Bricolage and Intellectual Workshop: Conceptual lenses for understanding team learning and change

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Bricolage and Intellectual WorkshopConceptual
lenses for understanding team learning and change

• Curtis Olson, PhD
• Tricia Tooman, MSc (MPhil)
• University of Wisconsin-Madison
• Making Health Care Safer
• Social Dimensions of Health Institute
• June 27, 2011

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Shared Goal, Different Perspectives
Improving Quality and Value of Healthcare
TRIP
Critical Event Analysis
PDSA
Systems Redesign
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Aims for this Session

• Provide a window into how individuals and groups
  in health care organizations learn in formal and
  informal ways
• Provide access to empirical, qualitative data are
  helping us understand the phenomenon of team
  learning
• Explore the relevance of this case to the larger
  enterprise of improving patient safety

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Studying the Arrow
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Context of Current Study

• One of 3 cases in larger study (Olson, Tooman,
  Alvarado, 2010)
• Linked to CDCs twelve step campaign to reduce
  antimicrobial resistance in US hospitals
• Success measurable, significant improvements in
  clinical outcomes
• Soft knowledge systems (Engel, 1997)
• social organization of change
• types and sources of KI used by the team to
  innovate

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Trinity Community Hospital ICU

• Medium-sized, 200-bed hospital in Midwestern US
• Focus on ventilator-associated pneumonia (VAP)
• preventable, nosocomial infection
• mortality attributable to VAP may exceed 10
• Initial rate 6.0 cases/1000 ventilator days
• Outcome 0 cases in 18 months prior to study

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Understanding team learning

• Bricolage (Levi-Strauss)
• Intellectual workshop (Revans)

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Bricolage

• Roughly, making do with what is at hand
• The highly synthetic and sometimes
  improvisational process by which project teams
  acquired, created, mobilized and assembled bits
  of KI into plans of action

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Intellectual Workshop

• The central site for bricolage
• Where bits of KI were forged into strategies,
  implemented, and evaluated
• Essentially, the project leadership team

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Work in the Workshop

• Obtain, produce, adapt, interpret, compare,
  share, synthesize, evaluate knowledge and
  information (KI)
• Evaluate current practice
• Fashion solutions out of bits of KI
• Plan implementation, formalize
• Track performance (process and outcome) problem
  solve
• Trace system implications and mobilize assistance
  to obtain cooperation, support, compliance from
  other units

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At the beginning

• ICU Medical Director learned about IHI 100,000
  Lives Campaign and the Breakthrough Series
• Longitudinal (3 meetings/9 months)
• Cohorted teams from several hospitals
• Limited clinical foci
• Emphasized evidence-based practices and practical
  knowledge
• Core approach was PDSA, measurement

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The Basic Model for Improvement
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The decision to engage

• . . . our hospital became involved with IHI, the
  Institute for Healthcare Improvement. The first
  project they did was for our CV group here, and
  we saw incredible success So we saw that, and
  IHI had offered something in the area of the
  intensive care unit, so we talked our
  administrators into spending the dough to send a
  bunch of us there.
• -ICU Medical Director

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The choice of VAP

• I don't think that it would have ever occurred
  to our group or even gone any, you know, our VAP
  rates weren't that bad. It wasn't a red flag out
  there for anybody.
• -Respiratory Therapist

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The project leadership team

• Led, assembled by CNS
• Evolved to include
• 2 lead ICU nurses
• Hospitals infection control specialist
• Hospitals lead respiratory therapist
• Multidisciplinary
• CNS provided link to IHI

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Early contributions of IHI

• VAP prevention interventions EBP
• Daily sedation vacation/assessment of readiness
  to extubate
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis
• Elevate head of bed to 45 degrees
• Bundle concept EBP
• Importance of data

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Three bundle elements in place

• Like mouth care . . . Ive gone through a
  conference and learned about how that could help
  prevent VAP back in 2002. So I came back and I
  implemented, got new products and implemented an
  oral care protocol by the end of the year.
• -CNS

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Learning the value of consistency

• Well, IHI is very evidence-based, so when were
  there and we hear about VAP reduction, and we see
  that theyve bundled these interventions that
  actually alone, in themselves, cause improvement.
  So when you bundle them, they become kind of
  synergistic.
• -CNS

