d14 e14 presentation - ihiapp.ihi.org/.../document-5887/d14_e14_presentation_1.pdf · safety /...
TRANSCRIPT
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Mercy Health – Anderson Hospital
Safety Across the SystemSuccesses with Fall Reduction, Handoff and SSI
D14 E14
Session Objectives
1. Participants will be able to describe the importance of
Attention, Understanding, Connection and Tempo in
order to realize rapid, significant change.
2. Participants will be able to describe small tests of
change, and how front line staff can use this to drive
monumental improvements
3. Participants will be able to describe improvements
related to falls, antibiotic redosing, surgical case
debriefs, handoffs, etc. while using these techniques.
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Disclosure
Mark Ziegler, MD
Janice Maupin, RN, MSN, CPHQ
Dominique Wells, RN
Carrie Herron, RN, BSN, ONC
Kristin Shelley, RN, MSN
Julie Holt, RN, MSN
These presenters have nothing to disclose.
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Cincinnati More than 100 locations
serving a population of 1.3 million people
Licensed beds 193
Staffed beds 178
Admissions 12,250
ED visits 47,656
Deliveries 1,822
Outpatient visits 117,595
Surgeries 9,954
Mercy Health – Anderson Hospital
2011
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Safety Across the System (SAS)
Key Principles:
• Identify potential risk for harm
• Hypothesize potential solutions
• Conduct small tests of change on potential
solutions
• Make rapid adjustments to small tests of change
• Implement solutions
• Spread solutions
• Change the culture of safety
SAS Infrastructure Overview
Med-Surg PeriopLeadership
SAS TEAM
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SAS Structure
Lead
Transformational
Agent
Transformational
Agent
(Staff)
Executive
Leadership
Team(Multidisciplinary, Managers & Staff)
Patient Advisory
Council (2013)
Leadership RepImprovement
Advisor
Transformational
Agent
(Staff)
Transformational
Agent
(Prof Practice)
Transformational
Agent
(Ancillary)
Keys to Success
Small Tests of Change (STOC)
Staff EngagementFrequent Data Use
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Small Tests of Change
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What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
PLAN
DOSTUDY
ACT
Outcome
PDSA Report Out
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Projects and Successes to Date
• 100% surgical cases conduct post-case debrief – baseline: 0%
• 95% surgical cases > 3 hours re-dosed with antibiotic –
baseline: 40%
• 79% decrease in Class 1 SSI infection rate – from 0.56 to 0.12
• Electronic WHO Surgical checklist implemented in CarePATH
• 25% reduction in inpatient fall rate
• 90% safety rounds on surgical units – baseline: 0%
• 100% bedside handoff in PACU – baseline: 0%
• 90% bedside handoff in ED admissions – baseline: 0%
• 5 Leadership Walkrounds per month; one on nights – baseline: 1/mo
• 95% completion of actionable items from Walkrounds – baseline: 80%
Leadership Workstream
Tests of Change related to:
•Leadership Walkrounds
•Spread to off shifts
•Increase accountability by posting results on intranet
•QOS Rounds- incorporate
•Calendar White Space
•Capacity for Improvement
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Leadership Principles
• Attention
• Understanding
• Tempo
• Connection
Bedside Handoff
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Common Factors Causing Adverse Events
72% Reduction
Bedside Handoff: Small Tests of Change
• 2011 – Bedside handoff within inpatient units
• 2012 – Bedside handoff between departments
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Inter-Departmental Handoff Compliance Data 2012
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Safety / Falls
Falls Prevention Driver Diagram
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Falls per 1000 Patient Days HospitalPre-SAS rate: 3.5
Post-SAS rate: 2.6 25%
353 days since fall w/harm
Begin SAS
Project
New nurse
call system155 days 353 days
Fall Prevention: Small Tests of Change
• “Stay With Me” Program
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Fall Prevention: Small Tests of Change
