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CLABSI Small Tests of Change

CLABSI Small Tests of Change. Jill Hanson Manager, Quality Improvement Improvement Advisor WHA. Today’s Call. Past 30 days PDSA Cycle Designing Tests Adapt, Adopt, Abandon Central Line Maintenance Next 30 days Continue with small tests of change

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CLABSI Small Tests of Change

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  1. CLABSISmall Tests of Change Jill Hanson Manager, Quality Improvement Improvement Advisor WHA

  2. Today’s Call • Past 30 days • PDSA Cycle • Designing Tests • Adapt, Adopt, Abandon • Central Line Maintenance • Next 30 days • Continue with small tests of change • Determine how test cycle results will be shared

  3. Previous 30 Days

  4. Mid Month Survey Results In the meantime……..I want to share some examples of staff safety assessment results Teams are still working on: Staff safety assessments Determining one small test of change

  5. Insertion - Staff Safety Assessment Findings Technique not adequate Not compliant with hand hygiene Line inserted without sterile technique Inadequate use of maximal barrier precautions Femoral line chosen instead of subclavian

  6. Insertion - Small Tests of Change Ideas Create a central line insertion kit Develop monitoring tools to assure compliance with insertion bundle components Empower nursing staff to stop procedure when bundle is not followed

  7. Maintenance - Staff Safety Assessment Findings Line not changed on timely basis Line in for too long Dressing not changed using aseptic technique IV tubing not properly labeled with change date

  8. Maintenance - Small Tests of Change Ideas Create central line maintenance kit Develop monitoring tools to assure compliance with maintenance bundle components Empower nursing staff to stop procedure when bundle is not followed Daily rounds to assess line necessity Daily rounds to assure appropriate maintenance

  9. Education & Staffing - Staff Safety Assessment Results Inexperienced clinical staff Staff not knowledgeable about central line bundle No protocol for dressing changes MD doesn’t get someone to assist with line insertion Staff too busy to check and change dressings

  10. Staff Education & Protocols - Small Tests of Change Ideas Develop department/hospital-wide education programs for insertion and maintenance practices Reorganize staffing to monitor and assure compliance Create protocols where nursing signs off on dressing rounds

  11. Poll Question #1 On average, how long does it take your hospital to adopt a new practice, from launch to full implementation? 1 to 2 years or more 6 months to 1 year 3 to 6 months Less than 3 months A couple of weeks – we just do it. 11

  12. Poll #1 Answer On average, how long does it take your hospital to adopt a new practice, from launch to full implementation? 1-2 years or more 6 months to 1 year 3 to 6 months Less than 3 months A couple of weeks – we just do it. 12

  13. A Common Improvement Approach The “old” 7 step process

  14. A More Sustainable Process Sustainable Improvement

  15. Go Slow Now To Go Fast Later Keep tests very simple to do Plan your testing approach Use quick huddles to get feedback from staff (you don’t need a meeting…) Make changes and re-test soon after Review hard numbers (process data) in meetings

  16. Why Go So Slow? Engagement is Non-linear 16

  17. Model for Improvement Make sure your team: Sets clear aims Establishes measures that will tell if changes are leading to improvement Identify changes that are likely to lead to improvement Uses the Plan-Do-Study-Act cycle to conduct small tests of change in real work settings

  18. How Do Small Tests Accelerate Change? Decreases the risk of resistance and “backsliding” Increases belief that the change is for the better Determines which, or which combination of changes drives improvement. Proves that the change will work! Avoids “Do-Overs”! 18

  19. Designing Tests of Change Find a willing “tester” Instruct them in the “what” Determine the when, how long, etc. Conduct the test Gather feedback from the test Learning: Will you adapt it, adopt it, or abandon it? 19

  20. Documenting Cycles of Testing Keeps the team “on task” Clarifies the reason for testing Clear accountability Assists with the learning from small tests because you can see what happened 20

  21. Revise and Re-evaluate: Key Decision Remember the first interventions usually do not work Adapt, adopt, abandon Adapt—make the changes needed to make it workable and test again. Adopt – keep it (document and report results). Abandon—let it go if it didn’t work, don’t try to force the adoption.

