Creating Sustainable Change to Prevent Harm in the ICU: Culture Matters

Creating Sustainable Change to Prevent Harm in the ICU: Culture Matters Pat Posa RN, BSN, MSA, FAAN Quality Excellence Leader St. Joseph Mercy Health Sytem Ann Arbor, MI patposa@gmail.com

Objectives Understand the importance of leadership engagement and strategies to attain it Review strategies to create a culture of safety including safe design principles, communication and focusing on learning from defects Discuss the 4 E s framework to deal with both adaptive and technical change 2

It is Time to Change!! 44,00 to 98,000 preventable death in hospitals related to medical errors annually (IOM report, 1999) 92,888 deaths directly attributable to safety indicators between 2005-2007 (HealthGrades 2009) Failure to rescue, pressure ulcers and post-op infections National Patient Safety Goals include prevention of Hospital Acquired Infections (HAIs) 1 out of 20 patient have HAI Lack of reimbursement for preventable injury 2013-lowest percent improvement/total Medicare cut $50 billion in total costs for preventable injury 3

What is Patient Safety? Patient safety was defined by the IOM as the prevention of harm to patients. Emphasis is placed on the system of care delivery that: 1. prevents errors 2. learns from the errors that do occur 3. is built on a culture of safety that involves health care professionals, organizations, and patients. Aspden P, Corrigan J, Wolcott J, et al., editors. Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004. 4

Value Sets Platform for Performance Improvement: The Vision of Health Care in the U.S. NOW 5

High Reliability Organizations High Reliability: consistent performance at high levels of safety over long periods of time Possess Collective mindfulness Means that everyone who works in these organizations, both individually and together, is acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse events, if some action is not taken to solve the problem Two other features: Eliminate deficiencies in safety processes through the use of powerful tools to improve their processes Create an organizational culture that focuses on safety, in which they remain constantly aware of the possibility of failure Chassin & Loeb, Health Affairs, April 2011; Chassin & Loeb, The Milbank Quarterly, Vol 91 No 3, 2013 pp 459-490 6

Key Components to Sustainable Change Leadership engagement Culture of safety Implementation framework that deals with both technical and adaptive change 7

Leadership Engagement

Leadership, get their interest It is the right thing to do patient stories their stories WIFM What s In it For Me (them) Cost avoidance estimation Patient Throughput Reduce turn-over Sources: 1. Duval-Arnould J, Mathews SC, Weeks K, Colantuoni E, Mukherjee A, Nundy S, Watson SR, Holzmueller CG, Lubomski LH, Goeschel CA, Pronovost PJ, Pham JC, Berenholtz SM. Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention. Jt Comm J Qual Patient Saf. 2012 Jan;38(1):41-7,1. 2. Waters HR, Korn R Jr, Colantuoni E, Berenholtz SM, Goeschel CA, Needham DM, Pham JC, Lipitz-Snyderman A, Watson SR, Posa P, Pronovost PJ. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011 Sep-Oct;26(5):333-9. 9

Leadership Engagement Leadership support Vice President or higher Support the work of the team Round on unit be purposeful Script the rounds How will the next patient in this unit be harmed? How can I help to remove barriers, so that the safety defects you are most concerned about can be better addressed? How well does teamwork occur on this unit? What doesn t work well? If there is a learning board, use this as the meeting point on the unit. Source: Sexton, JB, Engaging Leaders Webinar, 2010 10

Goals of Executive Safety Partnerships Near term goal: to build capacity for quality improvement within the unit Medium term goal: to have staff bring up solutions rather than problems Long term goal: for staff to say: We don t need to meet monthly with the executive I would feel safe being treated here as a patient I felt like I was heard today I made a difference today 11

Create a Culture of Safety Application of safe design principles Improve communication and teamwork Focusing on learning from defects

Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of single individuals. Lucien L. Leape, MD Harvard School of Public Health 13

Why Mistakes Happen? Variable input (diff pts) Inconsistency/variation Complexity Too many/complicated steps Human intervention Tight time constraints Hierarchical culture Process Factors Fatigue Inattention/distraction Unfamiliar situations/new problem Using past solutions Equipment design flaws Communications errors Mislabeling/inadequate instructions People Factors 14

A Positive Culture of Safety..recognizes the inevitability of error and proactively seeks to identify latent threats Nieva, V F Qual Saf Health Care 2003;12(suppl) 15

Safe Design Principles 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 that teams make wise decisions with diverse and independent input 16

Improve Communication and Teamwork

Communication Breakdowns Cause Treatment Delays Root Causes of Treatment Delays(1995-2004) 18

Communication Breakdowns Cause Infection-associated Events Root causes of infection-associated events (2005) 19

Effective Teamwork s Positive Impact on Health Care Reduced length of stay Lower nurse turnover Higher quality of care Greater ability to meet family member needs Better patient outcomes Better patient experience with care scores 20

% of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan ICUs 100 90 80 70 The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care 60 50 40 30 20 No BSI = 5 months or more w/ zero 10 0 No BSI 21% No BSI 44% No BSI 31%

