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Improving Care Throughout New Jersey Peter Pronovost, MD, PhD

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RT and Nursing flow sheet. Our To Do List. Establish team- include executive ... A Practical Tool to Reduce Medications Errors During patient Transfer from an ... – PowerPoint PPT presentation

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Title: Improving Care Throughout New Jersey Peter Pronovost, MD, PhD


1
Improving Care Throughout New Jersey Peter
Pronovost, MD, PhD
2
Objectives
  • Who are we?
  • Where are we going?
  • How are we going to get there?

To move from Why to How
3
Who are We?
4
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5
Where are we going?
  • BSI below 25th percentile
  • ICU and hospital LOS reduced by 1 day
  • ICU and hospital mortality reduced 30
  • VAP reduced 50
  • Culture improved 50
  • Improve turnover and direct costs 30

Commit to eliminating hospital acquired infections
Where no state has gone before
6
How will we get there?
  • Every system is perfectly designed to achieve
    the results it gets

7
A Medication Error Story
Fax system for ordering medications is broken
Patient receives a medication to which he is
allergic
Nurse borrows medication from another patient
Tube system for obtaining medications is broken
Patient arrests and dies
Reason
ICU nurse staffing
8
System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Adapted from Vincent BMJ
9
What is needed for transformation
  • Will create will with personal stories of
    current reality
  • Executive will
  • Team will
  • Staff will
  • Team
  • Compelling direction clear, consequential, and
    challenging
  • Accountable and responsible for outcome
  • Correct people, skills and resources
  • Measurement system (information technology
    resources)
  • Reward system for team
  • Expert coaching
  • Execute
  • Standardize
  • Independent checks
  • Evaluate defects

10
Approach
  • Pick an area
  • Identify what we should do
  • Measure if we are doing it
  • Ensure we do what we should
  • Document outcomes improved

Measure and Test
11
How to ensure patients receive the care they
should
  • Create culture of safety
  • Ensure team knows goals, evidence
  • Standardize what is done, when it is done
  • Reduce complexity
  • Create independent checks for key processes
  • Measure and evaluate defects

Measure how you are doing
12
Improving Reliability
Defects 10-1
Standardize
Independent check define defect
Defects 10-2
Surface failures
Defects 10-3
13
How are we going to get there?
  • CUSP
  • Daily goals and multidisciplinary rounds
  • BSI bundle
  • Ventilator bundle
  • Medication reconciliation
  • Other

Testing and Measuring
14
Comprehensive Safety Program
  • Evaluate culture of safety
  • Educate staff on science of safety
  • Identify staffs safety concerns
  • Executive adopt an ICU
  • Prioritize improvement efforts
  • Implement improvements
  • Share stories and disseminate results
  • Evaluate culture

15
Safety Climate Across 100 Clinical Areas WICU
SICU Climate Pre-Post CUSP
 
of respondents within a clinical area
reporting good safety climate
16
Impact of CUSP on LOS and Turnover
17
  • How to Implement Daily Goals and
    Interdisciplinary Rounds

Small tests with one patient, one doctor one nurse
18
Pronovost, Dorman JAMA 2002
19
Percent Understanding Patient Care Goals
20
Key attributes of ICU physician staffing
  • Present
  • Posses skill/knowledge
  • Works as a team
  • Helps to leads and manage the ICU

21
Journey to achieve key attributes
  • Ensure nurses know who to call
  • Start daily rounds
  • Midlevel providers
  • Hospitalists partner with teaching hospitals
  • Regionalization
  • Intensivist

Intensivist staffing is an intervention that
reduces mortality 30
22
Impact on ICU Length of Stay
Daily Goals
654 New Admissions 7 Million Additional Revenue
23
How to Reduce CR-BSI
Small tests with one patient, one doctor one
nurse Weekly goals
24
Strategies for Prevention 5 Key Best Practices
  • Remove Unnecessary Lines
  • Hand Hygiene
  • Use of Maximal Barrier Precautions
  • Chlorhexidine for Skin Antisepsis
  • Avoid femoral lines

MMWR. 200251RR-10
25
Improve reliability of evidence-based process
  • Culture
  • Education with HEIC
  • Policy nurses assist with beginning of line
  • Standardize
  • Complexity
  • Line cart store all equipment in one place
  • Work with purchasing to get chlorhexadine prep
  • Redundancy
  • Check list

