Peter J. Pronovost MD, PhD.Johns Hopkins University School of

MedicineQuality and Safety Research Group

Project overview (Immersion Call 1)

Immersion call ScheduleTitle Date /Time

13:00 ESTPresented by

Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP

Comprehensive Unit-Based Safety Program CUSP

March 4, 2011 Christine Goeschel MPA MPS ScD RN

Central Line Blood Stream Infection Elimination

March 11, 2011 David Thompson DNSC, MS

Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS

Ventilator-Associated Pneumonia Reduction

March 25, 2011 Sean Berenholtz, MD

Hand-0ffs: Transitions in Care April 1, 2011 Ayse Gurses, PhD

Data we Can Count on April 8, 2011 Lisa Lubomski, PhD.

Team Building April 15, 2011 Jill Marsteller, PhD, MPP

Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD

Learning ObjectivesLearning Objectives

• To delineate the goals of Cardiac Surgery CER Project

• To describe the project organization

• To define the interventions

• To outline the planned learning sessions

• To identify who to call for help

Project OrganizationProject Organization

Multi-site Project coordinated by Quality and Safety Research Group with collaboration from SCAF

Learning collaborative model (e.g., multisite participation, 2 face-to-face meetings, monthly calls)

Standardized data collection tools and evidence

Local unit modification of how to implement interventions

Improving Care

CUSP

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

CLABSI

www.safercare.net

1. Remove Unnecessary Lines

2. Wash Hands Prior to Procedure

3. Use Maximal Barrier Precautions

4. Clean Skin with Chlorhexidine

5. Avoid Femoral Lines

7

Pronovost, Berenholtz, Needham BMJ 2008

Median and Mean CRBSI Rate

0123456789

Time (months)

CR

BS

I R

ate

Median CRBSI Rate Mean CRBSI Rate

CRBSI Rate Over Time

9

Impact of Statewide Quality Improvement Initiative on Hospital Mortality

Lipitz: BMJ 2011

Michigan ICU Safety ClimateImprovement

Effect of CUSP on Safety Climate

87

47

0

10

20

30

40

50

60

70

80

90

100

Pre vs. Post Intervention

% "

Need

s I

mp

rovem

en

t" *

Pre-CUSP (2004) Post-CUSP (2006)

* “Needs Improvement” - Safety Climate Score <60%

11

On the CUSP: STOP BSI

Preliminary data

Lessons Learned

Technical WorkWork for which there is known scienceEvidence and Measures

Adaptive workWork for which there is no scienceRequires changes in values attitudes belief

Need to get both technical and adaptive work rightAdaptive work is usually why programs falter

14

Project GoalsPrimary Goal: Reduce mortality and length of stay of

cardiovascular surgical patients in a cohort of hospitals across the United States.

Secondary Goals:Reduce / Eliminate Surgical Site Infection rates Reduce / Eliminate Central line Infection rates to <1/1000

catheter days.Reduce / Eliminate Ventilator Associated Infection rates in

the ICU.Reduce handoff errors at patient transition pointsImplement a unit based safety program to address defects

at the local levelImprove patient safety culture in the CVOR, CVICU and

Inpatient floor

IMPROVE

CUSPComprehensive Unit based

Safety program

1. Educate staff on science of safety

2. Identify defects3. Assign executive to adopt

unit4. Learn from one defect per

quarter5. Implement teamwork tools

(TRiP) Translating Evidence Into Practice

1. Summarize the evidence in a checklist

2. Identify local barriers to implementation

3. Measure performance4. Ensure all patients get the

evidence

How Often Do we Harm?Are Patient Outcomes

Improving?

Measure

www.onthecuspstophai.org

Have We Created a Safe Culture?How Do We know We Learn

from Mistakes?

Ensure Patients Reliably Receive EvidenceEnsure Patients Reliably Receive Evidence

  Senior TeamStaff

leaders leaders

Engage How does this make the world a better place?

Educate What do we need to do?

ExecuteWhat keeps me from doing it?How can we do it with my resources and culture?

Evaluate How do we know we improved safety?Pronovost: Health Services Research 2006

Major Intervention AreasCLABSIVAPSSICUSPCross-unit integration(For selected sites) Handoffs and

Transitions of care

Specific Aims AIM 1: To implement and evaluate the impact of a

patient safety program on surgical site infection (SSI) rates and operating room (OR) safety culture in a cohort of cardiac ORs.

 AIM 2: To implement and evaluate the impact of a patient safety program on rates of central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and safety culture in a cohort of cardiovascular surgical intensive care units (CVICUs)

AIM 3: To improve the safety of transitions of care/hand-offs from the cardiac OR to the cardiovascular ICU (CVICU), from the CVICU to the surgical inpatient floor, and from the surgical inpatient floor to hospital discharge.

AIM 4: To facilitate and improve teamwork, communication, and coordination across the three clinical areas/units.

IMPROVE

CUSPComprehensive Unit based

Safety program

1. Briefing/Debriefing2. Morning Huddle3. Learning from defect4. Hand-off tools 5. Shadowing another provider

AIMS

1. Surgical Site infection reduction2. Central Line Associated Blood

Stream Infections3. Improve unit culture4. Ensure all patients get the

evidence

How Often Do we Harm?Are Patient Outcomes

Improving?

OR Measures

Have We Created a Safe Culture?How Do We know We Learn

from Mistakes?

IMPROVE

CUSPComprehensive Unit based

Safety program

1. Daily Goals2. Conducting a Morning

Briefing3. Shadowing another provider4. Learning from defect5. Observing Rounds

AIMS

1. Surgical Site infection reduction continued

2. Central Line Associated Blood Stream Infections Reduction

3. Ventilator- Associated Pneumonia reduction

4. Improve unit culture5. Ensure all patients get the

evidence

How Often Do we Harm?Are Patient Outcomes

Improving?

ICU Measures

Have We Created a Safe Culture?How Do We know We Learn

from Mistakes?

IMPROVE

CUSPComprehensive Unit based

Safety program

1. Daily Goals2. Shadowing another provider3. Learning from defect4. Hand-off tools 5. Identifying who is on call

AIMS

1. Surgical Site infection reduction continued

2. Central Line Associated Blood Stream Infections continued

3. Improve transitions in care4. Improve unit culture5. Ensure all patients get the

evidence

How Often Do we Harm?Are Patient Outcomes

Improving?

CV Inpatient Floor Measures

Have We Created a Safe Culture?How Do We know We Learn

from Mistakes?

Action Items

• Send us key contact person and ID• Start to form interdisciplinary team in each area • eview content of website at www.safercare.net

• Toolkits• Slidesets• Manuals• Project Management Checklists

– Pre-Implementation Checklist– CEO/ Senior Leader Checklist– Infection Preventionist Checklist

To Get HelpTo Get Help

Email David Thompson DNSc, RN for study related questions. dthomps1@jhmi.edu

Talk to your team leader

ReferencesReferences

Measuring Safety

Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199.

Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699.

Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

ReferencesReferences

Measuring Safety

• Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199.

• Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699.

• Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

ReferencesReferences

• Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.

• Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.

Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75.

• Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337.

• Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.

• Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.