Leading the Best Care...Always! Campaign

1. Leading the Best Care...Always! Campaign Dena van den Bergh, Michele Youngleson, Gary Kantor, Yolanda Walsh June 25th Cape Town

2. Agenda • Welcome • Introductions • Best Care…... Always! (BCA) • Fundamentals of the QI approach • Measuring for BCA • A framework for leading BCA • LUNCH • QI in action • Next steps

3. Burden of HAI in LMI countries Prof Shaheen Mehtar UIPC, TBH & SUN Cape Town

4. Situation Analysis of LMI countries • There is very little published data relating to HAI but it is recognised that the rates of HAI are higher in LMI countries • IPC programmes are poorly supported and established without recognition or career paths for trained IPC practitioners • There is little accountability by HCW which lead to inadequate clinical care • Clinical commitment is essential under Duty of Care

5. Comparative data- HIC and LMICBurden of endemic health care associated infection in developing countries: systematic review and meta analysis- B Allegranzi et al, Lancet, 2011, 377: 228-41

6. Crude HAI IR: TBH. Impact of an established IPC programme

7. ICU with highest IR: TBH

8. Comparing TBH to meta- analysis

9. Summary • By carrying out surveillance a statistically significant decrease in HAI has been noted associated with device related infection. • Policies and SOPS are necessary for compliance by clinical staff • Bundling is a highly specialised system of reducing HAI with zero tolerance • Questions to be answered • Who will ensure that two people are available for each procedure carried out? • Who will do the data collection? • Who will make sure that the same bundle is followed each and every time a procedure is carried out? • How will this be inforced?

10. The BCA Quality Improvement approach • All learn all teach • Learning by doing • Building a shared sense of the system and the approach to improvement • Applicable across disciplines

11. The impact of Healthcare Associated Infections on the hospitals

12. The impact of HAIs on the hospitals • Mortality and morbidity • Lab and pharmacy costs • Antibiotic use • Bed occupancy • Work load

13. The impact of HAIs on your hospital • Fill in the column graphs • peripheral vascular catheter associated infection (PVCAI) • central line associated bloodstream infection (CLABSI) • ventilator associated pneumonia (VAP) • catheter associated urinary track infection (CAUTI) • surgical site infection (SSI)

14. The fundamentals of the Quality Improvementapproach used in BCA

15. A brief history of systems improvement IHI Lean Overview Andy Brophy (MSc Lean Operations)

16. Quality Improvement requires two Types of Knowledge Subject Matter Knowledge: Professional, content, evidence based knowledge. ‘What’ Subject Matter Knowledge Improvement Knowledge ‘How’ Improvement Knowledge (Deming): The interaction of the theories of systems, our ‘theory of knowledge’,variation in measurement, and psychology.

17. Improvement Improvement: develop effective changes that lead to an improvement. Subject Matter Knowledge ‘What’ ‘Where’ Improvement Knowledge ‘How’ Langley: Improvement Guide p76

18. Improvement Knowledge Subject Matter Knowledge Improvement Knowledge W.E. Deming (1900-1993) System of Profound Knowledge

19. Improvement Knowledge • 4 fields of interaction • - theories of systems • - our ‘theory of knowledge’ • psychology of change • variation in measurement Subject Matter Knowledge Improvement Knowledge

20. Complex Dynamic Systems • Step 1 – Everyone stand up • Step 2 – Without speaking; pick two people but don’t say who they are or point at them (Keep it a secret) • Step 3 - Move to be equidistant from both of the people • Step 4 – Move one person and repeat

21. The power of the system NO Do you have a 2-digit Number? Step 1: Pick a number from 3 to 9 Step 2: Multiply your number by 9 Step 3: Add 12 to the number from step 2 YES Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I Step 4: Add your 2 digits together Step 5: Divide # from step 4 by 3 to get a 1 digit number Step 7: Write down the name of a city that begins with your letter Step 9: Write down the name of an animal (not bird, fish, or insect) that begins with your letter from Step 8 Step 10: Write down the color of your animal Step 8: Go to the next Letter: A to B, B to C, C to D, etc. Output: Color____________ Animal___________ City__________

