The Surgical Initiative concluded on March 31, 2014; the first system Hoshin to “graduate” to everyday work. Join us for an interactive discussion of the lessons learned over four years of transformational change.

1. 1
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)

2. 2
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!

3. 3
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.

4. 4
The Environment
 October 2009:
Patient First Review released;
Speech from the Throne

5. 5
 September 2009 – First Surgical Guiding Coalition and Executive
Sponsorship Group meeting held in Saskatoon
 A biannual event
 Shared ownership
Building the Team

6. 6
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

7. 7
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

8. 8
March 2010 – The Plan is Announced

9. 9
March 2010 – The Plan is Announced
Sooner, 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”

10. 10

11. 11
What was different?
 Emphasis on patient experience, quality, safety, access and
sustainability
 Looking at every stage of the patient journey
Diagnostics
Laboratory
Diagnostics
Laboratory
Referral to
Specialist Home
Rehab
Health
Promotion
Prevention
Post-Op
Recovery/
Ward
Therapies
Primary
Care
Pre-Op
/ PAC
Surgery

12. 12
“Listening doesn’t mean you
have heard, and looking
doesn’t mean you have seen.”
Involving Patients and Families

13. 13
Patient advisors

14. 14
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.

15. 15
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.

16. 16
SAFER – Results:
Surgical Volume and Checklist Compliance (Saskatchewan)
0
1,000
2,000
3,000
4,000
5,000
6,000
Apr-12
M
ay-12Jun-12Jul-12Aug-12Sep-12O
ct-12Nov-12
Dec-12Jan-13Feb-13M
ar-13Apr-13
M
ay-13Jun-13Jul-13Aug-13Sep-13O
ct-13Nov-13
Dec-13Jan-14Feb-14M
ar-14
Date
#ofSurgeries
Performed
0
10
20
30
40
50
60
70
80
90
100
ChecklistCompliance
(%)
# of surgeries performed
Checklist Compliance (%)
Data Source:
Saskatchewan
Health Quality
Council website

17. 17
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.

18. 18
“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?”

19. 19
Don't ask “What's the matter”;
ask “What matters to you?”
- IHI Conference

20. 20
SMARTER – Continuous Improvement
 Surgical Initiative the first system-wide project to benefit
from Lean methodology:
Standardized process
Visible targets and results
Replicating results

21. 21
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

22. 22
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

23. 23
SMARTER – Clinical Pathways
 Pathways promote timely and appropriate care aligned with the
patient’s preference.
 Clinical pathways implemented:
1. Hip/knee
2. Spine
3. Pelvic floor
4. Prostate
5. Bariatric Surgery
 Acute Stroke Care and Lower Extremity Wound Care pathways
are in development

24. 24
“Only those that provide the
care can improve the care.”
- Don Berwick, IHI, Orlando; Dec 7, 2011

25. 25
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.

26. 26

27. 27
Laurel Trujillo, M.D., Medical Director of Quality
Palo 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

28. 28
Lesson Learned – Shared Vision
 Committed, consistent leadership:
Drive it
No other option
Provide the tools and resources
 But, those closest to the work must fix it
Own it
Drive it
Celebrate the successes
Learn from the failures

29. 29
0100002000030000
Saskatchewan: All Specialties: Number Waiting by Time Already Waited
Month End Dates (Data Source: 30Mar2014 refresh of the SK Surgical Patient Registry)
NumberofCasesWaitingatMonthEnd
28Feb2005 28Feb2006 28Feb2007 29Feb2008 28Feb2009 28Feb2010 28Feb2011 29Feb2012 28Feb2013 28Feb2014
28,679 28,923
27,229
26,671
27,756 27,799
25,345
21,843
19,544
15,776
18,852
18,012
16,793
15,766 15,978 16,003
12,950
9,291
7,868
4,380
13,570
12,420
11,103
10,456 10,387 10,075
7,686
4,645
3,920
1,691
8,092
6,874
5,599
5,051 4,678
4,150
2,763
1,060 947
319
4,558
3,852
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

30. 30

31. 31
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.

32. 32
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

33. 33
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

34. 34
Results for the Health System
More than shortening wait times
System wide culture shift to patient-centred care and
continuous improvement
Simultaneously improved quality, safety and efficiency
Serve the patient as a whole person – consider the entire
patient journey
Visible incremental targets and measures

35. 35
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

36. Questions?
Contact Me:
Terry Blackmore
A/Executive Director, Saskatchewan Health
Terry.Blackmore@health.gov.sk.ca
www.qualitysummit.ca
#QS14