Making and Keeping Promises to Patients: Where Are We

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Making and Keeping Promises to Patients Where
Are We?

• Carol Haraden, PhD
• Vice President
• Institute for Healthcare Improvement

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Congratulations!

• First state to join IMPACT
• First Hospital and Healthcare Organization to
  join the Campaign!

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• What promises are you prepared to make to
  patients and their families?

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• Every system is perfectly designed to get
  exactly the results it produces.
• - Don Berwick

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Leadership System for Improvement

• Building will for change
• Finding ideas for an improved system
• Executing changes to the system

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Building Will

• Articulate your vision and make the case for
  change
• Invest time and other resources
• Set goals and build confidence that they can be
  achieved
• Provide encouragement and appreciation

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Making the Case for Change

• Speak truthfully about the current reality
• Focus on patients and other customers
• Articulate the financial implications
• Connect with goals, values, and ambitions of
  individuals
• Use measurement to compare your performance to
  desired levels

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Finding Good Ideas

• Interview a patient per month
• Set up channels to experts
• Use librarians as scanners
• Find internal great performers - study what they
  do
• Buy airline tickets
• Steal them
• Send out scouts

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Execution

• Review and guide key initiatives
• Knowledge of important projects - meet with team
  leaders at regular intervals
• Customer focus - meeting customer needs is deeply
  held value - customer needs and opinions sought
  for strategic initiatives
• Spread improvement within organization
• Spread is the norm and supported through formal
  structure

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Holding the Gains

• Building the change into the normal operating
  system
• Burn the bridge
• Overrides and defaults matter
• Monitor (and talk about) the gains over time
• Celebrate success!

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Where do we start?

• Dont kill me
• Dont hurt me
• Dont leave me in pain
• Dont make me wait
• Dont make me helpless

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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions
• Reliable Use of Ventilator Associated Pneumonia
  Bundles
• Reliable Use of Central Venous Line Bundles
• Surgical Site Infection Prophylaxis
• Prevention of Adverse Drug Events with
  Reconciliation

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1. Rapid Response Teams

• HOW? Reliable use of Rapid Response Teams to
  decrease failure to rescue
• A Rapid Response Team may be summoned at any time
  by anyone in the hospital to assist in the care
  of a patient who appears acutely ill, before the
  patient has a cardiac arrest or other adverse
  event.
• No prior permission is required to call the Team.

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The Dramatic Effects of Rapid Response Teams
From Bellomo R, et al. MJA. 2003179283-287.
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The Dramatic Effects of Rapid Response Teams
From Bellomo R, et al. MJA. 2003179283-287.
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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions

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Component vs. Composite Treatment of Pneumonia
in Medicare Patients

• COMPONENT 63.1 receive first dose of
  antibiotics within four hours of hospital arrival
• COMPONENT 67.9 receive an antibiotic choice
  consistent with current guidelines
• COMPONENT 81 have blood cultures collected
  before treatment
• COMPOSITE 26 get all three of these

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2. Reducing Acute Myocardial Infarction Mortality

• HOW? For appropriate AMI patients, reliable use
  of all of
• Early administration of aspirin
• Aspirin at discharge
• Early administration of a beta-blocker
• Beta-blocker at discharge
• ACE-inhibitor or angiotensin receptor blocker
  (ARB) at discharge (if systolic dysfunction)
• Timely reperfusion
• Smoking cessation counseling

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AMI Reliability McLeod Regional Medical Center
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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions
• Reliable Use of Ventilator Associated Pneumonia
  Bundles

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3. Preventing Ventilator Associated Pneumonia

• HOW? Reliable use of the Ventilator Bundle
• Elevate head of the bed to 30 degrees
• Peptic ulcer prophylaxis
• Deep venous thrombosis prophylaxis
• Daily sedation vacations
• Daily assessment of readiness to extubate

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VAP ResultsBaptist Memorial DeSoto
Courtesy of Manoj Jain, MD, MPH
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A Success Story

• Our Lady of Lourdes, Binghamton, NY
• As of 1/31/2005 310 days since last VAP!