Learn from a defect SBAR (Team STEPPS) Daily rounds/goals Pre-procedure briefing (Team STEPPS) Morning briefing (Team STEPPS) Huddles Shadowing Crucial Conversations Executive Safety Rounds/Partnership Handoff standardization (Team STEPPS) 22

SBAR provides A framework for team members to effectively communicate information to one another Communicate the following information: Situation what is the situation? Background what is the clinical background? Assessment what is the problem? Recommendation what do I recommend/request be done? Remember to introduce yourself 23

Multidisciplinary Rounds with Daily Goals What is it? A strategy to assemble the patient care team members to review important patient care and safety issues and improve collaboration on the overall plan of care for the patient Improve communication among care team and family members regarding the patient s plan of care Goals should be specific and measurable Documented where all care team members have access Checklist used during rounds prompts caregivers to focus on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU or discharge home Measure effectiveness of rounds team dynamics, communication, quality measure compliance, LOS 24

Evidence For Impact Of MDR Rounds Research studies on the effect of structured interdisciplinary rounds show: Earlier identification of clinical issues More timely referrals Improved ratings by nurses and physicians on teamwork, communication and collaboration. Research also indicates variable effects on LOS and cost, with some studies showing improvement and others having no impact. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. O'Leary KJ, et. al, Journal Of General Internal Medicine [J Gen Intern Med], ISSN: 1525-1497, 2010 Aug; Vol. 25 (8), pp. 826-32; PMID: 20386996 25

Multidisciplinary Rounds with Daily Goals Challenges and Opportunities Should be done in ICUs and all units in hospital Hard initiative to implement, especially if you have an open unit and/or no intensivists or in non-icu area Standardize the structure and process for all units Benefits seen even if physician can not attend consistently or at all Second rounds should be done in afternoon include at least physician and bedside nurse Evaluate if goals for day have been met; readjust if necessary Identify if patient can be discharged (or transferred ) the next day and if so, what needs to be accomplished 26

Multidisciplinary Rounds with Daily Goals Challenges and Opportunities (continued) Focused first on defining daily goals and recording those either on the white board in the room or on a sheet of paper Then standardize rounds who should attend and what is discussed Implemented nursing objective card to clearly define role of nurse in multidisciplinary rounds 27

Interdisciplinary Rounds: Nursing Objective Card Pain, Agitation and Delirium Mobility VAE SEPSIS CAUTI/CLABSI

Why Checklists? Levels of cognitive function are often compromised with increasing levels of stress and fatigue in certain fields of work. Aviation, aeronautics, and product manufacturing have come to rely heavily on checklists to aid in reducing human error. The checklist is an important tool in error management across all these fields, contributing significantly to reductions in the risk of costly mistakes and improving overall outcomes. Such benefits also translate to improving the delivery of patient care. Despite demonstrated benefits of checklists in medicine and critical care, the integration of checklists into practice has not been as rapid and widespread as with other fields. J Crit Care 2003;21:233 229

Huddles Enable teams to have frequent but short briefings so they can stay informed, review work, make plans, and move ahead rapidly. Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings. They keep momentum going, as teams are able to meet more frequently. Use this strategy to begin to recover immediately from defects---ie: falls, sepsis. Use daily to focus on unit outcomes 30

Components Metric 1: Quality/Safety Metric 2: Patient Satisfaction Metric 3: Operations Daily Critical Communications Information Ideas in Motion How to do it? Beginning or mid shift 5-10 minutes Lead by member of unit leadership team 31

SICU Huddle Board 32

Focus on Learn from Defects

What Is a Defect? Anything that you do not want to happen again. 34

Errors Provide Useful Information We can learn more from our failures than from success Our processes can be improved when studied Give me a fruitful error anytime, full of seeds, bursting with its own corrections. You can keep your sterile truth to yourself. Vilfred Pareto copyright 2008 by the Trustees of Columbia University in the City of New York Rights Reserved 35

Learn from a Defect Designed to rigorously analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences. Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues Patient, team, task, caregiver factors Training, education, technology factors Local or institutional environment 36

Learning From Defects 1 2 3 4 5 What happened? From view of person involved Why did it happen? How will you reduce it happening again? How will you know the risk is reduce? With whom will you share the learnings? 37

Brainstorm #1 38

Brainstorm # 2 Why Did It Happen? 339

Brainstorm # 3 Solution Finding.All ideas are Welcome Necessary 40

Start with Low Hanging Fruit 41

A Good Solution Must Be Clear in how we measure the success Trialable and easy to test Compatible with or improve existing workflows Low cost, low fidelity 42

Building Resiliency Into Interventions Forcing functions and constraints Automation and computerization Standardization and protocols Strongest Checklists and independent check systems Rules and policies Education and information Vague warnings Be more careful! STRENGTH OF INTERVENTION 43 Weakest 43

LFD: CLABSI 44

LFD: CAUTI 45

4E s Implementation Framework CLABSI CAUTI

Technical and Adaptive Change One of the most common leadership mistakes is expecting technical solutions to solve adaptive problems." Ron Heifetz 1 Leadership Without Easy Answers (Cambridge: Harvard University Press, 1994) 47