22. Understanding Systems “Every system is perfectly designed to achieve the results it gets” Paul Batalden Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

23. Hand washing practice in the PICU? from a Report of a participative observational study done during January and March 2006 Candice Bonaconsa and Minette Coetzee Child Nurse Practice Development Initiative Prof Andrew Argent, Red Cross Hospital

24. Calculating the % of hand washing How we did this? Actual x 100 = % Opportunity

25. Goal 90%

26. Force Field Analysis • The current situation • The desired situation • The situation if no action is taken • Forces driving toward desired situation • Forces resisting change • ……

28. Forces in the system keeping hand washing rates where they are A B Time Lewin K (1951) Field Theory in Social Science New York: Harper

29. Understanding Systems “Every system is perfectly designed to achieve the results it gets” Paul Batalden “All improvement needs a change Not all change is an improvement” Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School.

30. Improvement Knowledge • 4 fields of interaction • - theories of systems • - our theory of ‘knowledge’ • psychology of change • variation in measurement Subject Matter Knowledge Improvement Knowledge

31. Theory of knowledge Our understanding of why things are the way they are.

32. The Implementation Gap PROBLEM EVIDENCE BASED SOLUTION PLAN “typical” attempts to change IMPLEMENT FAIL

33. Overcoming barriers at the frontline of care IMPLEMENT ACT DO SUCCEED/ SUSTAIN STUDY SYSTEM ANALYSIS to identify barriers to care PROBLEM GREAT IDEAS Quality Improvement Mentoring PLAN

34. PLAN PLAN PLAN PLAN DO DO DO DO ACT ACT ACT ACT STUDY STUDY STUDY STUDY Model for Improvement What are we trying to accomplish? What can we change that will result in an improvement? How will we know that a change is an improvement?

35. PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN DO DO DO DO DO DO DO DO DO DO DO DO ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY Unit 2 Improving many parts of the system at once Unit 1 Bundle 1 Bundle 2

36. Improvement Knowledge • 4 fields of interaction • - theories of systems • our theory of ‘knowledge’ • psychology of change • variation in measurement Subject Matter Knowledge Improvement Knowledge

37. Psychology of Change Population Late Majority Early Majority Early Adopters Traditionalists Innovators Source: E. Rogers. Diffusion of Innovation

38. Improvement Knowledge • 4 fields of interaction • - theories of systems • - our theory of ‘knowledge’ • psychology of change • variation in measurement Subject Matter Knowledge Improvement Knowledge

39. Understanding Variation • Walter Shewhart’s (1891-1967) • – understanding variation through • Statistical Process Control (SPC)

40. Flip a coin

41. ICU: VAP infections 2010

42. Measurement Common mistakes • Using bar graphs rather than run charts • Not enough data points (12 at least to understand normal variation) • Not making allowances for normal variation when interpreting data • Not measuring trends over a long enough period - cut off at year end or financial year end

43. Reacting to Variation

44. Measuring forBest Care….Always!

45. Measurement • Builds will • Assesses impact • Drives improvement • Keeps the project alive • Sustains the gains

46. Measurement • Data must be visually appealing and accessible • Owned and used at the frontline of care • Routinely reviewed at monthly management meetings • An active, encouraging feedback loop from management to frontline staff

47. Measurement Leaders need to know i) what measures are being used for • incidence of HAIs • bundle compliance (implementation of bundles) ii) how data is being presented iii) how to • interpret the data • respond to the data

48. Measurement for BCA • Outcome measures (HAIs) • Process measures (bundle compliance) • Balancing measures • Morbidity and mortality reviews

49. Outcome measures • the incidence of HAIs • impact of changes made

50. Infection Rates • Total number of infective cases per 1,000 device days: Numerator Total No. of VAP cases X 1,000 Ventilator days Denominator Good for aggregate data but high variation for units when events are rare (<10%)