Getting Better at Getting Better V O L U M E 1, I S S U E 1

Getting Better at Getting Better V O L U M E 1, I S S U E 1 A quarterly newsletter from the Office of the Chief Quality & Patient Safety Officer IN THIS ISSUE VPH Workshop Accelerates Change Letters From the CQO Chasing Zero Premiere Pillar Goals in Practice: Reduce the Number of HAIs Exemplars of Quality & Patient Safety: Stories From the Field VPH Workshop Accelerates Changes n June, Vanderbilt Psychiatric Hospital I (VPH) leaders held a four-day Rapid Process Improvement Workshop (RPIW) focused on strengthening and streamlining handover processes. The Joint Commission has mandated a standardized patient handover process since 2006, yet many handover methods remain scattered and unfocused, compromising patient safety. VPH leaders Stephan Heckers, MD, department Chair; Avni Cirpili, RN, MSN, Chief Nursing Officer; and Harsh Trivedi, MD, Executive Medical Director and Chief of Staff, championed the RPIW team s efforts to organize and execute a large-scale redesign of the handover processes. This was the first RPIW at VUMC, applying Lean methodology to patient care practices. The goal of the workshop was to develop a Psychiatry Transition Bundle: a set of Letters from the CQO Hello, and welcome to the inaugural issue of our quarterly newsletter, Getting Better at Getting Better. We ll use this space to provide an in-depth view of the people at Vanderbilt who are driving the work of quality improvement. As we connect the quality efforts across the clinical enterprise we increasingly leverage one another s hard work, energy, and enthusiasm for providing the very best and safest care for our patients. Each edition of our newsletter will explore the range of improvement work from the Workshop participants gathered for a final report on their results. standardized checklists to identify key information that must be provided when a patient is changing treatment locations or treatment providers. The multidisciplinary RPIW team reviewed current processes from frontline of care to more foundational changes. We hope that you are inspired by these stories, and that you ll let us know when you have something to share. Thank you for reading, Julie Morath (Continued on page 2)

P A G E 2 Quality (Continued from page 1) the point of a referral for inpatient admission through to the point of transition to outpatient status. The team found multiple opportunities for improvement and standardization to enhance patient safety and the quality of care. Examples include the patient admission process, face-to-face information exchange, and reliable physician sign-off. Workshop participants organized in three groups, each tasked with a distinct phase of the Transition Bundle. The Admissions Team developed a strategic plan to implement a streamlined admission process to decrease patient wait time and minimize patient handovers via a one-stop process. The Unit Team studied patient flow from the moment of transition from the VPH admitting service onto an inpatient unit, to address the lack of standard workflows and communication methods across disciplines (MD, RN, Social Worker) and practice sites (Vanderbilt University Hospital, Monroe Carrell, Jr. Children s Hospital at Vanderbilt, the Emergency Department [ED], etc.). The Discharge Process Team created a plan to implement a multidisciplinary treatment team meeting, improve documentation of the treatment plan, and integrate with both the Discharge Wizard and Team Summary. Implementation of the process changes began in July, with the transition to a onestop admissions process for patients referred to VPH from the ED. The process change streamlines the patient s intake and transfer to the VPH unit, bypassing checkin with the Psychiatry Respond team. Process changes cut four hours from the average wait time between referral and arrival on the VPH unit. Patients admitted from non-ed areas still use Respond, but their wait time has been significantly decreased through streamlining the Respond processes and changes to the physical layout. A total of seven tools were created in the RPIW and will be implemented in the coming months. We relentlessly pursue and measure ourselves against the highest quality performance in all areas, from patient care to scholarship. Chasing Zero Premiere The documentary film Chasing Zero: Winning the War on Healthcare Harm, premiered on the Discovery Channel on April 24th. The film, which includes footage shot at VUMC, was produced by the Quaid Foundation and the Texas Medical Institute of Technology (TMIT). Actor Dennis Quaid and his wife, Kimberly Quaid, were inspired to create the Foundation following their personal experience with near-fatal medication errors that affected their newborn twins in 2007. The documentary centers on the stories of families who have experienced harm in the healthcare system, and the professionals who are working to prevent medical events from happening. Chasing Zero is the first of a series of patient safety documentaries produced by TMIT. Future installments, one of which will prominently feature VUMC, will provide arc to action stories to inspire leaders. The film may be viewed online at http:// discoveryhealthcme.discovery.com/zero/ zero.html. G E T T I N G B E T T E R A T G E T T I N G B E T T E R

