Transcript quality & patient safety

How to Develop a Robust Quality
Program
L. Olivia Sweetnam
Presented by:
Sandra Kemmerly
Ochsner Health System
Topics
•
•
What is Quality
– Quality vs Patient Safety
– Why are Quality Programs important?
How to Build a Quality Department
– Structure
 Board, Leadership, Reporting etc
– Process
 Continued evaluation of plan, RCA etc
– Outcome
•
 Data collection, analysis and dissemination
PDSA cycle
Rationale
QUALITY & PATIENT SAFETY
4
Institute of Medicine
(IOM)
1999, [It] is not acceptable for patients to
be harmed by the healthcare system [and]
that is supposed to offer healing and
comfort
(Kohn, Corrigan, & Donaldson 2000)
2001, focuses more broadly on how the health system
can be reinvented to foster innovation and improve the
delivery of care. Toward this goal, the committee
presents a comprehensive strategy and action plan
for the coming decade.
5
Quality
•
Institute of Medicine defines quality as the degree to which health
services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge (ION, 1990)
•
Six dimensions through which quality is expressed: safety,
effectiveness, patient centeredness, timeliness, efficiency and equity
•
“The most recent IOM work to identify the components of quality
care for the 21st century is centered on the conceptual components
of quality rather than the measured indicators: quality care is safe,
effective, patient centered, timely, efficient, and equitable. Thus
safety is the foundation upon which all other aspects of quality care
are built.”
Committee on the Quality of Health Care in America. Crossing the quality chasm: A new health system for the
21st century. Washington, DC: National Academy Press; 2001.
Quality
•
•
HHS states that QI is not simply an end goal, but rather
a continuous process that employs rapid cycle
improvement
Three dimensions for quality of care:
– structure which represents the attributes of settings where care
is delivered;
– the process, or whether or not good medical practices are
followed;
– and the outcome, which is the impact of the care on health status
Definition of Quality (IOM + OHS)
(“STEEP RATE”)
– Care that is
Safe
Timely
Effective
Efficient
Patient centered
Reliable
Affordable
Doing the right thing, at the right time, for
Transparent
the right person, and having the best
possible result– AHRQ
Equitable
8
Patient Safety vs Quality
•
Patient safety was defined by the IOM as “the prevention
of harm to patients.” Emphasis is placed on the system
of care delivery that
(1) prevents errors;
(2) learns from the errors that do occur; and
(3) is built on a culture of safety that involves health care
professionals, organizations, and patients
The AHRQ Patient Safety Network Web site expands upon the
definition of prevention of harm: “freedom from accidental or
preventable injuries produced by medical care”
Patient Safety vs Quality
•
•
•
Safety has to do with lack of harm; quality has to do with
efficient, effective, purposeful care that gets the job done
at the right time for the right cost
Safety focuses on avoiding bad events, quality focuses
on doing things well
Safety makes it less likely that mistakes happen. Quality
raises the ceiling so the overall care experience is a
better one
Examples of Patient Safety
•
•
•
•
•
•
Appropriate use of prophylaxis to prevent venous
thromboembolism in patients at risk
Use of maximum sterile barriers while placing central
intravenous catheters to prevent infections
Use of real-time ultrasound guidance during central line
insertion to prevent complications
Appropriate use of antibiotic prophylaxis in surgical patients to
prevent postoperative infections
Asking that patients recall and restate what they have been
told during the informed-consent process to verify their
understanding
Use of pressure-relieving bedding materials to prevent
pressure ulcers
Quality and Safety
12
Why is Quality Improvement so Important?
We have not effectively used the abilities science has already given us.
And we have not made remotely adequate efforts to change that. When
we're made a science of performance, however-thousands of lives have
been saved.
Indeed, the scientific effort to improve performance in medicine-an effort
that at present gets only a miniscule portion of scientific budgets-can
arguably save more lives in the next decade then bench science, more
lives than research on the genome, stem cell therapy, cancer vaccines,
and all the other laboratory work we hear about in the news.
The stakes could not be higher.
13
Atul Gawande, MD
Author of & Excerpt from “Better”
Rationale for Quality & Safety
•
•
•
•
•
It’s an OHS strategic
imperative - “Quality: Errorfree care that’s affordable”
What would you want for your
patients in your clinic?
