada en el paciente Eficiente Equitativa

Cómo queremos cambiar el mundo?

II. Metodologías y enfoques de implementación y mejora de calidad No es el que, sino el como Casos estudio

Implementación ANALISIS DEL SISTEMA La Brecha BUENAS IDEAS (De adentro, de afuera) P IMPLEMENTACION A CICLOS DE PRUEBAS PEQUENAS CON CONOCIMIENTO LOCAL H E EXITO / SOSTENIBILIDAD

Sistema Colaborativo: todos enseñan, todos aprenden Participantes Selección del tema Grupo de Planificación Desarrollar el marco y los cambios Trabajo de preparación SA 1 A P S D SA 2 A P S D SA 3 Publicaciones, eventos para compartir aprendizaje, etc

E + P = R Estructura + Proceso = Resultado Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI, Health Administration Press, 1980. E + P + C = R

Paquetes de Cambio PBE + EBP

Metas Específicas (Enero 2013) Mortalidad (SMR): reducción del 15% Eventos adversos: reducción del 30% Neumonía asociada a ventilación: 0 o 300 CVC-BSI: 0 o 300 Azúcar en sangre controlada (ITU/HDU): 80% controlada Staph aureus bacteraemias: reducción del 30% Crash Calls (pacientes deteriorados): reducción del 30% Daño causado por anti-coagulación: reducción del 50% en ADEs Infecciones quirúrgicas in situ: reducción del 50% (limpio)

Teoría del cambio Metas claras y una metodología definida, con soluciones definidas ( bundles, etc) Formación de capacidades en calidad y seguridad Acciones concretas del liderazgo Desarrollo de lideres futuros Medición mensual de procesos y resultados, compartida y transparente Colaboración constante

Scotland 7% reduction in HSMR 1.5 Standardised Mortality Ratio 1.3 1.0 0.8 0.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p

0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio 0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio 0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio 0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio 0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio 0.5 0.8 1.0 1.3 1.5 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010* Jan- Mar 2011p Standardised Mortality Ratio HSMR results 2008-2011

Jul-11 12 10 8 6 4 2 0 Central line infection rate (per thousand line days) 92% reduction 2.34 0.18 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jan-08

12 10 8 6 4 2 0 Central line infection rate (per thousand line days) March 2011: zero central line infections in whole country Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Apr-08 Jan-08

20 18 16 14 12 10 8 6 4 2 0 VAP rate (per thousand ventilator days) Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 62% reduction 9.11 3.49

4.5 4 3 3.5 2.5 2 1 1.5 0.5 0 Critical care C-Difficile rate (per thousand bed days) Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 90% reduction 1.61 0.165

12 10 8 6 4 2 0 Critical Care SAB rate (per thousand bed days) Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 1.785 79% reduction 0.38

6.5 6 5.5 5 4.5 4 3.5 3 Critical Care LOS Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 4.81 12% reduction (0.6 days) 4.21

0.6 0.5 0.4 0.3 0.2 0.1 0 General ward SAB rate (per thousand patient days) Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 0.335 31% reduction 0.23

2.5 2 1.5 1 0.5 0 General ward C.Difficile rate (per thousand patient days) Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 1.18 88% reduction 0.14

90 85 80 75 70 65 60 55 50 % of medicines reconciled 81% 15% improvement 66% Jul-11 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jan-09

Jul-11 100 95 90 85 80 75 70 65 60 % of procedures with surgical checklist 9% improvement 83% 92% Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jan-09

Mar-11 May-11 Jul-11 100 95 90 85 80 75 70 65 60 55 50 % on-time antibiotics Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 74% 13% improvement 97% Nov-08 Sep-08 Jul-08

NHS Lothian adverse event rate Rate of Adverse Events per 1000 patient days (as at August 2011) 80 70 60 50 40 30 20 10 0 52 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 AEs per 1000 patient Days Oct-10 RIE, WGH & SJH 30 8 data points below current median = a shift in the data. New process median provisionally 30 per 1000. This is a 42% reduction from 43% reduction Month of Discharge

