On the CUSP: Stop BSI NICU Project

1. On the CUSP: Stop BSI NICU Project Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com Kimberly O’Brien, MHA Director, Program Development Missouri Center for Patient Safety Jefferson City, MO kobrien@mocps.org Coaching Call 3 Learning from Defects and Maximizing the Value of Safety Culture Assessments 4/25/2012

2. Documents for Coaching Call 3 • Coaching Call 3 Presentation (this document) • Coaching Call 3 Team Leader Monthly Checklist • Sample Agendas for Apr/May Unit Team Meeting • Learning from Defects Tool

3. Learning Objectives • To introduce the Learning from Defects tool • To educate on how to implement Learning from Defects process • To review examples of safety culture assessment models, discuss models currently being used in units, and explain how to use the results

4. The “Secret Ingredient”Comprehensive Unit-based Safety Program Pre-CUSP work • Assemble a safety team • Partner with a Senior Executive • Measure unit culture • Educate on the Science of Safety • Identify Defects (Staff Safety Assessment) • Senior Executive Partnership • Learn from Defects • Implement Teamwork & Communication Tools

5. 4. Learning from Defects

6. Learning from Defects 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

7. 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

8. Learning from Defects • 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

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

10. 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

11. 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 11

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

13. 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.

14. 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

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

16. 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

17. 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

18. 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

19. Section 3: Action PlanWhat can you do to reduce the risk? Survey residents and PAs regarding central line placement process and elicit their suggestions for improvement 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. Reform BSI checklist to ensure proper sequence of line insertion procedure Provide re-education to staff on surgical asepsis. Educate staff on pre-procedure briefing process Review current line cart restocking process Order vein finder

20. 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.

21. Chart Review No excess blood products given on these patients Median blood glucose was <140 mg/dl All of the patients that had CLA-BSI 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

22. 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?

23. 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)

24. Safety Tip: Follow established procedure for all central lines 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. Opportunities for Improvement 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 System Failures Educate RN related to use of maximal barrier precautions during slick catheter insertion Lack of knowledge by RN related to slick catheters Formalized twice a day stocking Line cart stocking process Educate residents on use of vein finder, recommend increased mentorship of residents during line insertion Skill of residents

25. 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

26. 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 • Observational audits to assess compliance with the new process • Survey staff at huddle Whom will you share the learning with? • All the staff

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

28. What do I do now? • Have your CUSP team prioritize a defect from the staff safety assessment • Educate your CUSP team on the Learn from a Defect process • Have them review the article • Review the process and an example at a team meeting • Take the defect and apply the LFD process • Share learning with all staff

29. Pre-CUSP Work: Measuring Unit Culture

30. Institute of Medicine “ The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm”

31. What is a Safety 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

32. A Positive Culture of Safety Nieva, V F Qual Saf Health Care 2003;12(suppl) …..recognizes the inevitability of error and proactively seeks to identify latent threats

33. High Reliability Organizations Chassin & Loeb, Health Affairs, April 2011 • High Reliability: consistent performance at high levels of safety over long periods of time • Possess “Collective mindfulness” • Everyone who works in the organization (individually and together) has awareness of even small failures in protocols or processes can lead to catastrophic adverse events, if action is not taken to solve the problem • Other features • Eliminate deficiencies in safety processes by using tools to improve processes • Create an organizational culture that focuses on safety - remaining constantly aware of the possibility of failure

34. Health Care Quality Comparison Overall Healthcare in US (RAND) Outpatient ABX for colds 1,000,000 Healthcare-associated infections (HAIs) 100,000 Hospital patients Injured through negligence Post MI β-blockers Defects per million 10,000 Airline baggage handling Detection & treatment of depression Adverse drug events 1,000 Anesthesia-related fatality rate 100 US industry best-in-class 10 Food safety 1 1 2 3 4 5 6 σ Level (% defects) (69%) (31%) (7%) (0.6%) (0.002%) (0.00003%)

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

36. Why Measure Unit Culture? • Determine how bedside staff are feeling related to communication and recognizing defects • Diagnose and assess the current status of patient safety culture. • Identify strengths and areas for patient safety culture improvement. • Examine trends in patient safety culture change over time. • Measure/evaluate the cultural impact of patient safety initiatives and interventions. • CUSP is the intervention that will help you improve culture results

37. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 42 items assess 12 dimensions of patient safety culture 1. Overall perceptions of patient safety 2. Frequency of event reporting 3. Supv/mgr expectations & actions promoting patient safety 4. Organizational learning--continuous improvement 5. Teamwork within units 6. Communication openness 7. Feedback & communication about error

38. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 8. Nonpunitive response to error 9. Staffing 10. Hospital Management support for patient safety 11. Teamwork across units 12. Handoffs & transitions Patient safety “grade” (Excellent to Poor) Number of Errors reported in the last year

39. Response Rates • Best if over 60%---representative sample • Between 50 and 60%---probably representative • Less than 50%---alone probably not representative • Gather/validate more information from staff • Look for similarities of issues between HSOPS, Staff Safety Assessment, incident reports and prior Root Cause Analysis on your unit

40. Reviewing the Results • Look at each dimension • Can calculate an overall percent of positive responses for each dimension • Focus on the dimensions that have less than 60% positive, or the lowest percent positive • Look at the questions in each dimension • Look for questions that demonstrate safety strengths (>75% positive) • Look for questions with percent positive is less than 60%---here are areas of opportunity

41. Reviewing the Results • Interpreting negatively* worded questions • Want to see greater that 60% in the disagree/strongly disagree response • Example: • *We have a patient safety problem on this unit • 51% disagreed/strongly disagreed with this statement, 27% felt that there was a patient safety problem on this unit and 22% neither agreed or disagreed • Result: want to see at least greater than 60% of the staff disagree/strongly disagree with this statement.

42. Survey Action Planning • Assessment data is likely to point to many different area of culture that can be improved • There will be many different ideas regarding potential actions • Incremental changes can be implemented and tested on a small scale, changing one process or practice at a time • Remember—in patient safety this is no one “silver bullet”

43. Evidence Based local solutions:Safety “If-Then” • If staff lack consensus about quality and safety issues? • ThenSafety as a System Training (free 27 Minute online course) www.dukepatientsafetycenter.com • If staff feel unengaged in safety and quality? • Then build grassroots with Learning from Defects • If staff feel unengaged, unsafe, & unresourced for quality? • Then build infrastructure & capacity with Structured Huddles and Executive Partnerships

44. Evidence based local solutions: Teamwork “If-Then” • If staffing levels inadequate/info lost at shift change: • ThenMorning/Shift Briefings/Huddles • If interdisciplinary patient management issues: • ThenDaily Goals • If conflicts unresolved/role clarity lacking: • ThenShadowing Exercise • If difficulty speaking up: • Then standardizing with SBAR,Critical Language, Crucial Conversations or TeamStepp training

45. Summarize 5 MOST positive • Supervisor/manager expectations/actions promoting safety • Considers staff suggestions for improving pt safety-76% • *My supervisor overlooks pt safety problems that happen over and over—76% disagree • Organizational Learning—Continuous Improvement • We are actively doing things to improve patient safety-80% • Teamwork • People support one another in this unit-86% • When a lot of work needs to be done quickly, we work together as a team-85% • In this unit, people treat each other with respect-78%

46. Summarize 5 LEAST positive • Communication Openness • Staff feel free to question the decisions or actions of those with more authority-39% • Feedback and Communication about Error • We are given feedback about changes put into place based on event reports—46% • Nonpunitive Response to Error • *Staff feel like their mistakes are held against them—46% disagree • *When an event is reported, it feels like the person is being written up, not the problem—43% disagree • *Staff worry that mistakes they make are kept in their personnel file-33% disagree

47. Summarize 5 least positive • Hospital Handoffs and transitions • *Things “fall between the cracks” when transferring patients from one unit to another-33% disagree • *Problems often occur in the exchange of information across hospital units-38% disagree • Teamwork Across Hospital Units • *Hospital units do not coordinate well with each other-39% disagree

48. Action Plan Development

49. What are your next steps? Collate, categorize and prioritize the staff safety assessment results Select a defect and apply Learn from a Defect tool Create action plan from safety survey results

50. Post -Coaching Call 3 Survey https://www.surveymonkey.com/s/LL3LH2M • Begin survey on 5/4/2012 (not before!) • Complete survey by 5/11/2012