1. Gary Kantor Discovery Health 1 Day 2

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

5. BEST CARE ALWAYS : COMPLIANCE : CLABSI Target

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

7. BEST CARE ALWAYS : COMPLIANCE : SSI Bundle

8. Process measures for Central Line Bundle

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

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

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

12. Gary Kantor Discovery Health 12 Checklists

13. Design for Reliability 13 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

14. 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 14

15. 2 experienced pilots…..who had never flown together before 15 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

16. 16 Hero? …….

17. 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. 17

18. 18 Hero Checklist Design Teamwork

19. 19 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

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

21. 21 How do you run a busy restaurant?

22. 22 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

23. At Johns Hopkins University – America’s #1 hospital – one or more simple steps required for central line insertion were missed 30% of the time 23

24. Pronovost P. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. NEJM Dec 2006 24 After checklist implementation (and more)…

25. 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. 25

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

27. 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 27

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29. 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” 29

30. 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 30 PREVENT CENTRAL LINE INFECTIONS

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34. 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

35. Design a way of measuring compliance with bundles (PDSA) 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

36. AI M: use a checklist to measure bundle complian ce PROBLEM : don’t know if all elements implemented every e What When Where Who How AIM Design a process measure to track implementation

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

38. 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

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

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

41. 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)

42. Leadership support InsertRemove MeasureFeedback

43. 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?

44. 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?

45. 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

46. AIM of this change: PROBLEM :

47. Plans to address the Biggest challenges Leadership involvement Understan ding the bundles Implementi ng bundles Diagnosing the infection Measurem ent Feeding back progress Team workMentoring and support

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