A Breakthrough Series collaborative was used to engage staff to change their clinical area, which has resulted in cardiac arrests being viewed as never events
Emma Donaldson, MBChB, MA, is quality improvement research fellow, Salford Royal Foundation Trust; Peter Murphy,MA, RGN, is assistant director of nursing services, quality improvement, Salford Royal Foundation Trust, and core adviser to Patient Safety First.
Donaldson E, Murphy P (2009) How empowering staff through collaborative working reduced the number of cardiac arrests. Nursing Times; 105: 47, early online publication.
Problem: At Salford Royal Foundation Trust, 179 patients suffered a cardiac arrest between March 2007 and April 2008.
Key measures for improvement: Our primary outcome measure was the number of cardiac arrests per 1,000 admissions.
Strategies for change: Eleven wards were invited to participate in a Breakthrough Series collaborative from April 2008-January 2009. It is a short term (6-15 months) learning system that brings together several teams to seek improvement, focusing on one topic. Frontline teams worked to develop changes in their clinical areas with the aim of reducing cardiac arrests by 50% in one year.
Results: April-December 2008 saw an reduction of 32% in the cardiac arrest rate, resulting in an average arrest rate of 0.79 per 1,000 admissions. Since the project began to upscale its work in January 2009, a further reduction has been noted. However, another four months’ data is required to assess whether this equates to a sustained change.
Conclusion: Preliminary data suggests that a Breakthrough Series collaborative is an effective method of engaging frontline staff in developing and implementing change, with improvements in patient care.
Keywords: Patient safety, Deterioration, Acutely unwell adults
- This article has been double-blind peer reviewed
- This project demonstrates that frontline staff can develop innovative solutions for organisational problems.
- Support, celebration and motivation are key to success.
- Senior leadership “permission” to undertake change is vital.
- Data can be a powerful way of driving change.
- Staff ownership of improvement is key to sustainability.
Engaging and empowering frontline staff are known to be influential ways of generating long term improvement, and are promoted by Patient Safety First. This national campaign encourages change to happen in small steps, following a plan do study act (PDSA) cycle (see Changing practice article). This method of testing minimises the risks associated with system change and allows weaknesses in a new system to be acknowledged and redesigned before widespread implementation. The aim is to reduce unintended harm and improve the reliabilityof the systems in which staff work.
Salford Royal Foundation Trust has used this method successfully, achieving a reduction in the number of cardiac arrests in its patients. Salford Royal is one of the 96% of acute trusts that have voluntarily signed up to Patient Safety First and is using the reducing harm from deterioration intervention tools to help support the work underway in this area.
At the trust, 179 patients suffered a cardiac arrest in the year from March 2007-April 2008. Medical evidence indicates that many patients show signs of deterioration during the 24 hours before cardiac arrest (Hillman et al, 2001), with various factors contributing to suboptimal care (Box 1). With this in mind, the trust sought to improve the situation by focusing on these factors.
The Department of Health (2000) report Comprehensive Critical Care addressed the recognition and management of acutely unwell patients. The report recommended establishing outreach teams whose remit would include avoiding critical care admissions by “identifying patients who are deteriorating and either helping to prevent admission or ensuring that admission to a critical care bed happens in a timely manner to ensure best outcome” (DH, 2000).
This has resulted in the widespread implementation of rapid response teams, critical care outreach teams and medical emergency teams in many organisations. The literature suggests this approach can result in a 25-30% reduction in cardiac arrests (for example, Goldhill et al, 1999).
However, Salford Royal approached the issue of improving recognition and management of deterioration in a different way. The acutely unwell adults (AUA) faculty decided to undertake organisational change before considering a specialist rapid response team. This approach makes the care of deteriorating patients everyone’s responsibility rather than devolving it to a specialist group of staff. This collaborative working and innovation has been successful in reducing cardiac arrests and, to date, Salford Royal does not have a specialist rapid response team.
The trust’s quality improvement strategy aims to reduce harm and save lives. The clinical area of care for acutely unwell adults was identified as a key area of work that would support this strategic vision. A faculty team (consisting of doctors, nurses, allied health professionals, a project manager and an improvement adviser) was set up in 2008. Together, they set an aim of reducing cardiac arrests on wards by 50%.
