Objectives. Beyond Traditional Bundles: THE ART OF GETTING THINGS DONE

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1 Beyond Traditional Bundles: THE ART OF GETTING THINGS DONE Denise Murphy, RN, BSN, MPH, CIC Vice President, Quality and Pt. Safety Main Line Health System Philadelphia, PA Objectives Review the evidence and best practices for reducing healthcare associated infections (HAI) Discuss strategies for initiating change in an organized manner Outline roles, responsibilities and power of data in driving change Discuss three critical success factors in engaging others: influence, persuasion and concise communication Understand unique issues in engaging physicians in quality and patient safety efforts Review tools/methods effective in improving outcomes

2 The State of the Science in Improving Clinical Outcomes Avoiding Preventable Harm BUNDLES of Prevention Measures, Best Practices or Evidence-based Medicine Standards Infection Prevention CLABSI CAUTI VAP SSI Pressure Ulcers Patient Falls Culture of Safety MLHS Central Line-Associated Bloodstream Infection (CLABSI) Prevention Appropriate criteria-based utilization of central lines Hand hygiene Central line kits/carts Use of checklist for every insertion Line site choice (femoral site<internal jugular<subclavian<picc) Chlorhexidine gluconate to cleanse skin before insertion Full barrier precautions for insertion Stabilization of cannula Transparent dressing and routine site check Daily assessment of need for central line Scrub the hub Drill down on use of PICC lines and using central line for blood draw Timely feedback about outcomes (rates) and process (bundles) Real time review of each infection by BSI prevention PI teams

3 MLHS Catheter-associated associated Urinary Tract Infection (UTI) Prevention Appropriate criteria-based Foley catheter insertion Hand Hygiene Nurse-driven urinary catheter removal protocol Evaluation of silver-coated catheters Daily assessment of need for catheter Point prevalence survey on documentation Education for residents and nurses on insertion technique Review of each case by UTI prevention PI team CMS Surgical Care Improvement Project requirement to remove on first or second post-op day (or document why catheter is necessary) MLHS Ventilator-associated associated Pneumonia (VAP) Prevention Hand Hygiene Daily weaning assessments, sedation vacation in standing orders Elevate head of bed (HOB) at least 30 degrees High-low evacuation endotracheal tubes for subglottic suction Oral care every 2 hours by nursing or respiratory therapy Chlorhexidine gluconate oral rinse twice/day Mandatory documentation fields for HOB and mouth care in electronic documentation Feedback to caregivers when opportunity for mouth care is missed No routine vent circuit changes Emphasis on minimal opening of vent circuits Ambulate as early as possible or investigate mobility options Review of each infection by VAP prevention PI teams MLSH Surgical Site Infection (SSI) Prevention NO RAZORS; if hair must be removed, use clippers CHG wipe (skin antiseptic) for hip/knee surgery patients Use of CHG/alcohol skin prep Pre-operative prophylactic antibiotic choice and timing Post-operative discontinuation of prophylactic antibiotic Meeting with surgical specialty group when cluster identified Normothermia (normal body temperature) Infection prevention rounds in surgical suites Review of each infection by SSI prevention PI teams

4 MLHS Falls Prevention Critical Assessment and re-assessment, include input from Pharmacy & Physical Therapy Falls risk communicated at handoffs Evaluate unit equipment: alarms, low bed use, mats High Falls Units Redesign unit care model (rounding, staffing, shift time) based on time of falls Re-institute Fall Huddle and post fall debriefing Consider Bedside reporting, collaborate on risk, assess environment Hospital/Unit Falls Champions Post # days since (date of) last fall MLHS Pressure Ulcer Prevention Pressure ulcer risk assessment for every patient on admission Reassess risk for all patients daily Inspect skin of at-risk patients daily Manage moisture Optimize nutrition/hydration Minimize pressure Experienced wound nurses to lead/educate Actively engage medical staff - documentation of ulcer present on admission is critical What Are Top Performers Doing? Evidence-based measures (bundles) Zero tolerance for PSAE (preventable serious adverse events) Just Culture of Safety Medical staff fully engaged Front line empowered Clear expectations set for safe behaviors Reciprocal accountability Commitment to teamwork Formal, standard communication system Transparency and rapid feedback system Systems approach to problem solving Reliability engineered into processes (cues, forcing functions, etc.) Standardized processes (e.g., order sets) Technology enabled best practice Real time analysis of events Certification for risky procedures Strong measurement/analysis Organized spread of learning Effective PI framework and tools Dedicated, skilled facilitators PI oversight function Simulation

