Improvements & Sustained Change through the Implementation of High Reliability Units Tammy Van Dyk, MSN, RN, CPEN Quality Management & Patient Safety Manager
Objective Describe how high reliability principles adopted at the unit level can positively impact process reliability and patient outcomes
East Tennessee Children s Hospital Comprehensive Regional Pediatric Center 152 Licensed Beds 35 ED Beds Annual ED Volume 70,000 Knoxville, TN
Background 1999-To Err is Human (IOM) Failure to Recognize & Delayed Reaction Lacked a Total Systems Approach Barriers to Unit Level/Staff Engagement Failure to Sustain Change & Outcomes
Ideal State Have we fixed our problems? What are the recommendations? What do other industries do?
Literature Review Weick & Sutcliffe 5 Principles of Mindful Structure Preoccupation with Failure Sensitivity to Operations Reluctance to Simplify Commitment to Resilience Deference to Expertise Helen Devos Children s Hospital Kamishibai Rounding
Align with Strategic Initiatives
Goal Solution: Creation of HRU Creates & maintains safe culture @ unit level Benefits Reduce retrospective chart audits Real-time coaching Improved collaboration Heightened awareness, transparency, ownership Increased accountability Alignment with hospital goals
HRU: Key Steps Leadership Support Education Error Prevention Training; Safety Coaches; High Reliability; Cause Analysis; Leadership Methods Identify key stakeholders to drive the change Implement Kamishibai Rounding Commit to Resilience Bounce back, shared learning, celebrate successes
Kamishibai Rounding
Available in CLABSI, CAUTI, VAP, Pressure Injuries, & Falls Coming Soon: Medication Safety, Readmission Discharge Bundle, Unplanned Extubation, VTE, PIVIE
Preoccupation with Failure: Real-Time Observation & Coaching
Sensitivity to Operations: Transparency & Learning
Deference to Expertise Driving Change & Accountability
Success HAC reduction and improved process reliability SPS Hospital of the Month in December 2015 SPS top performing hospital: CAUTI, CLABSI, VAP Increased near miss reporting (Preoccupation with failure) Family Participation in HAC prevention Press Ganey Pinnacle of Excellence Award 2015 Reduced Cost
Number of HACs HAC reduction 45 40 35 30 ETCH Hospital Acquired Conditions 46% reduction; 22 fewer patients harmed 25 20 15 10 5 0 2014 2015 Includes CLABSI, CAUTI, VAP, VTE, ADE, Fall w/injury; SSI; PU in all inpatient care areas
Reliability to the Prevention Bundle in % Improved Process Reliability 100 Catheter Associated Urinary Tract Infection (CAUTI) Maintenance Bundle Reliability 90 80 70 June 2015 HRU launch with Kamishibai bundle rounding 60 50 40 30 Achieved 640 Days CAUTI free! % Hospital reliability to bundle Centerline 20 10 0
14-Jan 14-Feb 14-Mar 14-Apr 14-May 14-Jun 14-Jul 14-Aug 14-Sep 14-Oct 14-Nov 14-Dec 15-Jan 15-Feb 15-Mar 15-Apr 15-May 15-Jun 15-Jul 15-Aug 15-Sep 15-Oct 15-Nov 15-Dec 16-Jan 16-Feb 16-Mar 16-Apr 16-May 16-Jun Reliability to Prevention Bundle in % Improved Process Reliability 100 Central Line Associated Blood Stream Infection (CLABSI) Maintenance Bundle 90 80 70 60 June 2015: Kamishibai card rounding & HRU implementation improved capture with real data capture of bundle compliance 50 40 30 2014: Reporting was mostly chart review and sporadic % Hospital reliability to bundle Centerline 20 10 0
14-Jan 14-Feb 14-Mar 14-Apr 14-May 14-Jun 14-Jul 14-Aug 14-Sep 14-Oct 14-Nov 14-Dec 15-Jan 15-Feb 15-Mar 15-Apr 15-May 15-Jun 15-Jul 15-Aug 15-Sep 15-Oct 15-Nov 15-Dec 16-Jan 16-Feb 16-Mar 16-Apr 16-May 16-Jun Reliability of Prevention Bundle in % Improved Process Reliability Pressure Injury Prevention Maintenance Bundle Reliability 100 90 80 70 60 50 June 2015: Kamishibai card rounding & HRU implementation improved capture with real data capture of bundle compliance % Hospital reliability to bundle 40 30 20 10 2014: Collection of Reliability was inconsistent and relied on retrospective chart review Centerline 0
Unit Level Performance: PICU HRU Add Daily CHG bath HRU HRU Sustained Improvement- PICU: 5 years VAP free
Unit Level Performance: PICU HRU HRU Reduction in harm with HAPI past 3Q after HRU/Kamishibai rounding Staff driven initiatives to improve medication delivery HRU
Increased Near Miss Reporting 250 Med Event Near Miss Reporting 208 200 181 150 100 15% increase in Near Miss Reporting from FY15 to FY16 50 0 FY15 Near Miss Reporting FY16 Near Miss Reporting
Financial Impact $1,200,000 Estimated Costs of ETCH Hospital Acquired Conditions $1,000,000 $800,000 Cost Savings of over $460,000 $600,000 $400,000 $200,000 $0 2014 2015 *Excludes Readmissions
HAC Cost References
"The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been." Donald M. Berwick, MD, MPP Former President and CEO Institute for Healthcare Improvement DESTINATION ZERO
Expansion of HRU Spring 2014 Oct 2014 Winter 2015 June 2015 Nov 2015 Apr 2016 June 2016 2017 Error Prevention Training Safety Coaches Leadership Methods & High Reliability Principles PICU Pilot HRU 2nd HRU: Inpatient Surgery 3rd HRU: NICU 4th & 5th HRU: Inpatient Med-Surg & Heme/Onc Expansion: OR, ED, Clinics
Resources ₁ Institute of Medicine (IOM). 2000. Committee on Quality of Health care in America; Kohn, LT, Corrigan, JM, Donaldson, MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press [Report issued in 1999, published in 2000} ₂ Jurecko, L. (2015). Lean tools help prevent hospital acquired infections. Children s Hospital Today, July 20. Retrieved from https://www.childrenshospitals.org/newsroom/childrens-hospitals- Today/Summer-2015/Articles/Lean-Tools-Help-Prevent-Hospital-Acquired- Infections ₃ National Patient Safety Foundation (NPSF). (2015). Free from harm: Accelerating Patient Safety Improvement Fifteen Years after To Err is Human. Boston: NPSF. ₄ Weick, K, & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco, CA: Jossey Bass.