What would you want for
yourself or a loved one?
What kind of reputation do you
want?
Do you want to receive full
payment for what we do?
14
How to Build a Program
•
•
•
Structure
Process
Outcome (s)
Building a Quality Program:
Structure
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Structure
Governing Board
Chief Executive
Officer
•
Organized Medical
Staff
Governing Board
– Oversight of all organization functions
 Quality, financial, strategic
= Approves the Quality Plan of the organization
– CMS Conditions of Participation dictate roles and responsibility
of the board
 Board bylaws address CMS regulations
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Structure and
Goals and Objectives
•
•
•
•
Governing Board
Chief Executive
Officer
Organized Medical
Staff
Incorporate organizational goals into PI plan
Use statements like “the 2009 PI priorities as defined by
leadership are attached in addendum X”
Can use an attachments to reference
dashboards/scorecards
When drafting or updating the PI plan, keep in mind the
annual evaluation
18
Governing Board
Methodology
•
•
Chief Executive
Officer
Organized Medical
Staff
State explicitly the methodologies the organization
employs to conduct PI projects
Can be tricky when have many methodologies that are
in use at any given time…methodologies include, but
are not limited to…
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Governing Board
Monitoring Structure
•
Chief Executive
Officer
Organized Medical
Staff
Organized Medical Staff
– Has its own set of bylaws, rules and regulations (approved by
governing board)
Medical Staff Bylaws
= Outlines the structure of the “self governing” Medical staff
= Outlines peer review activities
Focused review process
= Outlines credentialing activities
Medical Staff Rules and Regulations
= Outlines what is expected of medical staff
E.g. H&P, Consents, Chart Completion, immediate
post procedure note
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SEC
Monitoring Structure
PI
Committee
Credentials
Therapeutics
Medication Safety
•
Glycemic
Critical Care
Rapid Response
Need to clearly delineate the monitoring structure in the quality plan
– Quality Committee
Monitoring function of quality plan (high risk, high volume,
problem prone areas)
Peer review
Identifies other areas for process improvement
Protocol approvals
– Therapeutics
Monitoring function of quality plan (high risk, high volume,
problem prone areas)
Orderset approval
Resource utilization
= Drug Formulary
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Sedation
Annual Review of Sentinel Event
Policy/Patient Safety Plan
•
•
•
LD standards state you have to implement at hospital wide
patient safety program
– Program usually equals written plan
Compare it to LD standards
2009 –
– Report to governance with written reports:
System process/failures
Sentinel Events
Whether patients/families were informed of events
Actions taken to improve safety
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Annual Review of Sentinel Event
Policy/Patient Safety Plan
•
•
•
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Is Sentinel Event defined?
Does the policy/plan address disclosure
Demonstrate the communication of sentinel event definition
throughout the organization
– Sentinel event alerts
Document them in committee/department meetings
Demonstrate communication of findings from RCAs/FMEAs
– Committee/Department meetings
23
What is evidence-based medicine?
Patient care that research has shown to result in
better outcomes for patients, such as lower:
• Mortality and morbidity
•
•
•
Disability
Length of stay
Readmissions
24
What is a core measure?
A core measure is way to track use of an evidence
based intervention that is known to improve clinical
outcomes in a sub-set of patients
It is calculated by the percentage of eligible patients
that receive the intervention in the patient population
Example: Percentage of AMI patients that receive
aspirin on arrival.
25
History of Core Measures
• Joint Commission ORYX indicators vs CMS Quality Alliance
•
•
– CMS and Joint Commission not originally aligned with reporting
requirements and reported measures
– Alignment has occurred and both continue to add more measures
and core measure sets (e.g. OP Core Measures)
Core Measure Data is submitted to both Joint Commission and CMS
CMS
– Public Reporting of Core Measure Data is the first step in
establishing a pay for performance (P4) system. Currently, system
is pay for publicly reporting
– Medicare annual payment update (APU) is now based on public
reporting : www.hospitalcompare.hhs.gov
HCHAPS (patient satisfaction)
Inpatient Core Measures
Outpatient Core Measures
26
Where are we today?
#1 Reason to adhere to EBM and Core Measures:
The PATIENT
It isn’t just about the numbers….
it is about the right care every time.