5 We know WHAT to do, it s s HOW to do it that s s so challenging! Driving Change where to begin Identify the need for change using data State the problem concisely with a relevant description of problem / desired outcome Get the right people involved Identify a sponsor, multidisciplinary champions, expert facilitator, and leaders (possibly one from each discipline) Get management s buy-in for project then commitment for their staff to participate Back your request for change with data: pertinent studies, statistical rigor, their own patients information Femoral line utilization point prevalence ANOVA for SCIP (antibiotic timing) No Razor Campaign Where to begin Find out what physician and team member priorities are then align your requests with their needs Best outcomes for their patients SPEED, efficiency Research support Financial re-numeration Explain process (what, how, why?) Explain roles and responsibilities clearly

6 Roles: SPONSORS Sanction change and hold others accountable Align key leaders Create environment that enables change Devote time, energy and resources to change Publicly demonstrate resolve that change will happen Track and analyze progress, provide feedback to others Ensure a communication strategy exists Make rounds and acknowledge those implementing the change Link change to benefits for individuals and the organization Talk with those who express concerns or resistance Roles: CHAMPIONS Demonstrate public and private support for an idea Act as role model by trying new ideas first Try to influence colleagues who don t support change Contribute expertise or direct experience with a change Become knowledgeable and be able to answer? about change Roles: *FACILITATORS/LEADERS^ Support sponsor (s) to be successful^ Supports the leader (usually content expert/process owner)* Help to plan, execute implementation of change* Teach new knowledge and skills*^ Provide technical support and expertise* Select tools and methods to design and implement change Through relationship skills, influence those who will be implementing the change^ Listen to concerns of those implementing change and obtain/support removal of barriers^

7 Back request for change with pertinent data, relevant information 40 83ICU (MICU) Femoral Line Utilization % and Primary Bloodstream Infection Rates ( ) 20 BSI Rate (per 1000 line days) Femoral Line Tracking Femoral Line Utilization Percent 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec BSI Mean Fem Line % Mean SOURCE: Barnes-Jewish Hospital, St. Louis SCIP: Pre-intervention state: colorectal service Prophylactic antibiotic received within one hour prior to surgical incision 100 BJH SIP Colorectal Procedures vs. BJH Overall SIP Procedures 90 % of compliance COLORECTAL SERVICE JULY AUG SEPT OCT NOV DEC JAN FEB Month OVERALL COLON Process Capability Analysis for Antibiotic Timing in Minutes LSL USL Six Sigma: reducing variation SOURCE: Barnes-Jewish Hospital, St. Louis SCIP: Post-intervention state SIP 1 Prophylactic antibiotic received within one hour prior to surgical incision COLORECTAL SERVICE % of compliance OVERALL COLON JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT 2004 Interventions: Month 2005 Colorectal pre-op and post-op standing orders were revised to reflect SCIP guidelines Roles were clarified Surgeons are responsible for writing pre-op antibiotic orders Anesthesia staff are responsible for administration of pre-op antibiotics An antibiotic question was added to the surgical time out A method was developed for rapid electronic feedback of individual service compliance rates to surgeons/anesthesiology Next steps: Roll out to all surgical services Develop control plans to sustain gain for colorectal services Electronic method to monitor post-op glucose in cardiac pts. Electronic method to monitor core temp in colorectal surg. pts. ColorectalSurgicalServiceAntibioticTiming August-Oct2005 Frequency Normal Minutes SOURCE: Barnes-Jewish Hospital, St. Louis

8 Summary of Hair Removal Studies with Infection Rates Associated with Different Hair Removal Methods Author, Year Published Infection Rate per Hair Removal Method Razor Clipper Depilator NONE y Seropoian & Reynolds, Alexander & Morris, 1983 Time of day P.M A.M Cruse & Ford, Ko & Krieger, Mishriki, 1990 Wound class Clean Clean-contam Contam Dirty Best Change Agents Influential clinical and administrative leaders How to find them Chiefs/division chairs Directors and managers Effective committee chairs Formal and informal staff leaders ID physicians, ICU Medical Directors, Hospitalists, leaders of the service you are trying to influence Patient Care/Dept Directors and Managers; Unit Council leaders; Experienced, influential supervisors, Clinical Nurse Specialists, Educators

