Learning Session 1Cape Town, February 2011

To reduce Healthcare Associated Infection (HAI) using aSystems Improvement approach

Overall goal of BCA Campaign

How are you doing so far?

How are you doing with

• Overall Progress

• Measurement

• Team work

Make your mark!• Overall Progress

• Measurement

• Team work

ExcellentNot good

Fair

0 5 10

Make your mark!• Overall Progress

• Measurement

• Team work

ExcellentNot good

Fair

0 5 10

Gauteng BCA Learning Network

Biggest challenges

Leadership invlovement

Understanding the bundles

Implementing bundles

Diagnosing the infection

measurement

Feeding back progress

Team work

Mentoring and support

Biggest challenges

x

x x

x x x x

x x x x

x x x x x x x xLeadership involvement

Understanding the bundles

Implementing bundles

Diagnosing the infection

measurement

Feeding back progress

Team work

Mentoring and support

Will

Ideas

Execution

What we need for success

Why spend our time and energy reducingHealthcare Associated Infections?

Building WillThe business case

Patients get “recommended care” ~ 50% of the time.

Adverse events occur in 10% of hospital patients.– 50% are preventable.– 7.5% of these patients die.

...the gap between evidence and practice

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NEJM 2003; 348:2635-2645

Qual Safety in Health Care 2008;17:216-223

Healthcare-Associated Infection

– Infection rates 5-10%– 1.4 million patients affected each day– USA 100,000 deaths, $6.5 billion / yr

JAMA 2009;301(12):1285-1287Lancet 2008;372(9651):1719-1720

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67.0

18.1

6.4 8.5

0.00.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

%

CompletelyAgree

Partially Agree Neutral PartiallyDisagree

CompletelyDisagree

Hospital-acquired infections are a serious problemn=94

Delegate Survey, FIDSSA Conference Aug 20-23 200985.1%

In the hospital(s) with which I am associated…

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Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet Dec 2010.

Number of HAI studies 1995-2008

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Healthcare-associated infections are 2-3 x more common in developing countries

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Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet Dec 2010.

SA Hospitals?

– 9.7% HAI point prevalence– 28.6% in ICU

Prof A Duse. SA-HISC study (unpublished)

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Private + Public Hospitals in Gauteng

1 in 7 patients who enter SA Hospitals are at risk for developing an HAI

Brink A et al., SAMJ 2006; 96(7)

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HAI Impact

• On the patient & family

• On you?

• On the hospital?

• Financial?

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IHI and others wondered if something could be done

• IHI (US) 100,000 lives campaign – 6 interventions including 3 of ours

• Canadian Safer Healthcare Now

• Scotland NHS Patient Safety Alliance

….and other successes around the world

Interventions were made into bundles

• What is a bundle and how does it work?A grouping of best practices that individually improve

care, but when applied together result in substantially greater improvement.

The science behind the bundle is so well established that it should be considered standard of care.

Bundle elements are dichotomous and compliance can be measured: yes/no answers.

Bundles shun the piecemeal application of proven therapies in favor of an “all elements” approach.

What was achieved when the bundles were implemented reliably

i.e.

all elements of the bundleto every patient

every time?

Results…Michigan (Keystone)

• 66% reduction in line-related infection

• Saved > 1,500 lives

• Saved $200 million in 18 months

New England Journal of Medicine. 2006; 355(26): 2725-2732

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24

HAI : SSI RATE

25

26

Why BCA?

• Better care, less harm

• Build the capacity to improve

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Learning together

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29

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Finding leverage and synergy to achieve sustainable, high quality health care…more quickly…at greater scale

Power of leverage and synergyLeverage: doing something smart that has a much bigger

impact.

Synergy: two or more people produce more together than the sum of what they could

have produced separately.

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Will

Ideas

Execution

What we need for success

4 infection prevention bundles• VAP (ventilator associated pneumonia)

• CLABSI (central line associated bloodstream infection)

• SSI (surgical site infections)

• CAUTI (catheter associated urinary tract infections)

Ideas for improvement

The size of the challengeat your facility

Ventilators

Central lines

Surgical Sites

Urinary Catheters

Unit 1

Unit 2

Unit 3

Unit 4

Exercise: i) mark the procedures relevant to each of your ICU or high care units with an ‘X’. ii) Prioritise the intervention most relevant to each unit by circling one of the X’s in each unit

The challenge at your facilityVentilators

Central lines

Surgical Sites

Urinary Catheters

ICU X X X X

Theatre X X X

High Care X X X X

Medical Ward

X X

Surgical Ward

X X

Emergency Unit

X XExercise: i) mark the procedures relevant to each of your ICU or high care units with an ‘X’.