V O L U M E 1, I S S U E 1 P A G E 3 Pillar Goals In Practice: Reduce the Number of HAIs Editor s note: We ll use this space to feature a different Quality Pillar Goal in each issue, along with some notable progress in the ongoing work supporting that Goal. We begin the series with the Goal of Reducing Healthcare- Associated Infections (HAIs). Goal Definition: VUMC has set a goal of zero preventable hospital-acquired infections. Efforts to prevent HAIs successfully reached the 2010 Pillar Goal of achieving a target Standardized Infection Ratio (SIR) of 1.26, which reflects the ratio of Observed HAIs to Expected values from the National Healthcare Safety Network. The 2011 Pillar Goal is more ambitious: to reach an SIR of 1.11. Types of infections, location and source, as well as compliance with best practices to reduce transmission of infections are tracked. Here are some encouraging signs in ongoing efforts to prevent central line-associated blood stream infections (CLABSI), a key component of HAI. CLABSI Prevention Efforts Gain Traction in FY2010 s of January 2010, VUMC s CLABSI rates A continued to be reported higher than our peers. In response, a BSI Prevention Bundle (of interventions) was introduced, with standard practices to manage central lines and minimize line days throughout the ICUs. Multiple teams throughout the Medical Center were focusing on CLABSI, and Neonatal Intensive Care Units (NICU) at MCJCHV and Stahlman joined the Tennessee Initiative for Perinatal Quality Care (TIPQC) CLABSI reduction project. The Pediatric ICU (PICU) began using Event Analysis to review each BSI occurrence. VUMC leadership reached out to external experts through membership in the Tennessee Center for Patient Safety Collaborative on BSI. Peter Pronovost, MD, from Johns Hopkins Hospital visited as an external consultant, and a team of quality leaders from VUMC made a site visit to Cincinnati Children s Medical Center to learn from their success. Through diligent work, the NICU s efforts to prevent CLABSI produced results, achieving 100 consecutive days with no infections by March 31 st. Contributing to their success were practice changes and vigilance, including hand hygiene, maximum barrier precautions while inserting central lines, two-person line-insertion technique, and monitoring to discontinue central lines as soon as possible to do so. The NICU also began publically posting the number of days without CLABSI, to serve as a visual reminder of the staff s ownership of infection prevention. To build on these successes, unit leaders helped spread their safety practices to other areas: Elevate boards were established in each ICU to count the days between infections and provide visible performance feedback on the unit. Bedside tools A comprehensive plan is set in motion NICU staff post quality indicators at the nurses station. NICU reaches 100 days without CLABSI In April, a housewide approach to reduce CLABSI was adopted and implementation initiated, with a focus on embedding standard expectations for line practices. Housewide efforts were made to assess, plan, and implement specific interventions (Continued on page 4) Safer line access

V O L U M E 1, I S S U E 1 P A G E 4 Reduce the Number of HAIs (Continued from page 3) to prevent CLABSI. These include preventing contamination of blood cultures, and standardization and reinforcement of evidence-based best practices during line insertion, maintenance, and discontinuance. Infection Prevention During Line Insertion: Real-time, unit-level data showing compliance with the insertion bundle was disseminated. A pilot study of a Line Cart to standardize and improve ease of access to supplies during insertion began in the MICU and Neuro ICU, with housewide implementation to follow. Other possible drivers for infection were studied, and key stakeholders developed guidelines to address potential risks. Infection Prevention During Line Maintenance: Comprehensive line maintenance guidelines were developed, with consensus regarding strict hubaccess practice. An Enhanced Education Program was introduced, and unit-based displays with best practice reminders. Ongoing Infection Monitoring: Real-time, unit-level key indicators such as device days, assessment of site, and assessment of need entered development. Unit-based analytic tools to track HAI were studied, to identify specific areas of concern and customize rapid intervention when infections develop. Reducing False Positives: An ongoing problem regarding contamination of blood cultures, which hampers accurate infection monitoring and can lead to morbidity in patients, was addressed, with prevention measures being piloted in the adult ED. To date, the number of contaminat- ed specimens in the ED has been reduced by more than 50% since the intervention of new prevention measures. VUMC issued Standards for Non-emergent Insertion and Management of Central Venous Catheters (CVCs), and began to monitor compliance with each element of insertion, care, access, and discontinuance. Visual cues to reinforce the standards were distributed, and all members of the CVC care team were empowered and obligated to identify and correct any deviation or potential deviation from the standards. New house staff were trained to follow the standards, and a Boot Camp on line insertion was repeated for current staff and unit champions. Nursing staff received the same basic training, with an annual review in the future. Strict adherence to standard practice during line insertion, maintenance, and discontinuance is critical in reducing CLABSI. Monitoring Performance In August, quality staff conducted a review of 15 months of CLABSI occurrences in the adult ICUs, to identify vulnerabilities in the care processes that may lead to infections. Specific attention was devoted to accurately capturing all central lines in place at the time of each CLABSI, as well as assessment of the time between line insertion and infection. Of the 165 infections studied, 73% occurred in patients with only one central line in place at the time of the CLABSI. More of the infections (Continued on page 5)

