Keystone Surgery: Translating Evidence into Practice

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Keystone Surgery Translating Evidence into
Practice

• Johns Hopkins University
• Quality and Safety Research Group
• April 2008

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Case Is this death preventable

• 65 yo male admitted for elective colon surgery
• Multiple comorbid diseases DM, CHF, Afib
• Received ancef prophylaxis on call to OR
• 120 min prior to incision
• On admission to ICU
• Glucose 210 mg/dl
• Temp 35.0
• Developed fistula, renal failure, and SSI
• Died POD 64

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RAND Study Confirms Continued Quality Gap
McGlynn et al, NEJM 2003 348(26)2635-2645
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Antibiotic Timing Related to Incision
Bratzler et al. Arch Surg 2005140174-182
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Discontinuation of Antibiotics
Patients excluded if documentation of an
infection during surgery or in the first 48 hours
after surgery.
Bratzler et al. Arch Surg 2005140174-182
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Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
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Moving Past The PDSA Cycle

• Act
• Adopt on a large scale
• Adapt
• Abandon

• Plan
• Set hypothesis
• Validate causes
• Plan a test

• Study
• Collect data to verify improvement

• Do
• Test on small scale

Developed by Shewhart in the late 30's. modified
by Deming. http//oqm.ors.od.nih.gov/
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Approaches to Improve TRiP
Adopted from Grol R. JAMA 20012862578-2585.
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Creating Reliable Health Care
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Need to get technical and adaptive components
right
Heifetz, Leadership Without Easy Answers
(Cambridge Harvard University Press, 1994)
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What have we learned?

• Engaging Staff
• telling stories, data feedback, partner with
  local experts (ie ICP, ID specialists), coaching
  calls, learning community, focus on culture
  (CUSP)
• Education
• provide educational materials, content calls,
  slides, sharing tools

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To Improve Reliability

• Standardize what is done, when it is done
• Reduce complexity
• Create independent checks for key processes
• How often do we do what we should
• Learn from defects
• How often do we learn from defects

Health Services Research 2006 Circulation (in
press)
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Eliminating CR-BSIs
VAD Policy
Checklist
Line Cart
Daily goals
Empower Nursing
Crit Care Med 200432(10) 2014-2020
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SSI Process Measures
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Execute

• Reduce complexity of the process
• Remove razors
• Checklists
• Local antibiotic guidelines posted in ORs
• Redundancy
• Add to briefing/debriefing
• Post reminders in the OR (White board)
• Post performance

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The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)

• Evaluate culture of safety
• Educate staff on science of safety
• Identify defects
• Senior Executive Partnership
• 5. Implement teamwork tools Learn from one
  defect per month
• 6. Evaluate culture of safety

J Patient Safety 2005 Jt Comm J Qual Saf.
200430(2)59-68. http//www.jhsph.edu/ctlt/traini
ng/patient_safety.html
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Team Check Up Tool

• Advances science of quality improvement
• Identify team behaviors that increase likelihood
  of success
• Identify barriers to progress
• Senior leaders to evaluate team performance and
  address barriers
• Completed monthly by QI team

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Advancing the Science

• How often did your senior executive
• meet with your improvement team?
• review your performance data?
• How often did your team
• meet?
• review your performance data?
• share results broadly with staff? And how?
• present your performance data to senior
  hospital/health system leadership?

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Did any of the following slow your teams
progress?

• Insufficient knowledge of evidence
• Lack of team member consensus regarding goals
• Inability of team members to work together
• Not enough time
• Lack of QI skills
• Not enough buy-in from other staff
• Burden of data collection
• Not enough leadership support from
• Executives
• Physicians
• Nurses

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Common Barriers
Not enough leadership support from physicians
Burden of data collection
Not enough time
Not enough buy-in from other physician staff
members
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Who are we?

• 75 participating hospitals
• 48 hospitals completed readiness survey
• 27 urban, 21 rural (including 10 critical access)
• 45 community, 16 w/ residents, 3 academic
• Median bed size 172 (14 - 1000)
• Median annual surgical volume
• In-patient 2148 (34 21,500)
• Out-patient 4442 (469 15,269)

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Next Steps

• Complete the readiness survey
• Discuss project with OR and hospital leaders
• Decide what OR teams to start with
• Consider initial focus on 2 specialties
• Create project team (surgeon, anesthesiologists,
  nurses, administrator) and meet to develop
  infrastructure select project manager
• Register for April workshop

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Next Steps

• Think about how you will implement CUSP
• Educate staff on Science of Safety
• Senior executive partnership
• Identify defects- How is the next patient going
  to be harmed?
• Teamwork tools (briefings/debriefings) and Learn
  From a Defect
• Think about how you will Translate Evidence into
  Practice
• Engage, educate, execute, evaluate

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Dial-In Number 877-591-4958 Call Title
Keystone Surgery Confirmation 9014941
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Discussion