Key concepts: Adaptive and Technical Work Technical Work CAUTI Prevention Appropriate Indication Insertion Maintenance CLABSI Prevention Insertion Maintenance Review daily if necessary Adaptive Work Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should The intangible components of work, like ensuring an ICU team holds each other accountable Work that lends itself to standardization (e.g., checklists and protocols) Culture change is not a checklist 48

4 E s for Implementing Change 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

Technical Adaptive Technical Adaptive 4E s Preventing CAUTI Frontline Staff CAUTI Prevention Engage Ask, how will CAUTI prevention make the world a better place? -Help staff understand preventable harm -Share stories about patients affected -Develop a business care -Include execute champion/physician leadership Define evidence related to preventing CAUTI Share CAUTI rate, number of patients harmed, Share patient stories Create business case related to the impact of CAUTI prevention--decreased hospital LOS and decreased ICU LOS, improved reimbursement--vbp Share business case with executive champion/ physician leadership Educate What do we need to do to prevent CAUTI in critically ill patients? -Convert evidence into behaviors -Evaluate awareness and agreement Review the literature Identify barriers to getting the catheter out Ensure appropriate insertion technique-who and how Adopt recommended indications for insertion of catheter Define appropriate catheter care Bladder Bundle Define your education plan (utilizing workshops, hands-on trainings, conferences, slides, presentations and interactive discussions via multiple modalities to cater to different learning styles) -Identify support through outreach to the leadership team Do you have a nurse driven catheter removal policy Implement an insertion checklist Who should be involved? On your unit and beyond Do we have all the equipment? Discuss as part of interdisciplinary rounds/daily goals -Learn from defects Execute How will we implement CAUTI prevention at our hospital give local culture and resources? -Listen to resisters -Standardize care and create independent checks -Make it easy to do the right thing -Learn from mistakes Evaluate How will we know that our efforts to prevent CAUTI in our patients made a difference? -Define measures -Regularly assess measures -Provide feedback to staff and celebrate success Audit compliance with components of the bladder bundle and insertion indication and technique Collect CAUTI rates and device utilization Define data collection plan

Technical Adaptive Technical Adaptive 4E s Preventing CLABSI Frontline Staff CLABSI Prevention Engage Educate Execute Evaluate Ask, how will CLABSI prevention make the world a better place? -Help staff understand preventable harm -Share stories about patients affected -Develop a business care -Include execute champion/physician leadership What do we need to do to prevent CLABSI in critically ill patients? -Convert evidence into behaviors -Evaluate awareness and agreement How will we implement CLABSI prevention at our hospital give local culture and resources? -Listen to resisters -Standardize care and create independent checks -Make it easy to do the right thing -Learn from mistakes How will we know that our efforts to prevent CLABIS in our patients made a difference? -Define measures -Regularly assess measures -Provide feedback to staff and celebrate success Define evidence related to preventing CLABSI Share CLABSI rate, number of patients harmed, Share patient stories Create business case related to the impact of CLABSI prevention-- decreased hospital LOS and decreased ICU LOS, improved reimbursement--vbp Share business case with executive champion/ physician leadership Review the literature Ensure appropriate insertion technique-who and how Identify barriers to getting the catheter out Avoid femoral line insertion Define appropriate catheter care Maintenance Bundle Define your education plan (utilizing workshops, hands-on trainings, conferences, slides, presentations and interactive discussions via multiple modalities to cater to different learning styles) -Identify support through outreach to the leadership team Do you have a policy related to care of the central line Implement an insertion checklist, and a line cart or line bag Do we have all the equipment? Dressings, disinfection caps Discuss as part of interdisciplinary rounds/daily goals Learn from defects Audit compliance with components of the insertion and maintenance bundles Collect CLABSI rates, SIR and device utilization Define data collection plan

CAUTI Prevention in the ICU Challenges High prevalence of urinary catheter High prevalence of fever Approach Focus on removing devices Clear consensus on when a urinary catheter is necessary in the critically ill patient are you going to do anything different each hour based on the urinary output? Provide alternatives to indwelling catheters Nurse driven removal protocols Improve urinary culture practices 52

CLABSI Prevention in the ICU Challenges Competing priorities Drift by staff in implementing evidence based practices Approach Team/champions identified to continue to focus on this work Educate new staff in standard practices/expectations Audit compliance with both insertion and maintenance of central lines Learn from each defect 53

Key Components to Sustainable Change Leadership engagement Culture of safety Implementation framework that deals with both technical and adaptive change 54

Top Strategies to hardwire prevention of CLABSI and CAUTI Identify local physician and nurse champions Standardize care based on the evidence Tap into the wisdom of frontline staff Partner with senior executive who sets expectations related to infection prevention Learn from defects 55

Top Strategies to hardwire prevention of CLABSI and CAUTI Track CLABSI and CAUTI prevention practices Interdisciplinary rounds on all units that reviews/ensures compliance with key prevention strategies Harness the power of local data to drive improvement efforts Train new staff in evidence-based care 56

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