CLINICIAN ENGAGEMENT MAY 13 TH, 2013 Julian Marsden Clinical Director BC Patient Safety & Quality Council

"It must be considered that there is nothing more difficult to carry out nor more doubtful of success nor more dangerous to handle than to initiate a new order of things; for the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from the incredulity of mankind who does not truly believe in anything new until they actually have experience of it." ---Machiavelli

Pronovost NEJM ICU’s across Michigan At least 1 RN and 1 MD as team leaders Knowledge & support provided Targeted 5 procedures recommended by CDC –Hand washing –Full barrier coverage –Avoid femoral site –Clean skin –Remove unnecessary catheters

Clinicians were educated about practices to control infection Central-line cart with necessary supplies created Checklist was used to ensure adherence to infection-control practices Providers were stopped if these practices were not being followed Pronovost NEJM 2006

Removal of catheters was discussed at daily rounds, and Teams received feedback regarding the number and rates of catheter-related bloodstream infection at monthly and quarterly meetings, respectively Pronovost NEJM 2006

The median rate of infection decreased from 2.7 per 1000 catheter-days at baseline to 0 within the first 3 months after the implementation of the intervention. The benefit from the intervention was sustained. Pronovost NEJM 2006

Peter J. Pronovost, MD, PhD, FCCM Sr. Vice President for Patient Safety and Quality, Johns Hopkins Medicine Director, The Armstrong Institute for Patient Safety and Quality

1.What does clinician engagement in quality mean to you? 2.How successful have you been personally in getting clinician participation? 3.What helped or hindered your success? Questions to Ponder

Objectives 1.Describe what clinician engagement is 2.Discuss why clinicians do and do not participate in improvement efforts 3.Discuss strategies to engage clinicians in creating and achieving a quality agenda

Clinicians are engaged in quality & safety … just differently

What does clinician engagement in quality mean to you?

Why are they hard to engage? Why are physicians different? Power AutonomyKnowledge Income

1.Care for patients 2.Quality of life for clinician 3.Compensation: “Time is money” Three Outcomes Of Interest

Why was this so successful?

On a sheet of plain paper: –Wash hands with soap –Clean skin with chlorhexidine antiseptic –Use sterile drapes over entire patient –Wear a mask, hat and sterile gown and gloves –Sterile dressing over the site after line insertion Pronovost

On a sheet of plain paper: –Wash hands with soap –Clean skin with chlorhexidine antiseptic –Use sterile drapes over entire patient –Wear a mask, hat and sterile gown and gloves –Sterile dressing over the site after line insertion Asked RNs to observe MDs for one month Over 1/3 missed at least one step Pronovost

Persuaded hospital leadership to authorize RN’s to: 1.stop MD’s if they skipped a step 2.ask MD’s each day whether any lines can be removed Over the next year, the 10 day line infection rate went from 11 % to ZERO in that ICU. Pronovost 2001

He travelled around the country with little success… Several reasons: –Checklist is beneath them –Another piece of paperwork that they did not have time for…patients not paper –Evidence was questioned –Only one hospital –Dr. Pronovost himself Pronovost

Didn’t tell hospitals to use the checklist …just collect data

1.Hospital leadership involved 2.1 RN and MD as co-team leaders 3.Knowledge & support provided 4.A central-line cart with necessary supplies created 5.A checklist was used 6.Providers were stopped if not being followed 7.The removal of catheters was discussed at daily rounds, and 8.The teams received feedback at monthly and quarterly meetings Pronovost NEJM 2006

1.How successful have you been personally in getting clinician participation? 2.What helped or hindered your success?

Engagement is not a step-by-step process but rather an organic process requiring empathy, thought, respect, flexibility and courage to initiate action to meet the needs of physicians. The Incomplete Guide

Reinertsen JL, et al. Institute for Healthcare Improvement; IHI White Paper: Engaging Physicians in a Shared Quality Agenda

Another Checklist

LET’S TAKE A CLOSER LOOK

1. Create conditions for engagement  Include early  Identify real leaders – not always those in charge  Develop shared vision (common ground )  Any quick wins? 2.Engage the scientist in all of us –Data = transparency – leads to competition –Learning rather than judgmental Strategies to Engage Clinicians

3.Engage the heart –Data without observation is ignorance –Report cards – cases – audits 4.Cultivate the relationship –Mutual respect, trust and autonomy 5.Communication is key –Why is this important to me, the patient, the team … –Goal is dialogue rather than discussion Strategies to Engage Clinicians

"You don't need to have all the answers, but you need the courage to ask the question, the clarity to address the task at hand, and the commitment to execute.” 2009 Fairfield University Commencement speech Peter Pronovost

Suggested Reading

Thank You