Rhetoric to Reality

Creating and Sustaining Culture Change

The Execution “Bundle” If evidenced based practice can be bundled

and effective in the clinical arena, then why not on the management side?

What are the principles that when consistently applied over time generate positive, sustainable change?

When do you use a sledgehammer and when do you use a scalpel?

Can I Give You Some A.D.V.I.C.E.? Assess Design Validate Innovate Confront Eliminate

Assess Facility values – what is important to the

stakeholders? Do they value change? Prefer status quo? What are the social norms Who are the pivotal characters Who or what are the obstacles

Design Physician Orientation to set the expectations Medical Staff Leadership Education Medical Staff Documents that support the

values• Mandatory protocol use• “Opt out” vs. “Opt in” language• Physician Conduct Policy with progressive discipline

OPPE that reflects individual, specialty specific, performance

Let the standards work for you

Validate Administrative Walk Arounds Town Hall Meetings “Lemonade Stand” Daily Dose The Buzz The Leader Patient Safety Climate Surveys

Innovate Resource Center Concept Concurrent Data Collection –

• Multidisciplinary CHF Rounds• PI Specialist stationed in PACU• Canopy list of all vaccine patients• Canopy list of possible POA Patients

Glycemic Control Team Mobility Team Crew Resource Management Projects Psychiatric Crisis Center

Confront Obsolete institutional belief systems Rumors and innuendo Informal Leaders Convoluted Processes Unsafe Practice

Eliminate Disruptive Behavior

• Physicians• Staff• Contractors

Negative Influence• Informal Leaders• “Naysayers”

Waste• Lean Principles• “6S”

ICU Length of Stay

5.72

4.554.27

3.67 3.69 3.49 3.45

22.5

33.5

44.5

55.5

6

FY02 FY03 FY04 FY05 FY06 FY07 FY08

3.34

2.71

1.48

2.77

0

0.5

1

1.5

2

2.5

3

3.5

4

Baseline FY06 FY07 FY08

Ventilator-Associated Pneumonia

Central Line BSI’s

2.412.72

2.93

3.51

4.07

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Baseline FY05 FY06 FY07 FY08

Sepsis Management Bundle

0

20

40

60

80

100

Dec-

05

Jan-

06

Feb-

06

Mar

-06

Apr-0

6

May

-06

June

'06

July

'06

Aug'

06

Sep'

06

Oct'0

6

Nov'

06

Dec'

06

Jan'

07

Feb'

07

Mar

'07

Apr'0

7

May

'07

Jun'

07

Jul'0

7

Aug'

07

Month

% P

atie

nts

Severe Sepsis/Septic Shock Mortality Protocol Patients

37.5

66.67

100

16.67

0

12.5

0 0

17

0

10 11

30

15

25

1419

12

23

14

00

20

40

60

80

100

Sep-05 Jan-06 Mar-06 May-06 July'06 Sep'06 Nov'06 Jan'07 Mar'07 Jun'07 Aug'07

Month

% P

atie

nts

2004 2005 2006* 2007FYTD

Average LOS

25 24 19 18

All Severe Sepsis/Septic Shock with at least one day in ICU, excluding palliative care

* Severe Sepsis/Septic Shock Protocol Orders and Bundles based on Surviving Sepsis Campaign guidelines implemented

Glucose Control

0

10

20

30

40

50

60

70

80

Month

% P

atie

nts

>150 mg/dL 60-150 mg/dL 0-59 mg/dL

Nurse driven policy to initiate Insulin drip protocol for two BG >150 mg/dL

Revised policy to Institute Insulin Drip Protocol for one BG >150 mg/dL

ICU Mortality FY02 – FY08

8.7 9.33 8.9 8.36 8.2

14.5114.22

0

2

4

6

8

10

12

14

16

FY02 FY03 FY04 FY05 FY06 FY07 FY08

ICU Collaborative October 2003

ICU 6 Year Outcomes FY03-FY08 40% reduction in ICU LOS 41% decrease in vent length of stay 57% reduction in VAP rate (3.34 to1.48).  41% drop in BSI rate (4.07 to 2.41).   40% decrease in sepsis mortality  ICU glycemic control between 60- 150 mg/dL

was averaging around mid 50% levels and improved to around 68-70%.

42% reduction in ICU mortality

4.5