On the CUSP: Lessons from the Michigan Keystone ICU Project

1. On the CUSP:Lessons from the Michigan Keystone ICU Project Going where no state had gone before…

2. Learning Objectives • To become familiar with a successful large-scale improvement project: Keystone ICU • To understand some of the Lessons from that project • To think about how those lessons might help in your local quality and patient safety improvement efforts

3. Keystone ICU • AHRQ:“Patient Safety Matching Grant” 2003-2005 • Johns Hopkins Quality & Safety Research Group and Michigan Health & Hospital Association Keystone Center • Over 100 intensive care units (77 hospitals) • Implemented The Comprehensive Unit based Safety Program “ CUSP” • Statistically significant improvement in safety and teamwork climate • Implemented evidence-based interventions to reduce catheter related blood stream infections in ICUs • Statistically significant reduction in CLABSI (66% reduction)

4. Understand the differences between leadership and authority: • Senior leader involvement is important • CUSP executive early builds the support system • Leadership however, is a skill not linked to “position” • Formal and informal leaders are both important • Invite all interested individuals to be part of the improvement team Goal: Cultivate Leaders

5. Recognize technical versus adaptive work • Technical work is knowledge based and focuses on CONTENT • Defining the project, selecting measures, defining variables and data collection methods, analyzing data and preparing reports are all TECHNICAL activities and most efficiently managed at a central level • Adaptive work is behavior, or values based and focuses on CONTEXT • Implementing interventions, respecting wisdom of the front-line, developing a plan that addresses both “head and heart” must be managed at a local level Goal: Get the Technical and Adaptive Work Right

6. Strive to find the sweet spot • Interventions with the strongest evidence • (lowest number needed to treat) • Interventions with the fewest implementation barriers • Minimize burden of data collection • Sacrifice on quantity, not quality of data Goal: Find a Balance What is both Scientifically Sound and Feasible?

7. Database Design is Critical • Match project goals, objectives and database design in the beginning • Clearly defined goals and objectives • Written plan to measure progress toward goals • Estimate of baseline performance • System for measuring performance • Critical to get reports back to frontline staff as well as administrative leaders • Transparency Goal: Begin with the End in Mind

8. Minimize the bias in data collection • Rigor of QI studies is often limited • Methods to minimize bias include: • Create a manual of operations and data dictionary • CDC has standard definitions; we need to use them • Pilot test data collection forms • Create a data quality control plan • Process to train data collectors & evaluate reliability • Imbed range checks in the database • Critical to minimize missing data • Greatest risk to validity of effort is poor data Goal: Strive to minimize bias; be transparent where it exists

9. Reduce the quantity not the quality of data • Be realistic about the burden of data collection • Appreciate the challenges of measure selection • Face validity • Physician engagement • Acknowledge the importance of complete data • Biased data is worse than no data Goal: Commit to data that is meaningful, feasible and answers the question: Is Care Safer?

10. Link culture and clinical outcomes • Creating a culture of safety and teamwork may enhance ability to implement clinical interventions • May be a relationship between unit climate and sustainability of improvement • The Comprehensive Unit-based Safety Program (CUSP) provides structured tools to help achieve culture improvement (adaptive change) Goal: Learn from linking culture and clinical data

11. Stay focused on original aims • Scope creep can kill a project • Enthusiasm to improve care • Frustration with challenges of project implementation • Deplete resources • Diffuse energy • No new interventions until achieve goal of “current” intervention Goal: clear, consistent focus on original aims

12. Keep a laser sharp focus on patients • Hospital, clinician and unit “perspectives” are unique • Conflicts WILL arise • Commitment: harm is untenable • Communication tools help bridge the gap • Address gaps between spoken support and actions • Patients are the north star Goal: What is best for patients guides the work

13. Expect the project to stall at intervals • Every project stalls • Important to listen for the “music beneath the words” • Listen deeply • Respond honestly • Most people don’t fear change; they fear loss • Surface issues; address fears; then move forward • Change happens “at the edges” • Understand that timeline may need to flex in order to meet project goals Goal: Look at “Pauses” as an opportunity for deep learning

14. Innovate to improve • Need methodologic rigor and strict data management in QI/Patient Safety studies • All teams are capable of both in a partnership model (central technical work/local adaptive work) • Data collection that is narrow but deep provides important knowledge for the industry • Studies that are poorly designed and implemented waste resources and mislead caregivers and the public Goal: Support QI activities that are efficient, effective, scientifically sound

15. Action Items • Commit: Harm is not tenable • Create a team • Assign responsibilities • Ensure you have a system for data collection • Create a system to regularly share project data • Participate on project calls • Implement interventions • Share experiences with other project teams

16. References • Goeschel CA, Pronovost PJ, Harnessing the Potential of Improvement Collaboratives: Lessons from the Keystone ICU Project. Advances in Patient Safety: New Directions and Alternative Approaches. AHRQ 2008 • Pronovost P J, Berenholtz S, Goeschel CA, Improving the Quality of Measurement and Evaluation in Quality Improvement Efforts, American Journal of Medical Quality, Vol 23, No 2. March/April 2008 • Goeschel CA., Bourgault A, Palleschi M, Posa P, Harrison D, Tacia L, et al. Nursing Lessons from the MHA Keystone ICU Project: Developing and Implementing an Innovative Approach to Patient Safety. Critical Care Nursing Clinics of North America . Vol 18. No 4. Dec. 2006. 481-492 • Needham DM, Sinopoli DJ, Dinglas VD, Berenholtz SM, Korupolu R, Watson SR,Lumbomski L, Goeschel C, Pronovost PJ. Improving data quality control in quality improvement projects. International Journal for Quality in Health Care. 2009. In press.