On the CUSP: STOP CAUTI Physician Engagement Mohamad Fakih, MD, MPH St John Hospital and Medical Center Detroit, MI February 7, 2012 Acknowledgments Special thanks to Drs Sanjay Saint and Sarah Krein for their review and the materials they provided for this presentation. 2 1
Physicians Play a significant role in shaping care in the hospital setting. Most are very autonomous and may not be employed by the hospital. Many are interested in treating illness, but not trained to focus on improving safety and preventing harm. Many are unaware of the efforts being implemented to promote safety in the hospital. Many may have a limited amount of time to volunteer for supporting the quality agenda. 3 What is Physician Engagement? Engaging: tending to draw favorable attention or interest (Merriam-Webster) Physician leader engagement: a physician feeling of energy and fulfillment as a consequence of being actively involved as a leader in creating changes in healthcare service delivery (Snell, Qual Health Res 2011; 21: 953) 4 2
How to Engage Physicians? (Reinertsen, IHI innovation series white paper, 2007) (Adapted from IHI framework for engaging physicians in quality and safety) 1. Have a common purpose (patient safety, efficiency). 2. View physicians as partners (not barriers). 3. Identify physician champions early. 4. Standardize evidence-based processes. 5. Provide support from leadership to the efforts of physician champion. 5 Common Purpose Explain why the effort is being implemented: 1. Provide a safer environment to your patients. 2. Risk of harm with catheter: infection, trauma, and immobility. 3. Share with physicians examples of adverse outcomes related to unnecessary urinary catheter use (eg, cases of infection or trauma), statistics if present related to your facility compared to national (eg, urinary catheter use, CAUTI rates). 6 3
Physicians as Partners Physicians are leaders of safety efforts. Make safety a home-grown product, not imposed on physicians, but owned by all of the stakeholders. Move physicians from reactive to proactive role (get involved in decision making related to safety, rather than reacting to a plan being implemented). Physicians responsible for safety: could I have prevented a CAUTI with bacteremia if I removed the catheter a few days earlier? 7 Physicians as Barriers: Active Resisters and Organizational Constipators (Saint, Jt Comm J Qual Patient Saf. 2009 May;35(5):239-46) Qualitative analysis of interviews with different hospital healthcare workers regarding barriers and facilitators. Defined active resisters as hospital personnel who vigorously and openly opposed various changes in practice. 1. Difficulty integrating new practices. 2. Competing authorities (a respected clinician not supporting the new recommended practice). 8 4
Active Resisters (Saint, Jt Comm J Qual Patient Saf. 2009 May;35(5):239-46) 1. Difficulty integrating new practices: do not want to change old habits. 2. Competing authorities (respected clinician not supporting the new recommended practice): attending instructing residents to follow his/her approach, not EBM. Potential solutions: 1. Monitor practice and feedback to the physician. 2. Key physician makes compliance mandatory. 3. Selecting an appropriate physician who can speak the language of the staff they are trying to sway. 9 Overcoming Active Resistance: 1) Sharing Local Data Director of an intensive care unit: Data seems to be the best motivation for physicians [they] compare rates to national rates it is sort of an incentive because once the rates are up there, everyone looks to the director and he or she will have to react to those. Slide courtesy of Dr Sanjay Saint 10 5
Overcoming Active Resistance: 2) Monitoring with Back-Up from Leaders MICU directordiscussing maximum barrier use (hat, mask, and sterile gown) during central catheter insertion: the nurses use a checklist they say, Well you know, Dr. Soand-So doesn t like to wear a hat because it messes her hair up So we go in and we get the clipboard, Doctor, you re wearing a mask, okay good. Let s see, were you going to wear a hat? and the resident says, What are you doing?? Oh I m just filling out this form for Dr. [MICU Director] and they say, Whoa whoa okay, gimme a hat. Slide courtesy of Dr Sanjay Saint 11 Overcoming Active Resistance: 3) Finding a Member of the Tribe A chief of staff (and a surgeon):...surgeons are very tribal so what you need to do if you have something that you think is a best practice at your hospital you need to get either the chair of surgery or some reasonable surgeon If you come in and you re an internist into a group of surgeons the first thing we re going to do is we re going to say, Look, you re not one of us the way to get buy-in from surgeons is you got to have a surgeon on your team. Slide courtesy of Dr Sanjay Saint 12 6
Organizational Constipators (Saint, Jt Comm J Qual Patient Saf. 2009 May;35(5):239-46) Do not directly resist the quality improvement effort. acting as insidious barriers to change by increasing the work required to implement evidence-based practices. 13 Overcoming Constipators: 1) Working Around the Constipator A quality manager: basically if I keep off the radar, I can do what I need to do, so that s what I did Slide courtesy of Dr Sanjay Saint 14 7