GRI VAP 0 10 20 30 40 50 60 70 80 90 100 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 % compliance 0 1 2 3 4 5 6 7 8 9 10 VAP rate

25 20 15 10 5 0 Glasgow Royal Infirmary VAP rate (per thousand ventilator days) 548 days Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Oct-07

El poder de una meta compartida, ambiciosa Y una visión sistémica, asociada a la meta principal a las metas conductivas

Primary Drivers Secondary Drivers Perder 10 Kilos en 12 meses (al 20 de Junio 2012)

Programa Escoces de Seguridad THE del COMMONWEALTH Paciente FUND (2008-2013) Diagrama de Drivers Disminuir la mortalidad y los eventos adversos hospitalarios en Escocia Drivers Primarios Medidas del Gobierno Escocés (Prioridad Estratégica SP) Adhesión de Comites Ejecutivos - Seguridad es Clave Prioridad Estratégica Lograr resultados (deliver) del programa Construir una Infrastructura Sustentable para el Mejoramiento Alinear PESP con el Programa Nacional de Calidad y las Mediciones Drivers Secundarios Líderes Nacionales adhieren abiertamente a las metas del PESP, el fracaso no es una opción - Tiempo y espacio establecidos para lograr mejoras (no un target:objetivo fijo) -Los Colegios Reales ayudan a nivel oficial -Seguridad es un elemento de todo programa - -Estrategia de desarrollo (Consejo Nacional) -Fuerte acuerdo sobre una serie de resultados y mediciones -Calidad -seguridad comprenden 25% de la agenda --Desarrollo de infrastructura que soporta la mejora continua y la medición -Metas de mejora claras en el plan estratégico -Segmentación de hospitales, enfoque customizado -Trabajo con IST, QIS y HES para desarrollar un enfoque de mejora unificado. -Apoyo a los CE de todo el país -Difundir nuevas estrategias de atención -Desarrollar expertos en imp. métodos, coaching -Sistema de medición nacional, análisis cultural -Trabajo de seguridad migra a agencias espec. -Programas de training desarrollados en Escocia - Trabajo con IST, QIS y HES para desarrollar un enfoque unificado de mejora -Align aims and measures with national programmes -Develop a portfolio and execution model -Build connection to safety in national work -Define within clinical governance

Logrando la meta Una teoria de como cambiar el sistema Efect o Conduce a Causa

Meta

Alineación

Todos los niveles alineados Microsistema Mesosistema Macrosistema

Liderazgo a todo nivel Minister, Boards on Board, Programme Management, Front Line

Desarrollo de capacidades en mejora IHI Open School, Kevin, Improvement Advisors (24 p/a), Fellowships (12 p/a)

Progresión Natural: Quality and Innovation Center Sostenibilidad como prioridad Expansión a otros temas

Caso estudio 2

Collaborative learning network PDSA cycles PDSA cycles Learning session 1 Learning session 2 Learning session 3 intensive QI support to facilities and managers 18-24 months

Ghana: Project Fives Alive PARTNERS:

Ghana Population 33 million Health systems: Government, faithbased, for profit National Health Insurance from 2008 Under 5 mortality 76/1000 (2010) Maternal Mortality 690/100,000 (2006)

Project Fives Alive: Agenda set by Funder (BMGF) Specific Aim: accelerate national reduction of U5 mortality Increase access to and utilization of high-quality health care services in the health system Improve performance and efficiency in key supporting systems Demonstrate unique role of faith-based systems in accelerating improvement in health care Build capacity for sustainable health systems improvement in NCHS and the GHS Disseminating the results of these large-scale improvement models outside of Ghana.