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Convergence around VAP data

• Then we needed to get, for this IHI
  collaborative, we had not been doing our VAP
  surveillance before that. Id been trying, but
  our last infection control person really had
  not had any experience doing that, and I just
  didnt know how even to start on my own. Id come
  from a hospital where I was getting that data
  from infection control and wanted that data, but
  it wasnt here, and I could not figure out how to
  do it myself.
• -CNS

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Learning from ICS training/experience

• ICS taught CNS how to do surveillance
• Did chart reviews with a one year baseline
• Used CDC VAP definition and national comparison
  data

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Contribution of science and policy

• At that point in time, because I knew about some
  of the national initiatives going on with the new
  CDC definition of infection, since they did not
  have any historical surveillance for pneumonia in
  the ICU, so we set up some processes in place to
  begin that.
• -Infection Control Specialist

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Learning from others outcomes data

• Because the collaborative had already been going
  on for a year, we could see other hospitals and
  other hospitals systems that have data that
  their VAP rate just dropped, in many cases to
  zero. We wanted to be there.
• -CNS

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Learning from practice-based evidence

• At the time, we were just starting to collect
  our VAP rates, and so what we did was we did a
  couple of months baseline and we were way above
  the national benchmark .
• -CNS

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Actions of the project team

• Goal implement missing piece of bundle and make
  implementation of all bundle elements more
  consistent
• Developed standards of care, audit process,
  roll-out strategy
• Did orientation and training
• Monitored compliance through observation and
  chart audits use of Practice-Based Evidence
• Provided feedback to staff

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Learning from others practical knowledge

• You know its stuff like writing the
  interventions into an order set or protocol,
  different ways to get other units and other
  departments on board So you know we shared
  signs, and we shared protocols, shared just ideas
  of other services to try to get on board, other
  ways, to get respiratory on board and people
  maybe that you hadnt thought of on board.
• -CNS

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Learning from experience

• The problem
• We were getting skid marks on peoples seats.
• -ICU Medical Director
• Addressed by adapting the HOB guideline
  (changed from 45 to 30 degree angle)

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Implemented IHI Bundle, but

• We were doing fine, and we thought, oh great, we
  implemented the bundle. Now were kind of in
  monitoring mode, and we had a period of time
  without any VAP. Then all of a sudden we had, I
  think, maybe two in a month and maybe one a
  couple of months later. And were like, whoa,
  whats going on here?
• -CNS

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Learning from adversity

• We realized its not a straight line. Its a
  course correction If you arent getting the
  results that you expect, then you need to step
  back and say, what can we do more? And really
  look back to the literature. Where do we have
  gaps? What can we do?.
• -CNS

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A critical re-examination of practice

• Everybody kind of took their area of expertise
  and then just kind of came back to the table with
  suggestions or ideas.
• -Respiratory Therapist
• Our sister hospital still had none, so we were
  comparing, okay, what are you whats different
  about us?
• -CNS

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Comparison with Sister Hospital

• We found out that our sister hospital was
  handling their irrigations using these little 5cc
  saline whatever theyre called, and here . . .
  people were just leaving them hooked up to the
  endotracheal tube. And then whenever they needed
  to come by, theyd just give it a squeeze until
  it was empty and then throw that one away. They
  werent doing that over at sister hospital, and
  they were showing a lower rate of infection.. . .
  We adopted their approach and showed some
  improvement in our infection rates.
• -ICU Medical Director

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Convergence around a new ET tube

• Were aware of a different style ET tube with
  innovative features (eg, allowed continuous
  subglottic suctioning)
• Was not adopted because ICU Medical Director had
  heard there were problems with it
• RT began to suspect design of current tube was a
  contributor to problem

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Reasoning through a potential cause

• We looked at the actual product the difference
  that we found was the old product with the end
  light suction, is that they only had a single
  port, a proximal port up here and not a distal
  port. And there wasnt really any research or
  really anything indicating that that was wrong or
  had any bad evidence behind it, but we did come
  across the product that has two ports and kind of
  do a little bit of research behind it, and again
  there is really no evidence-based research out
  there, but the theory or the thought was there is
  potential when you would, every time you go down,
  you suction down into a patients lung, youre
  taking that tip and youre introducing it into
  the body.
• -Respiratory Therapist

