Transcript Project Report - Lean Sigma - Massachusetts Coalition for the

On the CUSP: STOP BSI
MA ICU Safe Care Initiative:
Comprehensive Unit Based Safety Program (CUSP)
Objectives
• Review the purpose of the ICU Comprehensive UnitBased Safety Program/CLABSI Initiative. Understand
how your ICU and your hospital will benefit from
participation.
• Build the skills of physicians, nurses, and other care
team to improve teamwork and build a safety
culture.
• Engage in discussion with national experts on best
practices in reducing infections, preventing central
line infections
© 2009
Goals
• Work to eliminate CLABSI
• Learn from two defects per quarter
– One local, one central
• Improve culture by 50%
© 2009
On the CUSP: Stop BSI
Intervention
Comprehensive Unitbased Safety Program
BSI-Reduction Bundle
-5 steps
-Best-evidence supplies,
organization of supplies
-Improve/reinforce good crossdisciplinary communication and
teamwork
-5 Evidence-based practices
-Checklist to ensure consistent
application of evidence
-Enhance coordination of care
-Investigate all infections
-Address overall patient safety
-Transparency about rates
-Work towards healthy unit culture
-Line maintenance
Learning Objectives
At the end of this session you will be able to:
• Explain the philosophy and approach of CUSP
• Describe the steps in CUSP
• Apply available teamwork tools on
www.onthecuspstophai.org
© 2009
Learning Objectives
You will also be able to:
• Describe the model for translating evidence into
practice
• Explain how to implement evidence-based
behaviors to prevent CLABSI
• Define strategies to engage, educate, execute and
evaluate
© 2009
The Vision of CUSP
The Comprehensive Unit-based Safety Program is a
cultural program designed to:
– educate and improve awareness about patient safety and
quality of care
– empower staff to take charge and improve safety in their
work place
– partner units with a hospital executive to improve
organizational culture and provide resources for unit
improvement efforts
– provide tools to investigate and learn from defects
– help improve communication and teamwork
© 2009
Pre CUSP Work
• Create a CUSP/CLABSI team
– Nurse, physician administrator, others
– Assign a team leader
• Measure culture in the unit
• Work with hospital quality leader or hospital
management to have a senior executive assigned
to CUSP/CLABSI team
© 2009
CUSP: 5 Steps
1.
Educate staff on Science of Safety
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
Implement teamwork tools
Pronovost J, Patient Safety, 2005
© 2009
Step 1: Science of Safety
• Understand system determines performance
• Use strategies to improve system performance
– Standardize
– Create independent checks for key process
– Learn from mistakes
• Apply strategies to both technical work and team work
• Recognize teams make wise decisions with diverse and
independent input
• http://www.safercare.net/OTCSBSI/Staff_Training/Entries/2009
/9/6_1._The_Science_of_Improving_Patient_Safety.html
© 2009
Local Examples
• How Science of safety training was rolled out
© 2009
Step 2: Identify Defects
• Review error reports, liability claims, sentinel events
or M and M conferences
• Ask staff how the next patient might be harmed
• List and prioritize all defects
© 2009
Step 2: Identify Defects
Complete the Staff Safety Assessment (Appendix C)
© 2009
Staff Safety Assessment Results
N=24*
*2 answered unit is safe
© 2009
Local Examples
• How Staff Safety Assessment was done, what results
were; how categorized and selected a defect to
work on
© 2009
Step 3: Executive Partnership
• Executive should become a member of unit team
• Executive should meet monthly with unit team
• Executive should review defects, ensure unit team has
resources to reduce risks, and hold team accountable
for improving risks and central line associated blood
stream infections
© 2009
Local Examples
• How an executive was identified, invited or
assigned, type of executive; how often they visit
unit, how they have been involved in the project
and in prioritizing and resolving defects
© 2009
Step 4: Learning from Mistakes
• Select a specific defect
– What happened?
– Why did it happen (system lenses) ?
– What could you do to reduce risk ?
– How do you know risk was reduced ?
• Creates early wins for the project
Pronovost 2005 JCJQI
© 2009
What Happened?
