On the CUSP: Stop CAUTI National Content Webinar

1. On the CUSP: Stop CAUTINational Content Webinar Welcome to the National Content Webinar! Today’s Topic: The Science of Safety: Revisiting the Cornerstone of CUSP Access slides, audio recording and transcript of today’s webinar on the national project website: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/content-calls/

2. Safe Design Principals Lisa H. Lubomski, PhD Assistant Professor Johns Hopkins University School of Medicine Armstrong Institute for Patient Safety and Quality Pat Posa, RN, BSN, MSASystem Performance Improvement Leader St. Joseph Mercy Health System

3. Learning Objectives • What is the Science of Safety? • What are the principles of safe design? • Introducing a new tool: The Fast Fact Sheet • Applying CUSP concepts and tools in the clinical area

4. CUSP for CAUTI Educate staff on the Science of Safety Identify defects Partner with senior executive Learn from defects Improve teamwork and communication Adaptive Components of CAUTI

5. Polling Question #1 Which CUSP modules/tools do you use in your clinical area? • Daily goals • Huddles • Learning from Defects • Morning briefing • Science of Safety video • Shadowing another professional • Staff safety assessment

6. How do Errors Happen? • People are fallible • Medicine is still treated as an art, not a science • Systems do not catch mistakes before they reach the patient

7. CUSP Framework http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/understand/index.html

8. Polling Question #2 Is Science of Safety training part of the orientation process in your clinical area? • Yes • No • Don’t know

9. Science of Safety in brief • Understand system factors determine performance and safety is a property of the system • Use strategies to improve system performance • Recognize teams make wise decisions with diverse & independent input.

10. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics

11. Principles of Safe Design • Standardize when possible • Create independent checks for key processes • Learn from mistakes

12. The Wisdom of Crowds • Teams make wise decisions with diverse and independent input.

13. Engage Viewers of Science of Safety • Discuss events in the clinical area • What systems may have led to these events? • How can the principles of safe design be applied to prevent future events? • How can staff, and others in the clinical area, improve communication? • How can these concepts be applied in the CAUTI project?

14. Science of Improving Patient Safety Fast Fact Sheet: CUSP for CAUTI • Briefly summarizes the evidence for “Why this is important” • Reviews the key points to the Science of Safety and helps teams to see how they can be used • Graphic illustration of the results that can be achieved through improving teamwork and culture change (the application of CUSP) • Next steps • References

15. Applying CUSP concepts and tools in your clinical area • Learning From Defects • Interdisciplinary rounds with daily goals • Independent checks/making it easy to do the right thing • Huddles

16. Learn from Defects: Take Time to Discuss • What happened? • Why did it happen? What factors contributed? What prevented it from being worse? • What can we do to reduce the risk of it recurring with different staff? • How will we know the risk was reduced? • With whom should we share learning?

17. LFD: Who Should Use This Tool? • Anyone who can pull together a group of care givers or staff to discuss a defect or system failure can use this tool. • Ideally, all staff involved in a defect or problem should be present when the defect is evaluated. However, a small group of five to six people is most practical. • Learning From Defects also can be used in huddles or during a more brief problem solving opportunity. (ie, post fall or new skin injury) • Use of this tool supports a unit’s/department’s ability to “learn how”

18. Learning From Defects Introductory Script When leading a Learning From Defects exercise, start by reminding the group of the points below. • Health care complexity: Health care is very complex. We all know perfection is not possible, and we need to increase the extent to which we learn from our defects and problems. • What is a Defect? A defect is any clinical or operational event or situation you would not want to happen again. These could include incidents that may put patients at risk or simply an operational failure or problem that caused waste or rework for staff. (eg, medication problem, equipment problem, billing problem, etc.) • Purpose of Learning From Defects Tool: The purpose of this tool is to provide a structured approach to help staff identify the types of systems that contributed to a defect or problem and follow up to ensure safety and operational improvements are achieved.

19. LFD: How to Use this Tool Use this tool on at least one defect per month. Start by identifying a defect or problem through one of the following ways: Ask: How is the next patient going to be harmed? A concern shared by a patient or family member Other issues/problems/risks identified in your area. Patient safety rounds Defects identified in huddles Employee concerns Problems entered in VOICE Problems with equipment or supplies Infection control issue

20. LFD: What Follow-up Is Required? • The Learning From Defects discussion should identify some changes or counter measures to reduce the risk of recurrence. • Someone should be identified as the lead person for each follow-up action. Also include a timeline for completion. • What about the completed form? Retention of the completed form is up to the unit/department. Many units are keeping them in their huddle communication books.

