leading the way in patient quality and safety · 3 unlabeled syringes-patient given wrong syringe...
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Leading the way in patient quality and safety
Leading the way in patient quality and safety
3
Unlabeled syringes-Patient given wrong syringe of medication
Wrong syringe is water for injection -no injury
Wrong syringe is medicines which requires that the patient is monitored for 24hrs
Wrong syringe is medicines which requires that the patient is treated with other medication and is monitored in ICU for an extended period
Wrong syringe is medicines which results in the patient's death
This is the only act that is controllable – the rest is luck/out of our control
Evolution of safety and quality improvement
We are
perfect/good
enough !
Get rid of
the bad apples
NO ACTION REACTION PROACTIVE
Quality
assurance
“Standards”
Minimal
Governance
•Governance
•Committees
•Incident reporting
•Counselling, Disciplinary
action
•Training, training, training
Improvement science
It does not
happen in our
hospital!
Standards are
deteriorating
Individual
champions of
improvement
REACTION
• Stories
•Pockets of Excellence
•Before and after
Projects
Focused, risk-based,
best practice, evidence
based, team based
System
thinking
Process improvement
Quality
improvement
•Best practice
•Measurement over time
•Engagement
•Stories
•Spread
Integrated Systems
Collaborative,
engagement
patients and
doctors,
INNOVATIVE
Value
•Breakthrough
• Minimise variation
•Sustainability
•Pursuing perfection
BetterQUALITY
Worse
?bettercare Reject
defects?
Requirement, specificationor threshold
Micro-manage
Filter theinformation
Increasefear
Kill themessenger
Carol Haraden BCA QI Summit 2013Source: Robert Lloyd, Ph.D.
Systems select for “winning”/low risk
Gaming/Cheating
Model 1: “Bad Apples” theory = someone to blame
Juran Trilogy:
Quality defects
Time
40
20
0
Quality
improvement
Original zone of
quality control
New zone of
quality control
e.g. % patient complaintspatient safety - HAI/Falls/Outside of clinical benchmark or target
Copyright 2018 © Dena van den Bergh. DNAVision.
Understanding systems
Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School
“Every system is perfectly designed
to achieve exactly the results it gets”
“All improvement needs a change Not all change is an improvement”
More of same change will not result in improvement
Complexity/Effort
Tools and dataTechnology, brochures, posters, SOPs, Reports
Process
Embedding who does
what, when, where
Culture
Behaviour,
leadership style
engagement
Imp
act
Evolution of safety and quality improvement
We are
perfect/good
enough !
Get rid of
the bad apples
NO ACTION REACTION PROACTIVE
Quality
assurance
“Standards”
Minimal
Governance
•Governance
•Committees
•Incident reporting
•Counselling, Disciplinary
action
•Training, training, training
Improvement science
It does not
happen in our
hospital!
Standards are
deteriorating
Individual
champions of
improvement
REACTION
• Stories
•Pockets of Excellence
•Before and after
Projects
Focused, risk-based,
best practice, evidence
based, team based
System
thinking
Process improvement
Quality
improvement
•Best practice
•Measurement over time
•Engagement
•Stories
•Spread
Integrated Systems
Collaborative,
engagement
patients and
doctors,
INNOVATIVE
Value
•Breakthrough
• Minimise variation
•Sustainability
•Pursuing perfection
Evolution of safety and quality improvement
We are
perfect/good
enough !
Get rid of
the bad apples
NO ACTION REACTION PROACTIVE
Quality
assurance
“Standards”
Minimal
Governance
•Governance
•Committees
•Incident reporting
•Counselling, Disciplinary
action
•Training, training, training
Improvement science
It does not
happen in our
hospital!