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Our Lady of Lourdes, Binghamton, NY

• VAP rate 1/31/2004 through 12/31/2004

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Our Lady of Lourdes, Binghamton, NY

• Began working in March 2004
• 100 Ventilator Bundle Compliance 9/1/2004 though
  12/31/2004

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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions
• Reliable Use of Ventilator Associated Pneumonia
  Bundles
• Reliable Use of Central Venous Line Bundles

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4. Preventing Central Venous Line Sepsis

• HOW? Reliable use of the Central Line Bundle
  
• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Appropriate catheter site and administration
  system care
• No routine replacement

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Central Line Associated Bloodstream Infections
(CLABs)(from Rick Shannon, MD, West Penn
Allegheny Health System)
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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions
• Reliable Use of Ventilator Associated Pneumonia
  Bundles
• Reliable Use of Central Venous Line Bundles
• Surgical Site Infection Prophylaxis

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5. Preventing Surgical Site Infection

• HOW? Reliable use of the SSI Bundle
• Guideline-based use of prophylactic perioperative
  antibiotics choice and timing
• Appropriate hair removal (avoiding shaving)
• Perioperative glucose control

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Reducing Surgical Site Infections at Mercy Health
Center Percentage of On-Time Antibiotic
Administration
Courtesy of Ronda Pasley-Shaw, Mercy Health
Center SIP Team
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Mercy Health Center SSI Rate
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Reducing Surgical Site Infections at Mercy Health
Center Number of Targeted Surgical Cases
without Infection
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Six Changes that Save Lives

• Rapid Response Teams
• Reliable Care for Acute Myocardial Infarctions
• Reliable Use of Ventilator Associated Pneumonia
  Bundles
• Surgical Site Infection Prophylaxis
• Reliable Use of Central Venous Line Bundles
• Prevention of Adverse Drug Events with
  Reconciliation

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6. Preventing Adverse Drug Events

• HOW? Medication Reconciliation
• Reliable Medication Reconciliation procedures
  to ensure that patients receive all intended
  medications and no unintended medications
  following transitions in care locations.

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McLeod Regional Medical Center Adverse Drug
Events
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Hackensack University Medical Center Adverse
Drug Events
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ICU Days and Adverse Events

• Nationwide study of a trigger tool for adverse
  events in ICU (IHI/VHA)
• Approximately 2 adverse events/ICU day

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Consecutive Adverse Events

• 1-Iatrogenic pneumothorax
• 2-Sternal wound infection
• 3-Thrombophlebitis
• 4-Post Surgical bleed
• 5-ICU delirium
• 6-Nosocomial pneumonia
• 7-Theophyline toxiciy/arrythmia
• 8-GI bleed
• 9-Iatrogenic pneumothorax
• 10-ICU delirium
• 11-Fluid overload
• 12-Oversedation
• 13-Urinary obstruction

• 14-ICU delirium
• 15-Rash
• 16-Aspiration pneumonia
• 17-Nausea
• 18-Pulmonary embolus
• 19-Nosocomial pneumonia
• 20-Sternal wound dehiscence
• 21-Dialysis induced hypotension
• 22-Severe hypotension with NTG
• 23-Renal failure post surger
• 24-ICU delirium
• 25-Sternal wound infection

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ICU Days and Adverse Events

• In dept evaluation of 25 consecutive events
  showed 54 extra ICU days
• Flow in the ICU means reducing adverse events in
  the ICU

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5.4
3.2
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6.5
4.1
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What have we learned?

• The ability to quantify quality is required for
  improvement
• Performance on complete bundle poor
• Clinicians relate to bundles
• The opportunity to improve care is enormous!

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Exercise Making the Case for Change

• Work in groups
• Spend 10 minutes scripting your case for change
  (use the outline in the slide)
• Make your case for change to another group (5
  minutes)
• Get feedback from them (5 minutes)
• Nominate one of you to present to the large group

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Unique Role of Leaders in Improving Care

• Do not settle for benchmarking
• Encouragement with expectations
• Ask important questions- What is preventing
  movement? How can we help?
• Expectations without capability breeds fear and
  hopelessness

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• Some people make things happen,
• Some watch things happen,
• While others wonder what has happened.
• - R. Kennedy