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Mercy Health – Anderson Hospital

Safety Across the SystemSuccesses with Fall Reduction, Handoff and SSI

D14 E14

Session Objectives

1. Participants will be able to describe the importance of

Attention, Understanding, Connection and Tempo in

order to realize rapid, significant change.

2. Participants will be able to describe small tests of

change, and how front line staff can use this to drive

monumental improvements

3. Participants will be able to describe improvements

related to falls, antibiotic redosing, surgical case

debriefs, handoffs, etc. while using these techniques.

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Disclosure

Mark Ziegler, MD

Janice Maupin, RN, MSN, CPHQ

Dominique Wells, RN

Carrie Herron, RN, BSN, ONC

Kristin Shelley, RN, MSN

Julie Holt, RN, MSN

These presenters have nothing to disclose.

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Cincinnati More than 100 locations

serving a population of 1.3 million people

Licensed beds 193

Staffed beds 178

Admissions 12,250

ED visits 47,656

Deliveries 1,822

Outpatient visits 117,595

Surgeries 9,954

Mercy Health – Anderson Hospital

2011

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Safety Across the System (SAS)

Key Principles:

• Identify potential risk for harm

• Hypothesize potential solutions

• Conduct small tests of change on potential

solutions

• Make rapid adjustments to small tests of change

• Implement solutions

• Spread solutions

• Change the culture of safety

SAS Infrastructure Overview

Med-Surg PeriopLeadership

SAS TEAM

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SAS Structure

Lead

Transformational

Agent

Transformational

Agent

(Staff)

Executive

Leadership

Team(Multidisciplinary, Managers & Staff)

Patient Advisory

Council (2013)

Leadership RepImprovement

Advisor

Transformational

Agent

(Staff)

Transformational

Agent

(Prof Practice)

Transformational

Agent

(Ancillary)

Keys to Success

Small Tests of Change (STOC)

Staff EngagementFrequent Data Use

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Small Tests of Change

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What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

PLAN

DOSTUDY

ACT

Outcome

PDSA Report Out

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Projects and Successes to Date

• 100% surgical cases conduct post-case debrief – baseline: 0%

• 95% surgical cases > 3 hours re-dosed with antibiotic –

baseline: 40%

• 79% decrease in Class 1 SSI infection rate – from 0.56 to 0.12

• Electronic WHO Surgical checklist implemented in CarePATH

• 25% reduction in inpatient fall rate

• 90% safety rounds on surgical units – baseline: 0%

• 100% bedside handoff in PACU – baseline: 0%

• 90% bedside handoff in ED admissions – baseline: 0%

• 5 Leadership Walkrounds per month; one on nights – baseline: 1/mo

• 95% completion of actionable items from Walkrounds – baseline: 80%

Leadership Workstream

Tests of Change related to:

•Leadership Walkrounds

•Spread to off shifts

•Increase accountability by posting results on intranet

•QOS Rounds- incorporate

•Calendar White Space

•Capacity for Improvement

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Leadership Principles

• Attention

• Understanding

• Tempo

• Connection

Bedside Handoff

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Common Factors Causing Adverse Events

72% Reduction

Bedside Handoff: Small Tests of Change

• 2011 – Bedside handoff within inpatient units

• 2012 – Bedside handoff between departments

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Inter-Departmental Handoff Compliance Data 2012

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Safety / Falls

Falls Prevention Driver Diagram

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Falls per 1000 Patient Days HospitalPre-SAS rate: 3.5

Post-SAS rate: 2.6 25%

353 days since fall w/harm

Begin SAS

Project

New nurse

call system155 days 353 days

Fall Prevention: Small Tests of Change

• “Stay With Me” Program

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Fall Prevention: Small Tests of Change

• Trial Variations of Patient Acuity Tool

Fall Prevention: Small Tests of Change

• Visual triggers for high risk fall patients

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Fall Prevention: Small Tests of Change

• Hourly Rounding

Fall Prevention: Small Tests of Change

• Safety Rounds

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Data Collection: Bed Alarm Compliance

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Peri-Operative

Peri-op Defect Board

Spread

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Surgical Safety Checklist (WHO)

Class 1 Surgical Site Infection Rate2008-3Q12

Begin SAS

Project

UCL

LCL

79% decrease

began

79% decrease

since SAS

began

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IPT3200m “Germinator”

Time

12-20 minutes per room

25-30 minutes per OR suite

• Mobile Ultra-violet

Technology

• Consistent sterilization

process; kills spores

• Photo chemical damage to

RNA & DNA

• Room tracking system

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Physician Engagement

New Peri-operative SAS Protocols

• Expanded time-out including the W.H.O. checklist

• Post procedure debriefing in the OR

• Peri-operative antibiotic re-dosing

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Ongoing Peri-Operative SCIP Projects

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Antibiotic Elimination Half Lives

Cefazolin 108 min

Cefoxitin 41 – 59 min

Cefuroxime 80 min

Ampicillin/Sulbactam 60 min

Metronidazole 6 hours

Vancomycin 4 – 6 hours

Peri-operative Antibiotic Re-Dosing

Protocol

•Responsibility of the Anesthesia Team

•Re-dosing schedule

•Memo of introduction

•Availability of Drug

•Initiation

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Anesthesia Record

Tests of Change

• Educate Anesthesia providers

• Identification of cases >3hrs

• Assign circulating OR nurse

• Laminated re-dosing protocols

• Re-educate Anesthesia staff

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Antibiotic Re-dosing Cases > 3 hrs

Lessons Learned•Change to improve patient care was well received

•Clear and well defined goals

•Honest evaluation of the steps to accomplish goals

•Early communication

•Frequent assessment of progress

•Continued monitoring

•Continued education

•Test of Change Methodology really works

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New Peri-operative SAS Protocols

Collaboration

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Hospital Culture Impact

• Patient Experience

• Employee Engagement

• Patient Safety Culture

SAS Meetings

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Patient Experience Points 2011- 12

SAS

begins

VBP: 2011: 0

2012: 26

Employee Engagement – Overall Satisfaction

3.00

3.20

3.40

3.60

3.80

4.00

4.20

4.40

4.60

B1 B3 A1/A3 SDS PACU ICU Cath Lab A2 ED

2011 2012

5 point scale

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NDNQI RN’s Perception

of Quality of Care

3.06

2.83

2.93

2.74

2.5

2.71

3.41

3.02

2.95

2.882.84 2.83

2.3

2.5

2.7

2.9

3.1

3.3

3.5

B1 A1/A3 B3 Day Surg OR PACU

2011 2012

4 point scale

SAS Spread and Sustainability

SAS Team

PeriopCath

Lab

A2

B1 ICU

B3

A1ED

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Next Steps

• Incorporate SAS and Small Tests of Change into our

overall Improvement Model.

• Transition to Partnership for Patients

• Continue to integrate more disciplines and

departments into process

• Blend Nursing Shared Governance and SAS

• Add Patient Advisors/Patient Advisory Committee in

2013

• Continue to spread throughout our system

Thank You to all those who

started the journey….Gyasi Chisley, Chief Operations Officer

Julie Holt, Chief Nursing OfficerJanice Maupin, Director of Quality Services

Edward Ruffennach, Director Peri-Operative Services

Terri Martin, Director Patient Care ServicesCarrie Herron, Orthopedic Ctr Excellence Mgr

Kristin Shelley, Manager, Medical Surgical NursingKim Hammock, Clinical CoordinatorAngela Joyce, Clinical Coordinator

Tiffany Hudson, Clinical CoordinatorDominique Wells, Mgr, PACU/SDS

Katie McClure, Staff RNDr. Mark Ziegler, Anethesiologist

Melissa Fritz, Staff RNDenise Evans, Manager OR

Denise Irizarry, RN Blackbelt Advisor