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Serendipitous acquisition of information

• The ICU Medical Director had gone to a
  critical care conference, and he learned about
  the improvements that were made in the design of
  that ET tube. There had been some problems with
  it when it was first launched a few years back.
  So a lot hesitate to implement those, but he had
  heard about and saw its presentation and was
  interested in presenting that back to us.
• -Infection Control Specialist

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The cost barrier

• It incurred a huge cost difference, it had to go
  all the way up through administration We had to
  go through multiple different departments,
  because we had to involve anesthesia. You
  actually truly need to involve outside resources,
  your ambulances that are intubating in the field.
  You have to involve your ED department, and it
  is substantially more expensive than the ET tube
  that you currently use so it has to go through
  all kinds of approval, financial processes, go
  through administration.
• -Respiratory Therapist

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Using practice-based evidence for the business
case

• We had to figure out how many patients, you
  know, in the year before, we had intubated and
  times that by the increase in the cost, and then
  do an analysis of, if we could just cut our VAP
  rate in half, we could save more money than the
  ET tubes cost. So by doing that financial
  analysis, then they said, well, yeah, it makes
  sense, if you can save a patient from having a
  VAP, youre saving at least 40,000. So we got
  the okay to go ahead and do that.
• -CNS

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Another iteration of change

• Redefining standards of care in ICU
• Planning and implementing roll-out
• Monitoring and feedback on process and outcomes
• Problem solving
• Concerns of ambulance crews
• Noise from continuous suctioning

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Refining the process

• At times they can cause a very loud, disturbing
  noise that irritates the bedside caregiver, and
  so there is a learning curve, and until we could
  get the RTs who were managing the tubes to truly
  be able to troubleshoot that and eliminate that
  annoying factor, we would find nurses that would
  disconnect it and then weve lost potential
  benefit And so there was a little bit of a
  fight there. Probably for a good six months we
  would find some disconnected.
• -Respiratory Therapist

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Naturally-occurring data

• When we initially . . . started seeing the new
  ET tubes on our patients, we had several RNs up
  in ICU that didnt buy in to it. No, thats not
  going to help its not going to do anything. I
  think what finally got them to buy in to it was
  the visualization, actually seeing these nasty
  secretions continuously coming through the line.
  I really think it opened everybodys eyes to go,
  I cannot believe there is that much down there.
• -Respiratory Therapist

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Signs of progress

• Before, when we reviewed chest X-rays we would
  constantly see potential haziness, possible
  infiltrate, slight opacity.. . . It was amazing
  how many after we implemented that ET tube were
  clear. Clear, clear, clear.
• Respiratory Therapist

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Success

• No case of VAP in 18 prior to the time of the
  study

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Caveats

• One case, but similar findings across the 3 cases
  in the larger study
• Important moderating factors include
• Having strong process and outcome measures
• Strong, stable leadership in ICU
• Good fortune
• IHI as a resource
• Provides one perspective on the phenomenon of
  team learning

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Some general observations

• Scientific evidence and EBPs played an important
  role
• Practice change process also involved practical
  knowledge, experiential learning, practice-based
  evidence.
• Practitioners were more than just users or
  consumers of knowledge created by others
• Change a longitudinal, cyclical process
• Practitioners were experimenters, seeking ways to
  move the needle on the dial

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Exploring the points of connection

• To what extent and how is this perspective on the
  process of team learning and change relevant to
  your context?
• How do our findings support/challenge current
  models and practice regarding improving patient
  safety?
• What new questions has this session raised for
  you?

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References

• Engel, P. G. H. (1997) The social organization
  of innovation A focus on stakeholder
  interaction. Amsterdam KIT Press.
• Gabbay, J., le May, A. (2011). Practice-based
  evidence for healthcare Clinical mindlines.
  Oxon Routledge.
• Levi-Strauss, C. (1974) The savage mind. (2nd
  ed). London Weidenfeld and Nicholson.
• Olson CA, Tooman TR, Alvarado CJ. Knowledge
  systems, health care teams, and clinical
  practice a study of successful change. Adv
  Health Sci Educ Theory Pract. Jan 13 2010.

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