Project Report - Lean Sigma

1
On the CUSP Stop BSI
Lessons from CUSP/CLABSI Getting to Zero and
Sustaining your Improvements
Jill Marsteller, PhD, MPP Armstrong Institute
for Patient Safety and Quality Elizabeth
Martinez, MD Massachusetts General Hospital
2
Learning Objectives

• To revisit key aspects involved in reducing
  infections
• To think ahead about ways to make your investment
  of time and improvements in BSI rates last
  forever (embed)
• To consider how to apply CUSP to other relevant
  topics (expand) and maintain its positive effects
  in your area (embed)
• To make sure all patients in your institution
  have access to the safest care (expand)

3
What it takes

• 12 Best Practices to Eliminate BSIs

4
Best Practices

• Commit to zero
• Teams where the senior executive committed to
  zero do better!
• ICU is accountable for the problem
• Senior leader holds the ICU-level leaders
  accountable
• Senior leader expects the unit leaders to present
  their data to the senior leaders, board of
  trustees
• Senior leader expects the unit to investigate
  every CLABSI

5
Best Practices

• Infection preventionists work with the unit
• Train, monitor and help investigate infections
• IPs should be a part of the team!
• Unit physicians and nurse leaders own the
  problem.
• Avoid the femoral site
• Key is avoidance of the site associated with
  highest infection rate Focus on this!

6
Best Practices

• Make doing the right thing easy!
• Have ALL of the necessary items for line
  placement easily available
• Line cart or Line kit with all of the items
  together
• Everybody knows where they are
• Make sure they are ALWAYS available
• Have a system in place to ensure this
• Standardize the line placement process across the
  ICU and the hospital.

7
Best Practices

• Empower all provides to STOP the process if a
  problem is noted during line placement
• Make certain that the front-line providers feel
  supported and they know who they can call.
• Investigate all CLABSIs as defects
• Avoidable errors
• Examine all steps of the process
• Was the checklist used?
• Where was it placed?
• Do they think it is associated with placement or
  maintenance?
• What is the plan for prevention of the next
  infection?

8
Best Practices

• Review and audit catheter maintenance
• Review the policies and practices
• Physically audit the process
• Are dressings in place?
• Observe the process of a dressing change.
• What are local processes for tubing changes?
• What is being done when lines are accessed?

9
Best Practices

• Train all new team members
• Have system to train new nursing staff
• Have system to train new resident/mid level staff
• Include in the training
• The expectations for placement and the ICUs goal
  of zero line infections
• That all staff are empowered to stop the process

10
Best Practices

• Share data
• Post data in the ICU so that everybody sees and
  understands it
• Post both quarterly rates AND weeks without any
  infections
• Report data with senior leaders
• EVERYBODY in the unit should know their CLABSI
  rates and weeks without an infection!

11
Two More Es

• EMBED
• EXPAND

12
Implementation Framework
Frontline Staff Team Leaders Senior Executives
Engage Ask, how does this make the world a better place?
Educate What do I need to do? Convert evidence into behaviors evaluate awareness and agreement
Execute How can I do it? Listen to resisters Standardize, create independent checks, and learn from mistakes
Evaluate How do I know we made a difference?
13
Implementation Framework
Frontline Staff Team Leaders Senior Executives
Embed Has this become business as usual? How do I know it will last? Make policies and procedures, train new people, walk the process
Expand Who else needs to know this? Whats next? Pass it on to other units Identify and address your next challenges
14
EmbedPlan for Sustainability

• Why worry about the distant future?
• What you can anticipate
• Turnover of staff/new staff
• Changes in policy (system, hospital, national)
• New projects/distractions
• Complacency
• Emergencies and complex cases (someone will call
  for exceptions to be made)

15
EmbedPlan for Sustainability

• Things you can do now to support long term
  viability of the CLABSI reduction
• Write it into policy
• Include in training for all new members
• Audit or monitor to be sure it is routine
  practice
• Set up reliable supply chain (borrowing protocol
  alert system assign someone)

