Sepsis and Defect Analysis Roger Resar, Senior Fellow, IHI Thursday, December

Session Objectives Learn a methodology that surfaces and scopes improvements in a complex process design (sepsis) Learn how to engage both the leadership and frontline in a ground up improvement work Develop the skill to utilize minimal (data, persons, time and meetings) resources P2P2

Assumptions I have Made You have formed a team A protocol has been designed by the team for implementation of the bundle guidelines in the affected departments Some early testing has been started P3P3

Sepsis 3 Hour Bundle Measure Lactate level Obtain blood cultures prior to administration of antibiotics Administer broad-spectrum antibiotics Administer 30mL/Kg crystalloid for hypotension or lactate >4 P4P4

Sepsis Bundle 6 Hour Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP)>65 mm Hg In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate> 4 mmol/L (36mg/dL): Measure central venous pressure Measure central venous oxygen saturation Remeasure lactate if initial lactate was elevated P5P5

Facts of Design Complex protocols require the design of multiple processes Processes need to be designed by the frontline that will be using the process or little chance of success let alone sustaining the process will be enjoyed Process design needs to have clearly articulated standard work (who, when, where, what, how and with what) P6P6

Team and the Dyad The team sets the overall goals and designs a protocol based on science (what we want to do and accomplish) The frontline designs the standard work of how are we going to actually accomplish this while still doing everything else they have to do It means rethinking the role of the frontline as a resource to actually do the design rather than a passive group that will bid the teams demands P7P7

Frontline Structured Conversation Frontline Structured Conversation Frontline Defects Clinical Non-clinical Collect Data Collect Data Suggest Strategies Suggest Strategies Identify Defects Identify Defects Frontline Engagement Small Tests Leading To Project Success Frontline Defect Driven Project Design

Surface Defects Surface Defects Scope Defects Validate Select specific work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Design R ResarR Resar

The Conversation with the Frontline Organize the visit to the unit beforehand SPECIFIC DUTIES Select a mix of frontline staff (6-8) Select a small “leadership” team (From the Sepsis workgroup) Arrange for at 60 minutes of conversation Arrange for a location on the unit for the conversation

The Conversation with the Frontline STEP 1 DESIRED OUTCOME Cross-section of staff working on the unit Enough time for all staff to have an opportunity to talk A location where interruptions are minimized 11

The Conversation with the Frontline STEP 2 Have each of the participants describe how they see their role in the protocol SPECIFIC DUTIES Establish a non-threatening atmosphere Limit this part of the conversation to the first minutes Purpose of this portion is to understand the work and work environment

The Conversation with the Frontline STEP 2 DESIRED OUTCOME Trust from the frontline staff this is not about assessing personal work performance Participants who are willing to talk about the work, how they do it, and how they add value to the processes being designed 13

The Conversation with the Frontline STEP 3 Assess using “anchoring questions” SPECIFIC DUTIES Use questions like: How does our protocol fit your work day? Tell us about how it worked the last time? Were you happy about the results of using the protocol? Use these questions to learn about both clinical and non-clinical situations Center questions around identified defects where actual harm discussions are avoided but potential of harm is present Steer discussion away from solutions

The Conversation with the Frontline STEP 3 DESIRED OUTCOME Find a specific example of a defect around which you can anchor subsequent questions about frequency, type of patient involved, previous attempts to fix, or what might happen with your day if it were resolved Keep the discussion to a completely non-threatening, blame-free environment to allow for maximal information sharing Keep a simple record of the defects surfaced for further discussion at the team level 15

The Conversation with the Frontline STEP 4 DESIRED OUTCOME Generate a list of defects that the frontline has surfaced Achieve buy-in from the frontline for possible action Achieve buy-in from the questioning team as to the need for action 16

Surface Defects Surface Defects Scope Defects Validate Select specific work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Design R ResarR Resar

Scoping the Projects Team needs to decide if this is within the abilities of a Dyad to solve Team needs to give specific direction to the Dyad in regards to methodology for design of that part of the process 18

Properly Scoped The Dyad will feel comfortable working on this particular defect in the design because the new design is integral with the current work they do The solution for the defect will easily be designed within a few weeks (max 30 days) Multiple designs for multiple defects can be taking place at the same time 19

Surface Defects Surface Defects Scope Defects Validate Select specific work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Design R ResarR Resar

Advantages Projects are accomplished by a dyad No team meetings No training other than JIT No data collection other than pencil and paper Creates enthusiasm for improvement 21