leading the way in patient quality and safety · 3 unlabeled syringes-patient given wrong syringe...

Leading the way in patient quality and safety

Leading the way in patient quality and safety

3

Unlabeled syringes-Patient given wrong syringe of medication

Wrong syringe is water for injection -no injury

Wrong syringe is medicines which requires that the patient is monitored for 24hrs

Wrong syringe is medicines which requires that the patient is treated with other medication and is monitored in ICU for an extended period

Wrong syringe is medicines which results in the patient's death

This is the only act that is controllable – the rest is luck/out of our control

Evolution of safety and quality improvement

We are

perfect/good

enough !

Get rid of

the bad apples

NO ACTION REACTION PROACTIVE

Quality

assurance

“Standards”

Minimal

Governance

•Governance

•Committees

•Incident reporting

•Counselling, Disciplinary

action

•Training, training, training

Improvement science

It does not

happen in our

hospital!

Standards are

deteriorating

Individual

champions of

improvement

REACTION

• Stories

•Pockets of Excellence

•Before and after

Projects

Focused, risk-based,

best practice, evidence

based, team based

System

thinking

Process improvement

Quality

improvement

•Best practice

•Measurement over time

•Engagement

•Stories

•Spread

Integrated Systems

Collaborative,

engagement

patients and

doctors,

INNOVATIVE

Value

•Breakthrough

• Minimise variation

•Sustainability

•Pursuing perfection

BetterQUALITY

Worse

?bettercare Reject

defects?

Requirement, specificationor threshold

Micro-manage

Filter theinformation

Increasefear

Kill themessenger

Carol Haraden BCA QI Summit 2013Source: Robert Lloyd, Ph.D.

Systems select for “winning”/low risk

Gaming/Cheating

Model 1: “Bad Apples” theory = someone to blame

Juran Trilogy:

Quality defects

Time

40

20

0

Quality

improvement

Original zone of

quality control

New zone of

quality control

e.g. % patient complaintspatient safety - HAI/Falls/Outside of clinical benchmark or target

Copyright 2018 © Dena van den Bergh. DNAVision.

Understanding systems

Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School

“Every system is perfectly designed

to achieve exactly the results it gets”

“All improvement needs a change Not all change is an improvement”

More of same change will not result in improvement

Complexity/Effort

Tools and dataTechnology, brochures, posters, SOPs, Reports

Process

Embedding who does

what, when, where

Culture

Behaviour,

leadership style

engagement

Imp

act

Evolution of safety and quality improvement

We are

perfect/good

enough !

Get rid of

the bad apples

NO ACTION REACTION PROACTIVE

Quality

assurance

“Standards”

Minimal

Governance

•Governance

•Committees

•Incident reporting

•Counselling, Disciplinary

action

•Training, training, training

Improvement science

It does not

happen in our

hospital!

Standards are

deteriorating

Individual

champions of

improvement

REACTION

• Stories

•Pockets of Excellence

•Before and after

Projects

Focused, risk-based,

best practice, evidence

based, team based

System

thinking

Process improvement

Quality

improvement

•Best practice

•Measurement over time

•Engagement

•Stories

•Spread

Integrated Systems

Collaborative,

engagement

patients and

doctors,

INNOVATIVE

Value

•Breakthrough

• Minimise variation

•Sustainability

•Pursuing perfection

Evolution of safety and quality improvement

We are

perfect/good

enough !

Get rid of

the bad apples

NO ACTION REACTION PROACTIVE

Quality

assurance

“Standards”

Minimal

Governance

•Governance

•Committees

•Incident reporting

•Counselling, Disciplinary

action

•Training, training, training

Improvement science

It does not

happen in our

hospital!