ii) Prioritise the intervention most relevant to each unit by circling one of the X’s in each unit

Will

Ideas

Execution

What we need for success

Learning Network

Learning session 1

© Institute for Healthcare Improvement

Learning session 2

Activity

phase:

Activity

phase:

Learning session 3

18 -24 months

Support, support, support

preparation

Make it do-ablePrioritise ONE bundle/ or aspect of the problem• size of the problem• size of the impact• leadership preference

Start small then build up as you gain confidence• one ICU/high care• small improvement team• one aspect of the bundle• expand as confidence grows (data)

Start where you’ll get the best results• the most support

Start small to gain confidence

i) Choose one intervention bundle that will have the greatest effectii) Choose one unit where you have the greatest chance of

successiii) Who will you have on your team?

Ventilators

Central lines

Surgical Sites

Urinary Catheters

ICU X X X X

Theatre X X X

High Care X X X X

Medical Ward

X X

Surgical Ward

X X

Emergency Unit

X X

Exercise:

Choosing the improvement team

Late Majority

Early Majority

Early Adopters Tradition-

alists

Innovators

2% 13% 35% 35% 15%

Getting Started KitTeam Exercise:

i) look up the elements of your selected ‘Bundle’

ii) What reduction in the level of infection has been achieved using the bundle you selected?Adult Ventilator Associated Pneumonia pg 9 & 10Central Line Associated Bloodstream Infections pg 8 & 9 Surgical Site Infections Catheter Associated Urinary Tract Infection pg 5 & 6

Know where you’re headingWhat’s Possible with the bundles?

1. Adult Ventilator Associated PneumoniaAverage 45% reduction. With every bundle element every time – Zero cases for over long periods of time (pg 7)

2. Central Line Associated Blood Stream InfectionsNearly eliminate CLABSI (pg 7&8)

3. Surgical Site Infections(incidence in clean cases 2-3% USA) 40 – 60 % infections are preventable (pg 6)

4. Catheter Associated Urinary Tract InfectionReductions of 46% - 81% have been achieved (pg 6)

Define an Aim (for your bundle)

• must have a number• must have a time frame• must stretch you - not achievable in the current system - requires change • benchmark against what has been achieved elsewhere

Statement of where you want to go -you don’t need to know how to get there yet

Defining the AimTo reduce (VAP, CLA-BSI, SSI, CA-UTI)

By ……………. amount

By implementing the whole ………bundle to every patient every time

By August 2012 (in 18 months)

A systems approach

12/2008

Understanding Systems

1) choose two people in the room, don’t tell them who they are

2) one of them must be a person selected by the facilitator

3) keep the same distance between yourself and each of the two people you have chosen

Complete each of the steps in this process

Step 1: Pick a number

from 3 to 9

Step 2: Multiply your number by 9

Step 3:Add 12 to the

number from step 2

Step 7: Write down thename of a city

that begins with your letter

Step 4: Add your 2

digits together

Step 5:Divide # from step 4

by 3 to get a 1 digit number

Step 6:Convert your

Number to a letter:1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I

Step 8: Go to the next Letter: A to B, B to C, C to D,

etc.

Step 9: Write down the nameof an animal (not bird,

fish, or insect) that begins with your letter

from Step 8

Step 10:Write down the color of

your animal

Do you have a 2-digit Number?

NO

YES

Output:

Color____________

Animal___________

City__________

“Every system is perfectly designed to achieve the

result it gets”

12/2008

‘Every improvement needs a change’

The changes:

1)Infection Control Bundles

1)A way of overcoming the implementation gap

Every element of the bundle To every patients Every time

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The Implementation Gap

PLAN

IMPLEMENT

FAIL

PROBLEM

EVIDENCE BASED SOLUTION

“traditional” attempts to change

I

DO

STUDY

ACTIMPLEMENT

SUCCEED/ SUSTAIN

Overcoming the Implementation Gap

GREAT IDEAS

SYSTEM ANALYSIS to identify barriers to carePROBLEM

PLAN

‘Every improvement needs a changeNot every change is an improvement’

Rapid Cycle Change –start small on one part of the bundle/system

Improving many parts of the bundle/system at once.

part 3 part 4part 1 part 2

Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? AIM

MEASUREMENTCHANGE

Measurement

Are we getting closer to our target?

Outcome measure

Measurement

Did we use the whole bundlein every patient every time?

Process measure (Bundle compliance)

Measurement

Was the change an improvement?

Measuring the impact of a change

Measuring over time

• a volunteer to write

• a volunteer to measure

• graph paper

Annotated Run Chart

Community Need

I Change Made in June

Interpreting Data: what is the story?

