Document 7377419

Report
Eliminating Catheter-Related Blood
Stream Infections in NICU Patients
The CCS/CCHA NICU
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
yes/no?
• Prohibit use of data for marketing or
competition
• Public release of aggregated data only
Days Without an Injury
100
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
measure.
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
environment
• All improvement is change, not all change is
improvement! We must know the difference
(P->D->S->A->P…DMAIC)!
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)
AIM
• 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
tests)
• Morbidity
• Mortality
• % Bundle compliance: all or none?
• Thermometer with: lives saved; days saved;
dollars saved
Implementation:
Microsystems
•
•
•
•
What are they?
How to assess their effectiveness?
How to improve?
How to hold the gains?
Creating a High Reliability
NICU
• Do the right thing the first time every
time!
• 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
Believe
• 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
careful)
• Healthcare workers are committed,
responsible, accountable, dedicated,
(see definition of lunacy)
What We Know v. What We
Believe
• 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
things
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
improvement
• Information and communication
Improving our
Microsystems
•
•
•
•
•
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
Microsystems
• P.123 Access to information…leads to
accountability
• 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
possible
• 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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