Eliminating Catheter-Related Blood Stream Infections in NICU Patients The CCS/CCHA NICU Improvement Collaborative Paul Kurtin, MD Chief Quality and Safety Officer Rady Children’s Hospital & Health Center

All Improvement is Local Think Globally Act Locally

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

Days Without an Injury 100

Days Without an Infection ?

27 Days

Days Without an Infection 270 Days

Days Without an Infection 27 Hours

Days Without an Infection How is your unit doing? Does everyone know? Is there a run chart in the staff lounge?

Days Without an Infection We can’t manage what we don’t measure.

The Case for Redesign “Every system is perfectly designed to get the results it gets!” “If we keep doing what we have been doing, we’ll keep getting what we have always gotten” “The definition of lunacy is keep doing what you’ve always done and expect a different result!”

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 gap…it’s a chasm Not about working harder or being more careful…must change the fundamentals of the process

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->D->S->A->P…DMAIC)! Build measurement into the process

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

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

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

Implementation: Microsystems What are they? How to assess their effectiveness? How to improve? How to hold the gains?

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 It’s the system …not the person (96.5 % v. 3.5 %)

What We Know v. What We Believe We know it’s 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)

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

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

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

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 P&P, ask the frontline)

Improving our Microsystems P.123 Access to information…leads to accountability P.124 Change concepts:manage 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/don’t have an infection problem?

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

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

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

Breakout Session Each team will: –Develop a SMART aim –List current metrics –Describe potential interventions