Getting Started on Catheter Associated Urinary Tract Infections

1. Getting Started onCatheter Associated Urinary Tract Infections Jill Hanson Manager, Quality Improvement WHA

2. Today’s Call • Initiative Timeline and Process • Measures • Review Findings from Kick-Off Brainstorming • Next 30 Days • View Science of Safety Video • Organizing the Team

3. Initiative Timeline Overview • 9 Month Collaborative • 1-Hr Webinar Each Month – 1st Wednesday 12:00-1:00 PM

4. Initiative Learning Process Learning Opportunities Webinars • Review progress of last 30 days • New content • Discussion and sharing • Plan for the next 30 days Discussion Group • Questions • Peer-to-Peer Sharing Quality Center • Data submissions • References and Toolkits • Reports (coming soon) Webinars Site Visits Discussion Group WHA Quality Center

5. Guide to Quality Centerhttp://www.whaqualitycenter.org/ Click Here

6. Theory of Constraints Reasons Improvement Projects May Have ‘Failed’ in the Past: • Moved too fast to ‘Protocol and Procedure’ • Did not have the right people involved • Did not engage frontline staff in trying new changes – little buy in • Measures were not monitored consistently over time • Did not reinforce training on the new way of doing things • Used the same core group of people to fix the problem • Participants in the initiative do not address the root causes of performance deficiency

7. Overcoming Constraints in Partners for Patients • Slow down the improvement train • Continuous measurement throughout initiative (and beyond) • Get the right people involved • Get new people involved • Small tests of change with many front-line staff • Opportunities to revisit training • Focus on project sustainability

8. Poll Question One Which of the following describes your facility best in terms of progress on CAUTI? • This is the first time we have worked on it • We’re trying, but don’t have buy in • We have worked on it, but haven’t been able to sustain the gains • We have successfully implemented changes and are sustaining the gains

9. Background • Urinary tract infection (UTI) causes ~ 40% of hospital-acquired infections • Most infections due to urinary catheters • Up to 25% of inpatients are catheterized • Leads to increased morbidity and costs

10. Urinary Catheter Prevalence • Up to 25% of inpatients are catheterized • Medical-surgical units: 10-30% • Intensive care units: 60-90% • 40-50% of these patients do not have a valid indication for urinary catheter placement Gokula, Am J Infect Control 2004:32:196-9 Apisarnthanarak, Am J Infect Control 2007;35:594-9 Edwards, Am J Infect Control 2007;35:290-301

11. Catheter Associated UTI (CAUTI) Catheter-risk of bacteriuria increases each day of use: • Per Day: 5% • One Week: 25% • One Month: 100%

12. Measures Outcome Measures:Focus on the customer or patient. What is the result? Choose One: • Catheter-Associated UTI Rate – All Tracked Units (CDC NHSN) • Catheter-Associated UTI Rate – Unit Specific (CDC NSHN) • Catheter-Associated UTI Rate – Unit Specific • Catheter-Associated UTI Rate – All Tracked Units

13. Measures Process Measures:Focus on theworkings of the system. Are the parts/steps in the system performing as planned? Choose One: • CAUTI Maintenance Compliance • CAUTI Insertion Compliance • CAUTI - Daily Review of Line Necessity • CAUTI – Proper Indications for Insertion

14. Importance of Measurement CAUTI Outcome Measure: CAUTI Infection Rate Why measure? • The purpose of measurement in QI work is for learningnot judgment! • Measures should be used to guide improvement and test changes. • Demonstrate change from a baseline, or initial measurement, and assess the degree of change after an intervention. I think we improved… but I’m not sure by how much?

15. Action Item #1 – Data Submission • Baseline outcome data due June 30th • Submit via WHA Quality Center portal • 2011 Data – Aggregate Num, Den & Start/End Date • 2012 Data (Monthly Jan – June) • Analyze baseline data

16. Findings from Kick-Off Meeting Follow-up from Post-Its • Concerns • Questions • Something to Share • CAUTI Discussion Forum on the Quality Center

17. Science of Safety – How Errors Happen The Swiss Cheese Model – by James Reason Important Concepts: • Holes in any layer increase the vulnerability of the whole system. • It is virtually impossible to eliminate all holes. • Must understand the whole system, not just the steps. • Continuously monitor the health of the whole system.

