How Culture Change Can Improve Care

Bradford D. Winters, Ph.D., M.D.The Quality and Safety Research Group

The Johns Hopkins University School of Medicine

The Harm In U.S. Healthcare system

Nearly 100,000 deaths from HAIs

400,000 CLABSIs occur per year in U.S.

CLABSIs are

1) Approximately 35,000 deaths from CLABSIs

2) Associated with mortality rates of 10% to 20%

3) Associated with prolonged hospitalization (mean of 7

days)and increase in medical costs > $32,000 USD

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The Quality Buck Stops Nowhere: Everyone Responsible, No One Accountable

3

Consumers“I’m busy; I

defer to regulators.”

Regulators“My budget’s too small; I

defer to accreditors.”

Accreditors“I get paid by providers; I

defer to them.”

Providers“Insurers don’t pay differently for quality; I

defer to them.”Insurers

“Purchasers don’t heavily weight quality in plan

selection; I defer to them.”

Purchasers“Consumers get mad if we restrict

choice or aggressively link

their out-of-pocket cost to quality; I defer to them.”

©2000 Arnie Milstein MD

adaptation 2010 c goeschel

Consumers UnionCAPS

CMS P4PHHS HAI Plan

TJC NPSG & Standards

Incentive Plans; Carrots and Sticks

Employer based healthcare declines as costs skyrocket

WHO IS Accountable

for CLABSI’s ?BOARDS? CEO’S? Doctors? Nurses??

The Johns Hopkins Data Median rate of zero

Longest tally of weeks without a CLABSI SICU=86 WICU=54 CSICU=48

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CRBSI Rate Over TimeMedian and Mean CRBSI Rate

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Baseli

ne

Interv

entio

n 0-3 4-6 7-910

-1213

-1516

-1819

-2122

-2425

-2728

-3031

-3334

-36

Time (months)

Median CRBSI Rate Mean CRBSI Rate

CRBSI Rate Summary DataStudy Period No. of ICUs No. of Infections Catheter Days Infection Rate IRR (95% CI)

Median (Q1, Q3)

Median (Q1, Q3)

Median (Q1, Q3)

Mean (SD)

Baseline 55 2 (1, 3) 551 (220, 1091) 2.7 (0.6, 4.8) 7.7 (28.9) Reference

During Implementation 96 1 (0, 2) 447 (237, 710) 1.6 (0, 4.4) 2.8 (4.0) 0.81 (0.61, 1.08)

After Implementation Initial Evaluation Period

0-3 mo 95 0 (0, 2) 436 (246, 771) 0 (0, 3.0) 2.3 (4.0) 0.68 (0.53, 0.88)

4-6 mo 95 0 (0, 1) 460 (228, 743) 0 (0, 2.7) 1.8 (3.2) 0.62 (0.42, 0.90)

7-9 mo 96 0 (0, 1) 467 (252, 725) 0 (0, 2.0) 1.4 (2.8) 0.52 (0.38, 0.71)

10-12 mo 95 0 (0, 1) 431 (249, 743) 0 (0, 2.1) 1.2 (1.9) 0.48 (0.33, 0.70)

13-15 mo 95 0 (0, 1) 404 (158, 695) 0 (0, 1.9) 1.5 (4.0) 0.48 (0.31, 0.76)

16-18 mo 95 0 (0, 1) 367 (177, 682) 0 (0, 2.4) 1.3 (2.4) 0.38 (0.26, 0.56)

Sustainability Period

19-21 mo 89 0 (0, 1) 399 (230, 680) 0 (0, 1.4) 1.8 (5.2) 0.34 (0.23, 0.50)

22-24 mo 89 0 (0, 1) 450 (254, 817) 0 (0, 1.6) 1.4 (3.5) 0.33 (0.23, 0.48)

25-27 mo 88 0 (0, 1) 481 (266, 769) 0 (0, 2.1) 1.6 (3.9) 0.44 (0.34, 0.57)

28-30 mo 90 0 (0, 1) 479 (253, 846) 0 (0, 1.6) 1.3 (3.7) 0.40 (0.30, 0.53)

31-33 mo 88 0 (0, 1) 495 (265, 779) 0 (0, 1.1) 0.9 (1.9) 0.31 (0.21, 0.45)

34-36 mo 85 0 (0, 1) 456 (235, 787) 0 (0, 1.2) 1.1 (2.7) 0.34 (0.24, 0.48)

Systems

Every system is designed to achieve the results it gets

To improve performance we need to change systems

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System Factors Impact SafetyHospital

Departmental Factors

Work Environment

Team Factors

Individual Provider

Task Factors

Patient Characteristics

Institutional

Adapted from Vincent

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Principles of Safe Design Standardize

Eliminate steps if possible

Create independent checks

Learn when things go wrong What happened Why What did you do to reduce risk How do you know it worked

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Marriage

Technical Work (What we do)

Adaptive Work (How we do it)

Each does not work alone

Eliminating CLABSI

PRIMARILY Technical (CLABSI)

CVC Insertion

CVC Line Cart

1. Contents inventory

Evidence based BSI prevention

(hands, site, skin prep, barrier,

removal)

1. Presentation of evidence

2. CLABSI factsheet

3. Insertion checklist

4. Vascular access quiz

5. Vascular access manual/ policy 6.Annotated bibliography

CVCManagement

1. Daily goals

2. Dressing change

3. Vascular access manual/ policy protocol

PRIMARILY Adaptive (CUSP)

