1. Improving Care Through Technical & Adaptive Work Chris Goeschel RN MPA Director, Patient Safety &Quality Initiatives JHU Quality & Safety Research Group cgoesch1@jhmi.edu

2. Central Mandate Local Wisdom Scientifically Sound Feasible X

3. The Johns Hopkins Comprehensive Unit-based Safety Program 1.Evaluate culture of safety 2.Educate staff on science of safety 3.Identify defects 4.Assign executive to adopt unit 5.Learn from one defect per month and implement teamwork tools 6.Evaluate culturewww.safetyresearch.jhu.edu Pronovost J Patient Safety 2005

4. Creating Reliable Healthcare Identify interventions associated with improved outcomes in specified population Select strongest interventions, convert to behaviors Develop measures (either process or outcome) Ensure patients receive the intervention

5. Preventing CLABSI Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines MMWR. 2002;51 RR-10

6. Technical Challenges Can be solved with existing science or technology Issues or challenges for which there is “an answer” Amenable to centralized development

8. Adaptive Challenges Require a change of values, attitudes or beliefs Local………..respecting the wisdom of the front line worker

9. How do we need to learn?

10. Leading Change Executive LeadersTeam LeadersStaff 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 Make the World a Better Place?  How do I create a unit that is safe for patients and rewarding for staff?  How do I touch their hearts? How Do I Make the World a Better Place?  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 Do I Need to Know?  What is the evidence?  Do I have executive and medical staff support?  Are there tools to help me develop a plan? What Do I Need to Know?  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 adaptive 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? What Do I Need to Do?  Do the Staff Know the plan and do they have the skills and commitment to implement?  Have we tailored this to our environment? What Do I Need to Do?  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 technical 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? How Will I Know I Made a Difference?  Have I created a system for data collection, unit level reporting, and using data to improve?  Is the work climate better?  Are patients safer?  How do I know? How Will I Know I Made a Difference?  What is our unit level report card?  Is the unit a better place to work?  Is teamwork better?  Are patients safer?  How do I know? © Quality and Safety Research Group, Johns Hopkins University

11. Collaborative Participants Agree to use common methods for improvement Data reporting and analysis, central Collaborative learning Training, support, coaching from the collaborative sponsor & faculty Benchmarking

12. Key Concepts The purpose of data is to help understand, control, and improve processes and systems Measurement for learning and testing, not for judgment Must measure to improve

13. Safety Measures How often do we harm patients? –BSI and VAP How often do we do what we should? –Vent bundle How often do we learn from defects? –Learn from one per month How well do we improve culture? –SAQ

14. Time periodMedian CRBSI rate Incidenc e rate ratio Baseline2.81 Peri intervention 1.70.53 0-3 months00.33 4-6 months00.31 7-9 months00.2 80% Reduction in BSI in One Year 433 prevented infections 108 deaths

15. Lessons Learned Need to get technical and adaptive work right –Centralized measurement, local ownership

16. Lessons Learned Technical lessons –Link culture and specific outcomes How have you used your SAQ and clinical results? –Data quality control Does your project team include and respect expertise of technical and adaptive experts ? (Infection control, education, QI, organizational development etc?)

17. Lessons Learned Adaptive lessons –Commit that harm is untenable; make harm visible What does this look like in your clinical area? –Ohana How have you shared what you are learning with other teams in the collaborative? –Local modification of execution Have you adapted the implementation in light of your organizational culture?

18. Important Research Questions How can we improve quality improvement? Will public reporting change focus from doing good to looking good ? What degree of evidence is required to develop a process measure? How will we know we made a difference?

19. Can We Cross the Chasm ? Science demands rigor Patients deserve reliability We are capable ~ Do we have the courage?

20. Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.” Margaret Meade