Rhetoric to Reality

Creating and Sustaining Culture Change

The Execution “Bundle”

 If evidenced based practice can be bundled and effective in the clinical arena, then why not on the management side?

 What are the principles that when consistently applied over time generate positive, sustainable change?

 When do you use a sledgehammer and when do you use a scalpel?

Can I Give You Some A.D.V.I.C.E.?



A

ssess 

D

esign 

V

alidate 

I

nnovate 

C

onfront 

E

liminate

Assess

 Facility values – what is important to the stakeholders?

 Do they value change?

 Prefer status quo?

 What are the social norms  Who are the pivotal characters  Who or what are the obstacles

Design

     Physician Orientation to set the expectations Medical Staff Leadership Education Medical Staff Documents that support the values • Mandatory protocol use • • “Opt out” vs. “Opt in” language Physician Conduct Policy with progressive discipline OPPE that reflects individual, specialty specific, performance Let the standards work for you

Validate

 Administrative Walk Arounds  Town Hall Meetings  “Lemonade Stand” 

Daily Dose



The Buzz



The Leader



Patient Safety Climate Surveys

Innovate

      Resource Center Concept Concurrent Data Collection – • Multidisciplinary CHF Rounds • • • PI Specialist stationed in PACU Canopy list of all vaccine patients Canopy list of possible POA Patients Glycemic Control Team Mobility Team Crew Resource Management Projects Psychiatric Crisis Center

Confront

 Obsolete institutional belief systems  Rumors and innuendo  Informal Leaders  Convoluted Processes  Unsafe Practice

Eliminate

   Disruptive Behavior • Physicians • • Staff Contractors Negative Influence • Informal Leaders • “Naysayers” Waste • Lean Principles • “6S”

ICU Length of Stay 6 5.5

5 4.5

4 3.5

3 2.5

2 5.72

4.55

4.27

3.67

3.69

3.49

3.45

FY02 FY03 FY04 FY05 FY06 FY07 FY08

Ventilator-Associated Pneumonia 4 3.5

3 2.5

2 1.5

1 0.5

0 3.34

2.77

2.71

Baseline FY06 FY07 FY08 1.48

Central Line BSI’s

4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 4.07

3.51

Baseline FY05 FY06 2.93

FY07 2.72

FY08 2.41

Sepsis Management Bundle

100 80 60 40 20 0 Month

Severe Sepsis/Septic Shock Mortality Protocol Patients

100

100

80 60

66.67

40

37.5

20

30 16.67

12.5

17 10 11 15 25 14 19 12 23 14

0

0 0 0 0 0

Sep-05 Jan-06 Mar-06 May-06 July'06 Sep'06 Nov'06 Jan'07 Mar'07 Jun'07 Aug'07 Month

All Severe Sepsis/Septic Shock

with at least one day in ICU, excluding palliative care

2004 2005 Average LOS 25 24 2006* 19 2007 FYTD 18 * Severe Sepsis/Septic Shock Protocol Orders and Bundles based on Surviving Sepsis Campaign guidelines implemented

Glucose Control

40 30 20 80 70 60 50 >150 mg/dL 60-150 mg/dL 0-59 mg/dL

Nurse driven policy to initiate Insulin drip protocol for

two

BG >150 mg/dL Revised policy to Institute Insulin Drip Protocol for

one

BG >150 mg/dL

10 0 O ct -0 5 N ov -0 5 D ec -0 5 Ja n 06 Fe b 06 M ar -0 6 A pr -0 6 M ay -0 6 Ju n 06 Ju l-0 6 A ug -0 6 S ep -0 6 O ct -0 6 N ov -0 6 D ec -0 6 Ja n 07 Fe b 07 M ar -0 7 A pr -0 7 M ay -0 7 Ju n 07 Ju l-0 7 A ug -0 7 Month

ICU Mortality FY02 – FY08

8 6 4 2 0 16 14 14.22

12 10 FY02 14.51

FY03 ICU Collaborative October 2003 8.7

9.33

8.9

8.36

FY04 FY05 FY06 FY07 8.2

FY08

ICU 6 Year Outcomes FY03-FY08

4.5

       40% reduction in ICU LOS 41% decrease in vent length of stay 57% reduction in VAP rate (3.34 to1.48).

41% drop in BSI rate (4.07 to 2.41).

40% decrease in sepsis mortality ICU glycemic control between 60- 150 mg/dL was averaging around mid 50% levels and improved to around 68-70%.

42% reduction in ICU mortality