Michigan’s Keystone ICU Project: An exemplar Chris Goeschel RN MPS MPS Johns Hopkins Quality and Safety Research Group

Consider in the end at the beginning: Are the citizens of Michigan less likely to harmed? How will we know ?

State wide effort to improve ICU care in Michigan Funded by AHRQ

Michigan: Facts Total Population: 10,120,860 (8). 2000 percent population 18 and over: 73.9; 65 and over: 12.3; median age: 35.5. Major Industries - car manufacturing, farming (corn, soybeans, wheat), timber, fishing 10,083 inland lakes and 3,288 mi of Great Lakes shoreline (most registered boaters in the US) 138 acute care hospitals (not all with ICU’s) 3 beds to 1500 beds

Keystone ICU The aim was to use evidence-based tools to improve quality and patient safety in Michigan intensive care units.

Goals of Keystone ICU Reduce harm: BSI and VAP Ensure 90% of patients receive EB interventions for preventing VAP, Learn from one defect per month Improve culture of safety 20% (SAQ) Improve quality improvement

Collaborative Process Written Commitment to Participate & Provide Resources to do the work Senior Leader as part of ICU Team Bi-weekly or Monthly Calls: Collaborative Leaders, Teams, Hopkins Content, Coaching and Team Sharing Monthly Standardized Web based Data Collection Transparency at local level “Harm is Untenable”

Comprehensive Unit-based Safety Program (CUSP) Evaluate culture of safety Educate staff on science of safety http://www.jhsph.edu/ctlt/training/patient_safety.html Identify defects Assign executive to partner with the unit Learn from one defect per month and implement teamwork tools; daily goals, a.m. briefing, culture checkup Evaluate culture www.safetyresearch.jhu.edu Pronovost J, Patient Safety, 2005

Interventions to prevent Central Line Blood Stream Infections: 5 Key Behaviors Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines I want to highlight 5 startgeies specifically because they are well supported by the evdience. 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 whther 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

ACTIONS TAKEN TO PREVENT HARM IN THIS CASE Safety Tips: Label devices that work together to complete a procedure Rule: stock together devices need to complete a task CASE IN POINT: An African American male ≥ 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that Matched the pacing wire was not stocked in this ICU since transvenous pacing wires are used infrequently. The wire was threaded and placed in the ventricle and staff Soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no Possibility for removal at that time. To reduce the patient’s risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape. SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT: Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath. Regular training and education, even if infrequently used, of all devices and equipment. Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity. Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together. Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire. Label wires and sheaths noting the appropriate partner for this device. ACTIONS TAKEN TO PREVENT HARM IN THIS CASE The bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together.

Slowing our progress

Insufficient Leadership Support

Leading Change One of most common leadership mistakes is expecting technical solutions to solve adaptive problems…. Ron Heifetz “Leadership without Easy Answers

Creating Reliable Health care Executive Leaders Team Leaders Staff Engage adaptive How Do I Make the World a Better Place? How do I create an organization that is safe for patients and rewarding for staff? How does this strategy fit our mission? How do I create a unit that is safe for patients and rewarding for staff? How do I touch their hearts? Do I believe I can change the world, starting with my unit? Can I help make my unit safer for patients and a better place to work? Educate technical What Do I Need to Know? What is the business case? How do I engage the Board and Medical Staff? How can I monitor progress? What is the evidence? Do I have executive and medical staff support? Are there tools to help me develop a plan? Why is this change important? How are patient outcomes likely to improve? How does my daily work need to change? Where do I go for support? Execute What Do I Need to Do? Do the Board and Medical Staff support the plan and have the skills and vision to implement? How do I know the team has sufficient resources, incentives and organizational support? Do the Staff Know the plan and do they have the skills and commitment to implement? Have we tailored this to our environment? Can I be a better team member and team leader? How can I share what I know to make care better? Am I learning from defects? Evaluate How Will I Know I Made a Difference? Have resources been allocated to collect and use safety data? Is the work climate better? Are patients safer? How do I know? Have I created a system for data collection, unit level reporting, and using data to improve? What is our unit level report card? Is the unit a better place to work? Is teamwork better? © Quality and Safety Research Group, Johns Hopkins University

JHU Toolkits to Assist Teams Engage (local work) Opportunity calculator, stories of harm Educate (central work) Original papers, fact sheet, slides Execute (local work) Standardize, create independent checks, learn Evaluate (central work) Web based data reports

Safety Scorecard State Hospital ICU How often did we harm? ( rate based measure: infections) How often do we do what we should? rate based (JCAHO, CMS, vent bundle) How do we know we learned from mistakes? (sentinel events, NQF Safe practices) Are We Improving Culture?

80% Reduction in BSI in One Year from 103 ICU Time period Median CRBSI rate Incidence rate ratio Baseline 2.7 1 Peri intervention 1.6 0.76 0-3 months 0.62 10-12 months 0.42 16-18 months 0.34 Data from 100 ICUs Analysis: multilevel GLLAMM

Safety Climate Across Michigan ICUs   % of respondents within an ICU reporting good safety climate

Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate   No BSI 21% No BSI 44% No BSI 31% No BSI = 6 months or more w/ zero

Develop an Eye for the Unexpected

RN Turnover and Teamwork Climate: 26 Keystone ICUs reporting 1 # RNs who left the ICU r=-.650, <.001 # leaving indicates both terminations and transfers within the organzation # indicates warm bodies, not FTEs

In Hindsight, the Successful KICU Project Looks Easy Impression: In Hindsight, the Successful KICU Project Looks Easy

FACT: Participants Say These Results Never Would Have Been Achieved Without the Johns Hopkins Keystone ICU Collaborative Why is That??

CLIP

Our Experience: Factors for Success Use evidence-based tools Pilot – Input from frontline staff is key Make sure tools are practical Treat the project like a clinical trial Involve frontline staff in the initiative– ownership AND provide feedback

Our Experience: Factors for Success Project goals must drive measurement Care most about patient level goals; others are predictor variables Design data collection and management plan at outset Reduce bias in data collection Give up on quantity not quality of data Central Development/ local implementation Strive for scientifically sound, feasible, useable

Our Experience: Factors for Success Adaptive lessons Commit that harm is untenable; make harm visible What are CLABSI rates? Do all clinical caregivers know them? Ohana How have you shared what you are learning with others? Administrators, clinicians, teams, facilities? Local modification of execution Have you adapted the implementation in light of your organizational culture?

Our Experience: Factors for Success Leadership Engagement Regional Collaborative Leaders Hospital Executive/Administration Clinicians Ownership The teams and staff must own the project Collaborative “Virtual Learning Community” OHANA