• Reconstruct the timeline and explain what
happened
• Put yourself in the place of those involved, in the
middle of the event as it was unfolding
• Try to understand what they were thinking and
the reasoning behind their actions/decisions
• Try to view the world as they did when the event
occurred
Source: Reason, 1990;
19
© 2009
Why did it Happen?
• Develop lenses to see the system (latent)
factors that led to the event
• Often result from production pressures
• Damaging consequences may not be evident
until a “triggering event” occurs
Source: Reason, 1990;
20
© 2009
What will you do to reduce risk ?
• Prioritize most important contributing factors and
most beneficial interventions
• Safe design principles
– Standardize what we do
− Eliminate defect
– Create independent check
– Make it visible
• Safe design applies to technical and team work
21
© 2009
What will you do to reduce risk?
• Develop list of interventions
• For each Intervention rate
– How well the intervention solves or reduces the problem
– The team belief that the intervention will be used as
intended
• Select top interventions (2 to 5) and develop
intervention plan
– Assign person, task follow up date
22
© 2009
Rank Order of
Error Reduction Strategies
Forcing functions and constraints
Automation and computerization
Standardization and protocols
Checklists and double check systems
Rules and policies
Education / Information
Be more careful, be vigilant
23
© 2009
How do you know risks were reduced?
• Did you create a policy or procedure (weak)?
• Do staff know about policy or procedure?
• Are staff using the procedure as intended?
– Behavior observations, audits
• Do staff believe risks were reduced?
24
© 2009
Summarize and Share Findings
• Summarize findings
– 1 page summary of 4 questions
– Learning from defect figure
• Share within your organizations
• Share de-identified with others in collaborative
(pending institutional approval)
25
© 2009
Safety Tips:
Label devices that work together to complete a procedure
Rule: stock together devices need to complete a task
CASE IN POINT: An African American male ≥ 65 years of age was admitted to a
cardiac surgical ICU in the early morning hours. The patient was status-post cardiac
surgery and on dialysis at the time of the incident. Within 2 hours of admission to the
ICU it was clear that the patient needed a transvenous pacing wire. The wire was
Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard
for PA caths, but not the right size for a transvenous pacing wire. The sheath that
matched the pacing wire was not stocked in this ICU since transvenous pacing wires
are used infrequently. The wire was threaded and placed in the ventricle and staff
soon realized that the sheath did not properly seal over the wire, thus introducing risk
of an air embolus. Since the wire was pacing the patient at 100%, there was no
possibility for removal at that time. To reduce the patient’s risk of embolus, the
bedside nurse and resident sealed the sheath using gauze and tape.
SYSTEM FAILURES:
OPPORTUNITIES for IMPROVEMENT:
Knowledge, skills & competence. Care providers lacked the
knowledge needed to match a transvenous pacing wire with
appropriate sized sheath.
Regular training and education, even if
infrequently used, of all devices and equipment.
Unit Environment: availability of device. The appropriate size
sheath for a transvenous pacing wire was not a stocked
device. Pacing wires and matching sheathes packages
separately… increases complexity.
Infrequently used equipment/devices should still be
stocked in the ICU. Devices that must work
together to complete a procedure should be
packaged together.
Medical Equipment/Device. There was apparently no label
or mechanism for warning the staff that the IJ Cordis sheath
was too big for the transvenous pacing wire.
Label wires and sheaths noting the appropriate
partner for this device.
ACTIONS TAKEN TO PREVENT HARM IN THIS CASE
The bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In
addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged
together.
Identified concern from Staff
Safety Assessment
(CUSP Step 2)
Recommended Improvements
(CUSP Step 4 & 5)
Interventions Implemented
Risk of central line associated bloodstream
infections
Make sure best practices are used for all central
line insertions.
A line cart and checklist are used for all central
line insertions.
Risk of central line associated bloodstream
infections due to poor compliance with IV tubing
changes
Make sure every central line IV tubing is changed
according to best practice.
New IV tubing labeling system used.
