Organizational Culture Change Results in Improvement in Outcomes, Value and Experience Elizabeth C. Wick, M.D.
Objectives To describe the burden and complexity of surgical site infections To outline the relationship between culture and clinical outcomes To describe the interplay between organization culture and perioperative improvement
SSI Definitions Superficial purulent drainage from wound positive wound culture pain, redness swelling diagnosis by surgeon Deep purulent drainage from deep aspect of wound dehiscence abscess on exam or CT scan Organ Space infection in surgical cavity (abdomen) 3
Background SSI is the most common nosocomial infection in the surgical patient SSI is the most common complication after colorectal abdominal surgery (3-30%) SSI is associated with increased mortality, length of stay and readmission An SSI costs between $6,200 - $15,000/per patient (superficial-organ space) Smith Annals Surg 2004 Wick JAMA Surg 2011 4
Colorectal Surgery Readmissions Johns Hopkins Hospital Readmission rate 17.6% (2009-12) Characteristics Readmitted Patients N=129, No. (%) Non- Readmitted Patients N=606, No. (%) P Odds Ratio Intra-operative Presence of ostomy: -Yes ostomy -No ostomy Length of operation, mean hours (range) 74 (57) 55 (43) 4.9 (1.5-12.2) 220 (36) 386 (64) 4.2 (1-14) <0.001 * * 2.59 * * Post-operative Surgical-site infection (SSI) -Superficial Incisional SSI -Deep Incisional SSI -Organ Space SSI Length of stay, median days (range) 30-day mortality 58 (45) 27 (21) 4 (3.1) 27 (21) 9 (3-65) 1 (.8) 108 (18) 89 (14.7) 2 (0.3) 17 (2.8) 7 (1-153) 19 (3.1) <0.001 0.043 0.004 <0.001 * * 3.39 1.74 14.78 11.54 * * Hechenbleikner JACS 2013 5
Pathogenesis of SSI Host Bacteria Procedure 6
Does SCIP gives us enough Johns Hopkins Hospital May 2010 SCIP Hospital Compare www.medicare.gov information? Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection Johns Hopkins 98% 97% Comparison Hospitals Surgery patients who were given the right kind of antibiotic to help prevent infection 98% 98% Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97% 96% Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream not a razor) 100% 100% Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. 98% 99%
NSQIP report 2009?? Johns Hopkins 8
So Many Solutions Technical Work Sweet spot Adaptive Work 9
The Vision of CUSP Improve patient safety awareness and systems thinking at the unit level Empower staff to identify and resolve patient safety issues Integrate Safety Practices into daily work of all staff members Create a patient safety partnership between executives and frontline caregivers Provide tools to help CUSP teams investigate and learn from defects and improve teamwork and safety culture 10
Successful Efforts to Reduce Preventable Harm Johns Hopkins ICU program 1 Michigan Keystone ICU program 2,3 National On the CUSP: Stop BSI program Reductions in central line-associated blood stream infections (CLABSI) 1. Crit Care Med. 2004;32:2014-20. 2. N Engl J Med 2006;355:2725-32. 3. BMJ 2010;340:c309.
Hospital Colon SSI Rates Correlate with Safety Culture Fan C et al. JACS 2016
It is NOT just about the checklist: Safety Culture and Improvement are KEY Safety Culture & Safety Intervention Patient Outcomes Safety culture moderates the effectiveness of safety and quality improvement efforts Safety climate scores correlated with the degree of reduction in mortality and morbidity achieved in the implementation of a surgical checklist (r =.71, p <.05) Haynes et al., 2011 13
What is Culture*? The way we do things around here 1 attitude = opinion everyone s attitude = culture Health and safety commission, 1993 Denham, 2007 *aka Climate JHU and JHHS, 2011 14 Slide courtesy of J. Bryan Sexton
Perception of Teamwork in the OR Surgeon: If the nurse follows my orders Nurse: If the surgeon listens to my concerns
Technical & Adaptive Work Technical Work Sweet spot Adaptive Work 17
Johns Hopkins Hospital COLORECTAL SURGERY Year 1
Identifying defects How will the next patient be harmed or have an SSI? What can we do to prevent the next patient from harm or SSI? 19
Gentamicin Increased amount of gentamicin available in the room Added dose calculator in anesthesia record Educated surgery, anesthesia and nursing in grand rounds Despite >95% compliance on SCIP
