Improving Care Throughout New Jersey Peter Pronovost, MD, PhD

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Improving Care Throughout New JerseyPeter
Pronovost, MD, PhD
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Objectives

• Who are we?
• Where are we going?
• How are we going to get there?

To move from Why to How
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Who are We?
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Where are we going?

• BSI below 25th percentile
• ICU and hospital LOS reduced by 1 day
• ICU and hospital mortality reduced 30
• VAP reduced 50
• Culture improved 50
• Improve turnover and direct costs 30

Commit to eliminating hospital acquired infections
Where no state has gone before
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How will we get there?

• Every system is perfectly designed to achieve
  the results it gets

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A Medication Error Story
Fax system for ordering medications is broken
Patient receives a medication to which he is
allergic
Nurse borrows medication from another patient
Tube system for obtaining medications is broken
Patient arrests and dies
Reason
ICU nurse staffing
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System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Adapted from Vincent BMJ
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What is needed for transformation

• Will create will with personal stories of
  current reality
• Executive will
• Team will
• Staff will
• Team
• Compelling direction clear, consequential, and
  challenging
• Accountable and responsible for outcome
• Correct people, skills and resources
• Measurement system (information technology
  resources)
• Reward system for team
• Expert coaching
• Execute
• Standardize
• Independent checks
• Evaluate defects

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Approach

• Pick an area
• Identify what we should do
• Measure if we are doing it
• Ensure we do what we should
• Document outcomes improved

Measure and Test
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How to ensure patients receive the care they
should

• Create culture of safety
• Ensure team knows goals, evidence
• Standardize what is done, when it is done
• Reduce complexity
• Create independent checks for key processes
• Measure and evaluate defects

Measure how you are doing
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Improving Reliability
Defects 10-1
Standardize
Independent check define defect
Defects 10-2
Surface failures
Defects 10-3
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How are we going to get there?

• CUSP
• Daily goals and multidisciplinary rounds
• BSI bundle
• Ventilator bundle
• Medication reconciliation
• Other

Testing and Measuring
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Comprehensive Safety Program

• Evaluate culture of safety
• Educate staff on science of safety
• Identify staffs safety concerns
• Executive adopt an ICU
• Prioritize improvement efforts
• Implement improvements
• Share stories and disseminate results
• Evaluate culture

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Safety Climate Across 100 Clinical Areas WICU
SICU Climate Pre-Post CUSP
 
of respondents within a clinical area
reporting good safety climate
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Impact of CUSP on LOS and Turnover
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• How to Implement Daily Goals and
  Interdisciplinary Rounds

Small tests with one patient, one doctor one nurse
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Pronovost, Dorman JAMA 2002
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Percent Understanding Patient Care Goals
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Key attributes of ICU physician staffing

• Present
• Posses skill/knowledge
• Works as a team
• Helps to leads and manage the ICU

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Journey to achieve key attributes

• Ensure nurses know who to call
• Start daily rounds
• Midlevel providers
• Hospitalists partner with teaching hospitals
• Regionalization
• Intensivist

Intensivist staffing is an intervention that
reduces mortality 30
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Impact on ICU Length of Stay
Daily Goals
654 New Admissions 7 Million Additional Revenue
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How to Reduce CR-BSI
Small tests with one patient, one doctor one
nurse Weekly goals
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Strategies for Prevention 5 Key Best Practices

• Remove Unnecessary Lines
• Hand Hygiene
• Use of Maximal Barrier Precautions
• Chlorhexidine for Skin Antisepsis
• Avoid femoral lines

MMWR. 200251RR-10
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Improve reliability of evidence-based process

• Culture
• Education with HEIC
• Policy nurses assist with beginning of line
• Standardize
• Complexity
• Line cart store all equipment in one place
• Work with purchasing to get chlorhexadine prep
• Redundancy
• Check list

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ICU catheter-related blood stream infections
Education
Line Cart
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Checklist
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Rate/1,000 Catheter days
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NNIS Mean
0
Jul
Jan
Sep
Jan
Jun
Oct
Feb
Nov
Dec
Feb
July
Apr
Aug
Mar
May
Mar
May
June
April
August
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How to Implement the Ventilator Bundle?
Small tests with one patient, one doctor one
nurse Weekly goals
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Bundle Revolution

