Presented by:CONFIDENTIAL

Northern California NSQIP Collaborative

Pascal Fuchshuber, MD

July, 2012

CONFIDENTIAL2

Kaiser PermanentePerformance Improvement Model

•Process map•Baseline data•Data collectionplan

•Training•Policy & procedures•Spread plan

•Define goal•Apply evidence-based practices•Plan PDSA•Plan data collection

AssessDevelop/ Identify

Change Test Implement/Control

What are we trying to accomplish?

How will we know that change is an improvement?

What change can we make that will result in improvement?

CONFIDENTIAL

What is a Clinical Pathway?

• Clinical evidence based• Defined clinical

population• Patient perspective and

treatment touchpoints• Specific care steps with

decision support• Process and outcome

metrics• Demonstration of reliable

implementation

CONFIDENTIAL

What is Clinical Performance Improvement?

Transform care for our members

Develop care processes to close gap between guidelines and bedside

Test methods to correct/change course as necessary.

Frail patients are not contracting pneumonia in the hospital

Systems to ensure that the head of bed is elevated, patients are ambulating, feeding tubes are appropriate

Testing the implementation process at the medical center

CPI uses the KP Improvement Model and Clinical Pathway concepts:

CONFIDENTIAL

NSQIP: How did we choose what to work on?

Criteria for Selecting Regional PI Project

Evidence-based interventions have been tested and equipment/technology is available

Interventions are relevant to perioperative care

Provide opportunity for local teams to quickly and effectively organize

High impact on patient safety (prevent harm)

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NSQIP: The effect of SSI on our members

HAI Infections

HAP

C Diff

SSI

CLABSI

CAUTI

2540 pts 365 deaths 21,900 days

2037pts 110 deaths 18,600 days

997pts 18 deaths 5,184 days

83 pts 4 deaths 395 days

163 pts 0 deaths 234 days

# Patients # Deaths # Attrib Pt Days# Patients with HAI/yr

# Attributable deaths

# Attributable Hosp Days

HAI Epidemiology - By ICD9 Codes

CONFIDENTIAL

What are we trying to accomplish?

Fewer Surgical Site Infections

How will we know that change is an improvement?

SSI rates are reduced

What change can we make that will result in improvement?

Select, test, and implement a bundle of local infection control measures

NCAL NSQIP Collaborative SSI Project

CONFIDENTIAL

NSQIP: The NCAL Colorectal SSI Bundle

CONFIDENTIAL

NCAL NSQIP CPI Workshop: CURRICULUM

11 .1 .2011 7.30.2012

1/1 /2012

11.8.2011Session 1

Problem Assessment

1.20.2012Session 2

NSQIP CPI Training

4.20.2012Session 3

NSQIP CPI Training

7.20.2012Session 4

NSQIP CPI Training

TESTDEVELOP/IDENTIFY CHANGE Define goal Apply evidence- based practices Plan PDSA Plan data collection

IMPLEMENT/CONTROL Training Policies/procedures

Spread plan

ASSESS Introduction to CPI Change Management Team Structure Member/Staff Voice Problem Assessment

Process Mapping Cause and Effect D iag

SMART Goals

FOR SESSION 2 Plan-Member/Staff

Voice Current State Process Map Cause and Effect D iag Ideal State SMART Goals Change Ideas

FOR SESSION 3 Data Collection Plan Develop PDSAs Conduct PDSAs

FOR SESSION 4 Conduct PDSAs Perform Analysis Develop Report

Presented by:CONFIDENTIAL

Topic Time Focus of Discussion Lead / Facilitator

Welcome & Introductions

8:30 – 8:355 min

Welcome Introductions

Pascal Fuchshuber, MDMolly Clopp, RN

Using Data to Lead 8:35 - 9:5075 min How to communicate data to drive performance Homework Review

Alan Whippy, MDTammy Peacock, RN

Bundle Update 9:50 -10:0010 min Review Colorectal SSI Reduction dashboard Update bundle definitions

