HAI Collaborative Meeting September 12, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Learning Objectives 1.Discuss how using the Learning from Defects or RCA process can help you identify how to improve. 2.Describe the essential elements of investigating an infection event. 3.Outline what specific actions you will do in the next week based on this information. 4.Identify the action steps your team should complete before the October meeting.

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Framing Our Meeting Putting Patients First: Preventing All Cause Harm Think of what worked and how you can learn from it What would you add/adapt to make it work in your hospital Think about what insights you gained

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Refocus Our Goals Reduce Hospital Acquired Conditions by 40% – CLABSI HAC Rate 0.67 per 1000 discharges CLABSI: <1/1000 central line days HHS HAI Action Plan 2013 Goals – CLABSI: SIR less than 0.5 – CAUTI: 25% reduction in rates

Learn. Act. Improve. Spread. Keep the Drum Beat Going. OUR PROGRESS SO FAR

Learn. Act. Improve. Spread. Keep the Drum Beat Going. CLABSI ICU summaryYQinfCountnumExpnumCLDaysInf RateSIRSIR_pvalSIR95CI 2011Q , Q , Q , Q , Q , Q , 1.175

Learn. Act. Improve. Spread. Keep the Drum Beat Going. CLABSI Reduction Progress

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Georgia GHAREF CLABSI SIR

Learn. Act. Improve. Spread. Keep the Drum Beat Going. What An Analysis Can Teach You The Following slides were adapted from the On the CUSP Stop BSI Education Series On the CUSP Stop BSI On the CUSP Stop BSI Learning from Infections

Learn. Act. Improve. Spread. Keep the Drum Beat Going. WHAT IS A DEFECT ? Anything you do not want to have happen again

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Higher Level Problem Solving Second Order Problem Solving − Reduces risks for future patients by improving work processes − Example: you create a process to make sure line cart is stocked *Anita Tucker 11

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Learning from Infections What happened? – From the people involved Why did it happen? – Evaluates positive and negative contributing factors What will you do to reduce the chance it will recur? – Specific actions needed to reduce the likelihood of recurrence. How do you know that you reduced the risk that it will happen again?

Learn. Act. Improve. Spread. Keep the Drum Beat Going. What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred Source: Reason, 1990; 13

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Why did it Happen? Develop lenses to see the system (latent) factors that lead to the event Often result from production pressures Damaging consequences may not be evident until a “triggering event” occurs Source: Reason, 1990; 14

Learn. Act. Improve. Spread. Keep the Drum Beat Going. What will you do to reduce the risk of it happening again Prioritize most important contributing factors and most beneficial interventions Safe design principles – Standardize what we do − Eliminate defect – Create independent check – Make it visible Safe design applies to technical and team work 15

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Prioritizing Contributing Factors Factor Importance in current event 1 low to 5 high Importance in future events 1 low to 5 high 16

Learn. Act. Improve. Spread. Keep the Drum Beat Going. What will you do to reduce risk Develop list of interventions For each Intervention rate – How well the intervention solves the problem or mitigates the contributing factors for the accident – Rates the team belief that the intervention will be implemented and executed as intended Select top interventions (2 to 5) and develop intervention plan – Assign person, task follow up date 17

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant 18 Staff Level Reliable Systems Design

Learn. Act. Improve. Spread. Keep the Drum Beat Going. How do you know risks were reduced? Did you do small tests of change and improved process? Did you create a policy or procedure (weak)? Do staff know about policy or procedure? – Ask 5 staff – do you get the same answer Are staff using the procedure as intended? – Behavior observations, audits Do staff believe risks were reduced? 19

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Summarize and Share Findings Summarize findings and improvements – 1 page summary of 4 questions – Learning from defect figure Share within your organizations Share de-identified with others in collaborative 20

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Key Lessons Focus on systems not people Prioritize which infections to investigate Use safe design principles Go mile deep and inch wide rather than mile wide and inch deep Test small, simple process, improve until process reliable Answer the 4 questions 21

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Action Plan Review the Learning from Defect tool with your team Review defects in your unit Select one defect per month to learn from Consider using in Morbidity and Mortality/QI conferences Post the stories of risks that were reduced Share with others 22

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Reliable Systems Process Design Education Please make plans to join our HAI collaborative meeting on October 10 from 11 – 12:30. Dr. Resar will walk through an HAI example of how to have front line staff create and test the process needed to keep patients safe. Request a hospital volunteer If you missed the RSPD Overview presentation you can listen to the recording and download materials at the HAI meetings page. Look under July 17 meeting.HAI meetings

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Next Steps: To be completed by October 10 Meeting 1.Meet with your team to assess progress. 2.Use the Learning from Defects or RCA tool to investigate an infection that occurred in the recent past. 3.Identify what improvement can be made to prevent further infections from occurring. 4.Determine a course to improve 5.Listen to the Reliable System Process Design webinar recording. Go to the link below and go to the July 17 HAI meeting information. The link to the recording and presentation is under this.HAI meeting 6.Complete the meeting evaluation by September 18 7.Submitted August Process Measure Data collection by September 26

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Action Step What is one action you will take in the next week to prevent CLABSI in your unit?

Learn. Act. Improve. Spread. Keep the Drum Beat Going. References Learning from Defects Tool: On the CUSP Tool KitOn the CUSP Tool Kit TJC RCA Framework Tool: Framework for a Root Cause AnalysisFramework for a Root Cause Analysis Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2): Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12): Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348: Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299: Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):

Learn. Act. Improve. Spread. Keep the Drum Beat Going. CONTACT INFORMATION Denise Flook