Separation of Dirty and Clean Instruments Built separate tray of instruments used for bowel anastomosis Extra suction and bovie tip and gloves opened and changed after anastomosis Educational sessions with scrub techs and nurses about instrument separation Audits and education on the spot
SSI Prevention Interventions Use of pre-operative chlorhexidine washcloths Mechanical bowel preparation with oral antibiotics Pre-warming in the pre-op area Standardized skin preparation with chloraprep Separation of dirty and clean instruments 22
Colorectal Surgical Site Infection Rate Baseline 27% 18% Hospital Target 15% ACS-NSQIP data Wick et al. JACS 2012
Johns Hopkins Hospital COLORECTAL SURGERY Year 2 Teamwork and Communication: Briefings and Debriefings
Briefing and Debriefing real-time identification of defects Team developed new form based on specific needs Candid discussion with surgeons about effective strategies for briefing/debriefing RN given protected time to address defects and communicate fixes Logbook of defects Hicks C et al JAMA Surg 2014
Examples of Defects Addressed: Postings Problem: Circulating RN and scrub could not tell from posting if an abdominal and perineal set-up was needed second setup needed added to posting sheet Impact: RN and scrub can set up before discussing case with surgeon, fewer delays 26
Hidden Cost-Savings: Antibiotic Irrigation Inconsistent use of antibiotic irrigation If effective, advocate for consistent use and if not proven stop using $537,000/ year on antibiotic irrigation No evidence Removed from formulary
Briefing Basics Compliance Opportunity for questions Expectations for assertiveness Contingency plans Critial goals Yes No Role introduction Name introduction 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Johnston Am J 2013
Colorectal Surgical Site Infection Rate Baseline 27% Hospital Target 15% 20% ACS-NSQIP data
Johns Hopkins Hospital COLORECTAL SURGERY Year 3 Surfacing Defects in SSI Prevention
SSI Investigation Process Every month Patients with infections identified by NSQIP Data abstracted by hand from many EMRs Hechenbleikner DCR 2014 31
Surfacing Defects on Patients with Infections SCIP Measures: Q1 2012 Q2 2012 Patients with Infections 15 19 CUSP group surgeons 9 11 Antibiotic Selection 100% 100% Antibiotic Timing 100% 100% Warmer Use in OR 100% 100%
Surfacing Defects on Patients with Infections Q1 2012 Q2 2012 Patients with Infections 15 19 CUSP group surgeons 9 11 Antibiotic Dose (Gentamicin) 50% 100% Redosing 20% 0% Normothermia Pre-op Warming* 55% 27% Incision Temp 44% 27% End Temp 44% 82% Recovery Room Temp 100% 91% Washcloths Use Pre-op* 55% 9% Standardized Skin Prep* 77% 64% Bowel Prep with Oral Antibiotics* 55% 36% Reduced Steroid Dosage 0% 100% *CUSP
ddressing Defects:Tablet-based Pre-op Education Patients did not know why we do the preparations we do Enhanced pre-op education Bowel prep provided free of charge Bowel prep and CHG washcloths included in medicine reconciliation phone call
Colorectal Surgical Site Infection Rate Baseline 27% 18% Hospital Target 15% ACS-NSQIP data
Johns Hopkins Hospital COLORECTAL SURGERY Year 4 Sustainability and Extending Scope of Work
Maintaining Engagement Further opportunity to decrease morbidity (infectious complications) and increase value (length of stay) Care of colorectal surgery patients at Johns Hopkins Hospital is highly variable
Statement of the Problem Colorectal surgery procedures are common and have high morbidity Opportunity to decrease morbidity (infectious complications) and increase value (length of stay) Care of colorectal surgery patients is highly variable pre-operative education anesthetic plan pain management fluid resuscitation resumption of oral intake mobility protocol Lacking critical review of performance
Enhanced Recovery in Colorectal Surgery
Enhanced Recovery 1990s developed in Europe Philosophy of ERAS - restore normal physiology as quickly as possible Reconciles all aspects of the patient encounter Improve patient communication and engagement Integrate evidence based processes
Enhanced Recovery Pre-Surgery Visit Pre-Anesthesia Visit ERAS Pre-Operative Area/PACU Transition to Home Operating Room Inpatient Unit
Accountability Model Wick et al. JACS 2015
