Learning Session 3 1June 2012

Dena van den Bergh, Michele Youngleson, Gary Kantor, Farzaneh Behroozi, Yolanda Walsh

When we launched the Best Care …Always Campaign at the joint FIDSSA and COPICON Conference in August 2009 we set an overall goal to build quality improvement (QI) skills and capacity in the South African health sector including both public and private sectors and to expand the reach of QI interventions to the front-line of care.

Dr Dena van den Bergh Chairperson BCA

•  Ini#al  focus  areas  were  four  well-­‐tested  infec0on  preven0on  interven0ons  and  a  pilot  an0bio0c  stewardship  program  that  had  not  yet  been  tested  as  a  campaign  elsewhere  in  the  world.  

•  Our  aim  was  to  accelerate  the  scale  and  pace  of  improvement  in  these  focus  areas  and  we  set  our  sights  on  achieving  a  bigger  impact  together  than  any  individual  hospitals  could  do  alone.      

•  In  order  to  bring  sound  improvement  methodology  to  this  work,  we  formally  partnered  with  the  Ins#tute  of  Healthcare  Improvement  (IHI)  and  adopted  the  Breakthrough  Series  Collabora#ve  model  as  a  key  improvement  strategy  for  spread  to  mul0ple  hospitals.    

•   The  methodology  advocates  shared  learning  and  collabora0on,  emphasizes  measurement  and  using  small  tests  of  change  in  the  front-­‐line  of  healthcare  to  create  sustainable  implementa0on  of  evidence-­‐based  interven0ons.  

Now  2  years  and  8  months  since  our  launch,  we  have  made  substan0ve  progress  on  our  journey.         1.  Western  Cape  Province  partnership  takes  great  strides  forward. 2.  Gauteng  Province  Collabora0on  goes  to  phase  2  and  adds  a  further  11  

hospitals   3.  Free  State  Province  -­‐  6  Hospitals  join  a  formal  collabora0ve  supported  

strongly  by  leadership   4.  Private  Sector  -­‐  spread  in  independent  hospitals,  improvement  in  key  

areas  and  collabora0on  on  poten0ally  publishing  results. 5.  An0bio0c  stewardship  program  goes  from  pilot  to  full  interven0on  and  

full  collabora0on  with  FIDSSA-­‐led  SAASP  ini0a0ve   6.  Exci0ng  future  possibili0es  that  have  opened  up.

Western  Cape  Province  Project  Progress  Assessment  Scale  For  initial  bundles  and  units  

HOSPITAL     George    

GSH    

GSH    

Mowbray  Maternity  

Mowbray  Maternity  

New  Somerset  

New  Somerset  

Paarl   Red  Cross  

Tygerberg  

Tygerberg  

WCRC  

Worcester  

BUNDLE   VAP   CLABSI  

CLABSI  

Peripheral  Lines  

SSI   VAP   Peripheral  Lines  

CAUTI  

VAP   CLABSI  

VAP   CAUTI  

VAP  

UNIT   ICU   Respiratory  ICU  

Surgical  ICU  

NICU  

Theatre  

ICU     NICU   Maternity  &  Gynae  

ICU   Surgical  ICU  

Med  ICU  

3  Spinal  Wards  

ICU    

Project  Progress  Score  

                         

5   Outstanding  sustainable  results  

                         

4.5   Sustainable  improvement  

                         

4   Significant  improvement  

  X       X           X        

3.5   Improvement       X         X     X     X      

3   Modest  improvement  

              X         X   X  

2.5   Changes  tested,  but  no  improvement  

          X                

2   Activity,  but  no  changes  tested  

X                          

1.5   Planning  for  the  project  has  begun  

                         

1   Forming  team                            

0   Not  started  or  lapsed  

      X                    

 