How can we get the system to work better? Building Will Methods for Systems Improvement Financing Workforce Governance Drugs and supplies Information systems Delivery systems Executing and spreading change

Phased Scale Up: QI Intervention to accelerate maternal and child survival across Ghana Months Phase 0: -6 to 0 Phase 1: 0 9 Phase 2: 10-27 Phase 3: 19-39 Phase 4: 34 51 Preparation Building will Baseline data Sub-districts with QI teams Piloting Building will Demonstration 35 Scale up 230 More Piloting 260 National Scale up 1800

Phase 0: Building Will Understanding environment and context: GHS has well developed ACSD plan with standard maternal and child survival strategy NCHS has network of hospitals and clinics around the country ( beachheads ) Northern rural regions worst U5 mortality. Data systems weak Build on culture of annual regional data-driven performance review Early engagement with regional leaders

Phase 1: Establishing a prototype Phase 1: 35 sub-districts in 3 regions Introducing QI, building will Testing innovations, getting results Understanding connections between community and different levels of care Understanding NCHS-GHS interactions Developing a change package for spread Getting buy-in from district leaders Building capacity (QI, data) for spread

Accelerate reduction of Under-5 mortality in Ghana by 60% before 2015 using QI methods PRIMARY SYSTEM DRIVERS OF IMPROVED HEALTH Seeking and obtaining care early Providing prompt, appropriate, adequate & client-centred care Using reliable health data to drive improvement HEALTH SYSTEM DESIGN FEATURES COMMUNITY Risk Awareness/Management Enhanced Value of Lives Financial /NHI Subscription Proximity to Health Services Attractiveness of Health Services HEALTH FACILITY Staff Attitude & Behaviour Staff Clinical Knowledge & Skills Protocol Adherence Staff Availability Reliable Referral System DATA QUALITY Use of Local Data to Drive Performance Improvement Regular Supervision, Coaching & Mentoring Appropriate Data Capture & Transmission Tools CHANGE INTERVENTION SS Client Self-Management & Family Aides Education Emergency Preparedness Community Education & Mobilization Outreach & Domiciliary Services Client-centred Design Acuity-oriented Design Staff Training, Practice & Monitoring Reminder Systems Supply Chain Management Staff Re-scheduling, Reassignment & Taskshifting Communications & Transport System Application of QI methods at Local Level Longitudinal Data Quality Assessments Longitudinal Facilitative Supervision Development & Use of Client Registers, Reporting Forms, Databases etc.

Intensive pilot/testing in Phase 1: Skilled Delivery /early neonatal review

Change package: 18 tested interventions associated with improved performance

Phase 2: Regional Spread Spread from 35 to 230 sub-districts in 3 regions Spreading the change package Closer engagement with GHS Testing of more QI remote support in preparation for national scale up (keeping the project team constant size, promote sustainability)

Scale up to 600 facilities in Phase 2: Attendance at Skilled Delivery

Phase 2b: in hospital U5 mortality 9 worst performing hospitals in the NCHS 39 hospital system Developed a theory of change for improving in hospital mortality Early recognition of disease and prompt treatment and referral (community and outlying facilities) Rapid in-hospital triage Reliable application of protocols

Rapid reduction of deaths due to severe acute malnutrition (SAM) Changes tested: targeted messages delivered through community radio (to counter cultural myths re SAM). Community health workers were trained to diagnose SAM with prompt referral to hospital. SAM destigmatized through patient friendly approach In hospital clinical management of SAM was improved through workshops Intensive feedback data and photos of successful interventions. SAM intervention started 22 deaths 2 deaths

Linking improved processes to outcomes

System-wide decrease in In- Hospital Mortality for Under-5s

Phase 4: going to full scale Months Phase 0: -6 to 0 Phase 1: 0 9 Phase 2: 10-27 Phase 3: 19-39 Phase 4: 34 51 Preparation Building will Baseline data Sub-districts with QI teams Piloting Building will Demonstratio n 35 Scale up 230 More Piloting 260 National Scale up 1800

Phase 4: main issues Growing confidence in results and change packages for communities and hospitals Postnatal change package still being developed Sufficient will? Sufficient capacity (QI, data)? Highly leveraged approach still untested

