improving the quality and safety of patient care · hygiene says a lot about our overall attention...

Pediatrics Grand Rounds

23 March 2012

University of Texas Health Science

Center at San Antonio

1

archildrens.org uams.edu arpediatrics.org archildrens.org uams.edu arpediatrics.org

Improving the Quality and Safety of Improving the Quality and Safety of Patient CarePatient Care

Lessons Learned from Hand HygieneLessons Learned from Hand Hygiene

W. Matthew Linam, MD, MS


DisclosuresDisclosures

• I have nothing to disclose.


ObjectivesObjectives

• Understand the basic components of the Model for Improvement

• Effectively use data to guide the improvement process

• Be able to design and run test a change

• List the steps needed to sustain improvement


WHY DO WE NEED TO IMPROVE?WHY DO WE NEED TO IMPROVE?


Medical ErrorsMedical Errors

Mortality • 44,000-98,000 Americans die each year from medical errors

(1999 est.)

Prevalence • 2.9%-3.7% hospitalized patients have an adverse event

(annual estimates) • Adverse drug reactions occur during 2.0%-6.7% of hospital

admissions (annual estimates)

Cost • Cost attributable to medical errors (2008 est.) is $19.5 billion • Total cost per error (2008 est.) is $13,000 • Annual cost attributable to surgical errors (2008 est.) is $1.5 billion

Institute of Medicine Committee on the Quality of Health Care in America . To Err is Human: Building a Safer Health System. November 1999.


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HealthcareHealthcare--Associated InfectionsAssociated Infections

Each year in U.S. hospitals alone:

• 1.7 million healthcare-associated infections

• 99,000 associated deaths

www.cdc.gov


Why do We Fail? Why do We Fail?

“One of the report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”

Institute of Medicine Committee on the Quality of Health Care in America . To Err is Human: Building a Safer Health System. November 1999.

How will we know that a change is an improvement?

Plan

Do Study

Act

What are we trying to accomplish?

What changes can we make that will result in

improvement?

The Improvement Model


So Why Hand Hygiene?So Why Hand Hygiene?

• Hand hygiene is one of the most important ways to prevent healthcare-associated infections (HAIs)

• How we treat a simple safety measure like hand hygiene says a lot about our overall attention to patient safety.

• Education and supply availability have not proven to be enough

• Complex behavior – Self efficacy – Behavior of role models and peers – Expectations of leadership – Long-standing habits


Evidence Supporting the Effectiveness Evidence Supporting the Effectiveness of Hand Hygieneof Hand Hygiene

• Hospitals that have improved the hand hygiene practices of their healthcare workers have: – Decreased their rates of (HAIs) by almost 50%

– Decreased the HAI rate of multi-drug resistant bacteria like MRSA from 0.52 to 0.24 per 1,000 patient-days

– Decreased the HAI rate of hospital-associated viral infections such as rotavirus from 5.9 to 2.2 episodes per 1,000 discharged patients

Pittet, D. et al. The Lancet. Vol 356. October 14, 2000: p1307-12.

Lederer J.W. et al. The Joint Commission Journal on Quality and Patient Safety. Vol 35. No 4 April 2009: p180-5.

Zerr DM et al. PIDJ. 2005 May;24(5): 397-403.

Lam BC et al. Pediatrics. 2004 Nov;114(5): e565-17.


What Actually HappensWhat Actually Happens

• Overall median hand hygiene compliance rate: 40%

• ICU settings: 40-50%

• Non-ICU settings: 50-60%

• Physicians: 32%

• Nurses: 48%

• Before care: 21%

• After care: 47% Erasmus et al. ICHE. March 2010, vol. 31, no. 3. p283-94.


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Plan

Do Study

Act



improvement?



Defining a ProblemDefining a Problem If I had only one hour to save the world, I would spend 55 minutes defining the problem and only five minutes finding the solution.

- Albert Einstein


Defining the ProblemDefining the Problem

• Collect data about the problem

– Key outcomes

– Processes related to the problem

• Review the literature

• Talk with people intimately related to the problem

– Frontline staff

– Patients and families


Hand Hygiene Improvement Project Hand Hygiene Improvement Project DesignDesign

• This was a quasi-experimental study using a staggered intervention design.

