PQCNC: NCABSI Kick-off Meeting

1. PQCNC: NCABSI Kick-off Meeting Dr. Sheri Carroll, NC State Lead

2. Agenda • Introduction Exercise: Lessons Learned • PQCNC CABSI 2009-Celebrating Our Success • Dot Exercise • PQCNC NCABSI 2011-Looking Ahead • Timeline • Guidelines • On the CUSP of Change • Lunch and Unit Team PDSA Exercise • Poster Presentations • Exploratory Lab on Line Change • Team Member Exercise • The Family Voice: “Gabby” • Wrap Up/Next Steps

3. PQCNC NCABSI-18 NC Units • ARMC (1) • BHCWC at NHRMC (6) • Brenner Children’s (8) • Catawba Valley (1) • CMC • CMC-NE (2) • ECU (5) • DUMC (5) • Forsyth (6) • Gaston Memorial • Mission (2) • Onslow (1) • Presbyterian (1) • Rex (3) • UNC (3) • WakeMed (2) • Wake Cary (2) • Women’s Greensboro (6)

4. NC Team Demographics

5. It takes a team! 16 teams, PQCNC, and March of Dimes=55 participants.

6. Teams Shared Lessons Learned in Our CABSI Improvement Journey So Far Key Drivers/Adaptive Change Practice Changes • Culture change • Hand hygiene • Engaging bedside nurse • Engaging families • Engaging staff via family stories-connecting to a common purpose • Constant learning, persistence • Team approach, communication • Recognition • Process approach • Visual EMR reminders for line change • Bedside rounding by infection team • Closed systems • Single person to set up all line change tubing • Sterile dress (hat, mask, and gloves) for line changes • Observed insertion • HCG hub care • Central Line Team

7. PQCNC: NCABSI Timeline North Carolina October 2011-September 2012 Web Meeting 2011 Web Meeting Oct Nov Dec Jan Feb March April May June July August Sept Sept: State Meeting April: State Meeting Kick-off Meeting October 27, 2011 • November-January • Reviewcurrent Measures & Performance • Formalizeaim and measures • Observecurrentpractice and variation • Select practicechange • Test and implementpracticechange (PDSA) • Prepareclinicalaim story • NC lead visits • May - July • Reviewcurrent Measures & Performance • Formalizeaim and measures • Observecurrentpractice and variation • Select practicechange • Test and implementpracticechange (PDSA) • Prepareclinicalaim story • February – April • Implement CUSP Training • Reviewcurrent Measures & Performance • Formalizeaim and measures • Observecurrentpractice and variation • Select practicechange • Test and implementpracticechange (PDSA) • Prepareclinicalaim story CUSP Education Monthly Conference Calls on Thursday

8. October – December 2011Our First 90 days…

9. Guidelines Comprehensive Unit-Based Safety Program (CUSP)-5 best practices 2006 Infusion Nursing Standards (INS) of Practice- 2011 Center for Disease Control (CDC)-Guidelines for the Prevention of Intravascular Catheter-Related Infections-2011 Healthcare Infection Control Practice Advisory Committee (HICPAC)-2011 NCABSI ACTION PLAN

10. Lunch and Learn: Identifying our next PDSA

11. Sharing Poster Presentations

12. Dot Exercise Polls Alcohol 6 Units CHG 10 Units

13. Line Care Exploratory Lab Similarities Differences • Sterile dress: varied from clean gloves to full hat, mask, gown, and 2 sets of sterile gloves • Various clave products: CVC, Carefusion Max Plus, Invision • Preassembled trifuse tubing • Interval of line change: 24 to 72 hr • Interval of main hub change: 72 hr to never • HAL syringe change process • 7 in extension remains • Curos/alcohol caps • Centurion hubguard • Securement device for PICC line • Start with clean surface • Neutral hubs

14. Role Communication Exercise: What do you want to know from your Fellow team members?

15. Neonatology (11MDs, 6NPs) Family Nursing Administration Infection Control • The TRUTH • Financial info • Listen to us “how we are different” • LOS: VON vs. DR • Data, real time and trends • Help with private room surveillance • Ongoing communication • More neonatology guidelines • Violations of hand washing • Speak up • Report violations • Advocate • Share if “sick” • Share perception of IV attempts • Share feelings if something is “not right” with our baby • Let us know how we can update you better • Good catches, tell us is you see a potential mistake • Informs us when staff/MD not following unit protocol • Confirm vague orders • Update us on number of line attempts • Update us on number of times line accessed • Differences in MD practice

16. Let’s take it home……… • Teamwork • Supportive • Stimulating • Educating • Inspiring • Interactive • Enlightened • Refocused • Hopeful • Togetherness • Energizing • Invigorating • Reinforced • Ready • Encouraging • Motivating • Succinct • Great • Refreshing • Educational

17. Learning Points • Identifying team interests prior to meeting for focus points • Mixture of interactive and didactic formats • Opportunity for center team and community interactive formats • Use of photography and video as tools for teaching and recording experience • Flip charts!