High Reliable Care = Highly Reliable Organization
(HRO)
27
Core Measure Diagnosis Groups (DRGs)
•
•
•
•
Heart Failure (HF)
Acute Myocardial Infarction (AMI)
Pneumonia (PN)
Surgical Care Improvement Project (SCIP)
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Measuring Quality
Core Measure Sets
PN
SCIP
AMI
CHF
Oxygenation Assessment
Prophylactic antibiotic received
within one hour prior to incision
Aspirin at Arrival
Discharge Instructions
Pneumococcal
screening/vaccination
Prophylactic antibiotic selection
Aspirin at Discharge
LVF Assessment
ACEI/ARB for LSVD
ACEI/ARB for LVSD
Blood Cultures performed in
ED prior toantibiotic
Prophylactic antibiotic discontinued
within 24 (48 Cardiac)
Smoking Cessation
Smoking Cessation
Counseling
Adult Smoking Cessation
Surgery patients with VTE
prophylaxis ordered
Beta Blocker at Discharge
Initial Antibiotic Rec'd Within
6hrs
Surgery patients with VTE
prophylaxis received within 24
hours perioperatively
Fibrinolytic Therapy
received wihtin 30 minutes
of hospital arrival
Initial antibiotic selection in
immunocompetent patients
CRS with postoperative
normothermia
Influenza Vaccination
Cardiac Surgery patients with
controlled post op glucose
Primary PCI received
within 90 minutes of
hospital arrival
Beta Blocker at Arrival
Inpatient Mortality
Appropriate hair removal
Patients on beta blocker therapy
who received beta blocker during
periop period
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What are we doing to improve care?
•
Best practice ordersets:
– AMI
– HF
– PN
30
How is the PACS score Calculated?
•
An Example:
CHF CORE MEASURE SET
Patient 1
Patient 2
LVF Assessment
Eligible for intervention and
received LVF assessment
Eligible for intervention and
received LVF assessment
Smoking Cessation Counseling
Non Smoker, did not need
intervention (not included in
calculation)
Smoker, did not receive
smoking cessation
counseling
Discharge Instructions
Eligible for intervention and
received discharge
instructions
Eligible for intervention and
received discharge
instructions
Discharge Medication
Eligible for intervention and
received discharge
medications
Eligible for intervention and
received discharge
medications
Patient PACS SCORE:
PACS SCORE FOR MEASURE SET:
100%
0%
1 of 2 patients received all eligible interventions
= 50% PACS
31
Standards and Regulations
•
•
•
What is certified verses accredited verses deemed?
CMS “Medicare Certification” and Accrediting
Organization (AO) “Deem” hospitals
Requirements for certification
– Civil Rights Documentation
– CoP Evidence of Compliance (via a State or AO survey
– Must be in compliance with CoP @ ALL times regardless of
“Deemed Status”
 State Operations Manual
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CMS CoPs
•
482.21 – Performance improvement projects.
– As part of its quality assessment and performance improvement
program, the hospital must conduct performance improvement
projects.
– The number and scope of distinct improvement projects conducted
annually must be proportional to the scope and complexity of the
hospital's services and operations.
– A hospital may, as one of its projects, develop and implement an
information technology system explicitly designed to improve patient
safety and quality of care. This project, in its initial stage of
development, does not need to demonstrate measurable
improvement in indicators related to health outcomes.
– The hospital must document what quality improvement projects are
being conducted, the reasons for conducting these projects, and the
measurable progress achieved on these projects.
33
The Joint Commission
•
•
•
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Basic entry level certification in quality and safety
18 Chapters of “Standards” (Medical Staff, Leadership, Medication
Management, Patient Care, Information Management, etc plus
National Patient Safety Goals)
– 1800+ of “Elements of Performance”
It is not an irrelevant, bureaucratic, exercise, rather it is a
comprehensive test of quality and they are deemed reviewers for
CMS
Survey process:
–
–
–
–
–
Collegial, educational
Tracer methodology
Informational sessions
Open and closed record review
Leader and staff dialogue, questions
Could JC Accreditation be considered a “Strategy”?