9 Team Engagement Describe what is needed, underscore what everyone brings to the table Be as honest about the time commitment as possible Apply rules of influence and persuasion Fundamental Principles of Persuasion People like those who like them Reciprocity Social proof Consistency Authority Scarcity The Process of Persuasion: 4 Steps 1. Establish credibility through expertise and relationships 2. Frame goals on common ground - describe benefits of your position; if you can t find shared advantages, adjust your position: compromise 3. Vividly reinforce your position, don t use ordinary evidence; make numerical evidence more compelling with stories, examples and metaphors that have emotional impact. 4. Connect emotionally adjust your emotional tone to match the audience s ability to receive your message. Learn how people have interpreted past events and predict how they will probably interpret/react to your proposal.

10 Effective Communication Handoffs and transfers are most critical time to ensure effective communication to prevent harm Organize your thoughts in bullet points Be concise, accurate and relevant Consider SBAR communication Communication framework taken from Crew Resource Management training Situational Briefing Model S B A R ituation ackground ssessment ecommendation Used with permission from Michael Leonard, MD, Kaiser Permanente Situation S Patient s name and location The one-liner Nancy Drew room 11103A Her mental status has changed. When I went to check on her just now she was awake and talking to me but not making any sense.

11 B Background Pertinent medical history Important events to date She is an 83 yo with a hx of PVD and is POD #1 from a thromboembolectomy of a left leg artery. I was in her room about 45 minutes ago to bring her meds to her metoprolol and Zocor and she seemed perfectly lucid then. She has no hx of dementia. I haven t heard anything about mental status changes from her previous nurse. Assessment A What is going on now Vitals Pertinent labs I took her vitals and they look fine: Temp 37.1, P 72, R 12, BP 114/68, O2 sat 97% RA, Accu check is 102 I m worried she might have had a stroke Recommendations R What you think needs to be done I d like you to come see her right away. Is there anything else I should do right now?

12 Physician Engagement: THE COMPACT Compact refers to the give and get that physicians expect as members of their organization The compact is often the unspoken psychological contract between an organization and its members Three aspects of a compact that physicians expect: autonomy, protection and entitlement Source: Argyis, C. Harvard Business School. Personality and Organization, New York, NY: Harper and Row, 1957 know when negotiating Autonomy: they want to take care of their patients without interference and retain control over daily operations; often leads to resistance to standardization Protection: they want administration to be buffer between them and market forces and change. Leads to resistance to participation. Entitlement: I give you my patients; I want to get what I need to take care of them. I bring patients so it s your job to make everything else work. Leads to resistance to participate and standardize. Tools to Facilitate Change Clinicians, especially physicians, are into outcome, not process They must understand the tools being used Make it fun, but relevant Lean and Six Sigma are stimulating, hold interest

13 Performance Improvement Six Sigma = 3/million defects Six Sigma and Lean Both methodologies attack complex problems with a team that follows a logical thought process, utilizes data and makes fact-based decisions to solve a problem Both are customer focused Hybrid between a Six Sigma project and Lean combines aspects of both methodologies Individually, both methodologies are effective for problem solving; together, they become much more powerful Six Sigma DMAIC Framework Define high-level project goals and the current process. Measure key aspects of the current process and collect relevant data. Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered. Improve or optimize the process based upon data analysis using techniques such as design of experiments, analysis of variance (ANOVA). Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process to sustain the gains.

