Curtis Olson, PhD Tricia Tooman, MSc (MPhil) University of Wisconsin-Madison

1. Bricolage and Intellectual Workshop:Conceptual lenses for understanding team learning and change Curtis Olson, PhD Tricia Tooman, MSc (MPhil) University of Wisconsin-Madison Making Health Care Safer Social Dimensions of Health Institute June 27, 2011

2. Shared Goal, Different Perspectives Improving Quality and Value of Healthcare TRIP Critical Event Analysis PDSA Systems Redesign

3. Aims for this Session • Provide a window into how individuals and groups in health care organizations learn in formal and informal ways • Provide access to empirical, qualitative data are helping us understand the phenomenon of team learning • Explore the relevance of this case to the larger enterprise of improving patient safety

4. “Studying the Arrow”

5. Context of Current Study • One of 3 cases in larger study (Olson, Tooman, & Alvarado, 2010) • Linked to CDC’s twelve step campaign to reduce antimicrobial resistance in US hospitals • Success: measurable, significant improvements in clinical outcomes • Soft knowledge systems (Engel, 1997) • social organization of change • types and sources of K&I used by the team to innovate

6. Trinity Community Hospital ICU • Medium-sized, 200-bed hospital in Midwestern US • Focus on ventilator-associated pneumonia (VAP) • preventable, nosocomial infection • mortality attributable to VAP may exceed 10% • Initial rate 6.0 cases/1000 ventilator days • Outcome: 0 cases in 18 months prior to study

7. Understanding team learning • Bricolage (Levi-Strauss) • Intellectual workshop (Revans)

8. Bricolage • Roughly, “making do with what is at hand” • The highly synthetic and sometimes improvisational process by which project teams acquired, created, mobilized and assembled bits of K&I into plans of action

9. Intellectual Workshop • The central site for bricolage • Where bits of K&I were forged into strategies, implemented, and evaluated • Essentially, the “project leadership team”

10. Work in the Workshop • Obtain, produce, adapt, interpret, compare, share, synthesize, evaluate knowledge and information (K&I) • Evaluate current practice • Fashion solutions out of bits of K&I • Plan implementation, formalize • Track performance (process and outcome); problem solve • Trace system implications and mobilize assistance to obtain cooperation, support, compliance from other units

11. At the beginning: • ICU Medical Director learned about IHI 100,000 Lives Campaign and the Breakthrough Series • Longitudinal (3 meetings/9 months) • Cohorted teams from several hospitals • Limited clinical foci • Emphasized evidence-based practices and practical knowledge • Core approach was PDSA, measurement

12. The Basic Model for Improvement

13. The decision to engage “. . . our hospital became involved with IHI, the Institute for Healthcare Improvement. The first project they did was for our CV group here, and we saw incredible success … So we saw that, and IHI had offered something in the area of the intensive care unit, so we talked our administrators into spending the dough to send a bunch of us there.” -ICU Medical Director

14. The choice of VAP “I don't think that it would have ever occurred to our group or even gone any, you know, our VAP rates weren't that bad. It wasn't a red flag out there for anybody.” -Respiratory Therapist

15. The project leadership team • Led, assembled by CNS • Evolved to include • 2 lead ICU nurses • Hospital’s infection control specialist • Hospital’s lead respiratory therapist • Multidisciplinary • CNS provided link to IHI

16. Early contributions of IHI • VAP prevention interventions [EBP] • Daily “sedation vacation”/assessment of readiness to extubate • Peptic ulcer disease prophylaxis • Deep venous thrombosis prophylaxis • Elevate head of bed to 45 degrees • Bundle concept [EBP] • Importance of data

17. Three bundle elements in place “Like mouth care . . . I’ve gone through a conference and learned about how that could help prevent VAP back in 2002. So I came back and I implemented, got new products and implemented an oral care protocol by the end of the year.” -CNS

