Post on 19-Sep-2020
Carrie Marr
Chief Executive CLINICAL EXCELLENCE COMMISSION
5 August 2016
Emergency Care Institute
Our Quality and Safety Focus in NSW
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CAUTI Human Factors
Socio -Technical Framework for Healthcare
• Senior leadership • Clinical Leadership • Reliable processes of care • Process improvement • Psychological Safety • Effective teamwork • Just and accountable culture • Person and Family Centred Care
GENERATIVE Organization wired for safety and
improvement
PROACTIVE Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC Systems in place to manage hazards
REACTIVE Playing defense – reacting to events
UNMINDFUL No awareness of safety culture
Safety is a process of enquiry
Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2012. www.health.org.uk/publications/the-measurement-and-monitoring-of-safety
Has care been safe
in the past?
Are our clinical systems &
processes reliable?
Is care safe today?
Will care be safer in the future?
Are we responding & learning
& improving?
Highly Reliable Organisations (HRO) Guiding Principles
Openness about failures Emphasis on learning Obligation to act Accountability Just culture Appropriate prioritisation of action Teamwork Leadership
Safety II
• A balanced approach to quality assurance and quality improvement
• Specific and measurable reliable processes for improving care – measurement of reliable application of improvement bundles
• Supporting staff through education and training in quality improvement
• Developing cultural competence in which leaders and staff focus on better care through clinical leadership, teamwork and engagement at all levels
Safety II
• A commitment to listen, learning and partnering with patients, carers and our communities – assuring their full participation in design, redesign, assessment and governance
• Systematic, transparent measurement and reporting of improvement – Quality Boards
• Moving from pockets of innovation to system wide improvement – at scale..
• What is best done State wide and locally? – The Boards responsibility for quality and safety?
• Developing learning systems- learning what is and is not working to help implementation become more successful
• The resources, expertise and architecture to enable the delivery of Safety II – learning from best practice
NSW Patient Safety Alliance
Adult Older Person Paediatric Maternity
& Neonate Mental Health Community
Phase 1 Phase 2
Patient Safety Essentials: Hand Hygiene Safety Huddles Leadership Team Culture
LHD/SHN Safety Priorities: Medicines Safety Falls VAP VTE CAUTI Pressure Injury SEPSIS BTF
CEC Organisational Structure – Functional
CHIEF EXECUTIVE Executive Support Unit
CORPORATE SERVICES
• Strategy • Performance • Corporate Governance • Audit • Workforce / HR • Finance • Corporate services • Communications • Briefs / Ministerials
INFORMATION MANAGEMENT
• IT Strategy • Analytics • Biostatistics • TRIM Records
Management
ORGANISATIONAL DEVELOPMENT
• Organisational Diagnostics
• Cultural competence • Diagnostic Error • Human Factors • Person Centred Care • End of Life Care • Clinical Handover and
Escalation • Team Effectiveness
and Culture
QUALITY IMPROVEMENT HUB
• Incident Management • RCA Committees • Special Committees • QI Academy • Patient Safety
Academy • Improvement
Support Team
CLINICAL GOVERNANCE & ASSURANCE
• Clinical Governance • HAI • QARS • Databases • Bloodwatch • External Reviews • National Q&S
Standards
STRATEGIC PARTNERSHIPS; KNOWLEDGE EXCHANGE
• Evaluation • Research • Publications • Strategic Partnerships • Evidence Analysis
ADULT/OLDER PERSONS PATIENT SAFETY PROGRAMS
PAEDIATRIC , MATERNITY & NEONATAL PATIENT SAFETY
ADULT; OLDER PERSON; AND PAEDIATRIC PATIENT SAFETY PROGRAMS
• Essentials of Safety • Evidence based change packages • Improvement collaboratives • Improvement coaches
Factors used by leading QI organisations to deliver improved outcomes
Build Infrastructure & Capacity
Quality program organisation Education
Leadership development
Priorities maintained during crises Stability of general management and
program management Choosing tools to support staff in their “day job”
of improvement
Program logistics Measurement systems Information systems
Culture: • Will and commitment • Measurement • Evidence based learning • Learning organisation
Ref: Staines 2009
6 Essential Capabilities to Creating High-Performing Organisations
(KP) • Leadership and the ability of leaders to identify the “vital
few breakthrough opportunities” • A systems approach • Measurement capability at all levels • The culture of a learning organisation (with an infrastructure
to harvest best practices for sharing and learning to create potential for spreading practices with the greatest impact)
• Team engagement from the bottom up • A strong internal capability to improve
Bosignano, M & Kennedy, C (2012) Pursing the Triple Aim
Key Learnings
• Moved from counting error to measuring harm and reliability
• Learn from others – “the best at getting better” • Aggregated data does not show the same outcome as
local data • Data for improvement not judgement • Shift from spray and pray to ruthless attention to the
microsystem - where change happens
Experts Senior
Leaders & Boards
Change Agents
(Middle
Managers, project leads)
Everyone
Staff
Teams
Continuum of PI Knowledge and Skills
Deep Knowledge
Many People Few People
What Skills Do We Need?
Source: Kaiser Permanente, 2008
Shared Knowledge
A key operating assumption of building capacity is that different groups of people will have different levels of need for QI knowledge and skill – what will you need people to have?
Our approach will be to make sure that each group receives the knowledge and skill sets they need when they need them and in the appropriate amounts.
Considerations • Do we know how good we are? • Do we know where our waste, unwarranted
variation and harm is? • Do we know how we compare compared to
the best in class? • Do we know what our rate of improvement is
over time?
Our leadership challenge • Our organisational strategy for improving
patient safety and our internal capability to improve?
• Our organisation-wide approach for creating a positive safety culture?
• Ensuring that safety can be better measured and monitored across the organisation?
carrie.marr@health.nsw.gov.au @carriemarr