Apr-­‐12Chris Hani Bara

Dr George Mukhari Edenvale

Far East Rand Hospital Germiston

Helen Joseph Kalafong

Leratong Hospital Pholosong

Rahima Moosa Hospital

Tambo Memorial Hospital

Tembisa  Hospital

all units

389 - Folateng 565 389 376 NICU

Adult ICU

Maternity ward

Neuro ICU

Trauma ICU

Medical ICU Adult ICU NICU all  units

Outstanding sustainable results 5.0

Sustainable improvement 4.5 X

Significant improvement 4.0 x x XImprovement 3.5 x x X

Modest improvement 3.0 x x x xChanges tested, but no

improvement 2.5Activity, but no

changes 2.0 x x x x xPlanning for the project

has begun 1.5 x x x x

Forming team 1.0 x x x

Lapsed 0.0

Sebokeng Hospital Steve Biko Academic

GAUTENG  PROVINCE  BEST  CARE  ALWAYS  -­‐  STATUSHospitals  wave  1

CMJA

Africa Forum on Quality & Safety in Healthcare - 2013

BCA Invitation to you all: Elevate our interventions to becoming “publication ready “. October/Nov – Learning session dedicated to presentations and posters

How wonderful it is that nobody need wait a single moment before starting to improve the world. Anne Frank, Diary of a Young Girl, 1952.

To improve patient safety using A Systems Improvement approach Phase 1: to reduce Hospital Acquired Infections (HAI)

Overall goal of BCA Campaign

Accelerating change and improvement through networking and collaboration.

Expert Meeting and

Planning Group formed

Learning session

1

May 2011

Learning session

2

Nov 2011

Repeated improvement

cycles:

Repeated improvement

cycles:

Learning session

3

June 212

18 Months (Oct 2012)

Mentoring and support

HAI Impact

•  On the patient & family

•  On you? •  On the hospital? •  Financial?

14

Impact of your BCA project

•  On you? •  On the unit? •  On the hospital?

15

What’s the most important thing you have learnt since the first Learning Session?

- healthcare systems improvement - reducing hospital acquired infections

How are we doing?

Hospitals reporting

0

2

4

6

8

10 nu

mbe

r of h

ospi

tals

Number of hospitals reporting (total 9)

Hospital   VAP   CLABSI   Peripheral  Lines  

CAUTI   SSI  

George   ICU                  

GSH       All  ICUs              

Mowbray  Maternity  

        Neonatal  HC       Theatre  

New  Somerset  

ICU       ICU          

Paarl               Maternity  &  Gynae  

   

Red  Cross   ICU                  

Tygerberg   Med  ICU   Surgical  ICU              

WCRC               3  Spinal  Wards  

   

Worcester   ICU                  

Initial bundles selected for piloting

Initial bundles piloted and spread

0

2

4

6

8

10

12

14

J2011 A S O N D J2012 F M A M J J A S O N D

num

ber o

f bun

dles

Number of Infection Prevention bundles selected versu number being tested and scaled up

# initially selected

# bundles being tested

# of bundles being scaled up

Map initial bundles, spread, and new bundles introduced

HOSPITAL NAME CLABSI VAP

SSI CAUTI

ICU A5 – May 2011

ICU B12 Oct 2011

Obstetrics C/S – Feb 2012

Measures

Aim

•  Stretch aim – not doable in our current system •  Benchmarked against the best in the world • Number – a certain amount •  Time frame – October 2012

Aim To reduce ………… (VAP, CLA-BSI, PLI, SSI, CAUTI)

By ……………. amount in ………. unit By implementing the whole ……… (VAP, CLA-BSI, PLI, SSI, CAUTI) bundle to every patient every time By December 2012 (in 18 months)

Outcome measures

Initial bundles piloted (12) that have an outcome measure

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Outcome measures

Welsh Safety Calendar

Rates

Days/case between infection

Outcome measures Have we made an improvement?

