An exemplar

Chris Goeschel RN MPS MPSJohns Hopkins Quality and Safety

Research Group

How will we know ?

Funded by AHRQFunded by AHRQ

Total Population: 10,120,860 (8). 2000 percent population 18 and over: 73.9; 65 and over: 12.3; median age: 35.5.

Major Industries - car manufacturing, farming (corn, soybeans, wheat), timber, fishing

10,083 inland lakes and 3,288 mi of Great Lakes shoreline (most registered boaters in the US)

138 acute care hospitals (not all with ICU’s) 3 beds to 1500 beds

The aim was to use evidence-based tools to improve quality and patient safety in Michigan intensive care units.

Reduce harm: BSI and VAP Ensure 90% of patients receive

EB interventions for preventing VAP,

Learn from one defect per month Improve culture of safety 20%

(SAQ) Improve quality improvement

Written Commitment to Participate & Provide Resources to do the work

Senior Leader as part of ICU Team Bi-weekly or Monthly Calls: Collaborative

Leaders, Teams, Hopkins Content, Coaching and Team Sharing

Monthly Standardized Web based Data Collection Transparency at local level “Harm is Untenable”

1. Evaluate culture of safety2. Educate staff on science of safety

http://www.jhsph.edu/ctlt/training/patient_safety.html3. Identify defects4. Assign executive to partner with the unit5. Learn from one defect per month and implement

teamwork tools; daily goals, a.m. briefing, culture checkup

6. Evaluate culture

www.safetyresearch.jhu.eduwww.safetyresearch.jhu.edu

Pronovost J, Pronovost J, Patient Safety,Patient Safety, 20052005

Remove Unnecessary LinesWash Hands Prior to ProcedureUse Maximal Barrier PrecautionsClean Skin with Chlorhexidine Avoid Femoral Lines

MMWR. 2002;51:RR-10

Regular training and education, even if infrequently used, of all devices and equipment.

Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together.

Label wires and sheaths noting the appropriate partner for this device.

ACTIONS TAKEN TO PREVENT HARM IN THIS CASEThe bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together.

Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath.

Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity.

Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire.

CASE IN POINT: An African American male ≥ 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that Matched the pacing wire was not stocked in this ICU since transvenous pacing wires

are used infrequently. The wire was threaded and placed in the ventricle and staff Soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no Possibility for removal at that time. To reduce the patient’s risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape.

Safety Tips: Label devices that work together to complete a procedureRule: stock together devices need to complete a task

Safety Tips: Label devices that work together to complete a procedureRule: stock together devices need to complete a task

SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT:

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One of most common leadership mistakes is expecting technical solutions to solve adaptive problems….

Ron Heifetz “Leadership without Easy Answers

Creating Reliable Health care

Executive Leaders Team Leaders Staff

Engageadaptive

How Do I Make the World a Better Place?How do I create an organization that is safe for patients and rewarding for staff?How does this strategy fit our mission?

How Do I Make the World a Better Place?How do I create a unit that is safe for patients and rewarding for staff?How do I touch their hearts?

How Do I Make the World a Better Place?Do I believe I can change the world, starting with my unit?Can I help make my unit safer for patients and a better place to work?

Educatetechnical

What Do I Need to Know?What is the business case?How do I engage the Board and Medical Staff?How can I monitor progress?

What Do I Need to Know?What is the evidence?Do I have executive and medical staff support? Are there tools to help me develop a plan?

What Do I Need to Know?Why is this change important?How are patient outcomes likely to improve?How does my daily work need to change?Where do I go for support?

Executeadaptive

What Do I Need to Do?Do the Board and Medical Staff support the plan and have the skills and vision to implement?How do I know the team has sufficient resources, incentives and organizational support?

What Do I Need to Do?Do the Staff Know the plan and do they have the skills and commitment to implement? Have we tailored this to our environment?

What Do I Need to Do?Can I be a better team member and team leader?How can I share what I know to make care better?Am I learning from defects?

Evaluatetechnical

How Will I Know I Made a Difference?Have resources been allocated to collect and use safety data?Is the work climate better?Are patients safer?How do I know?

How Will I Know I Made a Difference?Have I created a system for data collection, unit level reporting, and using data to improve?Is the work climate better?Are patients safer?How do I know?

How Will I Know I Made a Difference?What is our unit level report card?Is the unit a better place to work? Is teamwork better?Are patients safer?How do I know?

© Quality and Safety Research Group, Johns Hopkins University

Engage (local work) Opportunity calculator, stories of harm

Educate (central work) Original papers, fact sheet, slides

Execute (local work) Standardize, create independent checks,

learn Evaluate (central work)

Web based data reports

State Hospital ICU

How often did we harm? ( rate based measure: infections)

How often do we do what we should? rate based (JCAHO, CMS, vent bundle)

How do we know we learned from mistakes? (sentinel events, NQF Safe practices)

Are We Improving Culture?

Safety Scorecard

Time period Median CRBSI rate

Incidence rate ratio

Baseline 2.7 1

Peri intervention

1.6 0.76

0-3 months 0 0.62

10-12 months 0 0.42

16-18 months 0 0.34

80% Reduction in BSI in One Year from 103 ICU

Data from 100 ICUs Analysis: multilevel GLLAMM

 

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Safety Climate Across Michigan ICUs

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No BSI 21%No BSI 21% No BSI 44%No BSI 44% No BSI 31% No BSI 31%

No BSI = 6 months or more w/ zeroNo BSI = 6 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

20 40 60 80% Reporting Good Teamwork Climate

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In Hindsight, the Successful KICU Project Looks Easy

Participants Say These Results Never Would Have Been Achieved

Without the Johns Hopkins Keystone ICU Collaborative

Why is That??

Use evidence-based toolsPilot – Input from frontline staff is

key Make sure tools are practicalTreat the project like a clinical trial Involve frontline staff in the

initiative– ownership AND provide feedback

Project goals must drive measurement Care most about patient level goals; others are

predictor variables

Design data collection and management plan at outset Reduce bias in data collection

Give up on quantity not quality of data Central Development/ local implementation

Strive for scientifically sound, feasible, useable

Adaptive lessons Commit that harm is untenable; make

harm visible▪ What are CLABSI rates? Do all clinical

caregivers know them? Ohana

▪ How have you shared what you are learning with others? Administrators, clinicians, teams, facilities?

Local modification of execution▪ Have you adapted the implementation in

light of your organizational culture?

Leadership Engagement Regional Collaborative Leaders Hospital Executive/Administration Clinicians

Ownership The teams and staff must own the project Collaborative “Virtual Learning

Community”▪OHANA