• Interventions were sequentially tested on 2 general pediatric units using the model for improvement.

• 12 months of baseline hand hygiene compliance data was obtained prior to interventions.

• Measurement of HCW hand hygiene compliance was performed by covert observations made during routine patient care.

Baseline Descriptive Characteristics of Unit A and Unit B

Characteristic Unit A Unit B

Number of single patient rooms 26 44

Primary patient population

adolescents

pulmonary/ cystic fibrosis

orthopedic

psychiatric

neurology

neurosurgery

general pediatric

child abuse

Percentage of patients in isolation other

than standard precautions 23.8% (n= 1668) 16.8% (n= 2542)

Location of sinks

Inside each patient door Inside each patient door

Location of alcohol gel dispensers

Inside and outside

each patient door

Inside each patient door

with 6 spaced along the hallways

Location of personal protective

equipment (gowns, gloves, and masks)

Multiple cabinets spaced throughout

the unit

Multiple cabinets spaced

throughout the unit

Percentage of hand hygiene supplies

partially available 1.7% (7 / 420) 1.6% (12 / 761)

Healthcare worker type n = 1668 n = 2553

Physician 15.6% 13.2%

Nurse 49.2% 53.7%

Patient care attendant 23.3% 22.8%

Respiratory therapist 3.6% 1.2%

Hand hygiene improvement interventions

on unit

1. Online module and presentation

2. Alcohol gel dispensers placed outside

patient doors

1. Multidimensional improvement

2. Online module

Percentage of Healthcare Worker Hand Hygiene Compliance

Both Before and After Patient Care by Unit from

November 1, 2007 through November 9, 2008

Unit A Unit B

Variable Percent n Percent n OR 95% CI P

Overall

Hand hygiene before

and after

64.6% 1595 73.8% 2434 0.65 0.56- 0.74 < 0.001

Hand hygiene before

care only

70.7% 1635 78.7% 2487 0.65 0.57- 0.75 < 0.001

Hand hygiene after

care only

76.1% 1626 82.3% 2489 0.68 0.59- 0.80 < 0.001

Isolation

Standard precautions 59.1% 1217 72.5% 2020 0.55 0.47- 0.64 < 0.001

Other isolation 82.5% 378 80.9% 403 1.12 0.78- 1.61 0.552

Hand hygiene

supplies

All supplies available 67.8% 398 71.3% 721 0.85 0.65- 1.11 0.228

Supplies partially

available

28.6% 7 83.3% 12 0.08 0.005- 1.06 0.045

HCW type

Physician 49.0% 253 67.5% 323 0.46 0.33- 0.65 < 0.001

Nurse 64.5% 785 75.5% 1310 0.59 0.48- 0.71 < 0.001

Patient care

attendant

71.9% 370 76.3% 556 0.8 0.59- 1.07 0.135

Respiratory therapist 90.9% 55 67.9% 28 4.74 1.41- 15.95 0.008


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Control Limits Percent Center Line Special Cause

Last update: 11-06-08 by M. Linam, Data source: Hand Hygiene Database

HAND HYGIENE COMPLIANCE

A6N

Statistical Process Control Chart Showing Percentage of Hand Hygiene

Compliance Both Before and After Patient Care by Month from January 1, 2008 through October 31, 2008 on Unit A


Literature ReviewLiterature Review

• HCWs knowledgeable about when, how and why to perform hand hygiene correctly

• Hand hygiene supplies consistently available at the point of care

• Leadership committed to improving hand hygiene compliance

• HCW behavior had to be addressed

– Create a change in culture

– Change long-standing habits Lederer J.W. et al. The Joint Commission Journal on Quality and Patient Safety. Vol 35. No 4 April 2009: p180-5. How-to Guide: Improving Hand Hygiene A Guide for Improving Practices among Health Care Workers.

