Systematic Improvement

1. Systematic Improvement Jill Hanson Manager, Quality Improvement Improvement Advisor • Courtesy Reminders: • Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) • Please do not take calls and place the phone on HOLD during the presentation.

2. Today’s Call • Past 30 days • Staff Safety Assessment • Intervention Analysis • Model for Improvement (including PDSA and Small Tests of Change) • Next 30 days • Assessing your change ideas • Complete one test of change

3. Past 30 Days

4. Past 30 Days Mid-Month Survey Results • Has your team scheduled regular meetings for the next nine months? Yes – 100% • Did your team watch the Science of Safety video? Yes – 60% • Have you reviewed the CLABSI toolkit on the WHA Quality Center? Yes – 80% • Have you submitted your baseline data? Yes – 100%

5. Past 30 Days Mid-Month Survey Results Interest in each of the following process measures (summary of very interested/interested): • CLABSI Bundle Adherence Rate - 40% • Insertion Compliance - 60% • Maintenance Compliance – 80% • Daily Review of Line Necessity – 100%

6. CLABSI Teams – Steps for Success • Educate staff about CLABSI, central line insertion and maintenance techniques • Process development to review all patients daily for line necessity • Guide communications regarding when to remove central line • Determine how you will integrate CUSP into your daily workflow and unit operations

7. Poll Question #1 What are your barriers to insertion and management practices? • No monitoring/measurement system in place • Active resistance to prevention strategy implementation from staff and/or physicians • Lack of accountability for appropriate and safe practices • Inadequate education/competency program • Difficulty enlisting champions • Unclear policies and procedures

8. Poll Question #1 - Results What are your barriers to insertion and management practices? • No monitoring/measurement system in place • Active resistance to prevention strategy implementation from staff and/or physicians • Lack of accountability for appropriate and safe practices • Inadequate education/competency program • Difficulty enlisting champions • Unclear policies and procedures

9. Think About the Big Picture… Everyone who touches the patient with a Central Line within your hospital

10. Guidelines to CLABSI Prevention

11. Current CLABSI Practices Many teams may have already….. • A CLABSI prevention program in place with a physician champion • A written plan that is communicated to staff • Adopted the “CLABSI Bundle”

12. Barriers to Insertion and Management But they may not have…. • Created a hospital policy to ensure all components of the bundle are followed • Developed automatic reminders to nursing for routine maintenance activities • Begun using a central line insertion checklist • Held staff accountable when insertion practices were not met

13. Keys to Successful Implementation • Educate physicians, nurses and other healthcare personnel about guidelines to prevent CLABSI (e.g., online and paper versions) • Develop and implement a catheter insertion checklist • EDUCATE the medical staff! • Before, during and after implementation • Include your medical staff champions/leaders in education • Hold staff accountable for following the process • Develop an agreed upon conflict resolution process (Medical Staff chain of command)

14. Concise Summary: “CLABSI Bundle” 1.Remove Unnecessary Lines 2.Wash Hands Prior to Procedure 3.Use Maximal Barrier Precautions 4.Clean Skin with Chlorhexidine 5.Avoid Femoral Lines Marschall et al. Infect Control Hosp Epidemiol 2008CDC

15. Translating Evidence Into Practice

16. Educating Staff - What is a Central Line? The following are examples of central lines as long as they terminate at or close to the heart or in one of the great vessels NOTE: This list is not all-inclusive • Non-tunneled central lines • Tunneled central lines • Introducers • Implanted ports • Hemodialysis catheters • Peripherally inserted central catheters (PICCs) • Femoral artery catheter The following are examples of devices that are not central lines NOTE: This list is not all-inclusive • Pacemakers • Implanted cardiac defibrillators • Radial, dorsalis pedis, brachialis, ulnar arterial lines

17. Identify Barriers • Ask staff - about knowledge of prevention recommendations - what is difficult about doing these behaviors • Walk the process of staff placing a central line • Observe staff placing central line

18. Ensure Patients Reliably Receive Evidence

19. Partnership To help with 4Es, partner with: • Infection control staff • Hospital quality and safety leaders • Nurse educators • Physician leaders • Front line staff Staff must assume responsibility for reducing CLABSI

20. Engage • Share about a patient who was infected • Share stories about when nurses ensured patients received the evidence • Post baseline rates of infections • Estimate number of deaths and dollars from current infection rates • Remind staff that most CLABSI are preventable

21. Educate • Conduct in-service regarding CLABSI prevention • Create forum to jointly educate physicians and nurses • Add CLABSI prevention to unit orientation • Give staff fact sheet, articles and slides of evidence

22. Execute • Standardize: Create line cart or kit that includes necessary supplies for line insertion • Create independent checks • Create line insertion checklist • Empower nurses to ensure that physicians comply with checklist • Nurses can stop takeoff for non-emergent insertions • Learn from mistakes • Review every infection using learning from defect tool

23. Daily Goals • What needs to be done for the patient to be discharged? • What is the patients greatest safety risk? • What can we do to reduce the risk? • Can any tubes, lines, or drains be removed Pronovost, Berenholtz, Dorman. J Crit Care 2003