Project Fives Alive: what will we measure? Acceleration of progress in MDG4 Did the interventions lead to increased access and utilization? Did processes improve faster than status quo? Role of faith based organization in promoting improvement of national system Sustainability

Acknowlegements Institute for Healthcare Improvement improvement experts, managers & leaders National Catholic Health Service improvement advisors, service providers, managers & leaders Ghana Health Service change agents, service providers, managers & leaders Communities Served by the Frontline Providers Donor: Bill & Melinda Gates Foundation

III. Reflexiones acerca de la Ciencia de Implementación

Clinical Research vs Implementation Science Clinical Research Aim: New knowledge Methods: Test blinded Eliminate bias Just in case Fixed hypothesis One large test Implementation Science Aim: Spread knowledge Methods: Test observable Stable bias Just enough data Adaptation of changes Sequential tests

Por qué necesitamos esta ciencia? (Gareth Parry IHI) Applied in a narrow range of contexts Improvement in 100% of sites

Pruebas iniciales: Numero pequeño de escenarios Applied in a wider range of contexts Improvement in 80% of sites

Mas escenarios, mas contextos Applied in a wider range of contexts Improvement in 70% of sites

La efectividad reduce al aplicar un protocolo fijo en distintos contextos Initial Trial sample Evaluation sample Immediate wide-scale implementation

La efectividad pudiese mantenerse si aplicamos la solución en lugares identicos Innovation sample

Adaptar la intervencion de manera que pueda funcionar mejor en contextos distintos / nuevos Innovation sample Learn which contexts it can be amended to work in as we move from Innovation to Prototype to Test and Spread

IV. El Futuro

IHI Open School www.ihi.org Mejorar las competencias para la atención de la salud y la seguridad de los pacientes de la próxima generación profesional, en todo el mundo.

IHI Open School

IHI Open School Course Catalog Todos los cursos en Español, gratuitos Quality Improvement: QI 101: Fundamentals of Improvement QI 102: The Model for Improvement: Your Engine for Change QI 103: Measuring for Improvement QI 104: Putting It All Together: How Quality Improvement Works in Real Health Care Settings QI 105: The Human Side of Quality Improvement QI 106: Level 100 Tools Upcoming Courses: Patient and Family Centered Care: PFCC 101: Dignity and Respect Operations Management: MHCO 101: How to Achieve Breakthrough Quality, Access, and Affordability Patient Safety: PS 100: Introduction to Patient Safety PS 101: Fundamentals of Patient Safety PS 102: Human Factors and Safety PS 103: Teamwork and Communication PS 104: Root Cause Analysis PS 105: Communicating with Patients After an Adverse Event PS 106: Introduction to the Culture of Safety Leadership: L 101: So You Want to Be a Leader in Health Care In development

Los Capitulos, la comunidad 350+ Chapters US Chapters in 45 states International Chapters in 50 countries

Progreso (2008-2011) >60,000 students and residents registered on IHI.org >9,000 faculty and deans registered on IHI.org >19,500 students and residents have completed an online course >1200 students and residents have earned their Certificate of Completion >350 Chapters in 45 states and 50 countries

La Triple Meta

THE COMMONWEALTH FUND Paradigmas futuros 1. Enfermedad Salud 2. Curación Prevención 3. Médicos Profesionales de la Salud 4. Especialidades Integración 5. Paciente pasivo Persona activa 6. Hospital Red 7. Contacto episódico Contacto continuo 8. Referencia-contrarreferencia Continuidad 9. Productividadeficiencia 10. Sistemas lineales Calidad-seguridad Sistemas complejos no lineales E. Ruelas

Redes

Construyendo un movimiento www.clicss.org

Gracias Pedro Delgado, Executive Director Institute for Healthcare Improvement 20 University Road, 7 th Floor Cambridge, MA pdelgado@ihi.org