18. Learning the value of consistency “Well, IHI is very evidence-based, so when we’re there and we hear about VAP reduction, and we see that they’ve bundled these interventions that actually alone, in themselves, cause improvement. So when you bundle them, they become kind of synergistic.” -CNS

19. Convergence around VAP data “Then we needed to get, for this IHI collaborative, we had not been doing our VAP surveillance before that. I’d been trying, but our [last] infection control person really had not had any experience doing that, and I just didn’t know how even to start on my own. I’d come from a hospital where I was getting that data from infection control and wanted that data, but it wasn’t here, and I could not figure out how to do it myself.” -CNS

20. Learning from ICS training/experience • ICS taught CNS how to do surveillance • Did chart reviews with a one year baseline • Used CDC VAP definition and national comparison data

21. Contribution of science and policy “At that point in time, because I knew about some of the national initiatives going on with the new CDC definition of infection, since they did not have any historical surveillance for pneumonia in the ICU, so we set up some processes in place to begin that.” -Infection Control Specialist

22. Learning from others’ outcomes data “Because the collaborative had already been going on for a year, we could see other hospitals and other hospital’s systems that have data that their VAP rate just dropped, in many cases to zero. We wanted to be there.” -CNS

23. Learning from practice-based evidence “At the time, we were just starting to collect our VAP rates, and so what we did was we did a couple of months baseline … and we were way above the national benchmark .” -CNS

24. Actions of the project team • Goal: implement missing piece of bundle and make implementation of all bundle elements more consistent • Developed standards of care, audit process, roll-out strategy • Did orientation and training • Monitored compliance through observation and chart audits [use of Practice-Based Evidence] • Provided feedback to staff

25. Learning from others’ practical knowledge “You know it’s stuff like writing the interventions into an order set or protocol, different ways to get other units and other departments on board … So you know we shared signs, and we shared protocols, shared just ideas of other services to try to get on board, other ways, to get respiratory on board and people maybe that you hadn’t thought of on board.” -CNS

26. Learning from experience The problem: “We were getting skid marks on people’s seats.” -ICU Medical Director Addressed by adapting the HOB guideline (changed from 45 to 30 degree angle)

27. Implemented IHI Bundle, but… “We were doing fine, and we thought, oh great, we implemented the bundle. Now we’re kind of in monitoring mode, and we had a period of time without any VAP. Then all of a sudden we had, I think, maybe two in a month and maybe one a couple of months later. And we’re like, whoa, what’s going on here?” -CNS

28. Learning from adversity “We realized it’s not a straight line. It’s a course correction … If you aren’t getting the results that you expect, then you need to step back and say, ‘what can we do more?’ And really look back to the literature. Where do we have gaps? What can we do?.” -CNS

29. A critical re-examination of practice “Everybody kind of took their area of expertise and then just kind of came back to the table with suggestions or ideas.” -Respiratory Therapist “[Our sister hospital] still had none, so we were comparing, okay, what are you … what’s different about [us]?” -CNS

30. Comparison with Sister Hospital “We found out that [our sister hospital] was handling their irrigations using these little 5cc saline whatever they’re called, and here . . . people were just leaving them hooked up to the endotracheal tube. And then whenever they needed to come by, they’d just give it a squeeze until it was empty and then throw that one away. They weren’t doing that over at [sister hospital], and they were showing a lower rate of infection.. . . We adopted [their approach] and showed some improvement in our infection rates.” -ICU Medical Director

31. Convergence around a new ET tube • Were aware of a different style ET tube with innovative features (eg, allowed continuous subglottic suctioning) • Was not adopted because ICU Medical Director had heard there were problems with it • RT began to suspect design of current tube was a contributor to problem

32. Reasoning through a potential cause “We looked at the actual product … the difference that we found was the old product with the end light suction, is that they only had a single port, a proximal port up here and not a distal port. And there wasn’t really any research or really anything indicating that that was wrong or had any bad evidence behind it, but we did come across the product that has two ports and kind of do a little bit of research behind it, and again there is really no evidence-based research out there, but the theory or the thought was there is potential when you would, every time you go down, you suction down into a patient’s lung, you’re taking that tip and you’re introducing it into the body.” -Respiratory Therapist