  22. Importance of Central Line Maintenance It impacts….. Central Line Insertion Central line dressing changes Replacement of IV administration sets Hang time for parenteral fluids Catheter hub cleansing Removal of unnecessary lines Education

  23. Central Line Maintenance Bundle • Hand Hygiene • Before and after accessing line, dressing and needleless device change • Proper Dressing Change • Use a twisting motion 10-15 x (or 10-15 sec) for cleaning • Change needless device aseptically every 96 hrs and with tubing change • Aseptic technique for accessing and changing needleless connector • Clean with chlorhexidine/alcohol • Use back and forth motion for 30 seconds • Change transparent dressing q 7 days, gauze dressing q 48 hr or PRN • Standardize tubing change/flushing lines • Daily review of catheter necessity

  24. PDSA – Test Documentation - Sample Project: Reducing central line infections Objective for this PDSA cycle: Test whether attaching alcohol wipes to the I.V. pole increases “scrub the hub” compliance IHI PDSA Worksheet

  25. PDSA - PLAN Questions: How can we ensure total compliance of scrub the hub? Predictions: Attaching alcohol wipe to the I.V. pole will help ensure total compliance of scrub the hub for the patient.

  26. PLAN - Scrub the Hub Testing Steps What Will You Test? Alcohol wipe on I.V. Pole What Do You Need to Test? IV Pole, Alcohol Who will be involved in the test? One (willing) nurse How will you educate/inform the participants? One- on-one conversation Where will you test? 4 North When will you test (Day, Time, Shift)? Today, 7 pm, second shift How will you know the test is successful? Ask the nurse testing for feedback

  27. Measuring the Test Plan for collection of data – who, what, when, where: • Who: Bonnie (willing nurse) • What: Whether scrub the hub protocol was followed • When: Today, 7 pm, second shift • Where: 4 North

  28. Documenting the PDSA Cycle DO Carry out the change or test. Collect and begin analysis. STUDY Complete analysis of the data • How did or didn’t the results of this cycle agree with the predications we made earlier? • Summarize the new knowledge learned by this cycle • Nurse followed scrub the hub protocol when alcohol wipes were attached to the I.V. pole

  29. Plan For The Next Cycle Adapt change, another test, implementation cycle? Test the criteria with three more nurses on day shift Test criteria with three more nurses Goal is to have 20% of those doing the work have a chance to test it, which is…. YOUR TIPPING POINT 29

  30. PDSA - ACT List actions we will take as a result of this cycle: Train other nurses and test further Consider adding visual cues (educational posters) as reminders to scrub the hub

  31. Test of Change Design

  32. Hospital NameIntervention Focus

  33. Action Item #1: Determine Your 20% # Staff involved in process x 20-30% =Tipping Point Example : 25 staff who touch patient with central line x 20% = at least 5 front line staff (tipping point)

  34. PDSA Cycles Consider conducting PDSA cycles on: Bundle Compliance (Insertion or Maintenance) Dressing Change Daily Goals

  35. Pre PDSA For Central Line Maintenance Consider surveying nursing staff to see how often they: Change access port every 96 hours Change trans. dressing every 5-7 days Clean insertion site with 2% CHG Scrub access port for 15 seconds

  36. Post PDSA Education for Central Line Maintenance Conduct nursing audits for the following: Scrub access port for 15 seconds IV tubing dated Scrub insertion site 30 seconds, let dry Dressing dated Transparent dressing changed every 7 days

  37. The Next 30 Days Tools Available On WHA Quality Center: Test of Change Planning Tool Test of Change Log Hospital Specific Test of Change Template PDSA Worksheet 37

  38. CLABSI Data Submission Outcome measures • Baseline data submission is complete • Monthly beginning June 2012 • NHSN OR Manual Entry thru WHA Data Portal Process measures – thru WHA Data Portal • Monthly beginning June 2012

  39. Entering CLABSI Process Measures WHA Quality Center Live Demo

  40. Reminder Please complete the three question survey before you close out of today’s webinar. Next Webinar: September 25 at 10 am Participating CLABSI Teams Report Out Staff Safety Assessments & Small Tests of Change 40

  41. Thank You! Questions? Jill Hanson Manager, Quality Improvement WHA Improvement Advisor (jhanson@wha.org) 41

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