- Risk reduction strategy for federal penalties
34
JC Standards: PI Chapter
•
Hospital improves performance
– Leaders prioritize identified improvement opportunities
– Hospital takes action on improvement priorities
– Hospital evaluates actions to confirm they resulted in
improvements
– Hospital takes action when it does not achieve or sustain
planned improvement
35
Department Performance Improvement
Projects: Questions to Ask Yourself
•
•
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What is your department PI project?
And….
What are the trends in your occurrence reporting data?
And….
Patient Safety Rounding
– “What patient safety issue do you see happen every shift, every
day?”
– “If you could improve one thing in this department, what would it
be?”
36
Continued Regulatory Readiness
•
•
Establish a rhythm and rigor around readiness
Tools:
– Tracers & audits
– Rounds
– Sweeps: Sweep Sheets - Documentation & Environment
- Customize them!
– Resources: Survey FAQ’s
– [email protected]
– [email protected]
It's not the will to win, but
the will to prepare to win
that makes the difference.”
- Paul "Bear" Bryant
37
Adverse Event Reporting
•
•
Estimates are that voluntarily reported medical errors
reflect 10 to 20 percent of actual errors, at best.
Why is this the case?
Lack of Voluntary Reporting – Why?
Recognition that
an error
occurred
Fear of punitive
response to
reporting
Reporting
systems can be
cumbersome
No bad outcome from the
error
Fear of blame and
punishment to oneself or
colleague, especially if
there is harm
Seek to collect as much
information as possible
for analysis
Example: RN
administers the incorrect
dose of medication to
patient with no ill effects
Increased if he/she has
seen a colleague
disciplined after reporting
an error
No harm – no reason to
get anyone in trouble
Difficult to set aside time
to complete the report,
may put it off or forget or
may decide not to bother
39
Impact of Latent Failures
Errors that lead to serious patient harm are rarely the
result of just one error involving one person. Rather,
there are typically a series of errors or breakdowns in
process, most of which have probably been occurring
for some time, just not all at once.
40
How You Can Make a Difference –
Next Steps:
•
Identify all defects, errors and workarounds
– Role model the “stop the line” in a collegial manner, so that
errors are identified and fixed before they can be passed on
– Encourage reporting of errors and defects by frontline staff
members
Building a Quality Program:
PROCESS
What Errors to Focus On?
•
All errors
•
Even the “small” ones
•
Why ?
Go Ahead – Sweat the Small Stuff!
There are 10
errors with
potential for
death or injury
For every 1
error that
results in
death or
serious injury
And 100
errors without
potential for
injury
Essentially, we
are being
“told”
110 times that
we may have
a serious
injury or death
about to occur.
How You Can Make a Difference –
Next Steps:
Identify workarounds
One study suggests….
90% of the instances when nurses encounter an operational
failure - they create a “workaround”.
I can’t easily and quickly access the medications I need, so I’m going to
keep some medications in this cart or in my pocket.
This room doesn’t have a suction canister, so I’m going to borrow one
from the next closest room.
What do they do the other 10% of the time?
― Ask someone for assistance
“Can you come read this order?”
“While you are over there, can you grab that medication?”
Normalizing Deviance
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•
•
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Working around small problems, or defects, may seem like the right
thing to do in a busy clinical environment.
– Improvising? Making do?
In fact, the tendency to work around problems is so common that it
has a name: “normalizing deviance.”
But those small problems aren’t just obstacles over which to climb.
They’re “weak signals” that the system isn’t working the way it
should.
We need you and your staff to identify and resolve the defects, the
work arounds, the warnings signs … the “weak signals”.
The “Natural History” of Quality Improvement
•
Stages in Improvement
1. Be dissatisfied with the status quo
2. Measure how we are doing
3. Design effective changes
1. Engage frontline employees
2. Small tests of change
3. Rapid cycles
4. Employ reliability science
4. Test design/Remeasure
5. Redesign/Iteration
6. Implementation
7. Spread
47
Implementing a Change and Working with People
8 Steps in Change
– Establish a Sense of Urgency
– Create a Guiding Coalition
– Develop a Vision and Strategy
– Communicate the Vision
– Empower Employees
– Generate Short Term Wins
– Consolidate Gains and Produce More Change
– Anchor Approaches in the Culture
• Understanding scale up
• Communication- 8 Times, 8 Ways
48
An example from the hospital….
A patient is admitted for confusion and falls.