Risk of medication errors
Point of care pharmacist available on units
Pharmacist assigned
Poor management of pain
Create guideline or protocol for pain assessment
and management
Pain card at every bedside
Poor communication among providers
Create Short Term (Daily) Goals Sheet
Short term goals sheet used during rounds
Poor communication during ICU discharge
leading to medication errors in transfer orders
Implement medication reconciliation process at ICU
discharge
Medication reconciliation done at discharge
Improve Pain Management
•
Educate Staff
•
Put visual analog pain scale (VAS) card at
bedside
•
Have residents report pain scores
•
Define defect as pain score > 3
Erdek Pronovost
Erdek & Pronovost
© 2009
Improve Pain Assessment
100
90
80
70
60
50
40
30
20
10
0
% with VAS
week week week week week week week
1
2
3
4
5
6
7
© 2009
Improve Pain Management
100
90
80
70
60
50
40
30
20
10
0
% with VAS < 3
week 1 week 2 week 3 week 4 week 5
© 2009
Step 5: Teamwork Tools
• Call list
• Daily goals
• AM briefing
• Shadowing
• Culture check up
Pronovost JCC, JCJQI
© 2009
Local Examples
• Experience using some of the CUSP teamwork tools
© 2009
CUSP is a Continuous Effort
• CUSP is a marathon not a sprint
• Add Science of Safety education to orientation
• Ask staff every six months how the next patient is going
to be harmed and invest the time and resources to
reduce this harm
• Learn from one defect per quarter, share lessons
• Implement teamwork tools that best meet
the unit’s needs
© 2009
Safety Culture-2 CUSP ICUs
Relative %
Increase Pre to
Post Program
Questions
1. The senior leaders in my hospital listen to
me and care about my concerns.
22
2. The physicians and nurse leaders in my area
listen to me and care about my concerns.
30
3. My suggestions about safety would be acted
upon if I expressed them to management.
30
4. Management/Leadership will never
compromise safety concerns for productivity.
22
5. I am encouraged by my supervisors and
coworkers to report any unsafe conditions I
observe.
32
© 2009
Safety Culture- 2 CUSP ICUs
Relative % Increase
Before vs After
Program
Questions
6.
I know the proper channels to report my safety
concerns.
30
7.
I am satisfied with availability of clinical leadership
(MD, RN, RPh).
44
8.
Leadership is driving us to be a safety-centered
institution.
35
9. I am aware that patient safety has become a
major area for improvement in my institution.
30
10. I believe that most adverse events occur as a
result of multiple system failures, and are not
attributable to one individual’s actions.
34
© 2009
Eliminating CLABSI
Pronovost, Berenholtz, Needham BMJ 2008
Evidence-based Behaviors
to Prevent CLABSI
• Remove Unnecessary Lines
• Wash Hands Prior to Procedure
• Use Maximal Barrier Precautions
• Clean Skin with Chlorhexidine
• Avoid Femoral Lines
MMWR. 2002; 51:RR-10
© 2009
Identify Barriers
• Ask staff about knowledge
• Ask staff what is difficult about doing these behaviors
• Walk the process of staff placing a central line
• Observe staff placing central line
• Observe present maintenance procedures
© 2009
Ensure patients reliably receive
the interventions: the 4Es
• Engage: stories, show baseline data
• Educate staff on evidence
• Execute
–
–
–
–
–
Standardize: Create line cart
Create independent checks: Create BSI checklist
Empower nurses to stop takeoff
Use line maintenance protocol
Learn from mistakes: review infections
• Evaluate
– Feed back performance
– Audit line maintenance
– View infections as defects
© 2009
Partnership
• To help with 4Es, partner with
− Infection control staff
− Hospital quality and safety leaders
− Nurse educators
− Physician leaders
ICU staff must assume responsibility for reducing CLABSI
© 2009
Engage
• Share about a patient who was infected
• Share stories about when nurses ensured patients
received the evidence
• Post baseline rates of infections
• Estimate number of deaths and dollars from current
infection rates (see opportunity calculator)
• Remind staff that most CLABSI are preventable
© 2009
Educate
• Conduct in-service regarding CLABSI prevention
• Create forum to jointly educate physicians and nurses
• Add CLABSI prevention to ICU orientation
• Give staff fact sheet, articles and slides of evidence
