1. Using Lean Six Sigma approach to reduce Central Line associated Bloodstream Infections at Hammoud Hospital University Medical Center
Ibrahim Zeid,PhD,MPH,MBBSS
Chief Quality Officer
Hammoud Hospital University Medical Center
Lebanon

2. Why Target Elimination of HAI?

3. Potential Model for Prevention of CLABSI Using a System Framework
Hammoud Hospital Value Stream Analysis – using principles of LEAN engineering aligned with a Six Sigma DMAIC (define, measure, analyze, improve, control) framework to
map out,
analyze,
redesign
and sustain
a more efficient, defect-free experience for the patient with a central line …and to eliminate CLABSI

4. Lean Management philosophy based on 2 key themes Key principles
Continuous elimination of waste
Respect for people and society
Key principles
Value is in the eyes of the customer
Make value flow without interuptions
Improve work flow
Standardize work processes
Pursue perfection

5. Lean
Culture
Stop and fix the problem as soon as it is identified
Toyota manufacturing culture
Process
Measure
Change
Change…..

6. Six Sigma Focus is to eliminate defects
Nonconformity of a product or service to its specifications
Six sigma processes have variation that result in <3.4 parts/million defects

7. Why Zero Defects is the Only Acceptable Quality Standard
At 99.9% quality levels in a 250 bed hospital
12 inpatients per year would die due to errors
6 day surgery patients would die
9,742 wrong medications would be delivered
4,923 incorrect laboratory tests would be reported
502 incorrect radiographs would be completed

8. What are the benefits of using Lean Six Sigma?
Organizations face rising costs and increasing competition every day.
Lean Six Sigma allows you to combat these problems and grow your business the following ways

9. How does Lean Six Sigma work?

11. Hammoud Hospital Value Stream Analysis – using principles of LEAN engineering aligned with a Six Sigma DMAIC

12. Background
Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable (CDC, 2016)
15 million central venous catheter-days per year in ICUs
Attributable mortality for these infections %
Bloodstream infections prolong hospitalization by a mean of 7 days 

13. Background
Central line-associated bloodstream infection prevention programs have shown great success in the intensive care units (ICUs).
Infection rates related to CLABSIs have been reported from various hospitals to the National Healthcare Surveillance Network ranging from 0.2 to 4.2 infections per 1,000 catheter days, showing a 38% decrease. Even though the infection rates have decreased, they still happen (Sons et al., 2012).

14. RIGHT THING TO DO FOR PATIENT SAFETY!!
Define Phase
PROBLEM STATEMENT:
CLABSI at HHUMC are preventable and are associated with increased morbidity and mortality , increased lengths of stay and increased costs.
Six Thousands central venous catheter-days per year in ICUs
CLABSI attributable mortality rate is 37.5%
Bloodstream infections prolong hospitalization by a mean of days 
Bloodstream infections cost an excess of $ 119,085 and excess LOS = days
Medical Insurance no longer pays excess costs
RIGHT THING TO DO FOR PATIENT SAFETY!!

15. Define Phase GOAL: By December 2015:
Reduce the CLABSI rate by ZERO percent
Improve Patient and family satisfaction
Setting the stage
SCOPE:
All inpatients older than 17 years, system-wide, who had a positive blood culture within 48 hours of admission or re-admission within 2 weeks with a confirmed CVC-related BSI based on the CDC definition. Patients with BSI secondary to tunneled lines, port line, dialysis lines, peripherally inserted central catheter (PICC) lines, or peripheral lines were excluded

16. Define Phase
An anonymous survey was administered to the medical caregivers patients whose Patient required a central venous catheter during their ICU stay.
The survey results demonstrated that staff perceive dressing as the most important aspect of central line care

17. Measure
We reviewed the charts of all patients who experienced a CLABSI in 2014
The pre-intervention CLA-BSI incidence was per 1000-Catheter days
Coagulase-negative staphylococci was the most prevalent pathogen (35.3%) and Staphylococcus aureus (22.2%)

18. Measure

20. Measure Total Extra Cost of this Period of All Patients with CLABSI 17
Number of patients with this condition
Average cost per each patient with this condition in USD
Average extra cost per each patient with this condition in USD
Total extra cost of all patients with this condition in USD 17
9875
7005
119,085
Total Extra Occupied Bed Days of this Period
Average length of stay per each patient with this condition
Average Extra length of stay per each patient with this condition
Total extra length of stay of all patients with this condition
19.75
14.01
238.17
Total Extra Deaths of this Period
Average mortality of patients with this condition
Number of patients who died with this condition
37.5%
6.3

21. Analyze
We constructed a cause and effect tree, and conducted focus groups with the nursing staff, and blind observations of routine care of central venous catheters to focus our analysis and intervention to three possible contributing factors
Drivers or Xs were identified by the team's cause-and-effect fishbone diagram.
The team used the fishbone diagram to identify the critical Xs of focus for this initiative.

22. Analyze For insertion bundle, critical Xs included
Perform hand hygiene before inserting or manipulating a catheter.
Avoid inserting catheters into femoral veins in adults unless other sites are unavailable.
Use a standardized, all-inclusive supply cart or kit for central venous catheter insertion.
Implement standardized protocol for maximum sterile barrier precautions during catheter insertion and for disinfecting catheter hubs and injection ports before accessing them.
Use a chlorhexidine-based antiseptic product to prepare the skin of patients older than age 2 months, unless contraindicated. (Povidine-iodine can be used for patients under age 2 months.) 
Assess all central venous catheters routinely and remove nonessential catheters
Bath ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis

23. Analyze
For Organizations as a part of insertion bundle, critical Xs included
Educate healthcare personnel about indications for central lines, proper procedures for insertion and maintenance and appropriate infection prevention measures.
Designate personnel who demonstrate competency for the insertion and maintenance of central lines.
Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of central lines
Provide a checklist to clinicians to ensure adherence to aseptic insertion practice
Reeducate personnel at regular intervals about central line insertion, handling and maintenance, and whenever related policies, procedures, supplies, or equipment changes
Empower staff to stop non-emergent insertion if proper procedures are not followed
Ensure efficient access to supplies for central line insertion and maintenance(i.e. create a bundle with all needed supplies)

24. Analyze Contributing Factors
Inconsistent use of an insertion checklist (Compliance rate:53%)
Inconsistent use of daily assessment of need
Poor Compliance with hand hygiene practices (67%)
Non-compliance with every step in central venous catheter care protocols.
Lack of education regarding care protocol steps and hand hygiene rules

25. Improve:
The following interventions were implemented aimed at correcting the factors identified that were likely contributing to the CLABSI
An educational campaign was conducted that focused on educating staff about the significance of CLABSIs in our unit.
It also provided education regarding proper hand hygiene techniques, maintenance care protocols for central venous catheters, and the use of Transparent dressings coated with chlorhexidine

26. Improve
Further interventions included the insertion of laminated copies of the insertion and maintenance protocols for easy reference by staff.
Finally, An element was added to the daily goals form and rounds in the unit, the need for a central venous catheter was assessed at least twice daily

27. Control

29. Future State Maintain CLABSI ZERO rate
>95% Compliance with CVC insertion and dressing change recommendations
Identify and evaluate complications related to CVC insertion (other than infection)

30. Thank you