21. Learning From Defects Tool

22. Polling Question #3 How often are you doing a LFD in your unit? • Once per quarter • Once per month • Multiple times per month • Haven’t done it yet

23. Case in point: Catheter related blood stream infection prevention best practices have been in place since August 2004. There have been minimal infections in most of the intensive care units since implementation. Though SICU’s total incidence of BSIs dropped by more than 60 percent, SICU continued to have one to two infections per month. It was decided to take a deeper look at potential causes. Ninety percent of all central lines in SICU are placed in the OR, and 10 percent are placed in SICU, yet half of all infected lines came from those placed in the SICU. Opportunities for Improvement: System Failures Educate RN regarding use of maximal barrier precautions during slick catheter insertion RN lack of knowledge related to slick catheters Formalized twice-per-day stocking Line cart stocking process Educate residents regarding use of vein finder; recommend increased resident mentorship during line insertion Skill of residents • ACTIONS TAKEN TO PREVENT HARM • Re-educate nursing staff regarding use of maximal barrier precautions during slick catheter insertion • Reformat BSI checklist to ensure it is in proper sequence of how the procedure should be done • Provide education to staff on surgical asepsis • Order vein finder to assist with central line placement • Provide feedback from resident survey and chart review to medical and nursing leadership • Display case summary tool in all ICUs for shared learning

24. Learn From Defects Tool

25. Principles of Safe Design • Learn from mistakes - just talked about this with application of the LFD tool • Standardize when possible • Create independent checks for key processes

26. Interdisciplinary Rounds with Daily Goals: What is it? • A strategy to assemble the patient care team members to review important patient care and safety issues and improve collaboration on the overall plan of care for the patient • Improve communication among care team and family members regarding a patient’s plan of care • Goals should be specific and measurable • Documented where all care team members have access • Checklist used during rounds prompts caregivers to focus on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU or discharge home • Measure effectiveness of rounds—team dynamics, communication, quality measure compliance, LOS

27. Standardize IDR with Daily Goals • Members and their roles • Time of day • Frequency • Process for each patient (include script for each member) • Checklist • Documenting • Which pieces of rounds? • Daily goal • Define daily goal follow-up process

28. Physician (resident) Rounding Card

29. Nursing Objective Card Standardized Process and Independent Checks Pain, Agitation and Delirium VAP Mobility SEPSIS CAUTI/CLABSI

30. Independent Check:Sepsis Pathway 30

31. Tools make it easy to do the right thing Pocket cards, posters

32. Huddles: Definition and Purpose • “Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.” (IHI) • “A tool for reinforcing the plans already in place for the treatment of patients and for assessing the need to change plans.” (TeamSTEPPS) • Provide team members with an opportunity to update each other on emerging or significant changes in the status of the environment so all team members can adapt appropriately

33. Huddles: Definition and Purpose • Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hourlongimprovement team meetings. • They keep momentum going, as teams are able to meet more frequently. • “Safety Briefings are a simple, easy-to-use tool that front-line staff can use to share information about potential safety problems and concerns on a daily basis.” (IHI, 2004)

34. High Reliability Organizations • High Reliability: consistent performance at high levels of safety over long periods of time • Possess “Collective mindfulness” • Everyone who works in the organization (individually and together) is aware of even small failures in protocols or processes can lead to catastrophic adverse events if action is not taken to solve the problem • Other features • Eliminate deficiencies in safety processes by using tools to improve processes • Create an organizational culture that focuses on safety, remaining constantly aware of the possibility of failure Chassin MR and Lobe JM. “The Ongoing Quality Improvement Journey: Next Stop, High Reliability.” Health Affairs 2011 Apr;30(4):559-68.

35. Polling Question #4 Have you implemented any type of huddles at your organization? • Organizational • Unit-based • After an event • None of these yet

36. Huddle Practices • Types • Organizational • Unit • After an event • Format • Defined time • Inclusive of all staff, disciplines • Agenda • Stand-up • Brief – try limiting to 15 minutes for unit huddles • Mandatory attendance (?) • Huddle board

37. Components Metric 1: Quality/Safety Metric 2: Patient satisfaction Metric 3: Operations • Daily critical communications • Information • Ideas in Motion How to do it? • Beginning or mid-shift • 5 minutes • Lead by member of unit leadership team

38. SICU Huddle Board

39. General Surgery Huddle Board

40. Next Steps • Train your clinical area staff on the Science of Safety • Share the Science of Safety Fast Fact Sheet with your clinical area staff • Complete at least one Learn From Defect exercise per month • Explore use of huddles as a tool to improve communication, teamwork and situational awareness within your unit • Review your unit’s current IDR process—have you applied the principles of safe design?

41. Thank you! Questions for our presenters? Press *1 to ask a question

42. Your Feedback is Important Thank you for participating in today’s call. Please take a moment to fill out this evaluation: https://www.surveymonkey.com/s/CAUTI_Content

43. Upcoming National Content Webinars

44. November National Content Webinar What to do when it’s time for Plan B Sanjay Saint, MD, MPH George Dock Collegiate Professor of Internal Medicine Division of General Medicine University of Michigan Health Systems Associate Chief of Medicine, Ann Arbor VA Medical Center Sarah Krein, PhD, RN Research Associate Professor, Division of General Medicine Department of Internal Medicine University of Michigan, Ann Arbor Kathlyn Fletcher, MD, MA Associate Professor, Medicine Medical College of Wisconsin