Engaging Executive and Additional Providers Support Renee Demski MBA Director JHHS Ron Werthman Claro Pio Roda John Hundt, MHS Peter Pronovost, MD, PhD CFO Administrator, Anesthesia Administrator, Surgery SVP and Safety Andy Benson, CRNA Other: Outpatient RNs Pre-anesthesia Clinic Inpatient NPs Residents Chris Wu, M.D. Liz Lins, MSN Anesthesiology/ Pain Management Nurse Manager, Marburg 2 Dreama Franklin, RN Care Coordinator Val Gaskins, RN Deb Hobson RN Patient Safety 43
Time and Resources Physician Time Disposables (education materials and OR monitors) Additional positions (advanced practice for pain service) 44
Education and Buy-in All CUSP teams part of pathway development Kickoff meeting with executive leaders ERP nurse attends all CUSP meetings Continuous sharing of data Audits of practice Learning from defects Armstrong Institute for Patient Safety and
JHH Enhanced Recovery Pathway Nurse led pre-op education focusing on patient engagement and expectation setting Liberal NPO policy (drink upto 2hrs before surgery) Intra-op anesthesia protocol Total intravenous anesthesia Limited intravenous fluids Multimodal pain management with acute pain service Epidural analgesia TAP blocks Nurse driven post-operative orders Early mobility, feeding starting in recovery room and no additional IVF
Key Materials: Performance Data
Key Materials: Patient Education
Length of Stay and Cost ERAS Baseline Net Savings Patients 330 310 Mean Length of Stay 5.3 days 7.2 days (-)1.9 days (26.4%)* Variable Direct Cost Wick et al. JACS 2015 Stone et al. JACS 2015 Wu et al. J Jt Comm. 2015 $9,036 $10,933 (-1)$1,897 (17.3%)** *p<0.001 **p=0.013
Baseline (N=67) COLORECTAL ERAS Effectiveness Integrated Recovery Pathway (N=40) Change HCAHPS domain Top Box Responses (% Always) Top Box Responses (% Always) p Nurse Communication Doctor Communication 75% 84% NA 83% 83% NA +11% Staff Responsiveness 24% 34% NA +10% Pain Management 68% 77% NA +9% Communication About Medications Discharge Information what number would you use to rate this hospital during your stay (0-10)? Would you recommend this hospital to your friends and 52% 71% NA 93% 92% NA 52% (35/67) 79% (52/66) 67% (26/39) 90% (35/39) NA +19% -1% 0.16 +15% 0.19 +11%
Colorectal Surgical Site Baseline 27% Infection Rate Post-ERAS 6% Hospital Target 15% Colorectal Operating Room CUSP ERAS ACS-NSQIP data
Johns Hopkins Hospital COLORECTAL SURGERY Year 5 Spread
Spread JHH (other procedures) 1. Gyn Oncology 2. Cystectomy 3. Hepatectomy 4. Other hospitals
Spreading to Other Surgery in JHH: Surgery Clinical Pathway Initiative Hepatectomy (Dr. Tim Pawlik)* Metric Pre ERAS Post ERAS Post - Pre Patients 42 56 Avg LOS 7.9 5.8 (-2.1) Avg VDirCost $12,761 $10,450 (-$2,311) MHAC rate 9.5% 0.0% (-9.5%) Gyn Oncology (Dr. Amanda Fader Nickles)** Pre Bundle SSI Post Bundle SSI Post-Pre Overall Ovarian Cancer Debulking Debulking + Bowel Resection 19.4% 3.6%* (-15.8%) 29.4% 8.1%* (-21.3%) Urology/Cystectomy (Dr. Trinity Bivalacqua) *Page A. et al. BJS 2015; Page A. et al. Annals Surg Onc 2015 **Wick E, Pronovost P, Fader Nickles A. Annals of Surg 2015
Spreading to Colon Surgery in JHHS: Surgery Clinical Community + Physician Leadership + ERAS Sibley (Dr. Martin Paul and Dr. Jason Rose) Cases Length of Stay Median Direct Cost Median Total Cost CY2015 Q1 36 3 (-1)$5,045 (-$1,650) $ 9,261 (-$2,296) CY2014 Q1 38 4$6,695 $11,557 Bayview (Dr. Susan Gearhart and Dr. Sara Satia) ACS NSQIP April 2015, ERAS September 2015 Howard County General Hospital ACS NSQIP January 2015 Suburban Hospital ACS NSQIP January 2015
Publications It s too early to say with certainty whether her efforts will curb complications, but the data so far are promising. --Dr. Rothman September 2014
NSQIP report 2015 Johns Hopkins 57
Conclusions We can improve perioperative outcomes, experience and value and safety interventions must be goal directed at unit level Local ownership with senior-level commitment Practical tools Culture is local; Change is local Change is more like cascading dominos than the Berlin Wall Respect the wisdom of the front line worker Enhanced recovery protocols are an exciting innovation in perioperative care
Thanks Colorectal Surgeons: J. Efron, S. Fang, S. Gearhart, B. Safar, E. Wick Anesthesia: C. Wu, A. Benson, S. Berenholtz Nursing: Ambulatory, Pre-op, PACU, Inpatient Pharmacy Infection Control Administration: J. Hundt, C. Pio Roda, L. Robertson