24. Evaluate • Post in the unit rates of infections per quarter • Post number of weeks or months without an infection

25. AIM Primary Drivers SecondaryDrivers CLABSI Driver Diagram Implement CLABSI bundle components CLABSI Bundle Adherence Rate Process to assess whether all bundle components are being followed Empower nurses to stop the line if element(s) of bundle are not being executed Adopt processes associated with appropriate catheter insertion Chlorhexidene for skin antisepsis Avoid use of femoral vein Maximal sterile barrier precautions Insertion Compliance Utilize appropriate hand hygiene Process to assure correct technique of aseptic insertion by all individuals inserting catheters Reduce CLABSI’s Adopt a practice for access to the central line (scrub the hub) “Bundling” all needed supplies in one area (e.g. Central Line Cart/Kit) Use of a “checklist” to ensure all insertion practices are followed Empower nurses to stop the line if element(s) of bundle are not being executed Adopt processes associated with appropriate maintenance Maintenance Compliance Training and competency testing of personnel responsible for catheter maintenance Standardize dressing change policies Process for removal of catheter as soon as possible Daily Review of Line Necessity Define appropriate timeframe for regular review of line necessity Daily review of line necessity

26. Science of Safety Recipe • Educate on the Science of Safety • Identify Defects (Staff Safety Assessment)* • Learn from Defects • Implement Teamwork & Communication Tools

27. The Staff Safety Assessment • How will the next patient be harmed? One way to make harm visible– get staff thinking about safety and how to improve it Frontline caregivers are the eyes and ears of patient safety • Use the Staff Safety Assessment to identify patient safety issues as it relates to CLABSI Insertion and/or Maintenance

28. Action Item #1 – Staff Safety Assessment Just two (2) very important questions for any clinical unit: Please describe where you think breakdowns are occurring with Catheter Insertion/Maintenance. Please describe what you think can be done to prevent or minimize the breakdowns. Thank you for helping improve safety in our workplace! Available in the CLABSI Systematic Improvement Webinar Folder on the Quality Center

29. Prioritizing Your Ideas • Review Driver Diagram and Staff Safety Assessment results • Find alignment between the two

30. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

31. Change Ideas To be considered a real test… • Test was planned, including a plan for collecting data • Plan was carried out and data was collected • Time was set aside to analyze data and study the results • Action was based on what was learned

32. A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Change Ideas IHI – Adapted from “The Improvement Guide” by Lloyd Provost Very Small Scale Test

33. PDSA Cycle for Learning and Improving Act Plan Objective, questions and predictions (why) Plan to carry out the cycle (who, what, where, when) What changes are to be made? Next cycle? • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data Study Do

34. CLABSI Specific PDSA Cycles • Keep standard equipment for central line placement available via a central line kit/cart • Use an insertion checklist that includes all bundle elements for insertion • Empower nurses to stop insertion if element(s) are not being executed • Include assessment for removal of central line days as part of daily goals sheet

35. CLABSI Specific PDSA Cycles • State the line day (e.g., “line day six”) during rounds as a reminder • Keep soap or alcohol-based hand gel dispensers prominently placed in/near patient rooms, universal precaution equipment such as gloves only available near hand sanitation equipment • Measure bundle compliance using an “all or nothing” measurement & share data with staff

36. Insertion Compliance - Example Catheter Insertion Competency • Use traveling mannequin • 100% of staff inserting central lines • Read policy • Take quiz • Perform procedure • Instant remediation and repeat demonstration

37. Insertion Compliance – Next Steps • Results of Competency share with CLABSI team • Developed new protocols regarding central line insertion • Annual competency training for all staff inserting central lines • Imbedded competency orientation/annual skills eval • CLABSI’s – Agenda item on every Leadership/Staff mtg • Feedback monthly to staff and physicians

38. Action Item #2 – Assess and Select an Intervention Considerations: • How would this intervention work on the unit? • Who would be willing to try the intervention? • Could you try this within the next three days? Example • Process to track daily review of line necessity

39. Action Item #3 – Test an Intervention Rule of One • Apply the Rule of one: try the intervention with one patient, one nurse, one hour, one room. • Expand the participants systematically three nurses, six patients, one shift. • The goal is to have at least 20% of those doing the work to have a chance to try it. Example • Process to track daily review of line necessity

40. Action Item #4 – Make a Prediction and Measure Benefits: • Know what you’re doing is make an impact • Early indicator that you may be getting off track • Opportunity to identify obstacles • Answers the question: “Can we rapidly adopt this practice?” Example • Process to track daily review of line necessity

41. Keep Track of Your Findings

42. The Next 30 Days • Tools available on WHA Quality Center: • Systematic Improvement Webinar Page • Staff Safety Assessment Survey Forms • Driver Diagram • Process Measure Forms • References and Toolkits

43. Reminder Please complete the three question survey before you close out of today’s webinar. Next Webinar: August 28 at 10 a.m. PDSA Cycle & Moving Beyond One Small Test of Change

44. Thank You! Questions? Jill Hanson Manager, Quality Improvement WHA Improvement Advisor (jhanson@wha.org)