HAI Collaborative Meeting September 12, 2012

1. HAI Collaborative MeetingSeptember 12, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

2. Learning Objectives Discuss how using the Learning from Defects or RCA process can help you identify how to improve. Describe the essential elements of investigating an infection event. 3. Outline what specific actions you will do in the next week based on this information. 4. Identify the action steps your team should complete before the October meeting.

3. Framing Our Meeting Putting Patients First:Preventing All Cause Harm Think of what worked and how you can learn from it What would you add/adapt to make it work in your hospital Think about what insights you gained

4. Refocus Our Goals • Reduce Hospital Acquired Conditions by 40% • CLABSI HAC Rate 0.67 per 1000 discharges • CLABSI: <1/1000 central line days • HHS HAI Action Plan 2013 Goals • CLABSI: SIR less than 0.5 • CAUTI: 25% reduction in rates

5. Our Progress So Far

6. CLABSI ICU 2011 - 2012

7. CLABSI Reduction Progress

8. Georgia GHAREF CLABSI SIR 2010 - 2012

9. Learning from Infections What An Analysis Can Teach YouThe Following slides were adapted from the On the CUSP Stop BSI Education SeriesOn the CUSP Stop BSI

10. Anything you do not want to have happen again What is a Defect?

11. Higher Level Problem Solving • Second Order Problem Solving • Reduces risks for future patients by improving work processes • Example: you create a process to make sure line cart is stocked *Anita Tucker

12. Learning from Infections • What happened? • From the people involved • Why did it happen? • Evaluates positive and negative contributing factors • What will you do to reduce the chance it will recur? • Specific actions needed to reduce the likelihood of recurrence. • How do you know that you reduced the risk that it will happen again?

13. What Happened? • Reconstruct the timeline and explain what happened • Put yourself in the place of those involved, in the middle of the event as it was unfolding • Try to understand what they were thinking and the reasoning behind their actions/decisions • Try to view the world as they did when the event occurred Source: Reason, 1990;

14. Why did it Happen? • Develop lenses to see the system (latent) factors that lead to the event • Often result from production pressures • Damaging consequences may not be evident until a “triggering event” occurs Source: Reason, 1990;

15. What will you do to reduce the risk of it happening again • 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

16. Prioritizing Contributing Factors

17. What will you do to reduce risk • Develop list of interventions • For each Intervention rate • How well the intervention solves the problem or mitigates the contributing factors for the accident • Rates the team belief that the intervention will be implemented and executed 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 Staff Level Reliable Systems Design 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. How do you know risks were reduced? • Did you do small tests of change and improved process? • Did you create a policy or procedure (weak)? • Do staff know about policy or procedure? • Ask 5 staff – do you get the same answer • Are staff using the procedure as intended? • Behavior observations, audits • Do staff believe risks were reduced?

20. Summarize and Share Findings • Summarize findings and improvements • 1 page summary of 4 questions • Learning from defect figure • Share within your organizations • Share de-identified with others in collaborative

21. Key Lessons • Focus on systems not people • Prioritize which infections to investigate • Use safe design principles • Go mile deep and inch wide rather than mile wide and inch deep • Test small, simple process, improve until process reliable • Answer the 4 questions

22. Action Plan • Review the Learning from Defect tool with your team • Review defects in your unit • Select one defect per month to learn from • Consider using in Morbidity and Mortality/QI conferences • Post the stories of risks that were reduced • Share with others

23. Reliable Systems Process Design Education Please make plans to join our HAI collaborative meeting on October 10 from 11 – 12:30. Dr. Resar will walk through an HAI example of how to have front line staff create and test the process needed to keep patients safe. Request a hospital volunteer If you missed the RSPD Overview presentation you can listen to the recording and download materials at the HAI meetings page. Look under July 17 meeting.

24. Next Steps: To be completed by October 10 Meeting • Meet with your team to assess progress. • Use the Learning from Defects or RCA tool to investigate an infection that occurred in the recent past. • Identify what improvement can be made to prevent further infections from occurring. • Determine a course to improve • Listen to the Reliable System Process Design webinar recording. Go to the link below and go to the July 17 HAI meeting information. The link to the recording and presentation is under this. • Complete the meeting evaluation by September 18 • Submitted August Process Measure Data collection by September 26

25. Action Step What is one action you will take in the next week to prevent CLABSI in your unit?

26. References • Learning from Defects Tool: On the CUSP Tool Kit • TJC RCA Framework Tool: Framework for a Root Cause Analysis • Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108. • Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033. • Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348:1051-6. • Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87. • Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5.

27. Denise Flook dflook@gha.org. 770-249-4518 Contact Information