1. Gary Kantor Discovery Health 1 Day 2

2. Process Measure Compliance with bundles Bar graphs measure the difference between different categories (elements of the bundle)

3. BEST CARE ALWAYS : COMPLIANCE : CLABSI Target

4. Process Measure Compliance with bundles Overall compliance to the bundle can only be as good as the worst element.

5. BEST CARE ALWAYS : COMPLIANCE : SSI Bundle

6. Process measures for Central Line Bundle

7. A line graph is used to measure bundle compliance over time

8. Process Measure Compliance with bundles What to measure How to collect the data How to analyse the data

9. Checklist for Central Line Insertion Measuring Compliance with bundles Step 1 Checklists help measure act as a guide

10. Gary Kantor Discovery Health 10 Checklists

11. Design for Reliability 11 Level 1 Intent, vigilance, hard work Level 2 Reliability science, process redesign, human factors Level 3 High Reliability Organisations Reliability: 1:10 1:100,000 Anesthesia-related deaths Unassisted humans can’t achieve better than 1:100 reliability 1:10,000

12. Human Error If each step in a ten-step process can be performed with 99% reliability, that system functions error-free 90% of the time. A similar process with 50 steps functions error-free only 61% of the time 12

13. 2 experienced pilots…..who had never flown together before 13 Captain Chesley "Sully" Sullenberger (57) Former fighter pilot, safety expert First Officer Jeffrey B. Skiles (49) On last leg of first assignment in the Airbus A320 since passing the training course

14. 14 Hero? …….

15. The windscreen quickly turned dark brown and several loud thuds were heard. Both engines ingested birds and immediately lost almost all thrust. Captain Sullenberger took the controls… …“my aircraft!” …while Skiles began going through the three- page emergency procedures checklist in an attempt to restart the engines. 15

16. 16 Hero Checklist Design Teamwork

17. 17 How do you build a skyscraper so it doesn’t fall down? A typical building site: Hundreds of workers Many subcontractors 16 or more different trades

18. 18 USA serious building failures: 20 per year among >100 million buildings = 0.00002% per year

19. 19 How do you run a busy restaurant?

20. 20 Mortality 1.5%  0.8% p=0.003 Inpatient complications 11%  7% p<0.001 Jan 29, 2009 Non-cardiac surgery 3,955 patient in 8 hospitals in 8 cities

21. At Johns Hopkins University – America’s #1 hospital – one or more simple steps required for central line insertion were missed 30% of the time 21 Peter Pronovost Michigan

22. Pronovost P. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. NEJM Dec 2006 22 After checklist implementation (and more)…

23. Within 3 months infection rate in Michigan’s ICUs decreased by 66%. The typical ICU cut its quarterly infection rate to zero. Michigan’s average ICU outperformed 90% of American ICUs. In the first 18 months,1500 lives saved. 23

24. Copyright ©2010 BMJ Publishing Group Ltd. Pronovost, P. J et al. BMJ 2010;340:c309 Sustained improvement !!

25. Checklists (Bundles): 2 Types 1.Applicable to tasks in which best practice is well understood 2.In situations of complexity/uncertainty, use checklists that foster teamwork and communication 25

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27. What you find, when the checklist is well made, is ….the checklist gets the dumb stuff out of the way so you can focus on the hard stuff” 27

28. Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection, with subclavian vein as the preferred site for catheters in adults Daily review of line necessity with prompt removal of unnecessary lines 28 PREVENT CENTRAL LINE INFECTIONS

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32. To your planning page add: 1.Your aim 2.The outcome measures i)Rate = numerator/denominator (describe) ii)Days between iii) Welsh Safety calendar iv) Other 3.A process measure 4.How you will feedback the data every month to i)The frontline staff ii)Management iii) Presentation of your process measure

33. To your planning page add: 1.Your aim 2. Process Measures (Bundle compliance) 3.The outcome measures i)Rate = numerator/denominator (describe) ii)Days between iii) Welsh Safety calendar iv) Other 4.How you will feedback the data every month to i)The frontline staff ii)Management Mark with a * areas that you want to strengthen

34. Using the priority * areas plan a PDSA to improve or measure compliance with bundles Design or implement a checklist How to collect the data (checklist / spot checks) How to sample the checklists How to analyse the data How to display and present the data Who to present it too

35. Select a priority area for improvement resolving it will have a big impact it is under your control to test a change you can start on Monday

36. Plan a PDSA using the Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement ? What are we trying to accomplish? aim measurementchange

37. AIM of this change: PROBLEM : Design a PDSA to improve one of the areas with a *

38. AI M: use the Welsh Safety Cross PROBLEM : staff aren’t engaged in the project What When Where Who How AIM increase awareness through measurement AIM: the Welsh Safety Cross is completed Staff know what it means Welsh Safety Cross will improve the profile of the project. Will need to engage staff with colouring it in or they won’t take any notice

39. Mapping the Process “ All work is a process” W. E. Deming

40. Process Mapping What is a process map? Simply put, it is a way of visualizing all the steps taken to get to the desired outcome. Steps are shown in sequence as they are taken over time Helps identify delays and losses, opportunities for change

41. Process Mapping Exercise As a whole group lets spend the next few minutes creating a process map for getting to work in the morning

42. Process Mapping Exercise How can we get there quicker?

43. Process Maps High or low level Follow –patient journey –staff (eg gathering equipment) –steps in the protocol –Equipment procurement –etc

44. Leadership support Insert Maintain Remove MeasureFeedback

45. Process Mapping Exercise Within your groups: –Choose 1 person and together map a process they work with (draw the process out) –Spend time as a group analyzing the process, asking each of the questions listed above –Make notations on the map indicating key learning, important constraints –Time permitting begin to think about how you would redesign this process (possibly draw an idealized map)

46. Process Map Analysis Time – How long? Space – Where did the step take place? Human Resources – Who did it? Geography – How far is the journey? Financial Resources – What is the cost and to whom?

47. Process Map Analysis How many steps are in the process? Examine the order of the steps in the process – are they ideally placed? How many transfers occur in the process? Where do delays occur in the process? Can you identify known bottlenecks in the process?

48. Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement ? What are we trying to accomplish? Aim MeasurementChange

49. How confident are you in your ability to improve on: –Teamwork –Measurement –Overall progress Feedback

50. How did you find the workshop? Feedback

51. Thank you for your participation