On the CUSP: Stop BSI NICU Project

1. On the CUSP: Stop BSI NICU Project Content Call 5 Identifying Defects and Learning from Defects 4/11/2012 Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com

2. Learning Objectives • Discuss identifying defect through the Staff Safety Assessment • Show how to prioritize defects • Discuss the Learning from Defects process 2

3. CUSP & CLABSI Interventions Adaptive/ Cultural CUSP Educate on the Science of Safety Identify Defects (Staff Safety Assessment) Senior Executive Partnership Learn from Defects Implement Teamwork & Communication Tools Technical CABSI/ NICU Insertion Maintenance • Assessment & Site Care • Tubing, Injection Ports, Catheter Entry 3

4. Step 2: Identify Defects 4

5. Step 2: Identify Defects • Staff feedback • Event reporting • Quality and safety measures • Gaps in application of the evidence • Staff Safety Assessment survey • How will the next patient be harmed? • What steps can you do to prevent this harm? • By either preventing the mistake, making the mistake visible or mitigating the harm 5

6. Staff Safety Assessment • What is it? • Why is it important? • What is the CUSP team going to do with the information? 6

7. Staff Safety Assessment: What is It? Two questions for bedside staff: • 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 7

8. Staff Safety Assessment: Why is This Important? • Frontline staff are the best people to identify safety issues • By asking them what the issues are, responding to their issues, and including their wisdom to develop solutions they become a part of improving safety on the unit • Staff will begin to understand their role and responsibility in the safety on the unit 8

9. Staff Safety Assessment: What is the CUSP Team Going to Do With This Data? • Collate the data • Identify issues/themes • Prioritize an issue/defect to resolve using the Learn from a Defect Tool 9

10. Prioritize Defects • Collate and categorize the ‘How the next patient will get harmed’ responses • Multivoting • Purpose: To narrow a long list of possibilities to just on that your team can work on 10

11. Prioritize Defects: Multivoting • Instructions: • Create the list and number the items • Give each team member a number of ‘votes’ equal to about 1/3 of the total number of items • Have team member ‘vote’ for items (can create criteria for selection-greatest risk for patient or most frequent occurrence) • List the number of votes each item gets • Briefly discuss and eliminate items with fewest votes (want list of 3 or less) • Pick the one with potentially largest impact or highest risk to work on 11

12. Step 4: Learn from Defects 12

13. Learn from a Defect • 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 13

14. Learn from a Defect • Select a specific defect • What happened? • Why did it happen (system lenses) ? • What could you do to reduce risk ? • How do you know risk was reduced ? • Creates early wins for the project 14

15. CLABSI Prevention Bundle • Remove/Avoid unnecessary lines • Hand hygiene • Maximal barrier • Chlorhexadine for skin prep • Avoid femoral lines • Care of lines post insertion 15

16. Our Expectations Weren’t Met • SICU continued to have 1-2 BSI per month—inconsistent with other units • Why is this happening in SICU?? • SICU’s line days are greater than all the other units combined monthly Further analysis/investigation was needed 16

17. SICU Initial Analysis • Infection Control Department • length of time catheter in place an issue for infections: > 7days • Majority of infected catheters were Internal Jugular • Baseline information—90% of all central lines are placed in the OR • Where infected lines were placed: 50% SICU; 50% OR • Critical Care Committee • Reviewed data and recommended that the problem was related to line insertion in SICU 17

18. SICU Initial Analysis • SICU Practice Council • Walked through the Learn from a Defect Tool 18

19. Learn from a Defect Tool • Divided into three sections: • Section 1 asks the users to identify what happened or the defect they want to investigate • Section 2 is a framework provided for the investigators to identify any contributing factors. These factors include: patient, task, caregiver, and team related, training and education, local environment, information technology and institutional environment. • Section 3 asks participants to develop an action plan with assigned responsibility for task completion and follow up dates for each item. 19

20. Section 1: What happened? • Asks the users to identify what happened or the defect they want to investigate Continued CLABSI in SICU even after best practices in place 20

21. Section 2: Why did it happen?Factors contributing to the defect 1.     High patient acuity with many co-morbidities increasing risk for infection 2.     Lack of clarity in the new procedure for line insertion and sterile technique 3.     Caregiver fatigue 4.     RN confidence and comfort in stopping procedure when break in sterile technique occurred 5.     Insufficient communication(verbal/written) amongst the team 6.     Insufficient support for residents during line insertion at bedside 7.     Insufficient training for residents related to line insertion 8.     Line cart not restocked regularly 9.    Unit workload didn’t always allow nurse to be in attendance through entire procedure 21

22. What will you do to reduce risk ? • Prioritize most important contributing factors and most beneficial interventions • Safe design principles • Standardize what we do • Eliminate defect • Create independent check • Make it visible • Safe design applies to technical and team work 22

23. What will you do to reduce risk? • Develop list of interventions • For each Intervention rate • How well the intervention solves or reduces the problem • The team belief that the intervention will be used as intended • Select top interventions (2 to 5) and develop intervention plan • Assign person, task follow up date 23

24. Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant 24

25. Section 3: Action PlanWhat can you do to reduce the risk? 1. Survey residents and PAs regarding central line placement process and elicit their suggestions for improvement 2.  Chart review of all patients with CR-BSI in SICU since new protocol in place. Components included number of blood products received, mean /median blood glucose levels and line insertion process documentation. 3.  Reform BSI checklist to ensure proper sequence of line insertion procedure 4.  Provide re-education to staff on surgical asepsis. 5.  Educate staff on pre-procedure briefing process 6.  Review current line cart restocking process 7.  Order vein finder 25

26. Resident/PA Survey Results • The line cart was very helpful, but often not stocked. • Felt that the nurse’s presence in the room was valuable, but not consistently happening. • Additional support and training was needed for them. 26

27. Chart Review • No excess blood products given on these patients • Median blood glucose was <140 mg/dl • All of the patients that had CLABSI had a slick catheter that had been placed by the nursing staff into an existing cordis introducer. • Further discussion identified that maximal barrier precautions were not being used during slick catheter placement 27

28. How do you know risks were reduced? • Did you create a policy or procedure (weak)? • Do staff know about policy or procedure? • Are staff using the procedure as intended? • Behavior observations, audits • Do staff believe risks were reduced? 28

29. Summarize and Share Findings • Summarize findings • 1 page summary of 4 questions • Learning from defect figure • Share within your organizations • Share de-identified with others in collaborative (pending institutional approval) 29

30. Example: Catheter Related Blood Stream Infections Case in point: • Catheter related blood stream infection prevention best practices have been in place since August, 2004. There have been minimal infections in most of the ICU units since implementation. Though SICU’s total incidence of BSIs dropped by greater than 60%, SICU continued to have 1- 2 infections per month. It was decided to take a deeper look at potential causes. Ninety percent of all central lines in SICU are placed in the OR, and 10% are placed in SICU, yet half of all the infected lines came from those placed in the SICU. 30

31. Example: Share Findings System Failures Opportunities for Improvement Educate RN related to use of maximal barrier precautions during slick catheter insertion Lack of knowledge by RN related to slick catheters Line cart stocking process Formalized twice a day stocking Educate residents on use of vein finder, recommend increased mentorship of residents during line insertion Skill of residents 31

32. Share Findings: Continued ACTIONS TAKEN TO PREVENT HARM • Re-educate nursing staff on use of maximal barrier precautions during slick catheter insertion • Reformat BSI checklist sot that it is in proper sequence of how the procedure should be done • Provide education to staff on surgical asepsis • Order vein finder to assist with central line placement • Provide feedback from resident survey and chart review to medical and nursing leadership • Display case summary tool in all ICUs for shared learning 32

33. Learning from Defects 5 Questions: What happened (Brief defect description)? Why did it happen (what factors contributed +&-)?: System factors, for example: staffing, workload, equipment, production pressure, other departments, caregiver factors (training/fatigue/attitude), management support, physical environment (space/noise), failure of policy/procedure, patient condition (complexity/language) What can we do to reduce the risk of it recurring with different caregivers? How will we know the risk was reduced? With whom should we share our learning? 33

34. Learning from Defects Fast Facts 1. What do I need to know? • The purpose of learning from defects in a structured way is to help this clinical area "learn how" to operationalize best practices so that they solve problems while building capacity to improve quality in the future. 2. What do I need to do? • Use brief (30 to 60 minute) defect learning discussions to explore and resolve system factors involved in the defect. Focus discussion on specific actions to reduce the likelihood of defect recurrence. 3. What should I be worried about? • Protected time to discuss monthly or in response to an event in the unit, meet in a safe place for open discussion, try to keep group size to 5 or fewer if possible. Source: Pronovost et al. Jt Comm J Qual Pt Saf 2006 Feb:32(2):102-8 Pronovost et al. Crit Care Med. 2006 Jul:34(7):1988-95 Tucker AL, et al. MANAGEMENT SCIENCE 2007 53:894-907 34

35. Learn from a Defect-NICU What happened? • Neonatal weights were inaccurate; identified through the VON data. Showed our neonates were losing weight Why did it happen: what factors contributed(system lenses) ? • What prevented it from being worse? • VON data review brought issue forward • Scales were assessed by engineering as accurate • What happened to cause the defect? • Not a clearly defined process for weights • Not realizing the impact on weight related to different items on warmer and what was in the drawers • Lots going on when initial weight being done 35

36. Learn from a Defect - NICU What can we do to reduce the risk? • Define a consistent process to weigh neonates • Team meeting to evaluate roles/golden hour How will we know the risk is reduced? • VON data, PQCNC data • Observational audits to assess compliance with the new process • Survey staff at huddle Whom will you share the learning with? • All the staff

37. Learning from Defects is one of the powerful tools to improve safety culture 37

38. A Healthcare Imperative “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.” - Atul Gawande, Better: A Surgeon’s Notes on Performance 38

39. Questions? 39