© 2009
Local Examples
• Engagement or development of communication
plan
© 2009
Execute
• Standardize: Create line cart
• Create independent checks: Create BSI checklist
• Empower nurses to ensure physicians comply with
checklist
– Nurses can stop takeoff
• Learn from mistakes: review every infection using
learning from defect tool
• Use recommended practices for line maintenance
© 2009
Local Examples
• Checklist modification
• Cart or kit creation, stocking, accountability plan
• How to get line removal evaluated and get lines
out in timely fashion
© 2009
Evaluate
• Monitor rates of infections using the Centers for
Disease Control Definitions
• Post in the unit rates of infections per quarter
(X axis is time)
• Post number of weeks or months without an infection
• Audit line maintenance procedures
© 2009
Local examples
• Unexpected infections; investigating an infection;
re-education efforts; sustainability planning
© 2009
Adventist Quarterly CLABSIs
per 1000 line days
Intervention 1 (n=23)
Baseline (2006)
Mar 07
1st Q (Apr-Jun 07)
2nd Q (Jul-Sep 07)
3rd Q (Oct-Dec 07)
4th Q (Jan-Mar 08)
5th Q (Apr-Jun 08)
6th Q (Jul-Sep 08)
BSI rate reduction
from baseline to 6th
quarter
BSI rate
4.48
4.71
1.12
1.83
1.33
0.96
0.88
0.85
IRR % of reduction
1.00
1.05
5%
0.25
-80%
0.41
16%
0.30
-11%
0.21
-8%
0.20
-2%
0.19
-1%
BSI
rate
2.71
2.16
0.56
0.52
0.83
-81%
Unpublished data—Not for circulation
April 8, 2015
Intervention 2 (n=22)
IRR
1.00
0.79
0.21
0.19
0.31
% of
reduction
-21%
-59%
-2%
12%
-69%
49
Action Plan-New Teams
• Meet with unit team, infection control staff, quality
and safety leaders, nurse educators and physician
champions
• Understand barriers (walk the process)
• Use 4Es grid to develop strategy to engage, educate,
execute and evaluate
• Make weekly task list
© 2009
Action Plan-New Teams
• Look over the CUSP manual with team members
• Brainstorm potential hazards with team
• Assess team composition with respect to CUSP
elements
© 2009
Action Plan—Old Teams
• Revisit the CUSP program--Try something you
haven’t tried yet
• Continue to learn from a defect at least once a
quarter—go for two!
• Consider applying your knowledge to new issues:
EXAMPLES:
VAP prevention
Sepsis identification and management
Intra-abdominal hypertension identification and
management
– Delirium and Progressive mobility
–
–
–
–
© 2009
References
•
Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a
comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.
•
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.
Improving communication in the ICU using daily goals. J Crit Care. 2003;
18(2):71-75.
•
Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A
model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.
•
Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning
briefing: Setting the stage for a clinically and operationally good day. Jt
Comm J Qual and Saf. 2005; 31(8):476-479.
© 2009
References
•
Pronovost PJ, Needham D, et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. New Eng J Med 2006 355(26):2725-32.
•
Gawande A. The checklist. The New Yorker 2007 Dec. Annals of Medicine
section.
•
Pronovost PJ, Berenholtz SM, et al. Improving patient safety in intensive care
units in Michigan. J Crit Care 2008 23(2):207-21.
•
Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in
patient care. Jt Comm J Qual and Saf 2006 32(2):102-8.
•
Lubomski LH, Marstellar JA, Hsu Y, Boeschel CA, Holzmueller CG, Pronovost PJ.
The team checkup tool: Evaluating QI team activities and giving feedback to
senior leaders. Jt Comm J Qual and Pat Saf 2008 34(10):619-23.
•
Goeschel CA, Pronovost PJ. Harnessing the potential of healthcare
collaboratives: Lessons from the Keystone ICU project. AHRQ Advances in
Patient Safety: New Directions and Alternative Approaches, in press.
© 2009
Objectives
• Review the purpose of the ICU Comprehensive UnitBased Safety Program/CLABSI Initiative. Understand
how your ICU and your hospital will benefit from
participation.
• Build the skills of physicians, nurses, and other care
team to improve teamwork and build a safety
culture.
• Engage in discussion with national experts on best
practices in reducing infections, preventing central
line infections
© 2009