NICU CLABSI Affinity Group Meeting May 9, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

Learning Objectives Discuss successful strategies being used by the NCABSI collaborative to reduce CLABSI in NICU. Describe how you can join the Community of Practice for the collaborative. Outline the first steps that you will take to begin to reduce CLABSI in your NICU. Identify the action steps your team should complete before the June meeting.

Goals Achievement of HAI goals: Reducing health care acquired infections by 40% CLABSI: <1/1000 central line days

Learning Network Expectations and Responsibilities Responsibilities of Participating Teams Pre-work activities Attend Learning Sessions Complete action items Communicate regularly with team Participate on conference calls Track and report on data measures Initiate, maintain and evaluate the change processes Share successes Steal shamelessly and share relentlessly!

How Will This Collaborative Work? Meeting format What needs do you have? How would you like to move forward – separate or parallel HAI collaborative?

Improvement Model – Rapid Cycle What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? AIM MEASURES CHANGES

CUSP Model On The CUSP Adaptive (CUSP) Assemble a CUSP team, Technical – Practices to Prevent Harm Evidence Based Practice 1. Evaluation 2. Systems Analysis 3. Process Development Education on the Evidence 1. Presentation of evidence 2. Fact Sheet 3. Cost Estimator 4. Summary of Professional Organization Recommendations 5. Annotated bibliography Implementation/ Sustaining 1.Checklist 2.Policy / Procedures 3. Protocol s 4. Monitoring 6. Feedback Adaptive (CUSP) Science of Safety 1. Science of Safety presentation 2. Attendance sheet Staff Identify Defects 1.Staff Safety Assessment form 2.Identifying Hazards presentation Senior Executive Partnership 1. Education 2. Briefings Learning from Defects 1. LFD toolkit 2.RCA of each incidence Implement Tools for Teamwork and Communication 1. Daily Goals 2. Shadowing 3. AM Briefing 4. Call List 5. Team Check Up tool 6. TeamSTEPPS Tools Assemble a CUSP team, Partner with a Senior Executive; Baseline Data Quality Improvement Tools 1. PDCA 2. Lean/Six Sigma 3. Reliable System Process 4. TCAB 5. Other CUSP Model

Five Phases of Improvement Project Identification Diagnostic Interventions Impact & Implementation Sustaining

Phase One – Project Identification Decide on the process that needs improving Form a team Write an aim Select methodology scientific approach Determine measures

Phase Two - Diagnostic How? See it! Feel it! Organize it! Do it! Voice of the Patient / Individual Process Flow Root Cause Analysis Brainstorm Organize it! Cause & Effect diagram Pareto Charts Run Charts What works for your organization? See it! Feel it! Do it!

Team Development Stage 1 of initial team development is to gain acceptance and to build trust Stage 2 is to function effectively Stage 3 is to improve function and work in concert Stage 4 is to sustain the gain and to spread the improvement

Choosing Your Team Is Key First – Engage a Senior Leader who will help champion and support team Must have all who are involved in the process present Unit based teams which include staff level leaders are most effective Unit opinion leaders should be on the team Diverse opinions enriches team Physician champion

Teamwork Form your team with an appreciation of the importance of WHO is on the team Carefully plan HOW you will act as a unified group Do a “pre-mortem” assessment—if this project were to fail, why would it? What could the QI team have done to prevent failure?

Conduct Productive Meetings Teams should meet regularly to maintain momentum and complete objectives Periodically evaluate team meetings to improve effectiveness Keep minutes of team meetings Spread the improvement

Process and Outcome Measures Process Measures Will use current sources and submitted data Adherence to Bundles, Checklist, Utilization Criteria Will be submitted via electronic survey Numerator and denominator data Device Utilization Ratios NHSN

Outcome Measures Infection Rates GHA Group in NHSN Confer rights to so GHAREF can download data Peer protection No patient identified data will be used or accessed If not using NHSN need to begin to use Will use baseline data from 2011 or most current when rights conferred Will also look at state SIR data

Next Steps: To be completed by June 13 Meeting Assess your internal baseline data Prioritize improvement Define goal/aim for reduction Meet with your Senior Executive champion Develop your team Conduct first team meeting Use the Pre-Implementation Checklist to assist you in beginning your work Complete the webinar evaluation by May 15

Denise Flook dflook@gha.org. 770-249-4518 Contact Information Denise Flook dflook@gha.org. 770-249-4518