CSTS: The Cardiovascular Surgical Translational Study CSTS: The Cardiovascular Surgical Translational Study

Senior Leadership of Quality and Safety Senior Leadership of Quality and Safety Initiatives in Health CareInitiatives in Health Care

Peter J. Pronovost, MD, PhDThe Armstrong Institute for Patient Safety

and Quality

Learning ObjectivesLearning Objectives

• To understand the differences between technical and adaptive work

• To understand the role of senior leaders in addressing both types of work in QI efforts

• To share tactics used successfully by senior executives and leaders to support QI

GoalsGoals

• Initially work to eliminate central line associated blood stream infections (CLABSI); state mean < 1/10000 catheter days, median 0, (then Surgical Site Infections, and finally Ventilator Associated Pneumonia).

• To improve safety culture by 50%• To learn from one defect per month• To increase Executive participation in your quality

and safety activites.

Safety Score CardSafety Score CardKeystone ICU Safety DashboardKeystone ICU Safety Dashboard

CUSP is intervention to improve these*

  2004 2006

How often did we harm (BSI) (median) 2.8/1000 0

How often do we do what we should 66% 95%

How often did we learn from mistakes* 100s 100sHave we created a safe culture% Needs improvement in

 

Safety climate* 84% 43% Teamwork climate* 82% 42%

Technical WorkTechnical Work

• Addresses problems for which the definition is clear, the potential solutions are reasonably clear, and usually require little or minimal learning

• Responsibility for implementing a solution is reasonably clear between leaders and followers.

Leadership Without Easy AnswersLeadership Without Easy Answers(Heifetz, 1994)(Heifetz, 1994)

• Leadership is

“activity to mobilize adaptive work” (p. 27).

Adaptive WorkAdaptive Work

• Addresses problems that require a change in attitudes, beliefs, and behaviors

• Involves shared responsibility for change: leaders share responsibility with organizational staff and key stakeholders.

Most Common Leadership ErrorMost Common Leadership Error

• Treating an adaptive problem as technical

The Work of Adaptive ChangeThe Work of Adaptive Change

• Determining the direction – what must change

• Determining the methods - how to change

Pronovost: Health Services Research 2006

  Senior TeamStaff

leaders leadersEngageadaptive

How does this make the world a better place?

Educatetechnical

What do we need to know?

Executeadaptive

What do we need to do?How can we do it with my resources and culture?

Evaluatetechnical

How do we know we improved safety?

Leading ChangeLeading Change

Leading ChangeLeading Change

• Is everyone clear on the goals, timelines, and mission?

• Is the necessary structure in place – people, roles, authority and responsibility?

• Are decision making, problem solving and conflict management processes clear?

• Are material resources in place – space, equipment, people, budgets (Senior Executive can help)?

• Are financial tracking mechanisms in place (CMS P4P implications)

Action Items for Senior LeadersAction Items for Senior Leaders

1. Make certain an executive is assigned to each unit and meets regularly as a member of the project team .

– let the staff know senior executives are invested and will work as hard as they do to make it a success.

2. Set clear project goals and expectations for the leaders and staff in critical care units.

– Provide opportunities for project teams to meet with senior executives and the board to discuss the project

3. Provide the necessary resources – time to work on the Project, funds for travel, training, equipment, supplies, etc.

Action Items for Senior LeadersAction Items for Senior Leaders

3. Support transparent communication with everyone– BSI rates– SSI rates– VAP rates– Process barriers and successes– Tell your own Josie Story; publically discuss a

patient who suffered preventable harm at your organization

4. Expect resistance and be prepared to address it effectively

5. Celebrate wins and provide encouragement, support, attention, and resources if there are set backs.

CSTS: The Cardiovascular Surgical Translational CSTS: The Cardiovascular Surgical Translational Study Study

Staff Safety AssessmentStaff Safety Assessment

Elizabeth Martinez, MD, MHSMassachusetts General Hospital

Harvard UniversityCSTS Content Call

Learning Objectives

• To understand Step 2 of CUSP: Identify Defects

• To understand how to Implement the Staff Safety Assessment

• To understand ways to use results of the Staff Safety Assessment

Goals

• To identify defects

• To leverage the wisdom of the front line worker

• To prepare a list of improvement opportunities that has face validity and provides a focus for local CUSP activities.

