Eliminating Catheter-Related Blood Stream Infections in NICU Patients

1
Eliminating Catheter-Related Blood Stream
Infections in NICU Patients

• The CCS/CCHA NICU
• Improvement Collaborative
• Paul
  Kurtin, MD
• 
  Chief Quality and Safety
  Officer
• 
  Rady
  Childrens Hospital Health Center

2
All Improvement is Local

• Think Globally
• Act Locally

3
Ground Rules

• Sharing individual site data Blinded yes/no?
• Prohibit use of data for marketing or competition
• Public release of aggregated data only

4
Days Without an Injury

• 100
  

5
Days Without an Infection

• ?

6
Days Without an Infection

• 27 Days

7
Days Without an Infection

• 270 Days

8
Days Without an Infection27 Hours
9
Days Without an Infection

• How is your unit doing?
• Does everyone know?
• Is there a run chart in the staff lounge?

10
Days Without an Infection

• We cant manage what we dont measure.

11
The Case for Redesign

• Every system is perfectly designed to get the
  results it gets!
• If we keep doing what we have been doing, well
  keep getting what we have always gotten
• The definition of lunacy is keep doing what
  youve always done and expect a different
  result!

12
The Case for Redesign

• The case for redesign was made in Crossing the
  Quality Chasm
• The gap between the healthcare we have and what
  is possible is not just a gapits a chasm
• Not about working harder or being more
  carefulmust change the fundamentals of the
  process

13
Design Goals

• Make it easy to do the right thing!
• Hardwire changes into routine practice via
  education, training, order sets, protocols, the
  environment
• All improvement is change, not all change is
  improvement! We must know the difference
• (P-gtD-gtS-gtA-gtPDMAIC)!
• Build measurement into the process

14
Model of Improvement

• AIM (smart) specific, measurable, attainable,
  relevant, timely
• Measures
• Execute with small tests and cycles of change
  (PDSA)

15
AIM

• To eliminate All hospital acquired catheter
  related blood stream infections in NICU patients
  by June 30, 2007
• Reduce by 50 or 90
• Selected populations e.g. post-op hearts or post
  bowel surgery

16
Potential Metrics

• Infections/1000 catheter days
• Days between infections
• Cost/infection (LOS, antibiotics, diagnostic
  tests)
• Morbidity
• Mortality
• Bundle compliance all or none?
• Thermometer with lives saved days saved
  dollars saved

17
Implementation Microsystems

• What are they?
• How to assess their effectiveness?
• How to improve?
• How to hold the gains?

18
Creating a High Reliability NICU

• Do the right thing the first time every time!
• Visual display of data as reminders
• Stop the line!
• Catheter cart to manage supplies and the
  environment
• Its the system not the person (96.5 v. 3.5 )

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What We Know v. What We Believe

• We know its the system but we believe that the
  individual, through hyper vigilance and extra
  effort, will not make a mistake (work harder, be
  more careful)
• Healthcare workers are committed, responsible,
  accountable, dedicated, (see definition of lunacy)

20
What We Know v. What We Believe

• We trust intelligence at the bedside, clinical
  experience and acumen, and our gut
• We question/doubt/distrust the system especially
  if the system slows us down and decreases our
  efficiency of doing things

21
The Culture Code

• Work who we are
• Quality it works
• Perfection is not possible and it limits
  learning by trial and error and our pioneering
  spirit

22
Making it stick!

• We are a microsystem. How do we design it to
  sustain the delivery of care which eliminates C-R
  BSIs?
• Focus on the patient
• Focus on the staff
• Shared leadership
• Focus on outcomes and continuous improvement
• Information and communication

23
Improving our Microsystems

• P.103 The Model of Improvement
• P.104 Team and meeting skills
• P.113 PDSA worksheet
• P.115 Improvement tools
• P.116 Process mapping (current process v. ideal
  gaps in planning gaps in execution)
• P.118 Flowcharting (is this what really happens?
  any steps left out or added? all the time, most
  of the time? Not the PP, ask the frontline)

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Improving our Microsystems

• P.123 Access to informationleads to
  accountability
• P.124 Change conceptsmanage time by reducing
  set-up time manage variation by standardization
  design to avoid mistakes with reminders and
  constraints
• P.125 Mental models why do we think we do/dont
  have an infection problem?

25
Tracking Our Improvement

• P.132 Run charts
• P.138 Control charts
• P.139 Pareto charts
• P.141 Change (will, ideas, resources)
• P.142 Spread of innovation

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Making Change Happen

• P.146 Sense of urgency
• Build a team
• Create vision and strategy
• Communicate 8X8
• Remove barriers (force field analysis)
• Celebrate small wins

27
Next Steps

• Baseline data where are we now? Trended if
  possible
• Site visits when and why?
• Microsystem assessment
• Resources continuing communication, web site,
  document posting, conference calls
• Hardwiring policies and procedures, staff
  education, non-staff education e.g. radiology

28
Breakout Session

• Each team will
• Develop a SMART aim
• List current metrics
• Describe potential interventions