hai collaborative meeting september 12, 2012 denise flook, rn, mph, cic hai collaborative lead vice...

HAI Collaborative MeetingSeptember 12, 2012

Denise Flook, RN, MPH, CIC

HAI Collaborative Lead

Vice President,

Infection Prevention/Staff Engagement

Learn. Act. Improve. Spread. Keep the Drum Beat Going.

Learning Objectives

1. Discuss how using the Learning from Defects or RCA process can help you identify how to improve.

2. Describe the essential elements of investigating an infection event.

3. Outline what specific actions you will do in the next week based on this information.

4. Identify the action steps your team should complete before the October meeting.


Framing Our Meeting

• Putting Patients First: Preventing All Cause Harm• Think of what worked and how you can learn

from it• What would you add/adapt to make it work in

your hospital• Think about what insights you gained


Refocus Our Goals

• Reduce Hospital Acquired Conditions by 40%– CLABSI HAC Rate 0.67 per 1000 discharges

• CLABSI: <1/1000 central line days• HHS HAI Action Plan 2013 Goals– CLABSI: SIR less than 0.5 – CAUTI: 25% reduction in rates


OUR PROGRESS SO FAR


CLABSI ICU 2011 - 2012

summaryYQ infCount numExp numCLDays Inf Rate SIR SIR_pval SIR95CI

2011Q1 114 111.93 59080 1.92 1.019 0.4349 0.840, 1.224

2011Q2 112 109.38 57426 1.95 1.024 0.4136 0.843, 1.232

2011Q3 109 104.60 54692 1.99 1.042 0.3464 0.856, 1.257

2011Q4 95 110.53 56692 1.68 0.860 0.0738 0.695, 1.051

2012Q1 100 131.17 66294 1.51 0.762 0.0027 0.620, 0.927

2012Q2 93 96.995 49460 1.88 0.959 0.3669 0.774, 1.175


CLABSI Reduction Progress


Georgia GHAREF CLABSI SIR 2010 - 2012

2010 2011 2012 20130.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

1.000

0.969

0.910

0.775

Georgia GHAREF CLABSI SIR 2010 - 2012

CLABSI SIR

Goal


What An Analysis Can Teach You

The Following slides were adapted from the On the CUSP Stop BSI Education SeriesOn the CUSP Stop BSI

Learning from Infections

http://www.onthecuspstophai.org/


WHAT IS A DEFECT?

Anything you do not want to have happen again


Higher Level Problem Solving

• Second Order Problem Solving−Reduces risks for future patients by improving

work processes−Example: you create a process to make sure

line cart is stocked

*Anita Tucker

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Learning from Infections

• What happened? – From the people involved

• Why did it happen? – Evaluates positive and negative contributing factors

• What will you do to reduce the chance it will recur? – Specific actions needed to reduce the likelihood of

recurrence.

• How do you know that you reduced the risk that it will happen again?


What Happened?

• Reconstruct the timeline and explain what happened

• Put yourself in the place of those involved, in the middle of the event as it was unfolding

• Try to understand what they were thinking and the reasoning behind their actions/decisions

• Try to view the world as they did when the event occurredSource: Reason, 1990;

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Why did it Happen?

• Develop lenses to see the system (latent) factors that lead to the event

• Often result from production pressures

• Damaging consequences may not be evident until a “triggering event” occurs

Source: Reason, 1990;

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What will you do to reduce the risk of it happening again

• Prioritize most important contributing factors and most beneficial interventions

• Safe design principles– Standardize what we do

− Eliminate defect

– Create independent check– Make it visible

• Safe design applies to technical and team work

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Prioritizing Contributing Factors

FactorImportance in current event

1 low to 5 highImportance in future events

1 low to 5 high

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What will you do to reduce risk

• Develop list of interventions

• For each Intervention rate– How well the intervention solves the problem or mitigates the

contributing factors for the accident– Rates the team belief that the intervention will be implemented and

executed as intended

• Select top interventions (2 to 5) and develop intervention plan– Assign person, task follow up date

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Rank Order of Error Reduction Strategies

Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and double check systems

Rules and policies

Education / Information

Be more careful, be vigilant

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Staff Level Reliable Systems Design


How do you know risks were reduced?

• Did you do small tests of change and improved process?

• Did you create a policy or procedure (weak)?

• Do staff know about policy or procedure? – Ask 5 staff – do you get the same answer

• Are staff using the procedure as intended?– Behavior observations, audits

• Do staff believe risks were reduced?

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Summarize and Share Findings

• Summarize findings and improvements – 1 page summary of 4 questions– Learning from defect figure

• Share within your organizations

• Share de-identified with others in collaborative

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Key Lessons

• Focus on systems not people

• Prioritize which infections to investigate

• Use safe design principles

• Go mile deep and inch wide rather than mile wide and inch

deep

• Test small, simple process, improve until process reliable

• Answer the 4 questions

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Action Plan

• Review the Learning from Defect tool with your team• Review defects in your unit• Select one defect per month to learn from• Consider using in Morbidity and Mortality/QI conferences• Post the stories of risks that were reduced• Share with others

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Reliable Systems Process Design Education

• Please make plans to join our HAI collaborative meeting on October 10 from 11 – 12:30.

• Dr. Resar will walk through an HAI example of how to have front line staff create and test the process needed to keep patients safe.

• Request a hospital volunteer• If you missed the RSPD Overview presentation

you can listen to the recording and download materials at the HAI meetings page. Look under July 17 meeting.

https://quality.gha.org/Home/HospitalEngagementNetworkHEN/LearningCollaboratives/HospitalAcquiredInfectionsHAI/Meetings.aspx


Next Steps: To be completed by October 10 Meeting

1. Meet with your team to assess progress.

2. Use the Learning from Defects or RCA tool to investigate an infection that occurred in the recent past.

3. Identify what improvement can be made to prevent further infections from occurring.

4. Determine a course to improve

5. Listen to the Reliable System Process Design webinar recording. Go to the link below and go to the July 17 HAI meeting information. The link to the recording and presentation is under this.

6. Complete the meeting evaluation by September 18

7. Submitted August Process Measure Data collection by September 26




Action Step

What is one action you will take in the next week to prevent CLABSI

in your unit?


References

• Learning from Defects Tool: On the CUSP Tool Kit

• TJC RCA Framework Tool: Framework for a Root Cause Analysis

• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.

• Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.

• Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348:1051-6.

• Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.

• Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5.

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http://www.onthecuspstophai.org/on-the-cuspstop-bsi/toolkits-and-resources/

http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/


CONTACT INFORMATION

Denise Flook

[email protected].

770-249-4518

mailto:[email protected]

hai collaborative meeting september 12, 2012 denise flook, rn, mph, cic hai collaborative lead vice...

Documents

drum beat

learning objectivesdiscuss

infection event

denise flook

patient harm

clabsi hac rate

essential elements

rca process