IBefore (Feb) After (Aug)

What is the real story?

Change Made

Change Made

Change Made

Change Made in June

Feb Aug

Feb AugFeb Aug

Feb Aug Feb Aug

I

Change Made

Median

Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift

Median

Median

Trend: 5 points in row headed in same directionNote: Ties between two consecutive points

don’t cancel or add to a trend

Rule 3

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Mea

sure

or C

hara

cerist

ic

Median 11.4

Data line crosses onceToo few runs: total 2 runs

Run Chart: Rules for Identifying Statistically Significant Change

Rule 1 Rule 2

Rule 4Rule 3

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Astronomical Point: a obviously, even blatantly different valueNote: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical

Runs: too few or too many runs

Provost and Murray

Run Charts• One of the most powerful tools for improvement

• Describe a process over time

• Shows trends the process is experiencing

• Can be used to analyse whether the change was an improvement

• Data can be used to drive change

Outcome measurement

Are we getting to our target?

Was the change an improvement?

How do we measure HAIs?

Measuring infection rates

Lessons from an ICU

Quality Improvement 101

Problem?

Measuring Infection Rates

• Total number of infective cases per 1,000 device days:

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Definition of VAP

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

Overcoming Numerator Issues

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Overcoming Numerator Issues

Checklists forDiagnosing the HA Infectionused by theteam

Overcoming Denominator Issues

At the same time every day theUnit managercounts devicesin use in the ward

Additional Tools

Measuring HAI

Percentages and rates

% (or rate) = Numerator/ denominator

eg

Rate of infection = readmissions for septic caesarian section wounds per week / number of Caesarian Sections performed per week

Rate of infection = Number of VAP / 1000 device days

Safety CalendarWelsh 1000 lives campaign

IDeveloped by Annette Bartley

Welsh Patient Safety Project

Measuring HAI

The concept of ‘days between’ infections

For measure ‘rare’ events (occur < 10%)

Off the internet, Google pictures

Off the internet, Google pictures

Off the internet, Google pictures

Off the internet, Google pictures

Maternal deaths – Malawi

For the “NO Maternal Death” Campaign a colorful, laminated A4 paper that said “Days without a Maternal Death: ______”. were hung in every Labour Ward for all (providers, patients and guardians) to see and the number was filled in daily with a dry erase marker

Days between icecreams

Days betweenicecream

Icecream

1st 2nd3rd 4th 5th

510

15

20

25

Days between events (infection)

Days Betweenevents(egInfection)

Sequence of events (eg Infection)

1st 2nd3rd 4th 5th

510

15

20

25

Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana

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IMeasuring rare events and time-between measures. James Benneyan IHI

July Aug Sep Oct

5/7 13/8 7/9 5/10

5/7 9/9 8/10

6/7 12/9 15/10

11/7 15/9 19/10

25/7 20/10

27/7 21/10

25/10

ICU: Sequence of VAP infections by date 2010

Use the tools to Display the data

July Aug Sep Oct

5/7 13/8 7/9 5/10

5/7 9/9 8/10

6/7 12/9 15/10

11/7 15/9 9/10

25/7 20/10

27/7 21/10

25/10

Date of infection

# Days since last infection

Days Be-tweenInfection

Sequence of Infections

So far we have:

1.Mapped the size of the project in your facility2.Prioritise a unit and bundle to start with3.Written an aim

Now, write down:

1.Your aim2.The outcome measures

i) Rate = numerator/denominator (describe)ii) Days betweeniii) Welsh Safety calendariv) Other

3.How you will feedback the data every month toi) The frontline staffii) Management

Mark with a * areas that you want to strengthen

Improving your Outcome Measure

1) NumeratorStandardised diagnosis of infection

2) What is the measure for HAI?Rate = Infection/device dayDays between (CLABSI, VAP, UTI)Days or cases between SSI

3) Collecting and collating data: What (definition)/ Where/ How (tools)/ Who/ When

4) Presenting the data:Format - Safety Cross, GraphsFeedback/presentation - Management platform

PDSA –testing a change

MARUWhat is Maru trying to achieve?How many ideas does he try?Is he successful?What was the possible negative outcome?

From YouTube

Rapid Cycle Change

What can we change that will result in an improvement?

How will we know that a change is an improvement?

What are we trying to accomplish?

AIM of this change: PROBLEM :

AIM: make our project and outcome measure ‘visible’ in the ward

PROBLEM : our staff are not engaged in the project

Use the Welsh Safety Cross

AIM of this change:

HOMEWORKDo a PDSA to solve a problem at home