Box 1. Factors leading to suboptimal care
- Chaotic systems
- Lack of knowledge/experience
- Inadequate supervision
- Failure to recognise the severity of a situation
- Reluctance to seek help
Source: Hillman et al (2001)
The trust ran a Breakthrough Series collaborative (Institute for Healthcare Improvement, 2003), using a model in which teams were able to learn both from each other and from local experts around a focused set of objectives (Fig 1).
Internationally, this collaborative approach has already been used successfully in decreasing Caesarean section rates (Flamm et al, 1998), and in improving diabetes and heart failure care (Glasgow et al, 2002).
Teams committed to working together over nine months (April 2008-January 2009) and to attend three one-day learning sessions.
The faculty team identified a project director and brought together a wider steering group of experts to include healthcare professionals from emergency medicine, critical care, anaesthetics, general medicine, surgery, elderly care and resuscitation training, as well as the executive sponsor of the collaborative (the executive director of nursing). The group met before the first learning session to review the evidence available on the care of acutely unwell patients.
As a result of this session, the steering group developed a number of key objectives for the programme of work. The trust then identified the wards with the highest numbers of cardiac arrests and invited them to participate in the collaborative. Eleven wards took part in the first phase. Representatives attended learning sessions and went on to coordinate ward improvement efforts. Teams were multiprofessional, and included junior and senior nurses, healthcare support workers, physiotherapists, doctors and nurse practitioners.
As well as including many different staff levels, the project was sponsored by the executive director of nursing, who attended the learning sessions to provide senior support and encouragement. Frontline staff were formally “liberated” to change systems in the pursuit of improved patient care and safety.
The first learning session focused on the theory and practice of improvement, and gave background information on the project aims and the local situation, including arrest data for individual wards and supporting evidence on best practice. Teams were also introduced to The Model for Improvement(Langley et al, 1996). This is a simple, powerful tool for accelerating improvement and is the method advocated by Patient Safety First.
Using the Breakthrough Series collaborative approach, the trust set out to answer three questions for acutely unwell adult patients. These were:
- What is the aim? To reduce cardiac arrests by 50% in one year;
- How will you know a change is an improvement? The trust will undertake measurement to ensure that change is an improvement (see below);
- What can be changed? To find out how the trust could change, participating wards were asked: “What can be done in your area to improve care for this group of patients?”
When wards identified an idea for system change they were then encouraged to test this idea on a small scale using multiple PDSA cycles. This technique allows an idea to be tested for efficacy before it is implemented more widely.
Further learning sessions took place, interspersed with action periods. During these periods teams tested the changes and had the opportunity to communicate with project directors, an improvement adviser and each other. Teams were able to meet once a week for a half hour discussion to share their learning and develop new tests. This helped to maintain the pace of change, with teams undertaking several small tests every week.
In the second and third learning sessions, the trust followed an “all teach, all learn” philosophy, where each team reported on their methods and results and discussed the lessons learnt.Teams discussed each others’ developments, suggested modifications and then decided whether the test had been successful. Tests were then adopted, adapted or abandoned.
To determine whether a change can be classified as an improvement, regular monthly measures were undertaken:
- Outcome measures – the measure of the aim’s success: cardiac arrest rate per 1,000 admissions (both by ward and for the organisation);
- Process measures – the processes involved in achieving the aim: these measures included completing the early warning score (a sample of charts were submitted);
- Balancing measures – looking at other factors that may be influenced unintentionally. For example, looking at percentage of ICU admission coming from individual wards.
Factors that promote staff engagement
Ward teams develop all changes and the expert group or senior sponsors have not mandated changes:this is vital to the success of the collaborative. Ward teams made changes they felt would be useful in their individual areas. Teams from other areas then tested successful changes and adapted them if necessary. The process prevented the imposition of a “one size fits all” solution to a problem with multiple factors involved.
Each ward receives monthly cardiac arrest data to direct and motivate improvement efforts: data has proven to be extremely useful in driving improvement. Before this collaborative, the trust did not formally collect data on the overall arrest rate and individual wards were not aware of their contribution. Each ward now receives monthly updates and takes pride in the sustained reductions achieved. There is tangible evidence that the work staff undertake is making a difference to patient care and this is crucial to maintaining enthusiasm on the frontline.