18. Healthcare Error Proliferation Model

19. Science of Safety Recipe • Educate on the Science of Safety • Identify Defects (Staff safety assessment) • Learn from Defects • Implement Teamwork & Communication Tools

20. How Can These Errors Happen? • People are fallible • Medicine is still treated as an art, not a science • Systems do not catch mistakes before they reach the patient

21. Why Do Mistakes Happen? • Inconsistency/variation • Complexity • Too many/complicated steps • Human error • Tight time constraints • Hierarchical culture • Fatigue • Inattention/distraction • Unfamiliar situations/new problem • Communication errors • Using past solutions • Mislabeling/inadequate instructions • Equipment design flaws Process Factors People Factors

22. Seven Concepts of Patient Safety

23. Seven Concepts of Patient Safety

24. Impact of Design on System Performance System-level factors including characteristics of: • Provider • Team • Work Environment • Department of hospital pressures

25. Principles of Process Design • Standardize - Eliminate steps if possible • Create independent checks • Think about near misses - What might happen? - Why? - What can you do to reduce risk? - How will you know it works?

26. System-Level Factors Can Predict Performance of CAUTI

27. What is a “Safety Culture”? Safety Culture encompasses the attitudes held within a workplace, from the leadership to the front lines. This includes: • How open staff is to discussing patient safety issues and concerns with their colleagues and their leaders • How safe they feel about speaking out if they think that a patient is in danger • How serious they think the organizational leadership is about patient safety • How well they think they work as a team.

28. Positive Safety Culture Indicators • People avoid making the same kind of mistakes by freely sharing lessons learned • When mistakes occur people take responsibility for them • Peer to Peer feedback and correction is seen as a gift • The team learns from their mistakes • The team shares their learning with others in the hospital

29. Action Item # 2 – View Patient Safety Video Create a roster of who on your team/unit needs to view the Science of Safety video. http://www.youtube.com/watch?v=GOJJHHm7lnM&feature=results_main&playnext=1&list=PL048D28C888FE3871

30. Organizing your Team Considerations • Who will you involve? • How will you communicate? • Within your team? (notify of meetings) • To others outside of the team? • How will you use the webinars? (use as weekly meeting?) • Identify team structure (key roles, expertise, leaders) • How will you keep everyone engaged?

31. Diverse and Independent Input Appreciate the wisdom of crowds • Remember health care is a team effort • Strive to create an environment where frontline providers can speak up if they have concerns and are heard when they express concerns • Get as many viewpoints as possible Alternate between convergent and divergent thinking • Divergent thinking occurs on rounds, during brainstorming sessions, and when trying to understand what might be going on • Convergent thinking occurs while formulating a treatment plan or getting down to a specific task

32. Action Item #3 - Organizing your Team Optional Tools to Use Agenda Team Charter

33. Polling Question Two Please select who will be part of your CAUTI team (select all that apply). • Executive Champion • QI Lead • Physician • Pharmacists • Mid-Manager • Front Line Staff Member / Members • Environmental Services • Other

34. Next Month • Safety Culture Assessment • Developing Aim Statements • The Model for Improvement

35. The Next 30 Days Tools Available On WHA Quality Center: • Science of Safety Video Link • Meeting Agenda (pre-populated) • Team Charter • CAUTI Partners for Patients Page

36. Polling Question Three Our July CAUTI webinar would have been on July 4 Which works best for an alternate July webinar date: • July 11 – 10 am to 11 am • July 12 – 10 am to 11 am • July 18 – 12 pm to 1 pm

37. Guide to Quality Centerhttp://www.whaqualitycenter.org/ Click Here

38. Questions? Thank you! Jill Hanson Manager, Quality Improvement WHA