• Trial Variations of Patient Acuity Tool
Fall Prevention: Small Tests of Change
• Visual triggers for high risk fall patients
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Fall Prevention: Small Tests of Change
• Hourly Rounding
Fall Prevention: Small Tests of Change
• Safety Rounds
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Data Collection: Bed Alarm Compliance
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Peri-Operative
Peri-op Defect Board
Spread
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Surgical Safety Checklist (WHO)
Class 1 Surgical Site Infection Rate2008-3Q12
Begin SAS
Project
UCL
LCL
79% decrease
began
79% decrease
since SAS
began
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IPT3200m “Germinator”
Time
12-20 minutes per room
25-30 minutes per OR suite
• Mobile Ultra-violet
Technology
• Consistent sterilization
process; kills spores
• Photo chemical damage to
RNA & DNA
• Room tracking system
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Physician Engagement
New Peri-operative SAS Protocols
• Expanded time-out including the W.H.O. checklist
• Post procedure debriefing in the OR
• Peri-operative antibiotic re-dosing
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Ongoing Peri-Operative SCIP Projects
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Antibiotic Elimination Half Lives
Cefazolin 108 min
Cefoxitin 41 – 59 min
Cefuroxime 80 min
Ampicillin/Sulbactam 60 min
Metronidazole 6 hours
Vancomycin 4 – 6 hours
Peri-operative Antibiotic Re-Dosing
Protocol
•Responsibility of the Anesthesia Team
•Re-dosing schedule
•Memo of introduction
•Availability of Drug
•Initiation
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Anesthesia Record
Tests of Change
• Educate Anesthesia providers
• Identification of cases >3hrs
• Assign circulating OR nurse
• Laminated re-dosing protocols
• Re-educate Anesthesia staff
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Antibiotic Re-dosing Cases > 3 hrs
Lessons Learned•Change to improve patient care was well received
•Clear and well defined goals
•Honest evaluation of the steps to accomplish goals
•Early communication
•Frequent assessment of progress
•Continued monitoring
•Continued education
•Test of Change Methodology really works
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New Peri-operative SAS Protocols
Collaboration
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Hospital Culture Impact
• Patient Experience
• Employee Engagement
• Patient Safety Culture
SAS Meetings
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Patient Experience Points 2011- 12
SAS
begins
VBP: 2011: 0
2012: 26
Employee Engagement – Overall Satisfaction
3.00
3.20
3.40
3.60
3.80
4.00
4.20
4.40
4.60
B1 B3 A1/A3 SDS PACU ICU Cath Lab A2 ED
2011 2012
5 point scale
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NDNQI RN’s Perception
of Quality of Care
3.06
2.83
2.93
2.74
2.5
2.71
3.41
3.02
2.95
2.882.84 2.83
2.3
2.5
2.7
2.9
3.1
3.3
3.5
B1 A1/A3 B3 Day Surg OR PACU
2011 2012
4 point scale
SAS Spread and Sustainability
SAS Team
PeriopCath
Lab
A2
B1 ICU
B3
A1ED
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Next Steps
• Incorporate SAS and Small Tests of Change into our
overall Improvement Model.
• Transition to Partnership for Patients
• Continue to integrate more disciplines and
departments into process
• Blend Nursing Shared Governance and SAS
• Add Patient Advisors/Patient Advisory Committee in
2013
• Continue to spread throughout our system
Thank You to all those who
started the journey….Gyasi Chisley, Chief Operations Officer
Julie Holt, Chief Nursing OfficerJanice Maupin, Director of Quality Services
Edward Ruffennach, Director Peri-Operative Services
Terri Martin, Director Patient Care ServicesCarrie Herron, Orthopedic Ctr Excellence Mgr
Kristin Shelley, Manager, Medical Surgical NursingKim Hammock, Clinical CoordinatorAngela Joyce, Clinical Coordinator
Tiffany Hudson, Clinical CoordinatorDominique Wells, Mgr, PACU/SDS
Katie McClure, Staff RNDr. Mark Ziegler, Anethesiologist
Melissa Fritz, Staff RNDenise Evans, Manager OR
Denise Irizarry, RN Blackbelt Advisor