Mother Frances Hospital Regional Health Care Center ON THE CUSP: NO BSI

1. Mother Frances HospitalRegional Health Care CenterON THE CUSP: NO BSI Update and Assessment Hospital Acquired Infections: ICU April 10, 2012 Presented in Webinar Format June 21, 2012

2. Trinity Mother Frances Hospitals And Clinics About Us • Independent, faith-based Integrated Delivery System • MFH-Tyler: 404 Total Beds, 70 ICU Beds • 25,000 annual inpatient admissions • 2,600 annual deliveries • 20,000 annual surgery volume • 75,000 annual Emergency Care visits • 2 Critical Access Hospitals • Affiliation w LTACH, Rehab hospitals • 275 physician multi-specialties; • on-site full-time (24/7/365) Intensivist program • “4-bar” Leapfrog ICU Staffing score (2009, 2010, 2011; 2012 expected) • 350,000 annual clinic visits

3. Pre-CUSP Improvements Quality in Strategic Plan 100 K Lives Sentinel Event 5 M Lives “Average” Performance Achieved ‘observed” 13 “expected “ 9 O/E: 1.4 ‘observed” 40 “expected “ 18 O/E: 2.2 ‘observed” 35 “expected “ 21 O/E: 1.7 ‘observed” 33 “expected “ 8.5 O/E: 3.9

4. Why we signed up for CUSP We have checklists We have protocols We have order sets We have CLABSI carts We have PDCA …………………. We don’t have the CULTURE We don’t have the STRUCTURE We don’t have ENGAGEMENT We don’t have PATIENT CENTERED-NESS

5. The CUSP Versionof Team Training The CUSP Premise • Leadership • Climate • Culture • Behavior • Outcomes “Adaptive” Work CUSP Focuses Here “Technical” Work

6. ON THE CUSP: NO BSI • THE MFH-Tyler GOAL IS: • ZEROCLABSI • ZEROVAP • INALL FOUR ICUs • For 6 consecutive months • BYJANUARY, 2012 • FOREVER

8. The CUSP Program Unit-Based Team Training • Form an interdisciplinary unit-based team for EACH participating ICU • Recruit Senior Leadership involvement (not just ‘support’) • Recruit medical staff, medical staff leadership engagement • Staff to view “The Science of Safety” video (97 of 112 attended) • January 2011: started viewing in critical care residency • January 2011: available on TMF intranet • September 2011: Integrate into orientation of new hires to ICU, Float pool working ICU • Measure Safety Culture of Unit(s); (97% response rate, n-122) • Debrief staff on culture survey results. --------------------------------------------------------------------------------------------------------------------------------- ENGAGE STAFF IN PROBLEM - SOLVING AND PROFESSIONAL ACCOUNTABILITY • STAFF identify defects affecting care / distraction • In 60- or 90-day cycles, learn from one defect… and fix it !! • Periodic updates: Status of Identified Safety Issues • Identify and engage group “Influence Leaders”. • Implement Team Building Tools • Root Cause “lite”; learn from defects • Daily (patient) Goals Checklist (nursing / medical staff) • Shift Briefing / “Huddle” (unit staff, unit leadership, medical staff) • Professional “shadowing” • Reliable physician contact information • Indicates ‘done’ or ‘continuing’

9. EXAMPLE Scope of Work CUSP 90-day Improvement Cycles Neuro Critical Care Round 1 CLABSI Insertion bundle, CLABSI maintenance bundle Aug 2010 Physician order illegibility; conflicting orders, physician care coordination Order entry, chart management (Unit Secretaries /PCA cross training) Round 2 CLABSI Insertion bundle, CLABSI maintenance bundle (scrub-a-hub, dressing Oct 2010 change standardization), general hand hygiene; Fall maintenance; alarm integration; fall risk identification / interventions Round 3CLABSI insertion bundle, maintenance bundle, sterile port caps, scrub-a-hub Jan 2011 end ‘y-siting) Respectful communication , staff collegiality; “call out” VAP Bundle; collaboration w/ Respiratory Care on oral hygiene. ANNUAL CUSP CELEBRATION: STAFF Review accomplishments, set goals 2011 April 2011 Round 4 VAP / CLABSI Bundles (“CALL OUT” violations in bundle management) May 2011Staffing ‘grid’; anticipate pending admissions, provide coverage. Round 5VAP / CLABSI Bundles (challenge patient need for device) Aug 2011 ICU competencies; list of required skills and mentors. Round 6 Increase staff engagement in CUSP initiative; instill accountabililty for outcomes Nov 2011 ICU competencies; list of required skills and mentors. . Round 7CAUTI Best practice guidelines, ‘bundles’ for insertion and maintenance. Jan 2012 “Routine” urine cultures all ICU admission; establish POA status for UTI. Impact of aggressive bowel management on CAUTI; prevention strategies

10. SWOT Analysis SWOT Analysis

12. RESULTS

13. TREND?

14. BONUS : CUSP DELIVERABLE VAP DataVentilator-days: All ICUs VAP DataVAP Infections: All ICUs Excludes CICU Includes ALL ICUs 2008-resent

15. PRELIMINARY RESULTS (3 mos)

16. “Secrets” • Team ‘buy-in’ • Use formal and INFORMAL leaders’ influence • Use the “powerful” and the “influential” • WIIFM? (What’s in it for me?) • Set expectations of behaviors (technical and personal) • Decisions will be made…with or without you • Celebrate successes • Diminish the “Flavor Of The Month” expectation • Set expectations with or without staff attendance • “No show, no vote”

17. Challenges“Secrets” • Maintain HAI / Team Skills as a unit priority • 45-day cycles, with mid-cycle check-ins • Relevant defects discussed to completion • Who, what, by when assignments • Maintain HAI / Team Skills as a CORPORATE priority • Regular reporting to senior leadership • Regular feedback as to barriers and facilitators • ROI updates based on results

18. Mother Frances Hospital Regional Health Care CenterHospital Acquired Infections: ICU DevicesFY 2011 vs 2010 • Estimated Financial Impact ALL ICUs • VAP Reduction $157,890 savings • 88 hospital-days saved • CLABSI Reduction $218,736 savings • 91 hospital-days saved • All Devices Combined $376,626 savings • 199 hospital-days saved • Capacity created for 49 additional ICU admits @ 4-day ICU LOS 24 –mos Total Estimated Savings $823, 490

19. Thank YouQuestions?