1. CSTS: The Cardiovascular Surgical Translational Study Senior Leadership of Quality and Safety Initiatives in Health Care Peter J. Pronovost, MD, PhD The Armstrong Institute for Patient Safety and Quality

2. Learning Objectives To understand the differences between technical and adaptive work To understand the role of senior leaders in addressing both types of work in QI efforts To share tactics used successfully by senior executives and leaders to support QI

3. Goals Initially work to eliminate central line associated blood stream infections (CLABSI); state mean < 1/10000 catheter days, median 0, (then Surgical Site Infections, and finally Ventilator Associated Pneumonia). To improve safety culture by 50% To learn from one defect per month To increase Executive participation in your quality and safety activites.

4. Safety Score Card Keystone ICU Safety Dashboard CUSP is intervention to improve these* 20042006 How often did we harm (BSI) (median) 2.8/10000 How often do we do what we should 66%95% How often did we learn from mistakes* 100s Have we created a safe culture % Needs improvement in Safety climate* 84%43% Teamwork climate* 82%42%

5. Technical Work Addresses problems for which the definition is clear, the potential solutions are reasonably clear, and usually require little or minimal learning Responsibility for implementing a solution is reasonably clear between leaders and followers.

6. Leadership Without Easy Answers (Heifetz, 1994) Leadership is “activity to mobilize adaptive work” (p. 27).

7. Adaptive Work Addresses problems that require a change in attitudes, beliefs, and behaviors Involves shared responsibility for change: leaders share responsibility with organizational staff and key stakeholders.

8. Most Common Leadership Error Treating an adaptive problem as technical

9. The Work of Adaptive Change Determining the direction – what must change Determining the methods - how to change

10. Pronovost: Health Services Research 2006 SeniorTeam Staff leaders Engage adaptive How does this make the world a better place? Educate technical What do we need to know? Execute adaptive What do we need to do? How can we do it with my resources and culture? Evaluate technical How do we know we improved safety? Leading Change

11. Is everyone clear on the goals, timelines, and mission? Is the necessary structure in place – people, roles, authority and responsibility? Are decision making, problem solving and conflict management processes clear? Are material resources in place – space, equipment, people, budgets (Senior Executive can help)? Are financial tracking mechanisms in place (CMS P4P implications)

12. Action Items for Senior Leaders 1.Make certain an executive is assigned to each unit and meets regularly as a member of the project team. – let the staff know senior executives are invested and will work as hard as they do to make it a success. 2.Set clear project goals and expectations for the leaders and staff in critical care units. – Provide opportunities for project teams to meet with senior executives and the board to discuss the project 3.Provide the necessary resources – time to work on the Project, funds for travel, training, equipment, supplies, etc.

13. Action Items for Senior Leaders 3. Support transparent communication with everyone – BSI rates – SSI rates – VAP rates – Process barriers and successes – Tell your own Josie Story; publically discuss a patient who suffered preventable harm at your organization 4. Expect resistance and be prepared to address it effectively 5. Celebrate wins and provide encouragement, support, attention, and resources if there are set backs.

14. CSTS: The Cardiovascular Surgical Translational Study Staff Safety Assessment Elizabeth Martinez, MD, MHS Massachusetts General Hospital Harvard University CSTS Content Call

15. Learning Objectives To understand Step 2 of CUSP: Identify Defects To understand how to Implement the Staff Safety Assessment To understand ways to use results of the Staff Safety Assessment

16. Goals To identify defects To leverage the wisdom of the front line worker To prepare a list of improvement opportunities that has face validity and provides a focus for local CUSP activities.

17. CUSP 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools CLABSI 1.Remove Unnecessary Lines 2.Wash Hands Prior to Procedure 3.Use Maximal Barrier Precautions 4.Clean Skin with Chlorhexidine 5.Avoid Femoral Lines Comprehensive Unit-Based Safety Program: CUSP

18. The smaller group that spreads the intervention to the rest of the unit The CUSP Team

19. Education and engagement activities in each clinical area BSI: Providing Evidence, Modeling the line placement steps; stopping insertions that violate protocol; having one-on-one talks where necessary; Facilitating CUSP Activities 6

20. Comprehensive Unit-based Safety Program (CUSP) 1. Educate staff on science of safety (www.safercare.net) 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools We are here You are here!!! 7

21. Martinez E,,Thompson D. Anesth Analg 2011;112:1061-74

22. Identify Defects Review error reports, liability claims, sentinel events or M&M conference Ask staff how the next patient will be harmed

23. Making project and progress visible to everyone Transparency

24. One way to make harm visible-- get staff thinking and talking about safety and how to improve it How are We Going to Harm the Next Patient?

25. Step 2: Staff Identify Defects Frontline caregivers are the eyes and ears of patient safety Identify clinical or operational problems that negatively impact patient safety (have or could) Use the Staff Safety Assessment tool – How will the next patient be harmed in our unit – What can be done to minimize patient harm or prevent this safety hazard Clinical area managers and CUSP team review suggestions, set the agenda for discussion with executive partner

27. Step 2: Staff Identify Defects What Team Leaders need to do: Hand out a Staff Safety Assessment form to all staff, clinical and non-clinical, in the unit Establish a collection box or envelope Identify and group common defects (such as communication, medications, patient falls, supplies, etc.) Summarize as frequencies (i.e., what percent of responses were for communication)

28. Prioritize Defects List all defects Discuss with staff what are the three greatest risks

29. Step 2: Staff Identify Defects Report the identified defects to staff, executive partner ICU managers and CUSP team prioritize defects identified by the potential level of risk to the patient Select one to work on with support of Executive Step 2 should be ongoing

32. CUSP Team activities- keeping on track Team meetings (recommend monthly) Review of data (monthly) Meet w/ Exec Partner (monthly or more) Executive review of data (monthly) Presentations to hospital colleagues – (leadership, frontline staff, board)

33. Comprehensive Unit-based Safety Program (CUSP) 1.Educate staff on science of safety (www.safercare.net) 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools We are here You are here!!!

34. Action Items 1.Educate staff on science of safety 1.Distribute staff safety assessment to ALL members of CV teams – Identity location for these to be returned anonymously – and in an ongoing fashion 2.Summarize the data 3.Review with CUSP team and senior executive to prioritize next steps