During a confused episode, the patient pulls off her “fall
risk” armband. The armband is not replaced.
The patient must leave the unit for a diagnostic study.
The “ticket to ride” is not entirely completed, and the fact
that the patient is a fall risk and is confused is not marked
on the form.
The transporter was delayed in picking up the patient and
when he arrives the nurse is now off the unit. Therefore,
no handoff communication occurs.
The transporter brings the patient to the department for the
diagnostic study, places the patient’s bed in a bay and
goes around the corner to give the desk clerk the chart.
The confused patient attempts to get out of bed and
falls, hitting her head
Responding to the Reports of Defects and
Errors
•
It’s all very well to say “it’s your duty as a health
professional to speak up about defects”. But if staff know
that our organization tends to respond poorly when
problems are reported, they are probably not going to
bother.
•
That’s why it’s very important that we have a deliberate
and reliable way of responding to staffs’ concerns.
Responding to the Reports of Defects and
Errors
The people doing work
must recognize they
have a problem.
The responsible person
must show up without
blame and with a desire
to solve the problem
collaboratively.
Someone must be
responsible for solving
that problem.
There must be enough
time and resources to
solve the problem.
The people doing work
must be able to notify
the responsible person
in a timely way.
The organization,
and each person
within it, must define
the new normal so
they can recognize
the abnormal.
Specimens – what’s abnormal?
VS.
The organization, and each person
within it, must define the new
normal so they can recognize the
abnormal.
52
Next Steps:
Create the cultural conditions to succeed
•
•
If we provide the previously-mentioned conditions, we
make it possible for staff to report many small problems
– which can lead to the resolution of big problems in
the future.
It also helps to create the Culture of Safety we desire.
Root Cause Analysis
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•
•
One tool to use in response to an adverse event
Sentinel Event = Performance Improvement
Intense Analysis = Department Leader, Department Staff
•
Very formal
•
Very informal, even a way of thinking
Focuses on the process, not the person
– “Wait….how could this not be someone’s fault?”
Examples:
= Administration of the wrong medication
= Pulling the wrong patient chart
54
Hmmmm…..
Aoccdrnig to rscheearch at Cmabrigde
Uinervtisy, it deosn't mttaer in waht oredr
the ltteers in a wrod are, the olny iprmoetnt
tihng is taht the frist and lsat ltteer be at the
rghit pclae. The rset can be a toatl mses
and you can sitll raed it wouthit a porbelm.
Tihs is bcuseae the huamn mnid deos not
raed ervey lteter by istlef, but the wrod as a
wlohe.
55
The Five Whys
• When the group identifies potential root causes, the
•
•
•
group should employ the “Five Whys” to further
evaluate.
This is an important step and the group should resist to
urge to stop at the first why.
Getting to the root cause of a sentinel event involves
asking “Why?” and then exploring the ramifications of
the response.
After listing examples, drill down further on each one
and determine what action could be put in place to
prevent the event or offer other alternative for action.
56
Endoscopy example
•
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•
•
•
•
We used a scope that hadn’t gone through the complete decontamination
process.
– Why?
When I grabbed it, I didn’t know it was “dirty”.
– Why?
It was hanging in the “clean” closet.
– Why?
The scope rep put it there.
– Why?
It was a loaner for a broken scope we sent back to the company. The rep
didn’t know where to hang it so she put it in the ‘clean” closet.
– Why?
The reps aren’t necessarily oriented to all of our protocols. And we don’t
have a clear process for when a loaner scope is introduced into the
department.
57
Building a Quality Program:
Outcomes and Data
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Rules for Collecting Data
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DATA COSTS MONEY!
Define all data elements
Give instructions for what do with data that is not on the
chart (or blank on data collection forms)
Don’t collect data you won’t use or if it use is for
something other than the improvement initiative
Don’t collect data forever!
NO RECREATIONAL DATA COLLECTION
61
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“Never be afraid to do something new.
Remember, amateurs built the ark;
professionals built [and operated] the
titanic.”
- Anonymous
Managing Common Cause Variation
•
To reduce common cause variation, one must find a
new process – one that is superior to that of the
original process
PLAN
Design an new process
DO
Do it on a trial in a small
group
STUDY
Is the new process superior
to the old process?