Setting Project Goals

S

M

A

R

T

SPECIFIC

MEASURABLE

ATTAINABLE

RELEVANT

TIME-BOUND


Goals vs. SMART GoalsGoals vs. SMART Goals

Goal: Improve the hand hygiene compliance of healthcare workers (HCWs) throughout the hospital

SMART Goal: To improve hand hygiene compliance among HCWs on units A and B from a baseline compliance of 65% and 74%, respectively, to > 90% within 6 months.


Plan

Do Study

Act



improvement?



Effective MeasurementEffective Measurement

• Outcome Measures – Measure the performance of the system under study

– Directly relate to the aim of the project

• Process Measures – Measure whether the parts/steps in the system

performing as planned

• Balancing Measures – Measure whether changes designed to improve one

part of the system cause problems in other parts of the system


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Measuring Quality Vs. Research Research

Quality

Vs.

Measuring Quality Vs. Research

Measurement for Research Measurement for Learning and Process Improvement

Purpose To discover new knowledge To bring new knowledge into daily practice

Tests One large "blind" test Many sequential, observable tests

Biases Control for as many biases as possible

Stabilize the biases from test to test

Data Gather as much data as possible, "just in case"

Gather "just enough" data to learn and complete another cycle

Duration Can take long periods of time to obtain results

"Small tests of significant changes"

www.IHI.org


Variation in Healthcare SystemsVariation in Healthcare Systems

INTENDED VARIATION

• Part of effective, patient-centered care

• One size does not fit all

• Often called purposeful, planned, guided or considered

UNINTENDED VARIATION

• Due to changes introduced into healthcare process that are not purposeful, planned or guided

• Creates inefficiencies, waste, rework, ineffective care, errors and injuries in our system


Sources of VariationSources of Variation

COMMON CAUSE

• Inherent in the process over time

• Affect all outcomes of the process

• Seen by chance

• Stable Process

• Process is in statistical control

SPECIAL CAUSE

• Not part of the process, arise from specific problems

• Assignable

• Unstable Process

• Process is not in statistical control

Langley GL, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition); 2009


Hand Hygiene ComplianceHand Hygiene Compliance

• Performance of acceptable hand hygiene both BEFORE and AFTER encountering the patient or the patient’s immediate care environment (bed, over-the-bed table, IV pump or pole, etc.).


Acceptable Hand HygieneAcceptable Hand Hygiene

• Application of an alcohol hand rub product with complete

coverage of hands and fingers

• Hand washing with soap followed by turning off the

faucet without using fingers or the palm of the hand

• For patients on isolation, appropriate personal protective

equipment (including gloves) donned upon room entry

then removed and hand hygiene performed before

exiting the room


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The Data Collection ProcessThe Data Collection Process

• Cohort of 15 patient attendants (12% of the 128 patient attendants)

• Patient attendants provide 24-hour bedside observation of patients who have medical or behavioral conditions that could result in self-injury, removal of medical devices, flight or abduction.

• Trained by the infection control staff

• Hand hygiene observations were recorded on a standard data collection tool

– Make up to 8 observations during an 8-hour shift

– No more than 2 observations on any one HCW during a shift

• Entered into a database by a single person

• To ensure consistency of the data collection

– handbook was created

– infection control staff met with the data collection team monthly

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plian

t

Control Limits Percent Center Line Special Cause

Last update: 11-06-08 by M. Linam, Data source: Hand Hygiene Database

HAND HYGIENE COMPLIANCE

A6N

Statistical Process Control Chart Showing Percentage of Hand Hygiene

Compliance Both Before and After Patient Care by Month from January 1, 2008 through October 31, 2008 on Unit A


Plan

Do Study

Act



improvement?



What is a Test?What is a Test?