Standards are

deteriorating

Individual

champions of

improvement

REACTION

• Stories

•Pockets of Excellence

•Before and after

Projects

Focused, risk-based,

best practice, evidence

based, team based

System

thinking

Process improvement

Quality

improvement

•Best practice

•Measurement over time

•Engagement

•Stories

•Spread

Integrated Systems

Collaborative,

engagement

patients and

doctors,

INNOVATIVE

Value

•Breakthrough

• Minimise variation

•Sustainability

•Pursuing perfection

Improving Hand hygiene practice in the PICU

Prof Andrew Argent, Red Cross Memorial Hospital

BCA Learning Session2 WC 2011

from a Report of a

participative

observational study

done

Candice Bonaconsa

and

Minette Coetzee

Child Nurse Practice

Development

Initiative

Calculating the %of hand hygiene

How we did this:

Actual x 100 = %

opportunity

Comparative table of hand hygiene – bed space

24%

38%

7%

75%

Doctors Nurses Other Visitors

Target 90%

Red Cross Memorial Hospital

BCA Learning Session2 WC 2011

Reviewing systemsTime Opportunities Used opportunities %

10:00 – 11:00 12 2 16.7

11:15 – 12:15 11 2 18.2

21:30 – 22:30 14 3 21.4

22:30 – 23:30 7 1 14.3

14:15 – 15:15 11 1 9.1

15:20 – 16:20 7 3 42.9

10:45 – 11:45 28 5 17.9

11:45 – 12:45 10 2 20.0

10:30 – 11:30 15 3 20.0

11:30 – 12:30 8 3 37.5

11:30 – 12:30 15 1 6.7

12:30 – 13:30 10 1 10.0

13:30 – 14:30 5 2 40.0

14:30 – 15:30 8 1 12.5

15:30 – 16:30 4 0 0.0

14:00 – 15:00 19 1 5.3

15:00 – 16:00 9 0 0.0

12:00 – 13:00 16 1 6.3

13:00 – 14:00 10 0 0.0

Red Cross Memorial Hospital

BCA Learning Session2 WC 2011

Eliminating Central Line Associated

Blood Stream Infections (CLABSI) in the

Newborn Intensive Care

The Children’s Hospital at Providence, NICU

Pediatrix Medical Group

Anchorage, Alaska

Jack Jacob, MD: jack_jacob@pediatrix.com

Debra Sims, RNC: debra.sims@providence.org

Grace Schmidt, RNC: grace.schmidt@providence.org

Carol Van de Rostyne, ANP: carol.vanderostyne@providence.org

Overview of the Problem:

• 2002-2003: We were performing in the median for nosocomial sepsis

when compared to similar NICUs. But………

• We saw deaths and severe morbidity related to line sepsis

CR

BS

Is /

10

00

Lin

e D

ay

s

201

0 Q1

Q4

Q3

Q2

200

9 Q1

Q4

Q3

Q2

200

8 Q1

Q4

Q3

Q2

200

7 Q1

Q4

Q3

Q2

200

6 Q1

Q4

Q3

Q2

200

5 Q1

Q4

Q3

Q2

200

4 Q1

Q4

Q3

Q2

200

3 Q1

Q4

Q3

Q2

200

2 Q1

30

25

20

15

10

5

0

_X=1

UCL=5.49

1 2 3

Fig 1 Catheter Related Blood Stream Infections / 1000 Line Days by Quarter

Q4, 2003 - Implemented Best Practices:

- Hand Hygeine

- Sterile Barrier Precautions for Line Insertion

- Certainty of Diagnosis

P-Value = 0.044 Q1, 2008

- Externs Prep IVs for Bedside Use

P-Value = 0.022

Q2, 2009

-breakdown in process for TPN

preparation by externs related to

TPN cycling

Our Initial Approach: Best Practices.

• 2003-2006: Implementation of evidenced-based practices and assuring

compliance with those practices

• Ongoing work to change the mental model that vulnerable infants in the

NICU are destined to get an infection

• 2005 to present: Use of Clinical Microsystems principles learned in “Your

Ideal NICU” VON improvement collaborative

© Nelson EC, Batalden PB, Home K, Godfrey MM, Campbell C, Headrick LA, Huber TP, Mohr JJ, Wasson

JH: Microsystems in Health Care: Part 2. Creating a Rich Information Environment. The Joint Commission

Journal on Quality and Safety. Volume 29 (1): 5-15, 2003.