33. Serendipitous acquisition of information “[The ICU Medical Director] had gone to a critical care conference, and he learned about the improvements that were made in the design of that ET tube. There had been some problems with it when it was first launched a few years back. So a lot hesitate to implement those, but he had heard about and saw its presentation and was interested in presenting that back to us.” -Infection Control Specialist

34. The cost barrier “It incurred a huge cost difference, it had to go all the way up through administration … We had to go through multiple different departments, because we had to involve anesthesia. You actually truly need to involve outside resources, your ambulances that are intubating in the field. You have to involve your ED department, and it is substantially more expensive than the ET tube that you currently use so it has to go through all kinds of approval, financial processes, go through administration.” -Respiratory Therapist

35. Using practice-based evidence for the business case “We had to figure out how many patients, you know, in the year before, we had intubated and times that by the increase in the cost, and then do an analysis of, if we could just cut our VAP rate in half, we could save more money than the ET tubes cost. So by doing that financial analysis, then they said, well, yeah, it makes sense, if you can save a patient from having a VAP, you’re saving at least $40,000. So we got the okay to go ahead and do that. -CNS

36. Another iteration of change • Redefining standards of care in ICU • Planning and implementing roll-out • Monitoring and feedback on process and outcomes • Problem solving • Concerns of ambulance crews • Noise from continuous suctioning

37. Refining the process “At times they can cause a very loud, disturbing noise that irritates the bedside caregiver, and so there is a learning curve, and until we could get the RT’s who were managing the tubes to truly be able to troubleshoot that and eliminate that annoying factor, we would find nurses that would disconnect it and then we’ve lost potential benefit … And so there was a little bit of a fight there. Probably for a good six months we would find some disconnected.” -Respiratory Therapist

38. Naturally-occurring data “When we initially . . . started seeing [the new ET tubes] on our patients, we had several RNs up in ICU that didn’t buy in to it. ‘No, that’s not going to help; it’s not going to do anything.’ I think what finally got them to buy in to it was the visualization, actually seeing these nasty secretions continuously coming through the line. I really think it opened everybody’s eyes to go, I cannot believe there is that much down there.” -Respiratory Therapist

39. Signs of progress “Before, [when we reviewed chest X-rays] we would constantly see potential haziness, possible infiltrate, slight opacity.. . . It was amazing how many after we implemented that ET tube were clear. Clear, clear, clear.” Respiratory Therapist

40. Success • No case of VAP in 18 prior to the time of the study

41. Caveats • One case, but similar findings across the 3 cases in the larger study • Important moderating factors include • Having strong process and outcome measures • Strong, stable leadership in ICU • Good fortune • IHI as a resource • Provides one perspective on the phenomenon of team learning

42. Some general observations • Scientific evidence and EBPs played an important role • Practice change process also involved practical knowledge, experiential learning, practice-based evidence. • Practitioners were more than just users or consumers of knowledge created by others • Change a longitudinal, cyclical process • Practitioners were experimenters, seeking ways to “move the needle on the dial”

43. Exploring the points of connection • To what extent and how is this perspective on the process of team learning and change relevant to your context? • How do our findings support/challenge current models and practice regarding improving patient safety? • What new questions has this session raised for you?

44. References Engel, P. G. H. (1997) The social organization of innovation: A focus on stakeholder interaction. Amsterdam: KIT Press. Gabbay, J., & le May, A. (2011). Practice-based evidence for healthcare: Clinical mindlines. Oxon: Routledge. Levi-Strauss, C. (1974) The savage mind. (2nd ed). London: Weidenfeld and Nicholson. Olson CA, Tooman TR, Alvarado CJ. Knowledge systems, health care teams, and clinical practice: a study of successful change. Adv Health Sci Educ Theory Pract. Jan 13 2010.