ACT
Implement, modify, discard
64
Testing a Change
•
•
•
•
Test on a small scale
(Small tests, not small
changes!)
Test under a variety of
conditions
Build knowledge
sequentially
Requires measurement and
monitoring of data
65
PDSA: Minimize Variation
– There will always be some variation in a process
– But we can work to minimize variation around a mean or target
70
Change Implemented
65
60
55
UCL
50
Mean
LCL
GOAL= reduce
variation
45
40
1
11
21
31
41
66
51
61
71
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Summary - How to Make a Difference
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Stop The Line
Identify and resolve errors, defects and workarounds
Learn and apply the science of improvement
Create the ideal cultural conditions for reporting errors
Re-Engineer/Re-Tool Your Daily Processes
Utilize the resources and tools provided
Engage your staff and docs in quality improvement and patient safety
efforts
Put quality and safety on the agenda of all your meetings
– Talk about results and improvement efforts in your area
– Learn it together- mini-journal clubs in your operational meetings
Hold yourselves and your team accountable for improving quality
– Have your folks report on their results and progress
67
It’s hard to drive change
We are removed form the reality of infections
“The key difference between the procedures: While
anesthesia combatted a "visible and immediate problem
(pain); the other combatted an invisible problem (germs)
whose effects wouldn't be manifest until well after the
operation," Gawande writes. And although both
approaches "made life better for patients, only
[anesthesia] made life better for doctors" by transforming
the surgical experience.”
Infection prevention and control measures
aim to ensure the protection of those who
might be vulnerable to acquiring an
infection both in the general community
and while receiving care due to health
problems, in a range of settings. The basic
principle of infection prevention and control
is hygiene.
Infection control is an essential component of any health care delivery.
Infection control measures can be as simple as hand washing and as
sophisticated as high-level disinfection of surgical instruments.
Implementing these measures can prevent transmission of disease in
health care settings and the community.
Infection control is a key concept in achieving the New York State
Department of Health mission to protect and promote the health of
New Yorkers through prevention, science and the assurance of quality
health care delivery
"This has been the pattern of many important but stalled
ideas," Gawande writes. "They attack problems that are
big but, to most people, invisible; and making them work
can be tedious, if not outright painful."
How do we make problems visible?
Effects of HAI
•
•
Effects of HAI range from small to devastating
A patient who requires a central line and acquires a
health care- associated bloodstream infection via central
line, will at minimum, require a longer period of treatment
with antibiotics, at worst the patient will die
“As humans, we perceive what we can see, what we smell,
what we can touch and what we can hear- and we act on
those perceptions. If we perceive nothing, as in the case
of the microbes, we must rely on our mental resources or
other artificial interventions to remember to act”
CLABSI System Rate
1.8
1.6
System Rate
1.4
Linear (System Rate)
1.2
1
0.8
0.6
0.4
0.2
0
$1,511,862
cost
avoidance
with
CLABSI
reduction!!
GOAL
“The health care organization must develop a culture of
safety such that an organizational design processes and
workforce as focused on a clear goal- dramatic
improvement in the reliability and safety of the care
process.”
Kohn, LT. To err is human, building a safer health system. Institute of Medicine, National Academy Press. 2000
Use that PI knowledge!!
•
•
•
Where is the fall out?
Did we have an infection?
Let’s walk through the process
Bring defects to the forefront
…before something bad happens!
Goal
•
•
•
Our data is to use the data we collect to inform, educate,
program plan and evaluate
Hopefully the increased awareness helps clinicians
incorporate best practices into daily work flow
But we need help!!
