Transcript Identifying Defects

Identifying Defects
Chris Goeschel
June 2009
Identifying Defects
What DO you know?
What SHOULD you know?
On the CUSP: Stop BSI
CUSP
1.
CLABSI
Educate staff on science of
safety
1. Remove Unnecessary Lines
2. Wash Hands Prior to Procedure
2.
Identify defects
3. Use Maximal Barrier Precautions
3.
Assign executive to adopt unit
4. Clean Skin with Chlorhexidine
4.
5.
Learn from one defect per
quarter
5. Avoid Femoral Lines
Implement teamwork tools
www.safercare.net
3
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
We are here
You are here!!!
5.
Implement teamwork tools
The CUSP Team
The smaller group that spreads
the intervention
to the rest of the unit
Education and engagement
activities on the unit
• Modeling the line placement steps;
stopping insertions that violate protocol;
having one-on-one talks where necessary
• Facilitating CUSP Activities
Team Effectiveness
Inputs
Outputs
Environment
Performance
Hospital & Unit
Context
Team
Composition
Task Design
Processes
Inside Team
Outside Team
Team Traits
Attitudes
Behaviors
Team composition
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Size
Multidisciplinary representation
Having a team leader
Having a champion
Someone gregarious
Someone detail-oriented
Everyone dedicated
Transparency
Making project and progress
visible to everyone
How are We Going to Harm
the Next Patient?
One way to make harm visible-get staff thinking about safety and
how to improve it
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)
• ICU managers and team review suggestions, set
the agenda for discussion with executive partner
• Use the Staff Safety Assessment form (Part of
CUSP manual, www.safercare.net )
– How will the next patient will be harmed in our unit
– What can be done to minimize patient harm or
prevent this safety hazard
Staff Safety Assessment - CUSP
Name:
Job Category:
Date:
Unit:
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm .
Return this form to your project leader
Thank you for helping improve safety in your workplace!
Step 2: Staff Identify Defects
• What you 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)
Step 2: Staff Identify Defects
• Report the identified defects to staff, executive
partner
• ICU managers and QI 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
Transparency
• Make harm visible to unit staff
– Share stories
– Discuss your baseline/ current BSI rates
– Link to patients
• Need to share data
– With team, unit, executive partner, Board
– Verbal report at meetings (huddles, energizers,
committee meetings)
– Posters on unit in non-public areas
– Written report (regular emails or newsletters on
project and progress)
Transparency
• Track progress visibly
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Bulletin boards
Memos (add a sidebar to a regular newsletter?)
Announcements at meetings
Powerpoint with time since last infection (or trend line
over time)
– Pictures of full barrier precautions (patient, MD and
person assisting)
• Frequent reminders, keep in the front of
caregivers’ minds
• Executive is visible--visits often, engages staff
• Demonstrate that issues raised are addressed
Team activities-keeping on track
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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)
Education and engagement
activities on the unit
• More Activities (add your ideas!)
– Internal seminar for staff
– Present project at all committee meetings
– Make BSI prevention part of a skills fair
– Have IC visit/ give a talk
– In-services/ demos
– New written policy
– Post the steps somewhere
– Put the prevention practices on all clipboards
– Update/ prepare line cart/ kit with checklist
– Hand out Fast Facts one-page info sheet
On The CUSP
Stop BSI
Assemble a safety team,
Partner with a senior executive;
Baseline Data
Exposure Survey and Technology Survey
Technical
CVC Insertion
CVC Line
Cart
1.
Contents
inventory
Evidence based
BSI prevention
(hands, site, skin
prep, barrier,
removal)
1. Presentation
of evidence
2. CLABSI
factsheet
3. Insertion
checklist
4. Vascular
access quiz
5. Vascular
access manual/
policy
6.Annotated
bibliography
Adaptive (CUSP)
CVC
Management
Science of
Safety
Training
1. Daily goals
2. Dressing
change
3. Vascular
access manual/
policy protocol
Staff Identify
Defects
Senior
Executive
Partnership
Learning
from
Defects
Implement Tools
for Teamwork and
Communication
LFD toolkit
1. Video of
Sorrell King
2. Science of
safety
presentation
3. Attendance
sheet
1. Staff safety
assessment
form
2. Indentifying
hazards
presentation
www.safercare.net
Briefings
1. Daily goals
2. Shadowing
3. AM briefing
4. Call list
6. Team
check up tool
What Should you do NOW?
1) Baseline/Monthly BSI data
2) Rejuvenate/Start Team meetings
3) Monthly Team checklist
4) Science of Safety Training for all staff
5) Identify Defects: How will patients be harmed?
6) Data Review/Action Planning
7) Post the Plan….Celebrate Accountability