• Bundle a group of interventions linked in time
  and space
• Simple rules
• How we think

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Ventilator Bundle

• Improve care of ventilated patients
• Elevate HOB
• Provide DVT prophylaxis
• Provide PUD prophylaxis
• Hold sedation
• Test for ability to extubate
• Control glucose
• Oral chlorhexadine/Gastric decontamination

Associated with reduced mortality
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Improvement Over the Course of the TICU Program
Aggregate Results for Participants in their 2nd
Year of the Program (2001 Launch)
Weaning Assessment was not measured during the
baseline period. Note Baseline data were
collected for four consecutive weeks in 3Q01.
After Year 1 data were collected over the
course of one month in 3Q02.
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VHA TICU Program
Ventilator Associated Pneumonia incidence per
1,000 ventilator days (n19)
ICU LOS in days (n20)
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Tips for success

• Culture
• Educate all staff
• Empower non physician staff
• Complexity
• Standard orders
• Glucose and SGD protocols
• Independent checks
• RT and Nursing flow sheet

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Our To Do List

• Establish team- include executive
• Use some project management tools
• Do one thing per week
• Complete CUSP
• Select BSI, daily goals and rounds, or ventilator
  bundle (ICUSRS and Med rec)
• Implement new intervention every 3 month
• Submit data

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Leadership is the capacity to translate vision
into reality
Warren G. Bennis
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Tips for success

• Common vision and goals
• Publicly commit that harm is untenable
• Culture, complexity and redundancy
• Measurement and feedback
• Recognition and visibility (work with PR)
• CELEBRATE SUCCESS !

All improvement is local we can provide
concepts you need to design interventions
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Is Safety your Hedgehog Concept ?
What can you be great at
What are you passionate about
What is important
Jim Collins
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Who is willing to shave their Head ?

• Who is willing to
• commit to improving
• patient safety in New Jersey?

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References

• Pronovost PJ, Angus DC, Dorman T, Robinson KA,
  Dremsizov TT, Young TL. Do intensivists improve
  the outcome of critically ill patients? JAMA.
  2002 2882151-2162 Pronovost 2004
• Pronovost PJ, Berenholtz SM, Ngo K, McDowell M,
  Holzmueller CG, Haraden C, Resar R, Rainey T,
  Nolan T, Dorman T. Developing and Pilot Testing
  Quality Indicators in the Intensive Care Unit.
  Journal of Critical Care. 2003 18(3)145-155.
• Pronovost P, Berenholtz S, Dorman T, Lipsett PA,
  Simmonds T, Haraden C. Improving communication
  in the ICU using daily goals. J Crit Care. 2003
  18(2)71-75.Joint Commission J of Quality
  improvement executive adopt ICU
• Pronovost P, Hobson DB, Earsing K, Lins ES, Rinke
  ML, Emery K, Berenholtz SM, Lipsett PA, Dorman T.
  A Practical Tool to Reduce Medications Errors
  During patient Transfer from an Intensive Care
  Unit. JCOM. 2004 11(1)26-33.
• Pronovost PJ, Weast B, Bishop K, Paine L,
  Griffith R, Rosenstein BJ, Kidwell RP, Haller KB,
  Davis R. Patient Safety, Senior Executive
  Adopt-a-Work Unit A Model for Safety
  Improvement. Joint Commission Journal on Quality
  and Safety. 2004 30(2)59-68.
• Pronovost PJ, Weast B, Schwarz M, Wyskiel RM,
  Prow D, Milanovich SN, Berenholtz S, Dorman T,
  Lipsett P. Medication Reconciliation A practical
  tool to reduce the risk of medication errors. J
  Crit Care. 2003 18(4)201-5.
• Pronovost PJ, Bereholtz S Improving sepsis care
  in the intensive care unit An evidence-based
  approach. VHA research series 2004 www.vha.com
• Pronovost PJ, Nolan T, Zeger S, Miller, M, Rubin
  H. How can clinicians measure quality and safety
  in acute care. Lancet. 2004 3631061-67.