Eliminating Catheter-Related Blood Stream Infections in NICU Patients

1. Eliminating Catheter-Related Blood Stream Infections in NICU Patients The CCS/CCHA NICU Improvement Collaborative Paul Kurtin, MD Chief Quality and Safety Officer Rady Children’s Hospital & Health Center

2. All Improvement is Local Think Globally Act Locally

3. Ground Rules • Sharing individual site data: Blinded yes/no? • Prohibit use of data for marketing or competition • Public release of aggregated data only

4. Days Without an Injury 100

5. Days Without an Infection ?

6. Days Without an Infection 27 Days

7. Days Without an Infection 270 Days

8. Days Without an Infection27 Hours

9. Days Without an Infection • How is your unit doing? • Does everyone know? • Is there a run chart in the staff lounge?

10. Days Without an Infection • We can’t manage what we don’t measure.

11. The Case for Redesign • “Every system is perfectly designed to get the results it gets!” • “If we keep doing what we have been doing, we’ll keep getting what we have always gotten” • “The definition of lunacy is keep doing what you’ve always done and expect a different result!”

12. The Case for Redesign • The case for redesign was made in “Crossing the Quality Chasm” • The gap between the healthcare we have and what is possible is not just a gap…it’s a chasm • Not about working harder or being more careful…must change the fundamentals of the process

13. Design Goals • Make it easy to do the right thing! • Hardwire changes into routine practice via education, training, order sets, protocols, the environment • All improvement is change, not all change is improvement! We must know the difference (P->D->S->A->P…DMAIC)! Build measurement into the process

14. Model of Improvement • AIM (smart) specific, measurable, attainable, relevant, timely • Measures • Execute with small tests and cycles of change (PDSA)

15. AIM • To eliminate All hospital acquired catheter related blood stream infections in NICU patients by June 30, 2007 • Reduce by 50% or 90% • Selected populations e.g. post-op hearts or post bowel surgery

16. Potential Metrics • Infections/1000 catheter days • Days between infections • Cost/infection (LOS, antibiotics, diagnostic tests) • Morbidity • Mortality • % Bundle compliance: all or none? • Thermometer with: lives saved; days saved; dollars saved

17. Implementation: Microsystems • What are they? • How to assess their effectiveness? • How to improve? • How to hold the gains?

18. Creating a High Reliability NICU • Do the right thing the first time every time! • Visual display of data as reminders • “Stop the line!” • Catheter cart to manage supplies and the environment • It’s the system …not the person (96.5 % v. 3.5 %)

19. What We Know v. What We Believe • We know it’s the system but we believe that the individual, through hyper vigilance and extra effort, will not make a mistake (work harder, be more careful) • Healthcare workers are committed, responsible, accountable, dedicated, (see definition of lunacy)

20. What We Know v. What We Believe • We trust intelligence at the bedside, clinical experience and acumen, and our ‘gut’ • We question/doubt/distrust the system especially if the system slows us down and decreases our efficiency of doing things

21. The “Culture Code” • Work = who we are • Quality = it works • Perfection = is not possible and it limits learning by trial and error and our pioneering spirit

22. Making it stick! • We are a microsystem. How do we design it to sustain the delivery of care which eliminates C-R BSIs? • Focus on the patient • Focus on the staff • Shared leadership • Focus on outcomes and continuous improvement • Information and communication

23. Improving our Microsystems • P.103* The Model of Improvement • P.104 Team and meeting skills • P.113* PDSA worksheet • P.115 Improvement tools • P.116* Process mapping (current process v. ideal; gaps in planning; gaps in execution) • P.118 Flowcharting (is this what really happens?; any steps left out or added?; all the time, most of the time? Not the P&P, ask the frontline)

24. Improving our Microsystems • P.123 Access to information…leads to accountability • P.124 Change concepts:manage time by reducing set-up time; manage variation by standardization; design to avoid mistakes with reminders and constraints • P.125 Mental models: why do we think we do/don’t have an infection problem?

25. Tracking Our Improvement • P.132* Run charts • P.138* Control charts • P.139* Pareto charts • P.141 Change (will, ideas, resources) • P.142 Spread of innovation

26. Making Change Happen • P.146 Sense of urgency • Build a team • Create vision and strategy • Communicate 8X8 • Remove barriers (force field analysis) • Celebrate small wins

27. Next Steps • Baseline data: where are we now? Trended if possible • Site visits: when and why? • Microsystem assessment • Resources: continuing communication, web site, document posting, conference calls • Hardwiring: policies and procedures, staff education, non-staff education e.g. radiology

28. Breakout Session • Each team will: • Develop a SMART aim • List current metrics • Describe potential interventions