Document 7377419

Eliminating Catheter-Related Blood
Stream Infections in NICU Patients
Improvement Collaborative
Paul Kurtin, MD
Chief Quality and Safety Officer
Rady Children’s Hospital & Health Center
All Improvement is Local
Think Globally
Act Locally
Ground Rules
• Sharing individual site data: Blinded
• Prohibit use of data for marketing or
• Public release of aggregated data only
Days Without an Injury
Days Without an Infection
Days Without an Infection
27 Days
Days Without an Infection
270 Days
Days Without an Infection
27 Hours
Days Without an Infection
• How is your unit doing?
• Does everyone know?
• Is there a run chart in the staff lounge?
Days Without an Infection
• We can’t manage what we don’t
The Case for Redesign
• “Every system is perfectly designed to
get the results it gets!”
• “If we keep doing what we have been
doing, we’ll keep getting what we have
always gotten”
• “The definition of lunacy is keep doing
what you’ve always done and expect a
different result!”
The Case for Redesign
• The case for redesign was made in
“Crossing the Quality Chasm”
• The gap between the healthcare we
have and what is possible is not just a
gap…it’s a chasm
• Not about working harder or being more
careful…must change the fundamentals
of the process
Design Goals
• Make it easy to do the right thing!
• Hardwire changes into routine practice via
education, training, order sets, protocols, the
• All improvement is change, not all change is
improvement! We must know the difference
Build measurement into the process
Model of Improvement
• AIM (smart) specific, measurable,
attainable, relevant, timely
• Measures
• Execute with small tests and cycles of
change (PDSA)
• To eliminate All hospital acquired
catheter related blood stream infections
in NICU patients by June 30, 2007
• Reduce by 50% or 90%
• Selected populations e.g. post-op
hearts or post bowel surgery
Potential Metrics
• Infections/1000 catheter days
• Days between infections
• Cost/infection (LOS, antibiotics, diagnostic
• Morbidity
• Mortality
• % Bundle compliance: all or none?
• Thermometer with: lives saved; days saved;
dollars saved
What are they?
How to assess their effectiveness?
How to improve?
How to hold the gains?
Creating a High Reliability
• Do the right thing the first time every
• Visual display of data as reminders
• “Stop the line!”
• Catheter cart to manage supplies and
the environment
• It’s the system …not the person (96.5 %
v. 3.5 %)
What We Know v. What We
• We know it’s the system but we believe
that the individual, through hyper
vigilance and extra effort, will not make
a mistake (work harder, be more
• Healthcare workers are committed,
responsible, accountable, dedicated,
(see definition of lunacy)
What We Know v. What We
• We trust intelligence at the bedside,
clinical experience and acumen, and
our ‘gut’
• We question/doubt/distrust the system
especially if the system slows us down
and decreases our efficiency of doing
The “Culture Code”
• Work = who we are
• Quality = it works
• Perfection = is not possible and it limits
learning by trial and error and our
pioneering spirit
Making it stick!
• We are a microsystem. How do we design it
to sustain the delivery of care which
eliminates C-R BSIs?
• Focus on the patient
• Focus on the staff
• Shared leadership
• Focus on outcomes and continuous
• Information and communication
Improving our
P.103* The Model of Improvement
P.104 Team and meeting skills
P.113* PDSA worksheet
P.115 Improvement tools
P.116* Process mapping (current process v.
ideal; gaps in planning; gaps in execution)
• P.118 Flowcharting (is this what really
happens?; any steps left out or added?; all
the time, most of the time? Not the P&P, ask
the frontline)
Improving our
• P.123 Access to information…leads to
• P.124 Change concepts:manage time by
reducing set-up time; manage variation by
standardization; design to avoid mistakes
with reminders and constraints
• P.125 Mental models: why do we think we
do/don’t have an infection problem?
Tracking Our Improvement
P.132* Run charts
P.138* Control charts
P.139* Pareto charts
P.141 Change (will, ideas, resources)
P.142 Spread of innovation
Making Change Happen
P.146 Sense of urgency
Build a team
Create vision and strategy
Communicate 8X8
Remove barriers (force field analysis)
Celebrate small wins
Next Steps
• Baseline data: where are we now? Trended if
• Site visits: when and why?
• Microsystem assessment
• Resources: continuing communication, web
site, document posting, conference calls
• Hardwiring: policies and procedures, staff
education, non-staff education e.g. radiology
Breakout Session
• Each team will:
– Develop a SMART aim
– List current metrics
– Describe potential interventions

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