• Putting a change into effect on a temporary basis and learning about its potential impact


Reasons to Test ChangesReasons to Test Changes

• To increase your belief that the change will result in improvement

• To evaluate how much improvement can be expected from the change

• To test whether the proposed change will work in the environment of interest

• To evaluate costs, social impact, and side effects from a proposed change

• To minimize resistance to the change

PDSA Model

Plan

Do Study

Act


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Appropriate Scope for a PDSA Cycle

Current Situation Resistant Indifferent Ready

Low Confidence that change idea will lead to Improvement

Cost of failure large

Very Small Scale Test



Cost of failure small



Small Scale Test

High Confidence that change idea will lead to Improvement

Cost of failure large


Small Scale Test

Large Scale Test

Cost of failure small

Small Scale Test

Large Scale Test

Implement

Staff Readiness to Make Change

Langley GL, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition); 2009 archildrens.org uams.edu arpediatrics.org archildrens.org uams.edu arpediatrics.org

PDSA PitfallsPDSA Pitfalls

• Tests that are miss-sized for the stage of the project (too big or too small)

• No prediction or hypothesis before testing the change

• Lack of a detailed execution plan

• Failure to perform the entire cycle

• Failure to use qualitative measures

• Not learning from “failures”


Testing vs. ImplementingTesting vs. Implementing

• Testing: Putting a change in place on a temporary basis

• Test on a small scale first

• Test under as many different conditions as possible

• Learn from successes and failures

• Adapt the change based on what is learned

• Implementing: Making the change a part of the day-to-day operation of the system

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Evidence

Best Practice

Testable Ideas

Use of PDSA cycles


Choosing a TestChoosing a Test

Does the choice of intervention matter?


• Prevent: Most improvement efforts begin with an intent to follow a uniform standard process or guideline. This can improve reliability to roughly 90%.

– Basic standardization

– Memory aids such as checklists

– Feedback mechanisms regarding compliance with standards

– Awareness-raising and training

Nolan T, et al. IHI Innovation Series: Improving the Reliability of Health Care. 2004


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• Identify and Mitigate: Strategies to reduce the opportunities for humans to make mistakes or “error-proofing” can improve reliability to at least 95%.

– Building decision aids and reminders into the system

– Making the desired action the default (based on evidence)

– Creating intentional redundancy

– Scheduling key tasks such as discharges

– Taking advantage of existing habits and patterns Nolan T, et al. IHI Innovation Series: Improving the Reliability of Health Care. 2004


• Passive interventions, such as increasing availability of alcohol-based hand products:

– Did not improve compliance unless they were coupled to interventions that also changed behavior

• Multimodal interventions that focused only on education and supply availability:

– Improved hand hygiene compliance to 55%-80%

• Multimodal interventions that addressed HCW behavior:

– Improved hand hygiene compliance to 80%-98%


• Hand hygiene habits are developed by around 9 years of age

• Hand hygiene driven by sense of self-preservation

• Our long-standing habits do not match up with what is expected in the healthcare setting

• When faced with time constraints HCWs make judgment calls based on the perceived risk

• Perceived hand hygiene is consistently better than what is actually measured

Whitby M, et al. Infect Control Hosp Epidemiol. 2006;27(5):484-492

Aim : To show sustainable

improvement in hand hygiene

compliance among healthcare

workers on units A and B from

a baseline compliance of 65%

and 74%, respectively, to

> 90%.

1. Leadership committed to

improving hand hygiene

compliance

Key Drivers/ Processes

Design Changes

Project Aim

4. Correct hand hygiene is

the social norm

3. Hand hygiene supplies

consistently available at

the point of care

Education

1. Online hand hygiene learning

module

2. Multimodal education using

unit education rounds

System Change

1. Reliable stocking and repair

process for supplies

2. Placement of additional

alcohol hand-rub dispensers

outside all patient rooms

Behavior Change

1. Visibly posting unit hand

hygiene data

2. Presentation to increase

awareness

3. Reminder signs on patient

doors

4. Identification and mitigation

of incorrect behavior

5. Facilitate HCWs reminding

each other

Measure: Performance of

acceptable hand hygiene both

BEFORE and AFTER

encountering the patient or

the patient’s immediate care

environment (bed, over-the-

bed table, IV pump or pole,

etc.).