CLABSI Rate: 2012 to Current
OMCNO
OMCWB
OBMC
Provider Number
Goal Rate (<0.5)
3.0
2.5
2.0
1.5
1.0
1.47
1.54
1.17
0.84
0.82
0.78
0.57
0.5
0.52
0.64
0.27
0.0
Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014
The Good News
• Statistically significant reduction in CLABSI
from 2012 to 2013
–
–
–
–
2012 = 1.300 CLABSIs per 1,000 central line days
2013 = 0.737 CLABSIs per 1,000 central line days
p = 0.0002, α = 0.05
Wilcoxon Rank Sums non-parametric procedure
• We believe this is due to many initiatives
Data Deep Dives and Data
Transparency
Example Using CLABSI Breakdown by
Floor and Service
ICU - Overall
Jan
0
No. CLABSI Infections
No. CL Days 785
CLABSI Rate 0.00
NHSN Percentile 10th
CL Utilization 0.86
NHSN Percentile >90th
CLABSI Bundle
79%
Compliance
Feb
Mar
Q1
Apr May
2014
0
679
0.00
10th
0.83
>90th
0
718
0.00
10th
0.80
>90th
0
2182
0.00
10th
0.83
>90th
0
740
0.00
10th
0.84
>90th
90%
86%
85%
90%
1
780
1.28
75th
0.86
>90th
Jun
0
643
0.00
10th
0.78
>90th
Q2 YTD
2013
2014 2014
1
2163
0.46
25th
0.83
>90th
97% 100% 95%
1
5021
0.20
25th
0.82
>90th
8
7859
1.02
50th
0.80
>90th
90%
N.D.
CNICU - Overall
Jan
Feb
Mar
Q1
Apr May
2014
Jun
Q2 YTD
2013
2014 2014
No. CLABSI Infections
No. CL Days
CLABSI Rate
NHSN Percentile
CL Utilization
NHSN Percentile
CLABSI Bundle
Compliance
0
672
0.00
10th
0.68
90th
0
519
0.00
10th
0.60
75th
1
538
1.86
90th
0.58
75th
1
1729
0.58
50th
0.62
75th
0
511
0.00
10th
0.55
75th
0
512
0.00
10th
0.56
75th
1
485
2.06
90th
0.56
75th
1
1508
0.66
50th
0.56
75th
95%
73%
68%
77%
92%
87% 100% 92%
2
2
3771 6596
0.53 0.30
50th 50th
0.59 0.64
75th 75th
87%
N.D.
Example Using CLABSI Variables
83
BMI
2014 CLABSI
Number of
CLABSIs
Jan
Q1
Q2 YTD
CLABSI Rate (per
Feb Mar 2014 Apr May Jun 2014 2014 2013 1000 CL Days) Jan
Q1
Q2 YTD
Feb Mar 2014 Apr May Jun 2014 2014 2013
BMT
0
1
0
1
0
0
0
0
1
1
BMT
0.00 11.76 0.00 5.52 0.00 0.00 0.00 0.00 3.24 1.70
CICU
0
0
0
0
0
0
0
0
0
1
CICU
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.76
CNICU
0
0
1
1
0
0
1
1
2
2
CNICU
0.00 0.00 1.86 0.58 0.00 0.00 2.06 0.66 0.62 0.30
CTSU
0
0
0
0
0
0
0
0
0
0
CTSU
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
GISS
0
0
0
0
0
0
0
0
0
0
GISS
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
ICU
0
0
0
0
0
1
0
1
1
8
ICU
0.00 0.00 0.00 0.00 0.00 1.28 0.00 0.46 0.23 1.02
IMTA
0
1
0
1
0
0
0
0
1
5
IMTA
0.00 4.24 0.00 1.29 0.00 0.00 0.00 0.00 0.64 2.38
MSU
0
0
0
0
0
0
0
0
0
1
MSU
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.44
NSU
N/A
0
0
0
0
0
0
0
0
N/A NSU
N/A 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 N/A
ONC
0
0
1
1
0
1
0
1
2
3
ONC
0.00 0.00 1.88 0.65 0.00 1.84 0.00 0.61 0.63 0.62
PEDS
0
0
0
0
0
0
0
0
0
1
PEDS
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.22
PICU
0
0
0
0
0
0
1
1
1
0
PICU
0.00 0.00 0.00 0.00 0.00 0.00 4.98 2.28 1.24 0.00
POSTOP
0
0
4
4
0
0
0
0
4
3
POSTOP
0.00 0.00 15.56 5.63 0.00 0.00 0.00 0.00 3.13 1.41
TSU
1
0
1
2
0
0
0
0
2
5
TSU
1.76 0.00 1.80 1.20 0.00 0.00 0.00 0.00 0.65 0.88
OMC Total
1
2
7
10
0
2
2
4
14
30 OMC Total
0.25 0.51 1.79 0.85 0.00 0.51 0.51 0.34 0.60 0.74
REHAB - ELM
0
0
0
0
0
0
0
0
0
0
