Eliminating Catheter-Related Blood Stream Infections in NICU Patients

The CCS/CCHA NICU Improvement Collaborative

Paul Kurtin, MD

Chief Quality and Safety Officer Rady Children’s Hospital & Health

Center

All Improvement is Local

Think Globally

Act Locally

Ground Rules

• Sharing individual site data: Blinded yes/no?

• Prohibit use of data for marketing or competition

• Public release of aggregated data only

Days Without an Injury

100

Days Without an Infection

?

Days Without an Infection

27 Days

Days Without an Infection

270 Days

Days Without an Infection

27 Hours

Days Without an Infection

• How is your unit doing?

• Does everyone know?

• Is there a run chart in the staff lounge?

Days Without an Infection

• We can’t manage what we don’t measure.

The Case for Redesign

• “Every system is perfectly designed to get the results it gets!”

• “If we keep doing what we have been doing, we’ll keep getting what we have always gotten”

• “The definition of lunacy is keep doing what you’ve always done and expect a different result!”

The Case for Redesign

• The case for redesign was made in “Crossing the Quality Chasm”

• The gap between the healthcare we have and what is possible is not just a gap…it’s a chasm

• Not about working harder or being more careful…must change the fundamentals of the process

Design Goals

• Make it easy to do the right thing!• Hardwire changes into routine practice via

education, training, order sets, protocols, the environment

• All improvement is change, not all change is improvement! We must know the difference

(P->D->S->A->P…DMAIC)! Build measurement into the process

Model of Improvement

• AIM (smart) specific, measurable, attainable, relevant, timely

• Measures

• Execute with small tests and cycles of change (PDSA)

AIM

• To eliminate All hospital acquired catheter related blood stream infections in NICU patients by June 30, 2007

• Reduce by 50% or 90%

• Selected populations e.g. post-op hearts or post bowel surgery

Potential Metrics

• Infections/1000 catheter days• Days between infections• Cost/infection (LOS, antibiotics, diagnostic

tests)• Morbidity• Mortality• % Bundle compliance: all or none?• Thermometer with: lives saved; days saved;

dollars saved

Implementation: Microsystems

• What are they?

• How to assess their effectiveness?

• How to improve?

• How to hold the gains?

Creating a High Reliability NICU

• Do the right thing the first time every time!

• Visual display of data as reminders• “Stop the line!”• Catheter cart to manage supplies and

the environment• It’s the system …not the person (96.5 %

v. 3.5 %)

What We Know v. What We Believe

• We know it’s the system but we believe that the individual, through hyper vigilance and extra effort, will not make a mistake (work harder, be more careful)

• Healthcare workers are committed, responsible, accountable, dedicated, (see definition of lunacy)

What We Know v. What We Believe

• We trust intelligence at the bedside, clinical experience and acumen, and our ‘gut’

• We question/doubt/distrust the system especially if the system slows us down and decreases our efficiency of doing things

The “Culture Code”

• Work = who we are

• Quality = it works

• Perfection = is not possible and it limits learning by trial and error and our pioneering spirit

Making it stick!

• We are a microsystem. How do we design it to sustain the delivery of care which eliminates C-R BSIs?

• Focus on the patient• Focus on the staff• Shared leadership• Focus on outcomes and continuous

improvement• Information and communication

Improving our Microsystems

• P.103* The Model of Improvement• P.104 Team and meeting skills• P.113* PDSA worksheet• P.115 Improvement tools• P.116* Process mapping (current process v.

ideal; gaps in planning; gaps in execution)• P.118 Flowcharting (is this what really

happens?; any steps left out or added?; all the time, most of the time? Not the P&P, ask the frontline)

Improving our Microsystems

• P.123 Access to information…leads to accountability

• P.124 Change concepts:manage time by reducing set-up time; manage variation by standardization; design to avoid mistakes with reminders and constraints

• P.125 Mental models: why do we think we do/don’t have an infection problem?

Tracking Our Improvement

• P.132* Run charts

• P.138* Control charts

• P.139* Pareto charts

• P.141 Change (will, ideas, resources)

• P.142 Spread of innovation

Making Change Happen

• P.146 Sense of urgency

• Build a team

• Create vision and strategy

• Communicate 8X8

• Remove barriers (force field analysis)

• Celebrate small wins

Next Steps

• Baseline data: where are we now? Trended if possible

• Site visits: when and why?• Microsystem assessment• Resources: continuing communication, web

site, document posting, conference calls• Hardwiring: policies and procedures, staff

education, non-staff education e.g. radiology

Breakout Session

• Each team will:

– Develop a SMART aim– List current metrics– Describe potential interventions