2. HCWs knowledgeable

about when, how and why

to perform hand hygiene

correctly

Leadership 1. Unit leadership committed

2. Unit leaders serve as role

models and educators


Identify and MitigateIdentify and Mitigate

• Patient attendants carry a handheld bottle of alcohol-based hand rub

• If a HCW enters the room, and forgets to perform hand hygiene the patient attendant kindly offers the HCW hand gel

• Initially tested only on unit A

• Due to its success it was quickly spread hospital-wide

• Observations were recorded based on the HCWs intended behavior

Annotated Statistical Process Control Charts Showing Percentage of

Hand Hygiene Compliance Both Before and After Patient Care by Month from November 1, 2007 through April 30, 2010 on Unit A


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Annotated Statistical Process Control Charts Showing Percentage of

Hand Hygiene Compliance Both Before and After Patient Care by Month from November 1, 2007 through April 30, 2010 on Unit B


Barriers and Keys to SuccessBarriers and Keys to Success

• Barriers – Trying to overcome long-standing habits – Lack of belief their hand hygiene was poor

• Keys to success

– Support from the unit leadership was crucial – Interventions built upon existing processes – Worked to increase awareness and urgency – The identify and mitigate process was able to improve

hand hygiene compliance to 90% or greater across multiple HCW types


Implementing a Successful ChangeImplementing a Successful Change

• Implementation is a permanent change to the way work is done

• If the change is not built into the process improvement often erodes over time

• Key components necessary for sustainability

– Process owner

– Ongoing monitoring process

– Redesign of the system


Designing for SustainabilityDesigning for Sustainability

• Process owner:

– who is going to oversee the new process?

– Who is going to monitor the data collection?

• Monitoring system:

– Integrate the data collection plan to monitor the process and continued improvement

– Have a process in place to address special causes and trends in the data


Designing for SustainabilityDesigning for Sustainability

• Redesigning the system:

– Update key stakeholders

– Create a revised process map

– Update policies and procedures

– Redesign job responsibilities

– Training employees in the new procedures and use of new equipment


SPREADING IMPROVEMENTSPREADING IMPROVEMENT


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Arkansas Children’s Hospital Hand Arkansas Children’s Hospital Hand Hygiene Improvement Project GoalHygiene Improvement Project Goal

• To improve hand hygiene compliance for each patient care unit to at least 90% and show sustained improvement for at least 6 months

To improve hand hygiene compliance for each patient care unit to at least 90% and show sustained improvement for at least 6 months

1. Leadership committed to

improving hand hygiene

compliance

Key Drivers/ Processes

Design Changes

Project Aim

4. Correct hand hygiene is

the social norm

3. Hand hygiene supplies

consistently available at

the point of care

Education and Training 1. ACH Moments for Hand

Hygiene posters

2. Online education module

3. Update new employee

orientation

Supply Availability 1. Reliable restocking process

for supplies

2. Placement of alcohol hand-

rub dispensers in the path of

care

Behavior Change

1. Sharing compliance data with

staff

2. Immediate positive feedback

to staff

3. Resident physician team-

based competition

Measure: Performance of

acceptable hand hygiene

upon ENTERING and

LEAVING the patient’s care

environment (zone).

2. HCWs knowledgeable

about when, how and why

to perform hand hygiene

correctly

Leadership 1. Senior leadership priority

2. Unit leadership makes hand

hygiene a priority

3. Hand hygiene Infomercial

HCW indicates healthcare worker.


Plan

Do Study

Act



improvement?



WHERE DO WE GO FROM HERE?WHERE DO WE GO FROM HERE?


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Additional ReferencesAdditional References

• Whitby M, et al. Am J Infect Control. 2008;36(5):349-355

• Pittet D, et al. Lancet. 2000;356(9238):1307-1312 • Lam BC, et al. Pediatrics. 2004;114(5):e565-571

• Lederer JW, et al. Jt Comm J Qual Patient Saf. 2009;35(4):180-185 • Won SP, et al. Infect Control Hosp Epidemiol. 2004;25(9):742-746 • Zerr DM, et al. Pediatr Infect Dis J. 2005;24(5):397-403

improving the quality and safety of patient care · hygiene says a lot about our overall attention...

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