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

Comprehensive Unit-Based Safety Program:Comprehensive Unit-Based Safety Program:

CUSPCUSP

The smaller group that spreads the intervention

to the rest of the unit

The CUSP TeamThe CUSP Team

Education and engagement activities Education and engagement activities in each clinical areain each clinical area

• BSI: Providing Evidence, Modeling the line placement steps; stopping insertions that violate protocol; having one-on-one talks where necessary;

• Facilitating CUSP Activities

6

Comprehensive Unit-based Safety Comprehensive Unit-based Safety Program (CUSP)Program (CUSP)

1. Educate staff on science of safety (www.safercare.net)

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!!!

7

Martinez E,,Thompson D. Anesth Analg 2011;112:1061-74

Identify Defects

• Review error reports, liability claims, sentinel eventsor M&M conference

• Ask staff how the next patient will be harmed

Making project and progress visible to everyone

TransparencyTransparency

One way to make harm visible-- get staff thinking and talking about safety and how

to improve it

How are We Going to Harm the Next Patient?

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)

• Use the Staff Safety Assessment tool– How will the next patient be harmed in our unit– What can be done to minimize patient harm or prevent this safety

hazard

• Clinical area managers and CUSP team review suggestions, set the agenda for discussion with executive partner

Appendix C

STAFF SAFETY ASSESSMENT – CUSP

Please describe how you think the next patient in your unit/clinical area will be harmed.

Name (optional): Job Category: Date: Unit:

Please describe what you think can be done to prevent or minimize this harm.

Thank you for helping improve safety in your workplace!

Purpose of this form: The purpose of this form is to tap into your knowledge and experiences at the frontlines of patient care to find out what risks are present on your unit that have or could jeopardize patient safety. Who should complete this form: All health care providers. How to complete this form: Provide as much detail as possible when answering the 2 questions. Drop off your completed safety assessment form in the location designated by the CUSP improvement team with your job category, date and unit in the top box (name is optional). When to complete this form: Assessing safety should be considered an iterative process with no defined end (like a moving bicycle wheel). Thus, it can be filled out by any health care provider at any time. At the very least, all health care providers should complete this form semiannually.

Step 2: Staff Identify DefectsStep 2: Staff Identify Defects

• What Team Leaders 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)

Prioritize DefectsPrioritize Defects

• List all defects

• Discuss with staff what are the three greatest risks

Step 2: Staff Identify Defects

• Report the identified defects to staff, executive partner

• ICU managers and CUSP 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

Appendix D

SAFETY ISSUES WORKSHEET FOR SENIOR EXECUTIVE PARTNERSHIP - CUSP

Date of Safety Rounds: Unit: Attendees: 1. 2. 3. 4. 5. 6. 7. 8. 9. (use back of form for additional attendees)

Identified Issue

Potential/Recommended

Solution

Resources Needed Not

Needed 1.

2.

3.

4.

5.

6.

7.

8.

9.

Copy form if more than 9 safety issues are identified.

Please return this form to your project leader

Appendix E

STATUS OF SAFETY ISSUES – CUSP

Unit: ___________________________________________

New and Ongoing

Date Safety Issue Contact Status Goal

Completed Date Safety Issue Contact Status Goal

Please return this form to your project leader

CUSP 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)

Comprehensive Unit-based Safety Comprehensive Unit-based Safety Program (CUSP)Program (CUSP)

1. Educate staff on science of safety (www.safercare.net)

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!!!

Action ItemsAction Items

1. Educate staff on science of safety

1. Distribute staff safety assessment to ALL members of CV teams– Identity location for these to be returned anonymously –

and in an ongoing fashion

2. Summarize the data

3. Review with CUSP team and senior executive to prioritize next steps