Eliminating CatheterRelated Blood Stream Infections in NICU Patients
Eliminating Catheter-Related Blood Stream Infections in NICU Patients The CCS/CCHA NICU Improvement Collaborative Paul Kurtin, MD Chief Quality and Safety Officer Rady Children’s Hospital & Health Center
All Improvement is Local Think Globally Act Locally
Ground Rules • Sharing individual site data: Blinded yes/no? • Prohibit use of data for marketing or competition • Public release of aggregated data only
Days Without an Injury 100
Days Without an Infection ?
Days Without an Infection 27 Days 2
Days Without an Infection 270 Days 3
Days Without an Infection 27 Hours
Days Without an Infection • How is your unit doing? • Does everyone know? • Is there a run chart in the staff lounge? 4
Days Without an Infection • We can’t manage what we don’t measure. 5
The Case for Redesign • “Every system is perfectly designed to get the results it gets!” • “If we keep doing what we have been doing, we’ll keep getting what we have always gotten” • “The definition of lunacy is keep doing what you’ve always done and expect a different result!”
The Case for Redesign 2 • The case for redesign was made in “Crossing the Quality Chasm” • The gap between the healthcare we have and what is possible is not just a gap…it’s a chasm • Not about working harder or being more careful…must change the fundamentals of the process
Design Goals • Make it easy to do the right thing! • Hardwire changes into routine practice via education, training, order sets, protocols, the environment • All improvement is change, not all change is improvement! We must know the difference (P->D->S->A->P…DMAIC)! Build measurement into the process
Model of Improvement • AIM (smart) specific, measurable, attainable, relevant, timely • Measures • Execute with small tests and cycles of change (PDSA)
AIM • To eliminate All hospital acquired catheter related blood stream infections in NICU patients by June 30, 2007 • Reduce by 50% or 90% • Selected populations e. g. post-op hearts or post bowel surgery
Potential Metrics • Infections/1000 catheter days • Days between infections • Cost/infection (LOS, antibiotics, diagnostic tests) • Morbidity • Mortality • % Bundle compliance: all or none? • Thermometer with: lives saved; days saved; dollars saved
Implementation: Microsystems • • What are they? How to assess their effectiveness? How to improve? How to hold the gains?
Creating a High Reliability NICU • Do the right thing the first time every time! • Visual display of data as reminders • “Stop the line!” • Catheter cart to manage supplies and the environment • It’s the system …not the person (96. 5 % v. 3. 5 %)
What We Know v. What We Believe • We know it’s the system but we believe that the individual, through hyper vigilance and extra effort, will not make a mistake (work harder, be more careful) • Healthcare workers are committed, responsible, accountable, dedicated, (see definition of lunacy)
What We Know v. What We Believe 2 • We trust intelligence at the bedside, clinical experience and acumen, and our ‘gut’ • We question/doubt/distrust the system especially if the system slows us down and decreases our efficiency of doing things
The “Culture Code” • Work = who we are • Quality = it works • Perfection = is not possible and it limits learning by trial and error and our pioneering spirit
Making it stick! • We are a microsystem. How do we design it to sustain the delivery of care which eliminates C-R BSIs? • Focus on the patient • Focus on the staff • Shared leadership • Focus on outcomes and continuous improvement • Information and communication
Improving our Microsystems • • • P. 103* The Model of Improvement P. 104 Team and meeting skills P. 113* PDSA worksheet P. 115 Improvement tools P. 116* Process mapping (current process v. ideal; gaps in planning; gaps in execution) • P. 118 Flowcharting (is this what really happens? ; any steps left out or added? ; all the time, most of the time? Not the P&P, ask the frontline)
Improving our Microsystems 2 • P. 123 Access to information…leads to accountability • P. 124 Change concepts: manage time by reducing set-up time; manage variation by standardization; design to avoid mistakes with reminders and constraints • P. 125 Mental models: why do we think we do/don’t have an infection problem?
Tracking Our Improvement • • • P. 132* Run charts P. 138* Control charts P. 139* Pareto charts P. 141 Change (will, ideas, resources) P. 142 Spread of innovation
Making Change Happen • • • P. 146 Sense of urgency Build a team Create vision and strategy Communicate 8 X 8 Remove barriers (force field analysis) Celebrate small wins
Next Steps • Baseline data: where are we now? Trended if possible • Site visits: when and why? • Microsystem assessment • Resources: continuing communication, web site, document posting, conference calls • Hardwiring: policies and procedures, staff education, non-staff education e. g. radiology
Breakout Session • Each team will: – Develop a SMART aim – List current metrics – Describe potential interventions
- Slides: 28