18. On the CUSP: Stop BSI NICU Project Content Call 2: Comprehensive Unit Safety Program (CUSP) Making your ICUs safer The secret ingredients are culture and team Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com

19. Your Feedback is Important! https://www.surveymonkey.com/s/DVZM2V3

20. Learning Objectives • Overview the Pre-CUSP work • Assemble a Safety Team • Partner with a Senior Executive • Measure Culture • Review the 5 CUSP Steps • Educate on the Science of Safety • Identify Defects (Staff Safety Assessment) • Senior Executive Partnership • Learn from Defects • Implement Teamwork & Communication Tools 20

21. What is CUSP? Framework to improve unit culture Developed at Johns Hopkins University Consists of five steps Aligns with “change models” CUSP implemented simultaneously with a clinical improvement

22. KEYSTONE PROJECT Statewide initiative-75 Hospitals, 127 ICUs In collaboration with Johns Hopkins Quality and Safety Research Group Reduce errors and improve patient outcomes in ICUs Combination of evidence based medicine and quality improvement 5 interventions implemented over a 2 year grant funded period Still going strong after 7 years!!!!

23. St. Joseph Mercy Hospital Story • CUSP in the ICU and beyond • Building on CUSP and CABSI for other work

24. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program Keep focus on this throughout the journey!!! • Overview the Pre-CUSP work • Assemble a Safety Team • Partner with a Senior Executive • Measure Culture • Review the 5 CUSP Steps • Educate on the Science of Safety • Identify Defects (Staff Safety Assessment) • Senior Executive Partnership • Learn from Defects • Implement Teamwork & Communication Tools

25. Pre-CUSP Work • Assemble a Safety Team • Partner with a Senior Executive • Measure Culture

26. Assembling a CUSP Team • Must be unit-based • If you want to understand and impact unit culture and safety, then your team members must include front-line staff • Who should be on the team? • Those involved in delivering patient care on unit – will vary by unit type • Team Leader • Nurses—representatives from all shifts • Physician—unit medical director, residents • Pharmacist • Infection control practitioner • Nurse manager/unit leader • Family representative

27. What is a Culture? That’s not the way we do it here!!! Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next Measure culture at the unit level

28. Culture Matters: The Evidence • Operating room staff that have the most aligned teamwork culture attitudes also have lower post-operative sepsis rates (Sexton, Anesthesiology, November 2006) • After the implementation of an interdisciplinary communication tool to improve rounds, average length of ICU stays were decreased 50% (Pronovost, Journal of Critical Care, 2003)

29. Safety Climate-Michigan ICUsSexton, CCM 2011 30

30. No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate Health Services Research, 2006;41(4 Part II):1599.

31. Low Turnover 7.9% Mid Turnover 10.8% High Turnover 16.0% Teamwork Climate &Annual Nurse Turnover % reporting positive teamwork climate

32. “Needs Improvement” Statewide Michigan CUSP ICU Results • “Needs Improvement” means less than 60% of respondents reported good safety climate • Statewide in 2004 84% needed improvement, in 2007 23% • Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

33. Unit CUSP TeamCulture Measurement and Action Plan Unit teams should meet at least monthly Develop action plan from culture survey results

34. 1. Educate on the Science of Safety Steps of CUSP

35. The Science of Safety • Understand system determines performance • Use strategies to improve system performance • Standardize • Create Independent Checks • Learn from Defects • Apply strategies to both technical work and team work • Recognize that teams make wise decisions with diverse and independent input

36. How Can These Errors Happen? Caregivers are not to blame People are fallible Medicine is still treated as an art, not science Need to view the delivery of healthcare as a science Need systems that catch mistakes before they reach the patient

37. Principles of Safe Design • Standardize • Eliminate steps if possible • Create Independent Checks • Learn from Defects • What happened? • Why? • What did you do to reduce risk? • How do you know it worked?

38. Steps of CUSP 2. Identify Defects

39. Staff Safety Assessment Please describe how you think the next patient in your unit/clinical area will be harmed Please describe what you think can be done to prevent or minimize this harm

40. Steps of CUSP 3. Senior Executive Partnership

41. Executive Partnership Executive should: • Be a member of the NICU CUSP CABSI team • Meet monthly with the NICU CUSP CABSI team • Review defects, ensure the NICU CUSP CABSI team has resources and assist with removing barriers • Round at least quarterly with goal of talking with at least 60% of the staff • Hold team accountable for improving risks and reducing CABSIs

42. Steps of CUSP 4. Learn from Defects (mistakes)

43. Learn from Defects Tool • Designed to rigorously analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences • Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues

44. Learn from Defects • What happened? • Why did it happen (system lenses)? • What could I do to reduce the risk? • How do you know the risk was reduced? • Create policy/process/procedure • Ensure staff know policy/process or procedure • Evaluate if change has occurred

45. Steps of CUSP 5. Teamwork and Communication Tools

46. Teamwork & Communication Tools • Daily Goals Checklist • Morning briefing • Shadowing • Culture debriefing • Huddles • Simulation • Crucial Conversations

47. Can we change practice through process improvement alone? or Will successful change require an altering of the value structure within the unit?

48. A Healthcare Imperative Atul Gawande, Better: A Surgeon’s Notes on Performance “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.”

49. Your Feedback is Important! https://www.surveymonkey.com/s/DVZM2V3

50. QUESTIONS ?