Science of Safety

Training

1. Science of safety

presentation

3. Attendance sheet

Staff Identify Defects

1. Staff safety

assessment form

2. Indentifying

hazards presentation

Senior Executive

Partnership

Briefings

Learning from

Defects

LFDtoolkit

Implement Tools for Teamwork and

Communication

1. Daily goals

2. Shadowing

3. AM briefing

4. Call list

6. Team check up tool

4

CUSP & CLABSI Interventions

1. Educate on the science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from Defects

5. Implement teamwork tools

CUSP CLABSI

1. Wash Hands Prior to Procedure

2. Use Maximal Barrier Precautions

3. Clean Skin with Chlorhexidine

4. Avoid Femoral Lines

5. Remove Unnecessary Lines

Technical Translate Evidence into Practice (TRiP model)

Standardization What, Who, When. How Reduces variability Public Framework for adherence Shared knowledge

Cognitive Tools Checklists

The Checklist: Democratizes knowledge Helps to prevent miscommunication which is a major

contributor to adverse events

Ensures all actions/elements are addressed (operationalizes the evidence)

Structure and predictability facilitates systematic delivery of care Reduces variability Improves performance

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Why a checklist? Humans are prone to error Stress Fatigue Illness Interruptions/distractions New situations Production pressures

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Seek Explicit Evidence Published literature (Embase, Cochrane, PubMED, Cinahl, etc) Evidence summaries Practice guidelines

Systematic reviews

RCTs, non-randomized trials, case series, etc.

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Tacit Evidence: The Wisdom of Crowds

Frontline Providers Ask staff about knowledge Use team check up tool

Walk the process of staff placing a central line

Knowledge Banks

Networks (social, professional)

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Generate the Checklist Compile a list of potential interventions

Go for the “low hanging fruit”

Consider: Which interventions have best evidence Which interventions are likely to have the greatest impact Which interventions will have the lowest barriers to

implementation. Ask your frontline staff

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Translate, Reduce, Repeat, Pilot Convert the bundle into concise, explicit, and

unambiguous behaviors

Narrow the list to 7+2 items

Break into sub checklists if necessary

The process should be iterative until consensus is achieved

Pilot test in units or simulation

Repeat as necessary (make it dynamic and adaptable)

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CUSP: the Foundation of Successful CLABSI Reduction.

What is CUSP (Comprehensive Unit Safety Program)? It is an intervention to learn from mistakes and

improve safety culture CUSP creates an environment where all providers Nurses Physicians Pharmacists OthersFeel comfortable and are encouraged to ask the

question:How are we going to harm the next patient?

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Pre CUSP Work

Create a team Nurse, physician administrator, others Assign a team leader

Measure culture

Work with hospital quality leader to have a senior executive assigned to team

The 5 Steps of CUSP

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Pronovost J, Patient Safety, 2005

Science of Safety Understand system determines performance

Use strategies to improve system performance Standardize Create independent checks for key process Learn from mistakes

Apply strategies to both technical work and team work

Recognize teams make wise decisions with diverse and independent input

Science of Safety Education

Create a plan to educate every staff member in your unit or clinical area Physicians, nurses, techs, clerical assistants, housekeeping Science of Safety Training Attendance Sheet

Create a plan to educate all future staff Incorporate education into orientation

Identification of Defects Review error reports, liability claims, sentinel events

or M and M conference

Ask staff how will the next patient be harmed and what we can do to mitigate that harm (2-item questionnaire)

Walk the Process

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Staff Safety Assessment

Prioritize Defects

• List all defects

• Discuss with staff what are the three greatest risks

• Identify if resources are needed− Select 3 that require resources and 3 that do not

• Executive partner should assist this process

Executive Partnership

Executive should become a member of team

Executive should meet monthly with team

Executive/Administrator should review defects, ensure team has resources to reduce risks, and hold team accountable for improving risks and central line associated blood steam infection rates

Learning from Mistakes What happened?

Why did it happen (system lenses) ?

What could you do to reduce risk ?

How do you know risk was reduced ? Create policy / process / procedure Ensure staff know policy Evaluate if policy is used correctly

Pronovost 2005 JCJQI

To Identify Most Important Contributing Factors

Rate each contributing factor

importance of the problem and contributing factors in causing the accident

importance of the problem and contributing factors in future accidents

To Identify Most EffectiveInterventions

• Rate Each Intervention

– 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

To Evaluate Whether Risks were Reduced

Did you create a policy or procedure

Do staff know about the policy

Are staff using it as intended

Do staff believe risks have been reduced

Teamwork Tools Implement tools that are intended to

support teamwork behaviors:

Call list

Daily goals

AM briefing

Shadowing

Culture check up

Pronovost JCC, JCJQI

CUSP is a Continuous Journey

• Add science of safety education to orientation

• Learn from one defect per month, share or post lessons with others

• Implement teamwork tools that best meet the teams needs

ICU Catheter-Associated Bloodstream Infections

NHSN Mean

Education:

The 5

behaviorsLine Cart

Checklist

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Standardize

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Safety Climate- Culture of Safety Survey

"Needs Improvement“ Statewide Michigan CUSP ICU Results

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Teamwork Climate Across Michigan ICUs

No BSI 21% No BSI 44%No BSI 31%

No BSI = 6 months or more w/ zero

The strongest predictor of clinical excellence:caregivers feel comfortable speaking up if they perceive a problem with patient care

Pronovost, BMJ 2008

Action Items for Reducing CLABSI Engage: stories, show baseline data

Educate staff on evidence

Execute Standardize: Create line cart Create independent checks: Create BSI checklist Empower nurses to stop the line insertion Learn from mistakes: review infections

Evaluate Feedback performance View infections as defects

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“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the

only thing that ever has.”-Margaret Meade

CUSP+CLABSI=Success=Safer Care