Standards are
deteriorating
Individual
champions of
improvement
REACTION
• Stories
•Pockets of Excellence
•Before and after
Projects
Focused, risk-based,
best practice, evidence
based, team based
System
thinking
Process improvement
Quality
improvement
•Best practice
•Measurement over time
•Engagement
•Stories
•Spread
Integrated Systems
Collaborative,
engagement
patients and
doctors,
INNOVATIVE
Value
•Breakthrough
• Minimise variation
•Sustainability
•Pursuing perfection
Improving Hand hygiene practice in the PICU
Prof Andrew Argent, Red Cross Memorial Hospital
BCA Learning Session2 WC 2011
from a Report of a
participative
observational study
done
Candice Bonaconsa
and
Minette Coetzee
Child Nurse Practice
Development
Initiative
Calculating the %of hand hygiene
How we did this:
Actual x 100 = %
opportunity
Comparative table of hand hygiene – bed space
24%
38%
7%
75%
Doctors Nurses Other Visitors
Target 90%
Red Cross Memorial Hospital
BCA Learning Session2 WC 2011
Reviewing systemsTime Opportunities Used opportunities %
10:00 – 11:00 12 2 16.7
11:15 – 12:15 11 2 18.2
21:30 – 22:30 14 3 21.4
22:30 – 23:30 7 1 14.3
14:15 – 15:15 11 1 9.1
15:20 – 16:20 7 3 42.9
10:45 – 11:45 28 5 17.9
11:45 – 12:45 10 2 20.0
10:30 – 11:30 15 3 20.0
11:30 – 12:30 8 3 37.5
11:30 – 12:30 15 1 6.7
12:30 – 13:30 10 1 10.0
13:30 – 14:30 5 2 40.0
14:30 – 15:30 8 1 12.5
15:30 – 16:30 4 0 0.0
14:00 – 15:00 19 1 5.3
15:00 – 16:00 9 0 0.0
12:00 – 13:00 16 1 6.3
13:00 – 14:00 10 0 0.0
Red Cross Memorial Hospital
BCA Learning Session2 WC 2011
Eliminating Central Line Associated
Blood Stream Infections (CLABSI) in the
Newborn Intensive Care
The Children’s Hospital at Providence, NICU
Pediatrix Medical Group
Anchorage, Alaska
Jack Jacob, MD: [email protected]
Debra Sims, RNC: [email protected]
Grace Schmidt, RNC: [email protected]
Carol Van de Rostyne, ANP: [email protected]
Overview of the Problem:
• 2002-2003: We were performing in the median for nosocomial sepsis
when compared to similar NICUs. But………
• We saw deaths and severe morbidity related to line sepsis
CR
BS
Is /
10
00
Lin
e D
ay
s
201
0 Q1
Q4
Q3
Q2
200
9 Q1
Q4
Q3
Q2
200
8 Q1
Q4
Q3
Q2
200
7 Q1
Q4
Q3
Q2
200
6 Q1
Q4
Q3
Q2
200
5 Q1
Q4
Q3
Q2
200
4 Q1
Q4
Q3
Q2
200
3 Q1
Q4
Q3
Q2
200
2 Q1
30
25
20
15
10
5
0
_X=1
UCL=5.49
1 2 3
Fig 1 Catheter Related Blood Stream Infections / 1000 Line Days by Quarter
Q4, 2003 - Implemented Best Practices:
- Hand Hygeine
- Sterile Barrier Precautions for Line Insertion
- Certainty of Diagnosis
P-Value = 0.044 Q1, 2008
- Externs Prep IVs for Bedside Use
P-Value = 0.022
Q2, 2009
-breakdown in process for TPN
preparation by externs related to
TPN cycling
Our Initial Approach: Best Practices.
• 2003-2006: Implementation of evidenced-based practices and assuring
compliance with those practices
• Ongoing work to change the mental model that vulnerable infants in the
NICU are destined to get an infection
• 2005 to present: Use of Clinical Microsystems principles learned in “Your
Ideal NICU” VON improvement collaborative
© Nelson EC, Batalden PB, Home K, Godfrey MM, Campbell C, Headrick LA, Huber TP, Mohr JJ, Wasson
JH: Microsystems in Health Care: Part 2. Creating a Rich Information Environment. The Joint Commission
Journal on Quality and Safety. Volume 29 (1): 5-15, 2003.
