Learning Session 1 Gauteng, March 2011 Workbook

To reduce Healthcare Associated Infection (HAI) using a Systems Improvement approach Overall goal of BCA Campaign

How are you doing so far? How are you doing with Overall Progress Measurement Team work

Make your mark! Overall Progress Measurement Team work Excellent Not good Fair

Make your mark! Overall Progress Measurement Team work Excellent Not good Fair

Gauteng BCA Learning Network

Biggest challenges Leadershi p invloveme nt Understan ding the bundles Implement ing bundles Diagnosin g the infection measure ment Feeding back progress Team work Mentoring and support

Biggest challenges x xx xxxx xxxx xxxxxxxx Leadershi p involveme nt Understan ding the bundles Implement ing bundles Diagnosin g the infection measure ment Feeding back progress Team work Mentoring and support

Will Ideas Execution What we need for success

Why spend our time and energy reducing Healthcare Associated Infections? Building Will The business case

Patients get “recommended care” ~ 50% of the time. Adverse events occur in 10% of hospital patients. –50% are preventable. –7.5% of these patients die....the gap between evidence and practice 12 NEJM 2003; 348: Qual Safety in Health Care 2008;17:

Healthcare-Associated Infection –Infection rates 5-10% –1.4 million patients affected each day –USA 100,000 deaths, $6.5 billion / yr JAMA 2009;301(12): Lancet 2008;372(9651):

Delegate Survey, FIDSSA Conference Aug % In the hospital(s) with which I am associated… 14

Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta- analysis. Lancet Dec Number of HAI studies

Healthcare-associated infections are 2-3 x more common in developing countries 16 Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet Dec 2010.

SA Hospitals? –9.7% HAI point prevalence –28.6% in ICU Prof A Duse. SA-HISC study (unpublished) 17 Private + Public Hospitals in Gauteng

1 in 7 patients who enter SA Hospitals are at risk for developing an HAI Brink A et al., SAMJ 2006; 96(7) 18

HAI Impact On the patient & family On you? On the hospital? Financial? 19

IHI and others wondered if something could be done IHI (US) 100,000 lives campaign – 6 interventions including 3 of ours Canadian Safer Healthcare Now Scotland NHS Patient Safety Alliance ….and other successes around the world

Interventions were made into bundles What is a bundle and how does it work? A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement. The science behind the bundle is so well established that it should be considered standard of care. Bundle elements are dichotomous and compliance can be measured: yes/no answers. Bundles shun the piecemeal application of proven therapies in favor of an “all elements” approach.

What was achieved when the bundles were implemented reliably i.e. all elements of the bundle to every patient every time?

Results…Michigan (Keystone) 66% reduction in line-related infection Saved > 1,500 lives Saved $200 million in 18 months New England Journal of Medicine. 2006; 355(26):

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HAI : SSI RATE 25

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Why BCA? Better care, less harm Build the capacity to improve 27

Learning together 28

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30 Finding leverage and synergy to achieve sustainable, high quality health care …more quickly …at greater scale Power of leverage and synergy Leverage: doing something smart that has a much bigger impact. Synergy: two or more people produce more together than the sum of what they could have produced separately. 30

Will Ideas Execution What we need for success

4 infection prevention bundles VAP (ventilator associated pneumonia) CLABSI (central line associated bloodstream infection) SSI (surgical site infections) CAUTI (catheter associated urinary tract infections) Ideas for improvement

The size of the challenge at your facility (workbook) High care or ICU Ventilato rs Central lines Surgical Sites Urinary Catheter s Unit 1 Unit 2 Unit 3 Unit 4 Exercise: i) Mark the procedures relevant to each of your ICU or high care units with an ‘X’. ii) Prioritise the area of most concern in each unit and circling the appropriate ‘X’ in that unit

The challenge at your facility Ventilator s Central lines Surgical Sites Urinary Catheter s ICUXXXX TheatreXXX High CareXXXX Medical Ward XX Surgical Ward XX Emergency Unit XX Exercise: i) mark the procedures relevant to each of your ICU or high care units with an ‘X’. ii) Prioritise the intervention most relevant to each unit by circling one of the X’s in each unit