Median

Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift

Median

Median

Trend: 5 points in row headed in same direction Note: Ties between two consecutive points don’t cancel or add to a trend

Rule 3

05

10152025

1 2 3 4 5 6 7 8 9 10Mea

sure

or C

hara

ceris

tic

Median 11.4

Data line crosses once Too few runs: total 2 runs

Run Chart: Rules for Identifying Statistically Significant Change

Rule 1 Rule 2

Rule 4 Rule 3

I

Astronomical Point: a obviously, even blatantly different value Note: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical

Runs: too few or too many runs

Provost and Murray

Outcome measures

Some challenges with numerators •  Comparison over the project •  Publishing •  Specific about what we are measuring

– eg SSI for Caesarian Section all sepsis or readmission for sepsis?

•  Alignment with project aims – VAP, VAT

Initial bundles piloted (12) that have an process/compliance measure

Compliance measures

• % overall compliance with the bundle • % compliance with individual bundle elements

Why do we measure compliance?

Compliance measures

‘We do what is inspected, not what is expected’

Just a waiting game

HAIS are rare events We read ‘non-events’ as ‘the system is safe’

HOWEVER When we look at the underlying processes that drive the outcome they are unreliable THEREFORE What appears as safe and reliable is often just an infrequent event just waiting to happen

OBSESS ABOUT PROCESSES

Carol Haraden IHI: Becoming Deeply Safe International Forum on Quality and Safety in Healthcare, Paris 2012

Just a waiting game

Unless our overall compliance is at > 95% We cannot say we have reliable care Chance is playing a hand in our outcomes It’s just a waiting game

OBSESS ABOUT PROCESSES

Carol Haraden IHI: Becoming Deeply Safe International Forum on Quality and Safety in Healthcare, Paris 2012

Just a waiting game

How reliable is our care?

Step 1 Step 3 Step 4 Step 5 Step 2

0.8 x 0.8 0.8 x 0.8 x 0.8 x

80% 80% 80% 80% 80%

= 33%

% compliance at each step influences overall compliance

% compliance at each step influences overall compliance

How reliable is our care?

Step 1 Step 3 Step 4 Step 5 Step 2

0.95 x 0.95 0.95 x 0.95 x 0.95 x

95% 95% 95% 95% 95%

= 77%

% Overall compliance with the bundle

How reliable is our care? Did we give •  The right treatment •  To every patient •  Every time

‘All or none’ measure for each patient

Audit - % Compliance with individual bundle elements

How reliably are we implementing each bundle element? Where are our strengths and weaknesses. Did the change make an improvement?

Mistakes with compliance measures

Mistake # 1 – not measuring compliance only outcomes, only auditing very infrequently

DO Plan

Do Do

Mistakes with compliance measures

Mistake # 2 – changing the target to make it more ‘realistic’

Target for every bundle element > 95%

Mistakes with compliance measures

Mistake # 3 – excluding or changing bundle elements because of individual preferences, or barriers

When is something not applicable? -  Agreement across the project eg chlorhexidine sponges for central line sites -  Medically contraindicated for individual patients eg HOB in neurosurgery patients

Another definition

Mistakes with compliance measures

3 Creative ways of avoiding Surgical Site Infections element

“appropriate hair removal”

•  Its not applicable - no clippers - patients profile

•  “We haven’t done that for years”

“Argue for your limitations and sure enough they’re yours” Richard Bach

Mistakes with compliance measures

Because the % Overall compliance is an ‘All or none’ score for each patient it can

-  never be bigger than the bundle element with the lowest compliance - is often even less than this

Mistake # 4 - incorrect assessment of % Overall Compliance

Compliant Non compliant

Patients Bundle

elements 1 2 3 4 5 Score/5

patients % compliance with individual bundle elements

HOB > 30 degrees √ X √ √ X 3/5 60%

Sedation Vacation √ √ √ √ √ 5/5

100% Oral Care √ X √ X X 2/5 40% PUD Prophylaxis √ X √ √ X 3/5 60% DVT Prophylaxis √ X √ √ X 3/5 60%