Clinical Microsystems
• We kept a detailed database on each case of sepsis and analyzed the data
• We used the concept of the “web of causation” to understand contributors to sepsis
• We tirelessly had reflective conversations with nursing staff around this issue and learned from them
• We developed a learning culture within the context of our daily clinical work
• We worked on processes and systems improvement
• We involved staff doing clinical care in our work
• We worked across hospital boundaries
• We added standardization to PDSA cycles
Results
CR
BS
Is /
10
00
Lin
e D
ay
s
2012
Q1
Q4
Q3
Q2
2011
Q1
Q4
Q3
Q2
2010
Q1
Q4
Q3
Q2
2009
Q1
Q4
Q3
Q2
2008
Q1
Q4
Q3
Q2
2007
Q1
Q4
Q3
Q2
2006
Q1
Q4
Q3
Q2
2005
Q1
Q4
Q3
Q2
2004
Q1
Q4
Q3
Q2
2003
Q1
Q4
Q3
Q2
2002
Q1
30
25
20
15
10
5
0
_X=0.71
UCL=3.95
1 2 3
1
Catheter Related Blood Stream Infections / 1000 Line Days by Quarter
Q4, 2003 - Implemented Best Practices:
- Hand Hygeine
- Sterile Barrier Precautions for Line
Insertion
- Certainty of Diagnosis
P-Value = 0.044
Q1, 2008
- Externs Prep IVs for Bedside
Use
P-Value = 0.002
Lessons Learned:
• Unit culture and mental models do not change overnight –
persistence and timely feedback of successes is important
• Go to the people who do the work – they have the
answers
• Evidence-based practice alone is insufficient if you want to
achieve perfection in health care
• Developing a learning culture within the context of your
clinical work and clinical Microsystems thinking within your
local context will allow you to obtain success not
imagined.
• The process of evidence-based practice implementation in
conjunction with the use of clinical Microsystems
principles can be applied in any setting to any topic
needing improvement
Leading the way in patient quality and safety
Model for ImprovementAim
What are we trying to accomplish?
ChangeWhat can we change
that could result in
an improvement?
MeasurementHow will we know
that a change
is an improvement?
• Motivating health care
professionals, leaders and
frontline staff to be change
leaders.
• Connect to WHY?
• A call to action
Building Will
“Some is not a number,soon is not a time…hope is not a plan”
Don Berwick IHI
Harnessing the power of the collectiveBreakthrough Series: QI method for collaborative improvement and spread
Accelerating change “together”: creating a learning network
• Learn from each other so we can make a bigger impact faster
• Input of skills, tools and reflective learning
• Identify common challenges and opportunities that we can work on
together
• Motivate and support each other to succeed
• Stretch the boundaries of what is possible
PDCA
cycles
Learning
sessions
Learning
sessions
Learning
sessions
PDSA
cycles
Leadership & Intensive support
No-one wants to do your project but they do want to contribute to a problem that
they agree needs to be solved
Copyright 2018 © Dena van den Bergh. DNAVision. 25
• Collaboration is not a passive process ofsharing ideas and attending events
• Needs strong leadership and a tightly heldcontainer that drives movement and tracksimpact
• Progress is not – “we are having a meeting”
• Strength of being part of something bigger
• Connecting to a significant “WHY”
February Collective Learning Session 1
March Collective Learning Session 2
JuneCollective Learning Session 3
August Collective Learning Session 4
OctoberData for Year End Quality Review
Framework for Collaborative Programme co-design and real-world testing
Fieldwork & Action Learning
Fieldwork & Action Learning
Fieldwork & Action Learning
Fieldwork & Action Learning
27
Adapted from David Munch BCA QI Summit 2013
• QI model breakthrough series
• Pharmacist allocated time
• 116 662 patients reviewed, 7934 interventions,
• 104 weeks standardised measurement & feedback
• 18,1% reduction in antibiotic use
AMS IMPLEMENTATION STUDY -
47 HOSPITALS
• 32,985 patients who received IVI antibiotics assessed forhang-time compliance with first doses of new antibiotic orders over 60-weeks.
• “hang-time” compliance to protocol improved from 41.2% to 78.4%
PHARMACIST-NURSE AMS
COLLABORATION AB TIMELINESS -
33 HOSPITALS
• Pharmacist-driven, prospective audit & feedback
• 70 weeks standardized measurements, 24 206 surgical
• composite compliance from 66.8%to 83.3%
• SSI rate improvement
PERI-OPERATIVE ANTIBIOTIC PROPHYLAXIS34 HOSPITALS
Three multi-center antimicrobial stewardship initiatives
28
Become part of a movement
of healthcare leaders
It’s the movement of people who want to
make real change in healthcare;
who are called to lead improvement and
innovation in quality
and
who are committed to co-creating
value and excellence in healthcare
Leading the way in patient quality and safety