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
SNF - ELM
OMC & ELM
Total
0
0
0
0
0
0
0
0
0
1
1
2
7
10
0
2
2
4
14
NHSN Pooled Mean
Hospital-Wide Goal Rate < 0.5
BMT = 2.7
CICU = 0.8
CNICU = 1.3
CTSU = 0.8
0.6
GISS = 0.8
ICU = 1.3
IMTA = 0.9
MSU = 0.8
NSU = 0.8
ONC = 1.9
PICU = 1.4
POSTOP = 0.9
TSU = 2.7
REHAB (ELM) =
PEDS = 1.1
SNF (ELM) = 1.0
REHAB - ELM
SNF - ELM
OMC & ELM
31 Total
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.92
0.24 0.49 1.71 0.82 0.00 0.48 0.49 0.33 0.57 0.74
NHSN Pooled Median
Hospital-Wide Goal Rate < 0.5
BMT = 2.4
CICU = 0.0
CNICU = 1.1
CTSU = 0.0
0.0
GISS = 0.0
ICU = 1.1
IMTA = 0.0
MSU = 0.0
NSU = 0.0
ONC = 1.2
PICU = 0.8
POSTOP = 0.0
TSU = 2.4
REHAB (ELM) =
PEDS = 0.0
SNF (ELM) = 0.8
Central line
Bundle Compliance 2014
2014 Year-to-Date
GISS
CARDMS
ED
OBS
CNICU
CTSU
ICU
TSU
BMT/ONC
REHAB
SNF
IMTA
MSU
PEDS
PICU
POSS
House-Wide
Compliant
73
58
0
0
106
0
143
74
35
2
24
16
14
12
19
21
597
Observed
87
66
0
0
126
0
160
105
72
4
43
31
17
16
20
26
773
Rate
84%
88%
N/A
N/A
84%
N/A
89%
70%
49%
50%
56%
52%
82%
75%
95%
81%
77%
2014 House-Wide Jan Feb Mar Apr May Jun
Compliant
99
96 71 121
95 115
Observed
135 132 113 147 110 136
Rate
73% 73% 63% 82% 86% 85%
Know Your Rates!!
87
Know Your Rates!!
88
CLABSI M&M
• When a unit has a CLABSI, receive M&M toolkit
to help them investigate
• Presentation includes
– Science of Safety Introduction
– Case discussion
– Evaluate process to eliminate defects
CLABSI M&M Standard
CLABSI Gemba Walk
“On the Gemba”
Gemba Walk: CLI’s
Executive Owner: Kathy
Baumgarten, MD
Summary of Patient Safety Challenge:
CLI’s continue to be a challenge for our facility. Many
other hospitals have been able to eradicate CLIS’s through a structured, planned approach. Although we have made
progress this year, we are committed to make CLI’s a “never event”.
Supporting/Relevant Data:
YTD June: 15
Action Item
Status
LDA documentation: Workflow issue within EPIC
In progress
Procedure Notes:
Complete
OR/Anesthesia dressings: Appropriate supplies in the OR
Complete
Physician education: Insertion, documentation, eICU support
Complete
Procedure team: Executive support to investigate further
In Progress
Equipment: Portable U/S machine, CUROS trial (8th fl, TSU)
Complete
CLI Huddles: Huddle to assess case – being performed in CC
Complete
SIM Class
•
Primary Goals: To obtain and maintain a zero Central
Line Associated Blood Stream Infection (CLABSI) rate.
– To minimize complications associated with central line placement
such as but not limited to arterial cannulation,
pneumothoracies, hematomas, perforation, air embolism.
•
Secondary Goals: To improve the safety culture at
Ochsner.
– To improve communication and facilitate team work.
(TEAMSTEPPs)
Focus on Hand Hygiene
Our primary
way to
prevent
CLABSI
Hand Hygiene Data Slide
Ochsner Baptist Hand Hygiene
Compliance
eICU
• Partnership to help during insertions
– Documentation
– Assistance for process
Continued Work to be Done
EPIC Use
• Reports, Data Validation, Alerts
Increased Hand Hygiene Compliance
Use data to Anticipate and Predict
• Proactive VS Reactive
Questions?
Thank You!