1. Boards on Board

2. Don Berwick
• Put the patient first
• Put the vulnerable first
• Start at scale
• Give the money back
• Act locally

3. “The tendency exists to argue
that the science of improvement
may be a lesser way of knowing,
because it concerns itself
primarily with a wide range of
applications in uncontrolled
settings; that is, the real world as
we find it every day”
Rocco Perla

4. Moving beyond safety

6. The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships between
patients, their families, and those delivering healthcare services
which respect individual needs and values, and which demonstrate
compassion, continuity, clear communication, and shared decision
making.
• Effective - The most appropriate treatments, interventions,
support, and services will be provided at the right time to everyone
who will benefit, and wasteful or harmful variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients from
healthcare they receive, and an appropriate clean and safe
environment will be provided for the delivery of healthcare services
at all times.

7. -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

8. -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

9. Three Part Problem...
• Improve Individual Experience
• Improve Population Health
• Control Inflation of Per Capita Costs
The Triple Aim

10. Evidence based medicine 
Evidence based care delivery
17 years to get 14% of evidence
into practice

11. “Conquering the world on horseback is easy: it
is dismounting and governing that is hard”
Genghis Khan

12. “quality improvement”
The combined and unceasing efforts of
everyone – health care professionals,
patients and their families, researchers,
payers, planners, administrators,
educators – to make changes that will
lead to
better patient outcome, better system
performance, and better professional
development.
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

14. Outcome Aims
• Mortality: 15% reduction
• Adverse Events: 30% reduction
• Ventilator Associated Pneumonia: 0 or 300 days
between
• Central Line Bloodstream Infection: 0 or 300 days
between
• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
range
• MRSA Bloodstream Infection: 30% reduction
• Crash Calls: 30% reduction

15. HSMR
Hospital Standardised Mortality Ratio

16. Scotland – 8.4% reduction in HSMR
1.5
Standardised Mortality Ratio
1.0
0.5
Oct- Apr- Oct- Apr- Oct- Apr- Oct- Apr- Oct- Apr-
Dec Jun Dec Jun Dec Jun Dec Jun Dec Jun
2006 2007 2007 2008 2008 2009 2009 2010 2010p* 2011p

17. 1.5 1.5
Standardised Mortality Ratio
1.3
Standardised Mortality Ratio
1.3
1.0
1.0
0.8
0.8
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
1.5
1.5
1.3
1.3
Standardised Mortality Ratio
Standardised Mortality Ratio
1.0
1.0
0.8
0.8
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 0.5
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
1.5 1.5
Standardised Mortality Ratio
1.3 1.3
Standardised Mortality Ratio
1.0
1.0
0.8
0.8
0.5
0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
HSMR results
2008-2011

18. Scotland level results

19. Central line infection rate
(per thousand line days)
12
10 March 2011:
zero central line infections
8
in whole country
6
4
2
0
08
10
09
11
8
1
9
0
9
8
0
1
0
8
9
l-0
l-1
l-1
l-0
r- 0
r- 1
r- 0
r- 1
-1
-0
-0
n-
n-
n-
n-
ct
ct
ct
Ju
Ju
Ju
Ju
Ap
Ap
Ap
Ap
Ja
Ja
Ja
Ja
O
O
O

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

21. 10
12
14
16
18
20
22
24
26
28
Jan-08
Mar-08
May-08
Jul-08
Sep-08
Nov-08 18.2%
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
% ICU mortality
Jul-10
14% improvement
Sep-10
Nov-10
Jan-11
Mar-11
May-11
15.7%
Jul-11

22. 0
0.5
1
1.5
2
2.5
Jan-08
Mar-08
May-08
1.18
Jul-08
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
(per thousand patient days)
Jul-10
Sep-10
88% reduction
Nov-10
General ward C.Difficile rate
Jan-11
Mar-11
0.14
May-11
Jul-11

23. How has the frontline done it?
• Get goals. • Get the facts.
• Get bold. • Get to the field.
• Get together. • Get a clock.
• Get a model (and • Get the numbers.
stick with it) • Get the stories.
• Get patients and
families

24. How has NHSScotland done it?
Policy Leadership Execution
Structure Process Outcome
Donabedian, A.
Explorations in Quality Assessment and
Monitoring. Volume I: The Definition of Quality
and Approaches to its Assessment.1980.

25. Having the best
professionals in the world
is no longer enough

26. The Capacity and Capability Aim
To build a sustainable
infrastructure that produces
highly reliable QI excellence
by (fill in the date).
How good? By when?
© 2010 Institute for Healthcare Improvement

27. Who needs to be developed?
Governance?
Executives?
Managers?
Supervisors?
Front Line Workers?
Improvement Advisors (IAs)?
Adapted from Tom Nolan, Associates in Process Improvement presented at the
IHI Strategic Partners Roundtable, April 17-18, 2006
© 2010 Institute for Healthcare Improvement

28. How many quality experts
do we need?
Two suggestions for determining this number:
√
Number of
employees
Or…consider that no employee should
be more than 2 steps (individuals)
away from a QI expert.
© 2010 Institute for Healthcare Improvement

29. Where next?
• Sepsis/VTE
• Paediatrics
• Primary care
• Mental health
• Maternity
• Person-centred care
• Early years

30. "Quality is never an accident;
it is always the result of high
intention, sincere effort,
intelligent direction and
skillful execution; it
represents the wise choice of
many alternatives.”
1941, William A. Foster