Clinical Microsystems

• We kept a detailed database on each case of sepsis and analyzed the data

• We used the concept of the “web of causation” to understand contributors to sepsis

• We tirelessly had reflective conversations with nursing staff around this issue and learned from them

• We developed a learning culture within the context of our daily clinical work

• We worked on processes and systems improvement

• We involved staff doing clinical care in our work

• We worked across hospital boundaries

• We added standardization to PDSA cycles

Results

CR

BS

Is /

10

00

Lin

e D

ay

s

2012

Q1

Q4

Q3

Q2

2011

Q1

Q4

Q3

Q2

2010

Q1

Q4

Q3

Q2

2009

Q1

Q4

Q3

Q2

2008

Q1

Q4

Q3

Q2

2007

Q1

Q4

Q3

Q2

2006

Q1

Q4

Q3

Q2

2005

Q1

Q4

Q3

Q2

2004

Q1

Q4

Q3

Q2

2003

Q1

Q4

Q3

Q2

2002

Q1

30

25

20

15

10

5

0

_X=0.71

UCL=3.95

1 2 3

1

Catheter Related Blood Stream Infections / 1000 Line Days by Quarter

Q4, 2003 - Implemented Best Practices:

- Hand Hygeine

- Sterile Barrier Precautions for Line

Insertion

- Certainty of Diagnosis

P-Value = 0.044

Q1, 2008

- Externs Prep IVs for Bedside

Use

P-Value = 0.002

Lessons Learned:

• Unit culture and mental models do not change overnight –

persistence and timely feedback of successes is important

• Go to the people who do the work – they have the

answers

• Evidence-based practice alone is insufficient if you want to

achieve perfection in health care

• Developing a learning culture within the context of your

clinical work and clinical Microsystems thinking within your

local context will allow you to obtain success not

imagined.

• The process of evidence-based practice implementation in

conjunction with the use of clinical Microsystems

principles can be applied in any setting to any topic

needing improvement

Leading the way in patient quality and safety

Model for ImprovementAim

What are we trying to accomplish?

ChangeWhat can we change

that could result in

an improvement?

MeasurementHow will we know

that a change

is an improvement?

• Motivating health care

professionals, leaders and

frontline staff to be change

leaders.

• Connect to WHY?

• A call to action

Building Will

“Some is not a number,soon is not a time…hope is not a plan”

Don Berwick IHI

Harnessing the power of the collectiveBreakthrough Series: QI method for collaborative improvement and spread

Accelerating change “together”: creating a learning network

• Learn from each other so we can make a bigger impact faster

• Input of skills, tools and reflective learning

• Identify common challenges and opportunities that we can work on

together

• Motivate and support each other to succeed

• Stretch the boundaries of what is possible

PDCA

cycles

Learning

sessions

Learning

sessions

Learning

sessions

PDSA

cycles

Leadership & Intensive support

No-one wants to do your project but they do want to contribute to a problem that

they agree needs to be solved

Copyright 2018 © Dena van den Bergh. DNAVision. 25

• Collaboration is not a passive process ofsharing ideas and attending events

• Needs strong leadership and a tightly heldcontainer that drives movement and tracksimpact

• Progress is not – “we are having a meeting”

• Strength of being part of something bigger

• Connecting to a significant “WHY”

February Collective Learning Session 1

March Collective Learning Session 2

JuneCollective Learning Session 3

August Collective Learning Session 4

OctoberData for Year End Quality Review

Framework for Collaborative Programme co-design and real-world testing

Fieldwork & Action Learning

Fieldwork & Action Learning

Fieldwork & Action Learning

Fieldwork & Action Learning

27

Adapted from David Munch BCA QI Summit 2013

• QI model breakthrough series

• Pharmacist allocated time

• 116 662 patients reviewed, 7934 interventions,

• 104 weeks standardised measurement & feedback

• 18,1% reduction in antibiotic use

AMS IMPLEMENTATION STUDY -

47 HOSPITALS

• 32,985 patients who received IVI antibiotics assessed forhang-time compliance with first doses of new antibiotic orders over 60-weeks.

• “hang-time” compliance to protocol improved from 41.2% to 78.4%

PHARMACIST-NURSE AMS

COLLABORATION AB TIMELINESS -

33 HOSPITALS

• Pharmacist-driven, prospective audit & feedback

• 70 weeks standardized measurements, 24 206 surgical

• composite compliance from 66.8%to 83.3%

• SSI rate improvement

PERI-OPERATIVE ANTIBIOTIC PROPHYLAXIS34 HOSPITALS

Three multi-center antimicrobial stewardship initiatives

28

Become part of a movement

of healthcare leaders

It’s the movement of people who want to

make real change in healthcare;

who are called to lead improvement and

innovation in quality

and

who are committed to co-creating

value and excellence in healthcare

Leading the way in patient quality and safety