Will Ideas Execution What we need for success

Learning Network Learning session 1 © Institute for Healthcare Improvement Learning session 2 Activity phase: Activity phase: Learning session months Support, support, support preparation

Make it do-able Prioritise ONE bundle/ or aspect of the problem size of the problem size of the impact leadership preference Start small then build up as you gain confidence one ICU/high care small improvement team one aspect of the bundle expand as confidence grows (data) Start where you’ll get the best results the most support

Start small to gain confidence i) Choose one intervention bundle that will have the greatest effect ii) Choose one unit where you have the greatest chance of success iii) Who will you have on your team? Ventilator s Central lines Surgical Sites Urinary Catheter s ICUXXXX TheatreXXX High CareXXXX Medical Ward XX Surgical Ward XX Emergency Unit XX Exercise:

Choosing the improvement team Late Majority Early Majority Early Adopters Tradition- alists Innovators 2% 13%35% 15%

Getting Started Kit Team Exercise: i) look up the elements of your selected ‘Bundle’ ii) What reduction in the level of infection has been achieved using the bundle you selected ? Adult Ventilator Associated Pneumonia pg 9 & 10 Central Line Associated Bloodstream Infections pg 8 & 9 Surgical Site Infections Catheter Associated Urinary Tract Infection pg 5 & 6

Know where you’re heading What’s Possible with the bundles? 1.Adult Ventilator Associated Pneumonia Average 45% reduction. With every bundle element every time – Zero cases for over long periods of time (pg 7) 2. Central Line Associated Blood Stream Infections Nearly eliminate CLABSI (pg 7&8) 3. Surgical Site Infections (incidence in clean cases 2-3% USA) 40 – 60 % infections are preventable (pg 6) 4. Catheter Associated Urinary Tract Infection Reductions of 46% - 81% have been achieved (pg 6)

Define an Aim (for your bundle) must have a number must have a time frame must stretch you - not achievable in the current system - requires change benchmark against what has been achieved elsewhere Statement of where you want to go - you don’t need to know how to get there yet

Defining the Aim To reduce ………… (VAP, CLA-BSI, SSI, CA-UTI) By ……………. amount By implementing the whole ………bundle to every patient every time By September 2012 (in 18 months)

A systems approach

12/2008 Understanding Systems 1)choose two people in the room, don’t tell them who they are 2) one of them must be a person selected by the facilitator 3) keep the same distance between yourself and each of the two people you have chosen

Complete each of the steps in this process Step 1: Pick a number from 3 to 9 Step 2: Multiply your number by 9 Step 3: Add 12 to the number from step 2 Step 7: Write down the name of a city that begins with your letter Step 4: Add your 2 digits together Step 5: Divide # from step 4 by 3 to get a 1 digit number Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I Step 8: Go to the next Letter: A to B, B to C, C to D, etc. Step 9: Write down the name of an animal (not bird, fish, or insect) that begins with your letter from Step 8 Step 10: Write down the color of your animal Do you have a 2-digit Number? NO YES Output: Color____________ Animal___________ City__________

“Every system is perfectly designed to achieve the result it gets” 12/2008

‘Every improvement needs a change’ The changes: 1)Infection Control Bundles 1)A way of overcoming the implementation gap Every element of the bundle To every patients Every time

I The Implementation Gap PLAN IMPLEMENT FAIL PROBLEM EVIDENCE BASED SOLUTION “traditional” attempts to change

I DO STUDY ACT IMPLEMENT SUCCEED/ SUSTAIN Overcoming the Implementation Gap GREAT IDEAS SYSTEM ANALYSIS to identify barriers to care PROBLEM PLAN

‘ Every improvement needs a change Not every change is an improvement ’

Rapid Cycle Change –start small on one part of the bundle/system PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT

Improving many parts of the bundle/system at once. PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT part 3 part 4 part 1 part 2 PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT