1. HAI Collaborative Meeting August 8, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Learning Objectives 1.Describe Georgia’s Standardized Infection Ratio (SIR) for CLABSI related to the national SIR 2.Outline steps to be taken to reduce CLABSI in the state 3.Review best practices for Process data collection and submission 4.Identify what specific actions you will do in the next week based on this information 5.Identify the action steps your team should complete before the September meeting.

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Framing Our Meeting Putting Patients First. Preventing All Preventable Infections 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 Goal – decrease HAIs by 40% Substantial CLABSI reduction by August 2012

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Net Forward Energy Share a win or success from the last month What did you try that worked?

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Refocus Our Goals Reduce Hospital Acquired Conditions by 40% CLABSI: <1/1000 catheter days CAUTI: 25% reduction in rates

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Review of Measures Refer to the HAI Measures Chart

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Process Measure Due Dates July Process Measure Data by August 15 August Process Measure Data by September 19 September Process Measure Data by October 17 October Process Measures Data by November 21 November Process Measures by December 19 Outcomes Data should be submitted into NHSN by the 21st of the month following the collection month.

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Where Are We On Our Quest To Zero

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Reliable Process Leads to Better Outcomes

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. SHARING DATA WITH TEAMS WILL HELP TO DRIVE PROCESS

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. USING RUN CHARTS TO EVALUATE PROGRESS Lynne Hall HAI Learning Collaborative 08/08/12 Attachment 2

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Run Charts – watching performance over time Purpose: to measure and track a key input, process, or output measure over time

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Run Charts – watching performance over time x Run charts got their name because of the practice of counting “runs” or sequences of consecutive points of either side of the median Too many or too few clusters are a signal that something special is happening within your process Graphs of data show improvement over time Tool for assessing the effectiveness of change

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS Run charts have a variety of benefits: Help improvement teams formulate aims by depicting how well (or poorly) a process is performing – Identifying problems, opportunities (trends, patterns, or output measure over time) – Determining potential root cause(s) – Follow-up and verification of results Provides a quick look at a process

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. IHI RESOURCES RUN CHART TOOL http://www.ihi.org/knowledge/Pages/Tools/RunC hart.aspx http://www.ihi.org/knowledge/Pages/Tools/RunC hart.aspx TRACKER TOOL http://app.ihi.org/Workspace/tracker/

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Monitoring Improvement… RUN CHARTS 1.Plot your data. 2.Find your mean or average 3.Identify runs 4.Look for Special Cause Variation 5.Note any changes made in the process

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Monitoring Improvement: Run Chart Rules Common Cause Variation – the random variation associated with a process (No process is a straight line) Special Cause Variation – a difference in the normal process variation – Six or more consecutive increasing or decreasing points – Nine or more consecutive points on the same side of the median – 14 or more consecutive points alternating up and down around the median

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Monitoring Improvement… RUN CHARTS x 1.Plot your data. 2.Find your mean or average 3.Identify runs 4.Look for Special Cause Variation 5.Note any changes made in the process Implemented new fall process

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS x

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Summary Run charts – provide a quick visual to look at a process over time – Identifies areas for improvement – Identifies if a change in a process is working – Looks at patterns over time – Helps determine potential root cause analysis – Follow-up and verification of results

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. A Word About Our Targets Our patients are counting on us to eliminate preventable infections How can we ramp up efforts to make it happen? How can GHA assist you? An offer: Lean Project Leader

22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Next Steps 1.Create a run chart showing your CLABSI, CAUTI rates for the last six months 2.Meet with your team and share the run chart, other data 3.Send your run chart to Denise Flook 4.Enter your process data into the Novi Survey by August 15 5.Complete the meeting evaluation by August 14

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

24. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Remember to join the Community of Practice Community of Practice for Partnership for Patients – Healthcare Communities Healthcare Communities

25. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Open Mic Ask questions Ask for special assistance Make offers and requests

26. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Resources www.onthecuspstophai.org http://www.cdc.gov/nhsn/PDFs/training/intro- AnalysisBasics-PSC.pdf. http://www.cdc.gov/nhsn/PDFs/training/intro- AnalysisBasics-PSC.pdf http://www.cdc.gov/nhsn/PDFs/AnalysisBasics.p df. http://www.cdc.gov/nhsn/PDFs/AnalysisBasics.p df

27. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CONTACT INFORMATION Denise Flook dflook@gha.orgdflook@gha.org. 770-249-4518