Gary Kantor

Discovery Health

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Day 2

Process Measure

Compliance with bundles

Bar graphs measure the difference between different categories (elements of the bundle)

BEST CARE ALWAYS : COMPLIANCE : CLABSI

Target

Process Measure

Compliance with bundles

Overall compliance to the bundle can only be as good as the worst element.

BEST CARE ALWAYS : COMPLIANCE : SSI Bundle

Process measures for Central Line Bundle

A line graph is used to measure bundle compliance over time

Process Measure

Compliance with bundles• What to measure

• How to collect the data

• How to analyse the data

Checklist for Central Line Insertion

Measuring

Compliance with bundles

Step 1Checklists • help measure • act as a guide

Gary Kantor

Discovery Health

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Checklists

Design for Reliability

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Level 1• Intent, vigilance, hard work

Level 2• Reliability science, process

redesign, human factors

Level 3• High Reliability Organisations

Reliability:

1:10

1:100,000

Anesthesia-related deaths

Unassisted humans can’t achieve better than 1:100 reliability

1:10,000

Human Error• If each step in a ten-step process can

be performed with 99% reliability, that system functions error-free 90% of the time.

• A similar process with 50 steps functions error-free only 61% of the time

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2 experienced pilots…..who had never flown together before

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Captain Chesley "Sully" Sullenberger (57)Former fighter pilot, safety expert

First Officer Jeffrey B. Skiles (49)On last leg of first assignment in the Airbus A320 since passing the training course

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Hero? …….

• The windscreen quickly turned dark brown and several loud thuds were heard. Both engines ingested birds and immediately lost almost all thrust.

• Captain Sullenberger took the controls……“my aircraft!”…while Skiles began going through the three-

page emergency procedures checklist in an attempt to restart the engines.

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Hero

Checklist

Design

Teamwork

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How do you build a skyscraper so it doesn’t fall down?

A typical building site: • Hundreds of workers• Many subcontractors• 16 or more different trades

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USA serious building failures: • 20 per year among >100 million buildings= 0.00002% per year

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How do you run a busy restaurant?

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Mortality 1.5% 0.8% p=0.003Inpatient complications 11% 7% p<0.001

Jan 29, 2009

Non-cardiac surgery3,955 patient in 8 hospitals in 8 cities

• At Johns Hopkins University – America’s #1 hospital – one or more simple steps required for central line insertion were missed 30% of the time

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Peter PronovostMichigan

Pronovost P. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. NEJM Dec 2006

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After checklist implementation (and more)…

• Within 3 months infection rate in Michigan’s ICUs decreased by 66%.

• The typical ICU cut its quarterly infection rate to zero.

• Michigan’s average ICU outperformed 90% of American ICUs.

• In the first 18 months,1500 lives saved.

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Copyright ©2010 BMJ Publishing Group Ltd.

Pronovost, P. J et al. BMJ 2010;340:c309

Sustained improvement !!

Checklists (Bundles): 2 Types1. Applicable to tasks in which

best practice is well understood

2. In situations of complexity/uncertainty, use checklists that foster teamwork and communication

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• What you find, when the checklist is well made, is ….the checklist gets the dumb stuff out of the way so you can focus on the hard stuff”

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• Hand hygiene• Maximal barrier precautions• Chlorhexidine skin antisepsis• Optimal catheter site selection, with subclavian vein as the

preferred site for catheters in adults• Daily review of line necessity with prompt removal of

unnecessary lines

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PREVENT CENTRAL LINE INFECTIONS

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To your planning page add:1.Your aim2.The outcome measures

i) Rate = numerator/denominator (describe)ii) Days betweeniii) Welsh Safety calendariv) Other

3.A process measure4.How you will feedback the data every month to

i) The frontline staffii) Managementiii) Presentation of your process measure

To your planning page add:

1.Your aim2. Process Measures (Bundle compliance)3.The outcome measures

i) Rate = numerator/denominator (describe)ii) Days betweeniii) Welsh Safety calendariv) Other

4.How you will feedback the data every month toi) The frontline staffii) ManagementMark with a * areas that you want to strengthen

Using the priority * areas plan a PDSA to improve or measure

compliance with bundles

• Design or implement a checklist

• How to collect the data (checklist / spot checks)

• How to sample the checklists

• How to analyse the data

• How to display and present the data

• Who to present it too

Select a priority area for improvement

• resolving it will have a big impact• it is under your control to test a change• you can start on Monday

Plan a PDSA using the Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? aim

measurementchange

AIM of this change: PROBLEM :

Design a PDSA to improve one of the areas with a *

AIM: use the Welsh Safety Cross

PROBLEM : staff aren’t engaged in the project

What WhenWhereWhoHow

AIM increase awareness through measurement

AIM: the Welsh Safety Cross is completed

Staff know what it means

Welsh Safety Cross will improve the profile of the project. Will need to engage staff with colouring it in or they won’t take any notice

Mapping the Process

“ All work is a process” W. E. Deming

Process Mapping

• What is a process map?

• Simply put, it is a way of visualizing all the steps taken to get to the desired outcome.

• Steps are shown in sequence as they are taken over time

• Helps identify delays and losses, opportunities for change

Process Mapping Exercise

• As a whole group lets spend the next few minutes creating a process map for getting to work in the morning

Process Mapping Exercise

• How can we get there quicker?

Process Maps• High or low level

• Follow – patient journey– staff (eg gathering equipment)– steps in the protocol– Equipment procurement– etc

Leadership support

Insert Remove

Measure Feedback

Process Mapping Exercise

• Within your groups:– Choose 1 person and together map a process

they work with (draw the process out)– Spend time as a group analyzing the process,

asking each of the questions listed above– Make notations on the map indicating key

learning, important constraints– Time permitting begin to think about how you

would redesign this process (possibly draw an idealized map)

Process Map Analysis• Time – How long?

• Space – Where did the step take place?

• Human Resources – Who did it?

• Geography – How far is the journey?

• Financial Resources – What is the cost and to whom?

Process Map Analysis• How many steps are in the process?

• Examine the order of the steps in the process – are they ideally placed?

• How many transfers occur in the process?

• Where do delays occur in the process?

• Can you identify known bottlenecks in the process?

Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? Aim

MeasurementChange

• How confident are you in your ability to improve on:–Teamwork

–Measurement

–Overall progress

Feedback

• How did you find the workshop?

Feedback

Thank you for your participation