Identifying Defects Chris Goeschel June 2009

Identifying Defects What DO you know? What SHOULD you know?

On the CUSP: Stop BSI CUSP 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools CLABSI 1.Remove Unnecessary Lines 2.Wash Hands Prior to Procedure 3.Use Maximal Barrier Precautions 4.Clean Skin with Chlorhexidine 5.Avoid Femoral Lines 3

Comprehensive Unit-based Safety Program (CUSP) 1. Educate staff on science of safety ( 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools We are here You are here!!!

The CUSP Team The smaller group that spreads the intervention to the rest of the unit

Education and engagement activities on the unit Modeling the line placement steps; stopping insertions that violate protocol; having one-on-one talks where necessary Facilitating CUSP Activities

Team Effectiveness Inputs Environment Hospital & Unit Context Team Composition Task Design Processes Inside Team Outside Team Team Traits Outputs Performance Attitudes Behaviors

Team composition Size Multidisciplinary representation Having a team leader Having a champion Someone gregarious Someone detail-oriented Everyone dedicated

Transparency Making project and progress visible to everyone

How are We Going to Harm the Next Patient? One way to make harm visible-- get staff thinking about safety and how to improve it

Step 2: Staff Identify Defects Frontline caregivers are the eyes and ears of patient safety Identify clinical or operational problems that negatively impact patient safety (have or could) ICU managers and team review suggestions, set the agenda for discussion with executive partner Use the Staff Safety Assessment form (Part of CUSP manual, ) –How will the next patient will be harmed in our unit –What can be done to minimize patient harm or prevent this safety hazard

Please describe how you think the next patient in your unit/clinical area will be harmed. Name: Job Category: Date: Unit: Please describe what you think can be done to prevent or minimize this harm. Return this form to your project leader Thank you for helping improve safety in your workplace! Staff Safety Assessment - CUSP

Step 2: Staff Identify Defects What you need to do: Hand out a Staff Safety Assessment form to all staff, clinical and non-clinical, in the unit Establish a collection box or envelope Identify and group common defects (such as communication, medications, patient falls, supplies, etc.) Summarize as frequencies (i.e., what percent of responses were for communication)

Step 2: Staff Identify Defects Report the identified defects to staff, executive partner ICU managers and QI team prioritize defects identified by the potential level of risk to the patient Select one to work on with support of Executive Step 2 should be ongoing

Transparency Make harm visible to unit staff –Share stories –Discuss your baseline/ current BSI rates –Link to patients Need to share data –With team, unit, executive partner, Board –Verbal report at meetings (huddles, energizers, committee meetings) –Posters on unit in non-public areas –Written report (regular s or newsletters on project and progress)

Transparency Track progress visibly –Bulletin boards –Memos (add a sidebar to a regular newsletter?) –Announcements at meetings –Powerpoint with time since last infection (or trend line over time) –Pictures of full barrier precautions (patient, MD and person assisting) Frequent reminders, keep in the front of caregivers’ minds Executive is visible--visits often, engages staff Demonstrate that issues raised are addressed

Team activities-keeping on track Team meetings (recommend monthly) Review of data (monthly) Meet w/ Exec Partner (monthly or more) Executive review of data (monthly) Presentations to hospital colleagues –(leadership, frontline staff, board)

Education and engagement activities on the unit More Activities (add your ideas!) –Internal seminar for staff –Present project at all committee meetings –Make BSI prevention part of a skills fair –Have IC visit/ give a talk –In-services/ demos –New written policy –Post the steps somewhere –Put the prevention practices on all clipboards –Update/ prepare line cart/ kit with checklist –Hand out Fast Facts one-page info sheet

On The CUSP Stop BSI Technical CVC Insertion CVC Line Cart 1. Contents inventory Evidence based BSI prevention (hands, site, skin prep, barrier, removal) 1. Presentation of evidence 2. CLABSI factsheet 3. Insertion checklist 4. Vascular access quiz 5. Vascular access manual/ policy 6.Annotated bibliography CVC Management 1. Daily goals 2. Dressing change 3. Vascular access manual/ policy protocol Adaptive (CUSP) Science of Safety Training 1. Video of Sorrell King 2. Science of safety presentation 3. Attendance sheet Staff Identify Defects 1. Staff safety assessment form 2. Indentifying hazards presentation Senior Executive Partnership Briefings Learning from Defects LFD toolkit Implement Tools for Teamwork and Communication 1. Daily goals 2. Shadowing 3. AM briefing 4. Call list 6. Team check up tool Assemble a safety team, Partner with a senior executive; Baseline Data Exposure Survey and Technology Survey

What Should you do NOW? 1)Baseline/Monthly BSI data 2)Rejuvenate/Start Team meetings 3)Monthly Team checklist 4)Science of Safety Training for all staff 5)Identify Defects: How will patients be harmed? 6)Data Review/Action Planning 7)Post the Plan….Celebrate Accountability