National Content Call

1. National Content Call Learning From Defects October 9, 2012 Pat Posa RN, BSN, MSA Mary Fine RNBC, QMHP, SANE Malissa Reardon RN

2. Session Objectives • Discuss CUSP and Tools used to identify defects • Review and share examples of the Learn From Defects Tool • Discuss how to implement the Learn From Defects Tool into daily work • Learn how hospital team implemented the Learn From Defects Tool on their units

3. Learning From Defects Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com

4. LearningObjectives Discuss structured huddles as a mechanism to apply LFD daily Show how to apply LFD tool Review Learn from a Defect Tool (LFD) Discuss CUSP and tools to identify defects

5. It is Time to Change! • 44,00 to 98,000 preventable death in hospitals related to medical errors annually (IOM report, 1999) • 92,888 deaths directly attributable to safety indicators between 2005-2007 (HealthGrades 2009) • Failure to rescue, pressure ulcers and post-op infections • National Patient Safety Goals include prevention of HAI’s • Lack of reimbursement for preventable injury • 2013-lowest percent improvement/total Medicare cut • $50 billion in total costs for preventable injury

6. It Is Time to Change!!

7. Health Care Quality Comparison Overall Healthcare in US (RAND) Outpatient ABX for colds 1,000,000 Healthcare-associated infections (HAIs) 100,000 Hospital patients Injured through negligence Post MI β-blockers Defects per million 10,000 Airline baggage handling Detection & treatment of depression Adverse drug events 1,000 Anesthesia-related fatality rate 100 US industry best-in-class 10 Food safety 1 2 3 4 5 6 (69%) (31%) (7%) (0.6%) (0.002%) (0.00003%) 1 σ Level (% defects)

8. Gains and Opportunities • Pockets of excellence coexist with enormously variable performance across the delivery system • In 2009, hospitals on average provided life-prolonging beta-blockers to heart attack patients 98% of the time. 97% of hospitals scored above 90% on this measure • BUT: • We have eluded thus far the ability to maintain consistently high levels of safety and quality over time and across all health care services and settings • We are experiencing an epidemic of serious and preventable adverse events • Risk of harmful error in health care may be increasing as the complexity of delivering effective care increases Chassin & Loeb, Health Affairs, April 2011

9. How Do We Become Highly Reliable Organizations? • It’s a JOURNEY • Examine your current framework for achieving health care quality • 3 critical changes must take place • Leadership commitment • Must focus on the journey from low to high reliability by making it their highest priority and requiring all levels of management to do the same • Safety Culture • Frontline workers trust each other in order to feel safe to identify and report problems • When a problem is reported it will be fixed • Reported problems lead to safety improvements • Robust Process Improvement • Six Sigma, Lean and Change Management Chassin& Loeb, Health Affairs, April 2011

10. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program Keep focus on this throughout the journey!!! Pre-CUSP work • Form a unit CUSP team • Measure unit culture • Educate staff on Science of Safety • Identify defects using the Staff Safety Assessment;prioritize defects 3. Executive adopts the unit 4. Learn from one defect per quarter 5. Implement team/communication tools

11. Process Factors Variable input (diff pts) Inconsistency/variation Complexity Too many/complicated steps Human intervention Tight time constraints Hierarchical culture People Factors Why Do Mistakes Happen? • Fatigue • Inattention/distraction • Unfamiliar situations/new problem • Using past solutions • Equipment design flaws • Communications errors • Mislabeling/inadequate instructions

12. Lucien L. Leape, MD Harvard School of Public Health Medical errors most often result from a complex interplay of multiple factors. Only rarely Are they due to the carelessness or misconduct of single individuals

13. Learn From a Defect • Designed to rigorously analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences. • Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues

14. Learning from Defects: Fast Facts 1. What do I need to know? • The purpose of learning from defects in a structured way is to help this clinical area "learn how" to operationalize best practices so that they solve problems while building capacity to improve quality in the future. 2. What do I need to do? • Use brief (30 to 60 minute) defect learning discussions to explore and resolve system factors involved in the defect. Focus discussion on specific actions to reduce the likelihood of defect recurrence. 3. What should I be worried about? • Protected time to discuss monthly or in response to an event in the unit, meet in a safe place for open discussion, try to keep group size to 5 or fewer if possible. Source: Pronovost et al. Jt Comm J Qual Pt Saf 2006 Feb:32(2):102-8 Pronovost et al. Crit Care Med. 2006 Jul:34(7):1988-95 Tucker AL, et al. MANAGEMENT SCIENCE 2007 53:894-907