Pascal Fuchshuber, MDMolly Clopp, RN

Break 10:00-10:1515 min

Spread and Sustainability

10:15-10:4530 min

Assessing readiness to spread within your facility Planning for sustainability as you move on to new

projects and initiatives

Jim Bellows, PhD

Leadership Skills Simulation Training

10:45-11:5570 min

Leading Without Authority: The Influencer Vital Behaviors The sources of influence

Simulation Training Team:Jeff Convissar, MDConnie Lopez, RNChristine Retta, RN

Meeting Wrap-up 11:55 – 12:005 min Conduct Plus-Delta feedback

Pascal Fuchshuber, MDMolly Clopp, RNRuth Shaber, MD

Lunch 12:00-1:0060 min Group Lunch, please enjoy with your team!!!

Next Meeting:Agenda:

CONFIDENTIAL

Regional Prevention Bundle for Colorectal SSI Prevention

NSQIP Training Session 

CPI Training

CONFIDENTIAL

Bundle Element: Use of 2% CHG

wipes prior to surgery on all

Colorectal Cases

90% Compliance with CHG bundle element

by 5/1/2012

Cycle 1: Elective Colorectal Cases Receive 2% CHG wipes in Surgery Clinic

Cycle 2: :Pre-op Nurses perform CHG wipes prior to surgery on all Colorectal patients

Educate staff on new standards

Spread to other Surgical patients

Standardize and document protocol

Retest and modify as neededMini-measure

tracks improvement

cycles

Cycle 3: : Inpatient Nursing to administer CHG wipes night prior to

surgery on Colorectal cases.

Analyze failures:% of Missed Cases. Why? Documentation issues. Also, cases not identified or communicated properly

to the team.

Example: Implementing 2% CHG Wipes Pre-operatively

CONFIDENTIAL 13

COLORECTAL SSI SURGEON MEASURES JAN - MAY 2012Facility A

14%

0%

56%

42%

26%

39%

50%

100%

84%

78%

100%

80%

27%

50% 50%

0%

20%

40%

60%

80%

100%

120%

Jan - Feb 4 (n=11) Feb 5 - 29 (n = 15) March (n=11) April (n=19) May (n=20)

Wound protector used during the procedure Surgeon double gloved Asst. surgeon/PA double gloved

Results – Bundle Implementation

CONFIDENTIAL 14

Results – Bundle Implementation

Bundle initiated

CONFIDENTIAL 15

Results – DASHBOARD

CONFIDENTIAL

NSQIP: How will we know when we get there?

■ Measure Bundle Compliance

■ Monitor Non-Risk adjusted Colorectal SSI rates (run chart)

■ Monitor risk adjusted NSQIP outcomes data

CONFIDENTIAL

Appendix: Operational Definitions (A work in progress !)

CONFIDENTIAL

Agenda

■ Describe the Northern California (NCAL) NSQIP Collaborative

■ Explain the Clinical Performance Improvement (CPI)Training plan

■ Describe the current regional improvement project

CONFIDENTIAL

NCAL NSQIP: How are we Organized?

Surgeon Champion

Clinical Reviewer

Report out to ORCC

and PI Locally

Collect data, form teams

and lead PI initiatives

Analyze regional data, support teams, drive regional PI

Regional NSQIP Team

Report out to SOLT and RPMG

Regionally

Facilities Regional

NCAL NSQIP Collaborative

CONFIDENTIAL

NSQIP NCAL Collaborative: Who and Why

Surgeon Champions and Clinical Reviewers from each Facility

– Reps from Quality Directors, AQL and Periop Peer groups

Purpose of the NCAL NSQIP Collaborative – Meet and Learn Opportunity for the Surgeon Champions and

Surgical Clinical Reviewers – Educate Surgeon Champions and SCRs on clinical

performance improvement methods– Create Regional NSQIP performance improvement initiatives– Encourage sharing and spread local best practices – Improve Surgical Outcomes across NCAL region