16
Implementation vs. Sustainability
Where will you be?
High Implementers Low Implementers
High Sustainers
Low Sustainers
Marsteller, Pronovost, Shortell. Improving
Quality of Care Good Implementation is not
Enough. 8/11. Submitted to a peer reviewed
journal do not copy, re-use or cite without
permission.
17
EmbedPlan for Sustainability

• Set up a Learning Network of peers
• Build infrastructure for sharing lessons locally
  and system-wide
• Plan your line of succession
• Promote, examine and work on culture of safety

18
4 yr CLABSI Results from ICUs in Michigan
Time period Median CLABSI rate
19-21 months 0
22-24 months 0
25-27 months 0
28-30 months 0
31-33 months 0
34-36 months 0
Pronovost et al. BMJ 2010
19
EmbedPlan for Sustainability

• Practices that aided sustainability in the
  Michigan Project
• Continued feedback of infection data that the
  team perceived as valid
• Improvements in safety culture that occurred as
  part of the overall Keystone ICU project
• An unremitting belief in the preventability of
  bloodstream infections
• Involvement of senior leaders who reviewed
  infection data and provided teams with the
  resources needed
• A shared goal rather than a competition to reduce
  infection rates throughout the state

20
EmbedPlan for Sustainability

• Things you can do now to support long term
  viability of your CUSP program
• Maintain your CUSP team
• Consider rotating membership
• 40 Teams at JHH-- some going 10 years
• Collect the Staff Safety Assessment on ongoing
  basis
• Keep Learning from Defects
• Keep your executive (the project is not over)
• Develop hospital-wide CUSP team or meeting

21
EmbedPlan for Sustainability continued

• Does everyone on your unit feel part of the CUSP
  team?
• If not, re-evaluate your CUSP team
• Are all staff encouraged to attend?
• Is your executive partner, physician, and
  infection preventionist present and engaged at
  every meeting?
• Are there others that need to join? (ex.,
  respiratory therapy)

22
EmbedPlan for Sustainability

• Is there a sense of ownership of the CUSP team on
  your unit?
• Incentives (evaluation, promotion) for
  second-order problem solving / learning from
  defects
• Everyone is a problem solver
• Repeat culture of safety surveys, may show CUSP
  success
• Use CUSP tools (Culture Checkup) to keep working
  on safety culture

23
Expand--Spread CLABSI Interventions

• Why think about expanding to other units?
• To make sure all patients in your institution
  have access to the safest care
• Solidifies own knowledge of CLABSI prevention,
  investigation
• Unique challenges of other units may offer new
  ideas and methods/may change your perceptions of
  your own implementation

24
Expand CUSP to Identify New Defects

• Why think about your next defect?
• Quality can always improve
• Use new capacity to change to make care better
• Maintain engagement of staff/interest and
  attention of management
• Allows some control over what the next initiative
  will be
• More rewarding environment

25
Expand CUSP to Other Units

• Why do we spread CUSP to other units?
• To make sure all patients in your institution
  have access to the safest care
• Improve culture throughout the institution
• To create a standard language and understanding
  of the science of safety
• To become a high reliability organization

26
Expand CUSP to Other Units

• How do we spread CUSP to other units?
• Requires leadership endorsement and support
• Resources allocated will determine extent and
  speed of spread
• Human resources, protected time on unit-based
  teams for champions, training needs
• Consider organizational infrastructure to expand

27
(No Transcript)
28
Reference List

• Buchanan D, Fitzgerald L, Ketley D, Gollop R,
  Jones JL, Saint Lamont S, Neath A and Whitby E.
  No going back A review of the literature on
  sustaining organizational change. International
  Journal of Management Reviews 2005 7(3)189-205.
• Evashwick C, Ory M. Organizational
  characteristics of successful innovative health
  care programs sustained over time. Fam Community
  Health. 2003 Jul-Sep26(3)177-93.
• Greenhalgh T, Robert G, Macfarlane F, Bate P and
  Kyriakidou O. Diffusion of innovations in service
  organizations systematic review and
  recommendations. Milbank Q 200482(4)581-629.
• Pronovost, PJ et al. Sustaining Reductions in
  Catheter-Related Bloodstream Infections in
  Michigan Intensive Care Units British Medical
  Journal, February 4, 2010 340c309.