15. Learning from Defects 5 Questions: What happened (Brief defect description)? Why did it happen (what factors contributed +&-)?: System factors, for example: staffing, workload, equipment, production pressure, other departments, caregiver factors (training/fatigue/attitude), management support, physical environment (space/noise), failure of policy/procedure, patient condition (complexity/language) What can we do to reduce the risk of it recurring with different caregivers? How will we know the risk was reduced? With whom should we share our learning?

17. Finding Defects to Learn From • Staff feedback/issues identified on unit • Event reporting • Quality and safety measures • Gaps in application of the evidence • Have staff complete short 2 question survey

18. Key to CUSP: Comprehensive UNIT-BASED Safety ProgramStaff Safety Assessment Step 1. What are clinical or operational problems that have or could have negatively impacted patient safety? Step 2. How might the next patient be harmed in our unit? Step 3. What can be done to minimize harm or prevent safety hazards?

19. Mistakes and Near Misses are Defects • Have each ICU present learning from a defect each quarter----now doing monthly • NG placed in the lungs • Missed respiratory treatments • Delay in radiology tests for ICU pts • Non-compliance with contact precautions This is very hard to continue to do, we did it first for the first year. We didn’t keep it up----but are now doing this almost daily through our huddles, The biggest challenge is following up on each action plan giving the feedback to the staff

20. Examples of Defects or Failures That Affect Patient Safety

21. Evaluate if Risks are 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?

22. CLABSI Prevention Bundle Remove/Avoid unnecessary lines Hand hygiene Maximal barrier Chlorhexadine for skin prep Avoid femoral lines Care of lines post insertion

23. Our Expectations Weren’t Met SICU continued to have 1-2 BSI per month—inconsistent with other units Why is this happening in SICU?? SICU’s line days are greater than all the other units combined monthly Further analysis/investigation was needed

24. SICU Initial Analysis • Infection Control Department • length of time catheter in place an issue for infections: > 7days • Majority of infected catheters were Internal Jugular • Baseline information—90% of all central lines are placed in the OR • Where infected lines were placed: 50% SICU; 50% OR • Critical Care Committee • Reviewed data and recommended that the problem was related to line insertion in SICU • SICU Practice Council • Walked through the Learn from a Defect Tool

25. Learning From Defects: Four Questions

26. Section 1: What happened? Asks the users to identify what happened or the defect they want to investigate Continued CLABSI in SICU even after best practices in place

28. What will you do to reduce risk ? • Prioritize most important contributing factors and most beneficial interventions • Safe design principles • Standardize what we do • Eliminate defect • Create independent check • Make it visible • Safe design applies to technical and team work

29. What will you do to reduce risk? • Develop list of interventions • For each Intervention rate • How well the intervention solves or reduces the problem • The team belief that the intervention will be used as intended • Select top interventions (2 to 5) and develop intervention plan • Assign person, task follow up date

30. Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant

31. Resident/PA Survey Results The line cart was very helpful, but often not stocked. Felt that the nurse’s presence in the room was valuable, but not consistently happening. Additional support and training was needed for them.

32. Chart Review No excess blood products given on these patients Median blood glucose was <140 mg/dl All of the patients that had CLA-BSI had a slick catheter that had been placed by the nursing staff into an existing cordis introducer. Further discussion identified that maximal barrier precautions were not being used during slick catheter placement

33. Summarize and Share Findings • Summarize findings • 1 page summary of 4 questions • Learning from defect figure • Share within your organizations • Share de-identified with others in collaborative (pending institutional approval)

34. Safety Tip: Follow established procedure for all central lines 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 ICU units since implementation. Though SICU’s total incidence of BSIs dropped by greater than 60%, SICU continued to have 1- 2 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% are placed in SICU, yet half of all the infected lines came from those placed in the SICU. Opportunities for Improvement: System Failures Educate RN related to use of maximal barrier precautions during slick catheter insertion Lack of knowledge by RN related to slick catheters Formalized twice a day stocking Line cart stocking process Educate residents on use of vein finder, recommend increased mentorship of residents during line insertion Skill of residents • ACTIONS TAKEN TO PREVENT HARM • Re-educate nursing staff on use of maximal barrier precautions during slick catheter insertion • Reformat BSI checklist sot that 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