Overcoming Constipators: 2) Early Discussion with the Constipator Hospital Director: essentially we ve brought a particular person who s known for having strong opinions into these discussions [Executive Board] and so we are able to vet them often organizations take that person and keep them out because they re going to block something that you wanted instead of bringing them into the fold In a couple of situations it s been so helpful to have that person there and have the dialogue and in a couple of instances they changed their mind and turned into a supporter Slide courtesy of Dr Sanjay Saint 15 Physician Champions Identify motivated physicians who want to be engaged, want to help improve safety, excited to have the opportunity of making a change, and appreciate the recognition associated with their role. Physicians that havean interest in reducing the harm related to the catheter are more likely to be engaged in the effort to reduce unnecessary urinary catheter use. Physician champions should be engaged from the start and should be visible to both staff and other physicians. 16 8
Characteristics of Physician Champions Believe in the safety effort. Have recognition and respect from other physicians, and are able to influence their peers. Early adopters of change. 17 Role of Physician Champions 1. Educate physicians on the guidelines for urinary catheter use and risks of the catheter (lectures, providing educational materials). 2. Encourage physicians to comply with the guidelines. 3. Support the work of the team to resolve any barriers to implementation. 4. Provide technical expertise for the team. 5. Provide feed back to other physicians about the progress of the project; share the results. 18 9
Physician Champions and Other Physicians Spread the word to physicians about the effort to reduce CAUTI and unnecessary utilization and the importance of physician support (may need to present the project to multiple disciplines in the hospital). Clarify with other physicians their concerns about any reasons for use that are not considered appropriate and work with physicians to gain their support (use EBM to help). Address physicians in training and midlevel providers to obtain their support. 19 Standardize Processes The HICPAC guidelines identify the appropriate uses of the urinary catheter. Some hospitals may consider having a limited number of additional institutionally based acceptable indications for urinary catheter use. Physician champion to obtain consensus on the additional locally acceptable indications from key physician leaders; this will likely provide you with support during the implementation. 20 10
The Physician Champion and Physician Supporters Emergency Medicine Physicians Infectious Diseases specialists/ Hospital Epidemiologist Urologists Intensivists CAUTI Physician Champion Hospitalists Surgeons Geriatricians Rehabilitation Medicine specialists 21 The Physician Champion and Physician Supporters A physician champion may be supported by other physicians from different specialties to help achieve his/ her goals. The supporting physicians may act as champions in their own groups to build support for the new practice (Damschroder, Qual Saf health Care 2009; 18; 434-40). 22 11
Physician Supporters: Reasons for Them to Support the Champion Infectious Disease Specialists Reduce CAUTI. Reduce antibiotic use. Reduce potential of increased resistance and Clostridium difficile disease. Hospitalists Infectious and mechanical complications. Potential catheter complications prolonging length of stay. Hospitalists care for a large number of patients. Their support may help significantly improve the appropriate use of the urinary catheter. Urologists Reduce trauma (mechanical complications): 1. Meatal and urethral injury 2. Hematuria Geriatricians Many elderly are frail. Urinary catheters are placed more commonly in elderly inappropriately. Urinary catheters increase immobility and deconditioning risk, in addition to infection and trauma. 23 Physician Supporters: Reasons for them to Support the Champion Rehabilitation Specialists The urinary catheter reduces mobility in patients: one point restraint. Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks). Intensivists A significant opportunity is present upon transfer from the ICU to discontinue no longer needed devices, including urinary catheters. Intensivists can support the evaluation of catheter need before transfer out of the unit and may significantly impact use. Surgeons Surgical Care Improvement Project: Remove catheters by postop day 1 or 2. Inappropriate urinary catheter use postoperatively will negatively affect the surgeon s profile. Risk of infection and trauma related to the catheter. Emergency Medicine physicians Up to half of the patients are admitted through the emergency department (ED). Inappropriate urinary catheter placement is common in the ED. Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide. 24 12
Physician Champions and the Team Meet with the other CAUTI team members regularly to discuss the progress of the work (keep meetings efficient and productive). Address the team s concerns about any physician barriers to implementation and work as a facilitator between the team and the physicians. Relay physicians concerns to the CAUTI team to address any barriers to implementation. 25 Physician Champions and Their Leaders Physician leaders should identify physician champions with passion for improving safety and support them to promote a safer environment. Physician leaders should support the physician champion to achieve the goals of the project. The physician champions are at risk of having challenges in their efforts to reduce inappropriate catheter use. Physician champions need to be empowered to be able to succeed. 26 13