14 Decision to Insert Prep for Procedure Insertion of Central Line Care & Maint. Line Removal Start Order for CL : ultrasnd supplies Monitor patient and site dec for line removal Decision to Insert Prep for Procedure Insertion of Central LIne Care & Maint Line Removal IV support/ line? : process order MD prep Initial Dressing Applied (RN) Transport to IVR No RN to page MD Patient Education Patient Prep and Drape Documentation (RN) LOC Dry Time Chest X-Ray Assemble equipment Patient sign paper consent MD prep: anesthesia : radiolo gy New line placement MD assessment of periphrials Start Daily access Call MD Communicate MD get ready (review labs, get consent, det. location) Time out & Local Anes. monitor pt & site Clinical decision for line removal Room Set-up Insert CVC & secure line Discuss continued need Assess need for alternative access & insert Prepare pt & meds MD clean site & apply dressing change dressing Aquire supplies for removal Drape & prep patients(gown, skin prep) Chest X-ray and read Document Remove Line : MD arrival Local onset Wati: results MD place orders Interprete & order Use/No Use Infusion managment Apply dressing & compress & pt educ about site Evaluate patient condition Insertion TIME OUT & local for orders RN Discontinue Line Move pt Document Choose MD : Labs Secure dressing Use of Line (lab draw, flush, med infusion) Document, assess, placement, removal Communicate with person to insert line Transport patient CXRay Clean up room : staff arrival Walk and Search Verification Daily observation (dressing, cath) Gather supplies CXRay Read Dressing changes Find and communicate with staff Environmental prep Use or Not Use? Infustion management Patient prep Documentation Checklist Documentation MD/RN Basic Elements of Lean Flow: The continuous creation or delivery of value without interruption 5S: A complete system for workplace organization, including the process for sustainment Visual Management: Using visual signals for more effective communication Pull: Working or producing to downstream demand only Standard Work: Identifying the best practice and standardizing to it, stabilizing the process (predictability) 1 by 1: Reducing batch size to one whenever possible to support flow Zero Defects: Not sending product or service to downstream customer (internal or external) without meeting all requirements VSA*: Improve the Experience of a Patient with a Central Venous Catheter High Level Current State Decision to Insert Start IV support/ line? No RN to page MD MD assessment of periphrials Choose MD Communicate with person to insert line Walk and Search Find and communicate with staff Prep for Procedure Order for CL : process order Patient Education Assess LOC Patient sign : MD paper consent arrival Evaluate patient condition : Labs Transport patient : staff arrival Gather supplies Environmental prep Patient prep Insertion of Central Line : ultrasnd supplies MD prep Patient Prep and Drape Dry Time for MD prep: local Local anesthesia onset Insertion TIME OUT Secure catheter and CXRay apply dressing CXR Verification Use or Not Use? Chart Documentation documentation Checklist MD/RN Care & Maint. Monitor patient and site Initial Dressing Documentation Chest X-Ray Applied (RN) (RN) : radiolo gy : results for orders Use of Line (lab draw, flush, med infusion) Daily observation (dressing, cath) Dressing changes Infusion management Line Removal Decision for central line removal Discontinue existing line for MD or Transport to IR Assemble equipment New line placement if necessary (e.g. PICC) Document assessment, placement, & removal *Value Stream Analysis Current State to Future State Current State Future State 6 fewer steps 11 fewer steps 7 fewer steps 47% Decrease in Steps!

15 RIE #3 Central Line Supplies/Equipment at Point of Care Needleless caps 3 Sterile Saline Flush 3 Filtered Needle or straw 1 Caps 2 Masks with Eye Protection 2 Sterile Gowns xl 2 Chloraprep 3 ml tinted 1 Lidocaine Label 1 Full Body Drape 1 Needle Driver 1 Sterile Towels 4 Sterile Pen 1 Op Site Dressing 1 Suture or Statlock 1 Safety Scalpel 1 Central Line Insertion Checklist 1 Benzoin 1 SOURCE: Barnes-Jewish Hospital, St. Louis Standard Cart SOURCE: Barnes-Jewish Hospital, St. Louis Procedure Cart Re-Stocking Standard Work SOURCE: Barnes-Jewish Hospital, St. Louis

16 Metrics for CVC Rapid Improvement Event # 3 Metric Baseline Post Experiment Standardized CL Kits POC CL Supplies Procedure Cart ICU 0% Nursing Division 0% ICU = 100% Nursing Division = 4.5% Target 100% 100% 100% 100% # Types of CL kits >3 1 1 Motion (ft) to Gather Supplies Time to Gather Supplies Nursing Division = 3810 ft (.72 mi) Nursing Division = min (~.5 FTE/year) 283 Ft Decrease by 25% 2.2 min (8 min to restock cart) 5 min # Items to Gather 17 2 Decrease by 50% SOURCE: Barnes-Jewish Hospital, St. Louis Estimated annual Item Current annual cost future cost CL catheter $14,938 $14,938* CL Kit $15, (single supplies $25.54 ea) $21,560 CL Carts N/A $39, Ultrasound N/A $92,000 Cost of CA- BSI Results $2,088,000 (58 BSIs over 12 mos) $1,368,000 (38 BSIs, 1/3 reduction) TOTAL $2,118,670 $1,536,019 Savings of $582,651 SOURCE: Barnes-Jewish Hospital, St. Louis Rewards for Team Members Arrange for leadership briefings, led by team members Acknowledgement Visible Recognition Make improvement work fun If possible, plan for publications/presentations Contract for services (Medical Staff) Education paid for, or texts, online modules, journal subscriptions EFFICIENCY Improved outcomes for patients