35. Safety Tip: Utilize the digital paging system whenever Anesthesia is needed. Case in point: There was a code blue called for a patient that had obstructed her airway secondary to swelling and secretions. Due to the patient’s difficult airway the ER physician was unable to successfully intubate the patient. Anesthesia was then paged overhead with no response. Anesthesia was in their sleep room and did not hear the overhead pages or the code blue. They were contacted by calling the room directly and they came down and fiber-optically intubated the patient. The problem identified in this case is that there was a delay in intubation with a potential for an adverse outcome. System Failures Opportunities for Improvement: Utilize digital paging for contacting Anesthesia. Overhead paging of Anesthesia. ER will bring cart to all code blues. Airway cart not available in CCU Anesthesia beepers not readily available, Current beeper numbers posted at each phone. • ACTIONS TAKEN TO PREVENT HARM • Paging operator will now page Anesthesia and the supervisor in the event of a code blue. • ER staff will now bring airway cart to all code blues. • All dead zones will be evaluated. • Overhead paging will be added to the sleep room. • Current list of pager numbers posted by each phone. • Communication to nurses on the need to digitally page Anesthesia when needed. • Current call list and beeper numbers will be provided by Anesthesia.

36. 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.

37. How Do I Implement Learning From Defects? • Identify a protected time to do this: during a monthly meeting, scheduled separately, during huddles • Call upon a coach or experienced peer to walk you through it the first time • Remember to apply this to local defects, issues you have ability to solve or address • Read you hang tag and go for it

38. Huddles Enable teams to have frequent but short briefings so they can stay informed, review work, make plans, and move ahead rapidly. Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings. They keep momentum going, as teams are able to meet more frequently. Use this strategy to begin to recover immediately from defects---IE: falls, sepsis. Use daily to focus on unit outcomes

39. Huddles Components: • Metric 1: Quality and 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

40. SICU Huddle Board

41. Surgical Unit Huddle Board

42. Medical Unit Huddle Board

43. “Quality is never an accident. It represents the wise choice of many alternatives.” “ Willa Foster

44. Implementing the Learn From Defects Tool and Process Mary Fine RNBC, QMHP, SANE Director of Quality, Ozarks Medical Center mary.fine@ozarksmedicalcenter.com Malissa Reardon RN ICU Nurse Manager, Ozarks Medical Center Malissa.reardon@ozarksmedicalcenter.com

45. Ozarks Medical Center • 114 bed community hospital with 21 outlying clinics • ICU CUSP team • 2N (surgical inpatient unit) CUSP team • 7 nursing units implemented CUSP communication and teamwork tools • Outpatient Surgery/GI CUSP team • Beginning 2S (med-surg) CUSP team

46. Ozarks Medical Center:Our Story of CUSP Implementation • Chose our ICU- 12 bed open unit • Began with CUSP kick off- 2hrs • Josie King video • Brief power point with CUSP overview • Science of Safety video by Dr Provonost (Kick off includes all team members that was selected) • Front line unit leaders present power point and Josie King to peers • Time is assigned to watch science of safety and attendance is recorded by completion of the staff safety assessment tool • Learning from defect is chosen from results • Then began rolling out to other floors

47. Ozarks Medical Center:Learning from Defects (LFD) ICU • Physician orders post surgery • Communication between floors with transfers • CLABSI • Pressure Ulcers • CAUTI

48. First LFD-Medications • Chosen from staff survey results • Was too broad • The tool was confusing for staff on negative or positively contributed to the event • Needed our physician sponsor • Physicians wanted precise summary

49. Tool Customized • II. Why could it happen? Why did it happen? Below is a framework to help you review and evaluate your case. Please read each contributing factor and evaluate whether it was involved. If so, did it contribute to the incident? Rate the most important contributing factors that relate to this event.

50. Physician Summary • Listed scenario • Listed System Failures (from LFD tool) with opportunities for improvement • Listed actions taken to prevent harm