1. Improving ICU Care Through Teamwork
Chris Goeschel RN MPA MPS

2. x Central Mandate Scientifically Sound Feasible Local Wisdom
Safety efforts are where the x is. We need to migrate to be more scientifically sound and tap into local wisdom

3. Can One Institution Get to Zero?
VAD Policy
Line Cart
Checklist
Daily Goals
Empower Nursing
Johns Hopkins is a learning lab to improve patient safety. We reduced infections at hopkins, packaged the intervention and offered it broadly.
Berenholtz et al. Crit Care Med. 2004;32:2014.

4. Project funded by the Agency for Healthcare Research and Quality
Can A State ?
Project funded by the Agency for Healthcare Research and Quality

5. Context Have we created a culture of safety?
Conceptual model for measuring safety
Structure
Process
Outcome
Have we reduced the likelihood of harm?
How often do we harm?
How often do we do what we are supposed to? IT
Context
Have we created a culture of safety?
Adapted from Donebedian

6. The Teams
Research Team from Hopkins provides evidence and interventions, data analysis and face to face time with teams
Keystone Team from MHA coordinates project (enrollment, data collection and management, conference calls and meetings)
Teams from each ICU Implement Interventions and report data. Senior leaders serve as members of each ICU team

7. Goals Work to eliminate CLABSI
Ensure 90% of ventilated patients receive evidence-based interventions
Learn from 2 defects a quarter
One local one central
Improve culture by 50%
Improve quality improvement

8. Comprehensive Unit-based Safety Program (CUSP)
Evaluate culture of safety
Educate staff on science of safety
Identify defects
Executive partnership/ adopt a unit
Learn from one defect per month; implement teamwork and clinical improvement tools;
Re-Evaluate culture
Pronovost J, Patient Safety, 2005

9. 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 adaptivework.
I have found that there are three key components to understanding the science of safety
Understand that the system determines performance.

10. Learning from Mistakes
What happened?
Why did it happen (system lenses)
What could you do to reduce risk
How to you know risk was reduced
Create policy/process/procedure
Ensure staff know policy
Evaluate if policy is used correctly
Pronovost 2005 JCJQI

11. Interventions to prevent Blood Stream Infections: 5 Key “Best Practices”
Remove Unnecessary Lines
Wash Hands Prior to Procedure
Use Maximal Barrier Precautions
Clean Skin with Chlorhexidine
Avoid Femoral Lines
I want to highlight 5 strategies specifically because they are well supported by the evidence. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. we should use MBP during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over IJ or femoral sites.
The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whether you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one and I would be happy to share with you our approach. What about hand washing?
MMWR. 2002;51:RR-10

12. Teamwork Tools Team Checkup Tool Daily Goals AM briefing Shadowing
Culture check up tool
Executive briefings
Safety Scorecard
Pronovost JCC, JCJQI

13. Safety Scorecard System Hospital Unit
How often did we harm? (infections)
How often do we do what we should? (JCAHO, ventilator bundle)
How do we know we learned from mistakes? (sentinel events, near misses, NQF never events)
% Need improvement in
Safety climate
Teamwork climate (SAQ)
This is our model to answer the tough question. Are we safer.
Pronovost JAMA 2006

14. How does this make the world a better place?
Framework for Change
Senior
leaders
Team
Staff
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
How can we do it with my resources and culture? What barriers must we overcome?
Evaluate
How do we know we improved safety?
This is the model we used for learning change. It recognizes the technical (science) part and the adaptive (emotional attitudes part.
Engaging people is adaptive work done locally by telling stories and showing current evidence of harm
Educate is technical. What is the evidence
Execute is adaptive and local. Given my resources, how do I ensure all patients reliably receive the evidence
Evaluate is technical. We have to measure in a scientifically sound way
Pronovost: Health Services Research 2006

15. Ideas for ensuring patients receive the interventions
Engage: stories, show baseline data
Transparency throughout project
Educate staff on evidence
Execute
Create line cart
Create BSI checklist
Empower nurses to stop takeoff
Evaluate
Feedback performance
View infections as defects
Feedback performance many ICUs posted graphs of number of weeks without infection

16. Safety Climate Across Michigan ICUs
% of respondents within an ICU reporting good safety climate
Resutls. This shows the improvement in safety culture across Michigan ICUs This is the first time, in any industry, to demonstrate on a large scale that culture is responsive to interventions.

17. Teamwork Climate Across Michigan ICUs
% of respondents within an ICU reporting good teamwork climate

18. 2 year results from 103 ICUs Pronovost NEJM 2006 Time period
Median CRBSI rate
Incidence rate ratio
Baseline
2.7 1
Peri intervention
1.6
076
0-3 months
0.62
4-6 months
0.56
7-9 months
0.47
10-12 months
0.42
13-15 months
0.37
16-18 months
0.34
From over 103 ICUs, we reduced the bsi rate to 0 for nearly two years after the interventions.
Pronovost NEJM 2006

19. Keystone ICU Safety Dashboard
2004
2006
How often did we harm
2.8/1000
How often do we do what we should
66%
95%
How often did we learn
100s
% Needs improvement in Safety climate
Teamwork climate
84%
82%
41%
47%

20. The Team Connections Ohana Harm is Untenable Valid measures
Rigorous data collection and evaluation
Patients as the North Star