Each ward publicly displays “days between” cardiac arrest certificates and takes pride in these achievements: this is a way of using data to celebrate success and boost staff morale. Wards that previously had at least one cardiac arrest a month are now celebrating over 100 days between arrests. Ward staff also report that patients like to see staff taking pride in achieving this as a measure and feel reassured there is constant striving to improve care.
Ward teams present their work to each other and to senior leadership at learning sessions, where their hard work is formally recognised: senior leadership is a key factor for success. At the first learning session the executive sponsor “liberates” staff to make changes. In a system with numerous committees and forms to complete, this is essential to ensure teams have the confidence to move forward. Presenting changes to ward teams and senior leadership provides an opportunity for staff to see the impact of the improvements they have made. This is a powerful justification of the opportunity they were given as part of the collaborative.
Regular newsletters celebrate the project achievements across the organisation: internal support from other collaborative teams is important, however a wider appreciation from the organisation is essential to sustain momentum. As part of this sustainability, a further 11 wards were invited to participate in phase two of the project, which started in January 2009. The project aims and achievements were known throughout the trust and other wards wanted to be part of it and make their contribution.
Teams have been encouraged to present their tests of change at conferences and submit articles for publication: there has been a great deal of pride in realising that the changes frontline teams have developed are of wider interest and can be presented to an interested audience. Teams are encouraged to attend conferences to present their own work and to take credit for their success.
This approach to reducing cardiac arrests has been presented to other trusts as part of Patient Safety First: the campaign is important nationwide and teams are proud that other hospitals want to learn from their approach to improvement.
Denying the status quo
Each learning session starts with a patient story, to focus attention on the impact of deterioration on real patients: this is possibly the most important part of the learning session. Staff no longer view cardiac arrests as unavoidable events but as tragedies that befall real people. This has enabled a patient focused approach to be maintained at all times and to keep the collaborative on track.
Cardiac arrests are now viewed as “never events” with each arrest reviewed at clinical governance for learning: as a result of the success of this collaborative, cardiac arrests have now become rare occurrences at the trust and are classified as “never events”. When a cardiac arrest does occur it generates an adverse incident report. The AUA faculty reviews the event and it is subjected to a formal root cause analysis, which is undertaken by the multidisciplinary ward team. Adverse incident reports on cardiac arrests are presented at the divisional governance meetings to ensure learning is shared across the organisation.
A number of quality improvement programmes are being developed at Salford Royal, for example Productive Ward, which began six months after the collaborative in AUA. All this work has the potential to improve the quality of patient care. However, the baseline data collected by the quality improvement directorate before Productive Ward did show a significant fall in cardiac arrest calls over the duration of the AUA quality improvement programme, which was already underway. This change in cardiac arrest calls had not previously been seen before the AUA Breakthrough collaborative began, suggesting this had made a clear impact.
One other potential limitation is that there may have been crossover between the collaborative and non collaborative sites. As wards noticed improvements made by their colleagues, changes were taken up on non collaborative wards before they officially became part of the programme. This results in additional improvement in some non collaborative wards and dilutes evidence showing the power of a collaborative approach.
This programme of work did not require any additional funding other than the time that staff invested in the collaborative.
Preliminary data suggests positive outcomes for patients although evaluations are ongoing and a full research report is due to be published at a later date. The experience so far at Salford Royal would suggest that this method of empowering and engaging with staff, to develop and make changes in their areas, is both powerful and effective.
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services. London: DH.
Flamm BL et al (1998) Reducing Caesarean section rates safely: lessons from a “Breakthrough Series” collaborative. Birth; 25: 2, 117-124.
Glasgow RE et al (2002) Self-management aspects of the improving chronic illness care Breakthrough Series: implementation with diabetes and heart failure teams. Annals of Behavioural Medicine; 24: 2, 80-87.
Goldhill DR et al (1999) The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 54: 9, 853-860.
Hillman KM et al (2001) Antecedents to hospital deaths. Internal Medicine Journal; 31: 6, 348-8.
Institute for Healthcare Improvement (2003) The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. Cambridge, Massachusetts: IHI.
Langley GL et al (1996) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey Bass.