17 Culture trumps strategy! Culture Intersects All Other Strategies Codes Outside the ICU Surgical Site Infections Central Line Infections Hand Hygiene Culture Falls Pressure Ulcers Patient Satisfaction and on, and on 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. MLHS Culture of Safety Goals 1. Leaders make safety a visible and vocal priority 2. We have zero tolerance for reckless behavior 3. Management sets clear expectations around safe(ty) behaviors 4. Staff understand their accountability 5. Managers hold staff accountable 100% of the time 6. Staff speak up about risk without fear 7. Peers observe, coach and hold one another accountable for safety 8. Staff are equipped with critical thinking skills and apply them when safety is at risk 9. Our patients and our workforce are surrounded by safe systems and processes enabling them to prevent harm 10. Staff proactively engage patients and families in their healthcare

18 Process Design Behavioral Accountability VAP Prevention 1. Elevation of the head of the bed to between 30 and 45 degrees 2. Daily sedation vacation and assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) Clinical Bundle People Bundle SS OO UU RR CC E E :: HH ee aa ll tt hh cc aa rr ee PP ee rr ff oo rr mm aa nn cc ee II mm pp rr oo vv ee mm ee nn t t,, LL LL C C.. AA LL LL RR II GG HH TT SS RR EE SS EE RR VV EE D D.. The Biggest Challenge: EXECUTION The most creative visionary strategic planning is useless if it isn t translated into action. Think simplicity, clarity and focus and review your progress relentlessly. Melissa Raffoni Harvard Management Update February 2003 Three Keys to Effective Execution 1. Maintain your focus Realistic: align goals and resources; map actions out on time chart and make sure all is doable Simplicity: prioritize the vital few, communicate simply and often Clarity: everyone is clear about their role in driving goals; use stories/examples to clarify what needs to be done (or not!) 2. Develop tracking systems that facilitate problem solving Metrics must be visible to everyone responsible for goals Keep asking why? to get to root cause of barriers to success Track process (Behavior) and outcomes Assign key success factors to only one accountable owner 3. Set up formal reviews Review process/outcome metrics and discuss barriers routinely Personnel and resources should be at the top of the agenda Source: Melissa Raffoni, Harvard Management Update 2/03

19 From Strategy to Performance 1. Keep it simple. 2. Challenge assumptions. 3. Speak the same language 4. Discuss resource deployment early. 5. Identify priorities. 6. Continuously monitor performance. 7. Develop execution ability. Source: Turning Great Strategy Into Great Performance Harvard Business Review: The High Performance Organization July-August 2005 Execution: Leader s s Seven Essential Behaviors 1. Know your people and your business: the day-to-day realities. 2. Insist on realism: make truth part of every dialogue. 3. Set clear goals and priorities: 4-5 are plenty; they should be on your calendar and in your check book! 4. Follow through: lack of it is major cause of failure to execute. 5. Reward the doers. 6. Expand people s capabilities through coaching. 7. Know yourself: be authentic, self-aware and humble. Practice self-mastery by keeping ego in check, taking responsibility, adapting to change, embracing new ideas and adhering to your standards of honesty and integrity under all conditions. Source: Adapted from EXECUTION: the discipline of getting things done. Larry Bossidy and Ram Charan; Crown Business, New York, 2002 Summary To engage leadership: make clear the need for change, the data/supporting evidence Communicate clearly about what you need and why; set role expectations; be honest about time commitments Use principles of influence and persuasion Know what makes physicians tick understand the compact they make with your organization Find strong champions and change agents

20 Summary Use proven performance improvement tools and experts that can facilitate change Recognize and reward those who make change happen and make it stick! Educate senior leaders about clinical bundles and people bundles. Understand critical success factors related to EXECUTION these also ensure sustained improvement over time. THANK YOU!!

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