% Overall Compliance

% compliance to all bundle elements ALL OR NONE – YES OR NO

Yes NO Yes NO NO 2/5 40%

Unit : Adult ICU Month Feb 2012 Week: 1

VAP bundle compliance example

Health Improvement Scotland's website

Compliant Non compliant

Patients Bundle

elements 1 2 3 4 5 Score/5

patients % compliance with individual bundle elements

HOB > 30 degrees √ X √ √ X 3/5 60%

Sedation Vacation √ √ √ √ √ 5/5

100% Oral Care √ X √ X X 2/5 40% PUD Prophylaxis √ X √ √ X 3/5 60% DVT Prophylaxis √ X √ √ X 3/5 60%

% Overall Compliance

% compliance to all bundle elements ALL OR NONE – YES OR NO

Yes NO Yes NO NO 2/5 40%

Unit : Adult ICU Month Feb 2012 Week: 1

Compliance for each element – horizontal result

Compliant Non compliant

Patients

Bundle elements

1 2 3 4 5 Score/5 patients

% compliance with individual bundle elements

HOB > 30 degrees √ X √ √ X 3/5 60%

Sedation Vacation √ √ √ √ √ 5/5

100% Oral Care √ X √ X X 2/5 40% PUD Prophylaxis √ X √ √ X 3/5 60% DVT Prophylaxis √ X √ √ X 3/5 60%

% Overall Compliance

% compliance to all bundle elements ALL OR NONE – YES OR NO

Yes NO Yes NO NO 2/5 40%

Unit : Adult ICU Month Feb 2012 Week: 1

Compliance for the whole bundle – vertical result

Exercise – bundle compliance

•  4 x weekly audits of 5 patients each •  Work in pairs •  Each pair take one audit and calculate

•  % compliance with individual bundle elements •  % overall compliance

•  Which element has the lowest % compliance? •  What is it and what is the % overall compliance?

Exercise

Answers – week 1

Answers – week 2

Answers – week 3

Answers – week 4

Y Y 5 100%

4 80%

Y Y 3 60%

! !

% Overall compliance - correct scoring

Mistakes with compliance measures

Mistake # 5 – ‘measurement is enough’

“If gaps are identified but not followed-up, data does not inform improvement, but increases the possibility of highlighting the same gaps in the next meeting”.

Sibusiso Hlatjwako AURUM INSTITUTE

DO Plan

Study Do

Not responding to measurement

! !

Making improvements

Resources Training Systems

ü ü ü

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Testing new ideas

Achieving success

“Implementing a bundle with high reliability requires redesign of work processes, communication strategies, and infrastructure, along with sustained measurement and vigilance”.

Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. pg 14

Thinking more laterally - infrastructure

•  VAP - Make things easier - the yellow dot on the wall

Thinking more laterally Involving ‘others’ in care

•  Sebokeng - the cleaners become part of the team

•  WCRC - patients in hand hygiene ‘gentle reminders’

•  MM – ask patients not to shave before elective caesars

•  Sebokeng – involved patients and families in wound care

4 BCA presentations Change in Work Processes

•  From a culture of ’can’t’ to ‘can’– GSH •  The VAP co-ordinator - RCCH •  Not applicable is N/A –WCRC •  Leadership walkabouts - NSH

Tea

Bundle Breakouts VAP,CLABSI, SSI, CAUTI

VAP – Yolanda Walsh CLABSI – Gary Kantor SSI – Life –Karmeli Williams / Dr Bamford NHLS/ Farzaneh Behroozi CAUTI – Netcare – Lowellna Myberg / Michele Youngleson

Bundle Breakouts VAP,CLABSI, SSI, CAUTI

Objective: “All Learn All Teach” •  Show progress •  Identify strengths and weaknesses •  Share ideas and support each other •  Make a list of changes to test

Bundle Breakouts “All Learn All Teach”

Each hospital present and share i)  Measures and data ii)  Audit tool and audit process iii)  Changes for each bundle element

As a whole group discuss any issues regarding definitions of numerators, denominators, or bundle elements

Use the learning from colleagues and the Change Packages to look for new ideas.

Use the Driver Diagram provided to identify strengths and weaknesses in your project – individual groups

Meet with other facilities that you can learn from or who you can teach

Lunch

Innovation – marshmallow tower