Transcript Michigan’s Keystone ICU Project:

An exemplar
Chris Goeschel RN MPS MPS
Johns Hopkins Quality and Safety Research Group
How will we know ?
Funded by AHRQ
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Total Population: 10,120,860 (8).
 2000 percent population 18 and over: 73.9;
 65 and over: 12.3; median age: 35.5.
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Major Industries - car manufacturing, farming (corn,
soybeans, wheat), timber, fishing
10,083 inland lakes and 3,288 mi of Great Lakes shoreline
(most registered boaters in the US)
138 acute care hospitals (not all with ICU’s)
 3 beds to 1500 beds
The aim was to use evidence-based tools to
improve quality and patient safety in
Michigan intensive care units.
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Reduce harm: BSI and VAP
Ensure 90% of patients receive EB
interventions for preventing VAP,
Learn from one defect per month
Improve culture of safety 20% (SAQ)
Improve quality improvement
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Written Commitment to Participate & Provide Resources to
do the work
Senior Leader as part of ICU Team
Bi-weekly or Monthly Calls: Collaborative Leaders, Teams,
Hopkins
 Content, Coaching and Team Sharing
Monthly Standardized Web based Data Collection
Transparency at local level
“Harm is Untenable”
1.
2.
3.
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6.
Evaluate culture of safety
Educate staff on science of safety
http://www.jhsph.edu/ctlt/training/patient_safety.html
Identify defects
Assign executive to partner with the unit
Learn from one defect per month and implement teamwork tools;
daily goals, a.m. briefing, culture checkup
Evaluate culture
www.safetyresearch.jhu.edu
Pronovost J, Patient Safety, 2005
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Remove Unnecessary Lines
Wash Hands Prior to Procedure
Use Maximal Barrier Precautions
Clean Skin with Chlorhexidine
Avoid Femoral Lines
MMWR. 2002;51:RR-10
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:
Knowledge, skills & competence. Care providers lacked the knowledge
needed to match a transvenous pacing wire with appropriate sized
sheath.
OPPORTUNITIES for IMPROVEMENT:
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.
70
60
50
March
April
May
June
July
40
30
20
10
0
Lack Time
Data Burden
Lack Buy-in
70
60
50
March
April
May
June
July
40
30
20
10
0
Executives
Physicians
Nurses
One of most common leadership
mistakes is expecting technical
solutions to solve adaptive
problems….
Ron Heifetz “Leadership without Easy Answers
Creating Reliable Health care
Executive Leaders
Team Leaders
Staff
Engage
adaptive
How Do I Make the World a
Better Place?
How do I create an organization
that is safe for patients and rewarding
for staff?
How does this strategy fit our
mission?
How Do I Make the World a Better
Place?
How do I create a unit that is safe for
patients and rewarding for staff?
How do I touch their hearts?
How Do I Make the World a Better Place?
Do I believe I can change the world, starting with my
unit?
Can I help make my unit safer for patients and a better
place to work?
Educate
technical
What Do I Need to Know?
What is the business case?
How do I engage the Board and
Medical Staff?
How can I monitor progress?
What Do I Need to Know?
What is the evidence?
Do I have executive and medical staff
support?
Are there tools to help me develop a
plan?
What Do I Need to Know?
Why is this change important?
How are patient outcomes likely to improve?
How does my daily work need to change?
Where do I go for support?
Execute
adaptive
What Do I Need to Do?
Do the Board and Medical Staff
support the plan and have the skills
and vision to implement?
How do I know the team has
sufficient resources, incentives and
organizational support?
What Do I Need to Do?
Do the Staff Know the plan and do
they have the skills and commitment to
implement?
Have we tailored this to our
environment?
What Do I Need to Do?
Can I be a better team member and team leader?
How can I share what I know to make care better?
Am I learning from defects?
Evaluate
technical
How Will I Know I Made a
Difference?
Have resources been allocated to
collect and use safety data?
Is the work climate better?
Are patients safer?
How do I know?
How Will I Know I Made a
Difference?
Have I created a system for data
collection, unit level reporting, and
using data to improve?
Is the work climate better?
Are patients safer?
How do I know?
How Will I Know I Made a Difference?
What is our unit level report card?
Is the unit a better place to work?
 Is teamwork better?
Are patients safer?
How do I know?
© Quality and Safety Research Group, Johns Hopkins
University
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Engage (local work)
 Opportunity calculator, stories of harm
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Educate (central work)
 Original papers, fact sheet, slides
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Execute
(local work)
 Standardize, create independent checks, learn
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Evaluate (central work)
 Web based data reports
Safety Scorecard
State Hospital ICU
How often did we harm? ( rate based
measure: infections)
How often do we do what we should?
rate based (JCAHO, CMS, vent bundle)
How do we know we learned from
mistakes? (sentinel events, NQF Safe
practices)
Are We Improving Culture?
80% Reduction in BSI in One Year
from 103 ICU
Time period
Median CRBSI Incidence
rate
rate ratio
Baseline
2.7
1
Peri
intervention
1.6
0.76
0-3 months
0
0.62
10-12 months
0
0.42
16-18 months
0
0.34
Data from 100 ICUs Analysis: multilevel GLLAMM
% of respondents within an ICU reporting good safety climate
100
Safety Climate Across Michigan ICUs
90
80
70
60
50
40
30
20
10
0
2006
2004
Teamwork Climate Across Michigan ICUs
% of respondents within an ICU reporting good teamwork climate
100
90
80
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
70
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50
40
30
20
10
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No BSI = 6 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
50
<.001
# RNs inwho
1
Year left
RN Turnover
r=-.650,
the ICU
40
30
20
10
1
0
20
40
60
% Reporting Good Teamwork Climate
80
In Hindsight, the Successful KICU Project
Looks Easy
Participants Say These Results Never Would
Have Been Achieved
Without the Johns Hopkins Keystone ICU
Collaborative
Why is That??
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Use evidence-based tools
Pilot – Input from frontline staff is key
Make sure tools are practical
Treat the project like a clinical trial
Involve frontline staff in the initiative–
ownership AND provide feedback
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Project goals must drive measurement
 Care most about patient level goals; others are predictor variables
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Design data collection and management plan at
outset
 Reduce bias in data collection
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Give up on quantity not quality of data
 Central Development/ local implementation
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Strive for scientifically sound, feasible, useable
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Adaptive lessons
 Commit that harm is untenable; make harm
visible
▪ What are CLABSI rates? Do all clinical caregivers know
them?
 Ohana
▪ How have you shared what you are learning with
others? Administrators, clinicians, teams, facilities?
 Local modification of execution
▪ Have you adapted the implementation in light of your
organizational culture?
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Leadership Engagement
 Regional Collaborative Leaders
 Hospital Executive/Administration
 Clinicians
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Ownership
 The teams and staff must own the project
 Collaborative “Virtual Learning Community”
▪OHANA