26
ICU catheter-related blood stream infections
Education
Line Cart
30
Checklist
20
Rate/1,000 Catheter days
10
NNIS Mean
0
Jul
Jan
Sep
Jan
Jun
Oct
Feb
Nov
Dec
Feb
July
Apr
Aug
Mar
May
Mar
May
June
April
August
27
How to Implement the Ventilator Bundle?
Small tests with one patient, one doctor one
nurse Weekly goals
28
Bundle Revolution
  • Bundle a group of interventions linked in time
    and space
  • Simple rules
  • How we think

29
Ventilator Bundle
  • Improve care of ventilated patients
  • Elevate HOB
  • Provide DVT prophylaxis
  • Provide PUD prophylaxis
  • Hold sedation
  • Test for ability to extubate
  • Control glucose
  • Oral chlorhexadine/Gastric decontamination

Associated with reduced mortality
30
Improvement Over the Course of the TICU Program
Aggregate Results for Participants in their 2nd
Year of the Program (2001 Launch)
Weaning Assessment was not measured during the
baseline period. Note Baseline data were
collected for four consecutive weeks in 3Q01.
After Year 1 data were collected over the
course of one month in 3Q02.
31
VHA TICU Program
Ventilator Associated Pneumonia incidence per
1,000 ventilator days (n19)
ICU LOS in days (n20)
32
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33
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34
Tips for success
  • Culture
  • Educate all staff
  • Empower non physician staff
  • Complexity
  • Standard orders
  • Glucose and SGD protocols
  • Independent checks
  • RT and Nursing flow sheet

35
Our To Do List
  • Establish team- include executive
  • Use some project management tools
  • Do one thing per week
  • Complete CUSP
  • Select BSI, daily goals and rounds, or ventilator
    bundle (ICUSRS and Med rec)
  • Implement new intervention every 3 month
  • Submit data

36
Leadership is the capacity to translate vision
into reality
Warren G. Bennis
37
Tips for success
  • Common vision and goals
  • Publicly commit that harm is untenable
  • Culture, complexity and redundancy
  • Measurement and feedback
  • Recognition and visibility (work with PR)
  • CELEBRATE SUCCESS !

All improvement is local we can provide
concepts you need to design interventions
38
Is Safety your Hedgehog Concept ?
What can you be great at
What are you passionate about
What is important
Jim Collins
39
Who is willing to shave their Head ?
  • Who is willing to
  • commit to improving
  • patient safety in New Jersey?

40
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41
References
  • Pronovost PJ, Angus DC, Dorman T, Robinson KA,
    Dremsizov TT, Young TL. Do intensivists improve
    the outcome of critically ill patients? JAMA.
    2002 2882151-2162 Pronovost 2004
  • Pronovost PJ, Berenholtz SM, Ngo K, McDowell M,
    Holzmueller CG, Haraden C, Resar R, Rainey T,
    Nolan T, Dorman T. Developing and Pilot Testing
    Quality Indicators in the Intensive Care Unit.
    Journal of Critical Care. 2003 18(3)145-155.
  • 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.Joint Commission J of Quality
    improvement executive adopt ICU
  • Pronovost P, Hobson DB, Earsing K, Lins ES, Rinke
    ML, Emery K, Berenholtz SM, Lipsett PA, Dorman T.
    A Practical Tool to Reduce Medications Errors
    During patient Transfer from an Intensive Care
    Unit. JCOM. 2004 11(1)26-33.
  • Pronovost PJ, Weast B, Bishop K, Paine L,
    Griffith R, Rosenstein BJ, Kidwell RP, Haller KB,
    Davis R. Patient Safety, Senior Executive
    Adopt-a-Work Unit A Model for Safety
    Improvement. Joint Commission Journal on Quality
    and Safety. 2004 30(2)59-68.
  • Pronovost PJ, Weast B, Schwarz M, Wyskiel RM,
    Prow D, Milanovich SN, Berenholtz S, Dorman T,
    Lipsett P. Medication Reconciliation A practical
    tool to reduce the risk of medication errors. J
    Crit Care. 2003 18(4)201-5.
  • Pronovost PJ, Bereholtz S Improving sepsis care
    in the intensive care unit An evidence-based
    approach. VHA research series 2004 www.vha.com
  • Pronovost PJ, Nolan T, Zeger S, Miller, M, Rubin
    H. How can clinicians measure quality and safety
    in acute care. Lancet. 2004 3631061-67.
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