V O L U M E 1, I S S U E 1 P A G E 5 Reduce the Number of HAIs (Continued from page 4) appeared to be the result of maintenance practice (44%) than insertion practice (25%), given the length of time between insertion and CLABSI infection. The review revealed that line insertion in the ED was not a primary contributor to the CLABSI rates, as was previously thought. Quality staff began creating processes to capture infection data in near real-time for review by Infection Preventionists, using the Vanderbilt Infection Prevention Electronic Resource (VIPER). Building on the PICU s efforts to conduct an Event Analysis for each CLABSI occurrence, a standardized Event Analysis tool entered development. The Tool is to be used in each instance of infection, to aid in the identification of trends and inform practice. Additional review and analysis is to be expanded to non-icu areas, as the changes related to eliminating CLABSI take hold and are successful. Seeing Results Quality improvement efforts in FY2010 resulted in significant reduction in CLABSI, with a fiscal year-end standardized infection ratio (SIR) below 1.0 (the Centers for Disease Control and Prevention benchmark) as of July 2010. Quality leaders and staff are energized to attain even greater reductions in the current fiscal year. While setbacks will continue to occur, it is anticipated these and other efforts over time will strengthen the infection prevention safety net as we continue Chasing Zero. HAIs At A Glance: CLABSI - 0.34, lowest SIR to date in October 2010 VAP - SIR continues to decline, within Target goal CAUTI - SIR is 0.51, within Reach goal SSI - Reductions in nearly all procedures tracked Hand Hygiene - Year s efforts achieve gains to 80%, on the way to >95% compliance - Tom Talbot, MD, Chief Hospital Epidemiologist Fiscal year 2010 CLABSI performance

P A G E 6 Exemplars of Quality & Patient Safety: Stories From the Field Editor s note: This section is devoted to highlighting individuals on the frontline of care who are putting Quality and Safety into their practice. Patient and Family Engagement Improves Hand Hygiene The efforts to improve hand hygiene at VUMC include measures to engage patients and families as part of the Infection Prevention safety net. There are signs that this practice is taking hold; in a recent example, an ICU patient s family was present when a caregiver from another unit arrived for a routine treatment. The family noticed that the caregiver had not washed his hands, and asked that he please do so before beginning the treatment. The caregiver thanked them for the reminder, washed his hands, and proceeded with the treatment. Lessons From a Top Performer The Adult Primary Care Clinic on the 7th floor of Medical Center East has had remarkable success with their campaign to improve hand hygiene, achieving 100% compliance from June through September 2010. Clinic manager Pat Covington, RN, credits the staff s engagement, and their willingness to ask other caregivers to wash their hands. Clinic leadership performed a human factors assessment, installing hand hygiene stations outside of clinic rooms where previously sinks had been exclusively in-room. The commitment of physician leaders was another key factor, with Attendings serving as role models for the 80 residents who work in the clinic each week. In the end, she says, There were no heroic measures, just a heightened awareness and cultural expectation, that drove performance. Do you have an Exemplar story to share? Send it to amie.hollis@vanderbilt.edu. VUMC is dedicated to achieving the Institutes of Medicine s Six Aims for Changing the Health Care System: Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered care. About Us The work of Quality and Patient Safety at Vanderbilt University Medical Center is centered upon Accountability, Clinical Effectiveness, Reliable Systems, and Compliance with Best Evidence Practices and Standards. Our mission is to bring together the individuals, departments, and services dedicated to improving the quality and safety of the clinical care provided at Vanderbilt, using rigorous data analysis and building upon lessons learned at VUMC and peer organizations. If you have a question, concern, or comment regarding healthcare quality and patient safety, please contact the office of Julie Morath, RN, MS, Chief Quality and Patient Safety Officer. Contact us at: Vanderbilt University Medical Center Quality & Patient Safety 2135 Blakemore Ave. Nashville, TN 37212 615.322.2560 G E T T I N G B E T T E R A T G E T T I N G B E T T E R