An Improvement Clinic Why QI ? “Between the health care we have and the care we could have lies not just a gap, but a chasm.” - Institute of Medicine, Crossing the Quality Chasm, 2001 • Best-known science is not reliably applied • Inefficiencies waste resource • Patients are being harmed Primary Drivers for Improvement QI Aims • To develop an ability to support, develop and influence a Quality Improvement intervention You are giving feedback • We want you to give feed back to this team: • We will give you two scenarios. Daily Goals - Some Key Issues: • Interdisciplinary communication tool > importance than specific statements • Modify form to meet needs • Not necessary to make form part of medical record • Reduced length of stay by one day Improving Communication in the ICU Using Daily Goals Journal of Critical Care 2003;18:71-75 Setting Daily Goals • Started Nov 08 – initially good progress • Initially very nurse led • Drs required lots of prompting – this has significantly improved • Still 2 or 3 late adopters (out of 9) • Very popular with nurses – clarifies what needs to be done Setting Daily Goals • Spread from one ICU to another • Compliance dropped from 100% to 60% • Varies on a week to week basis DAILY GOALS COMPLIANCE - weekly spot check - segmented by unit 100% 90% 80% % compliant 70% 60% ICU 1% COMPLIANT 50% C.I.S. 40% ICU 2% COMPLIANT IMPLEMENTATION 30% 20% 10% 0% week comm You are asked for advice • What advice do you have to help the team? • Should they go for perfection - every patient every time ? ADEPT • Aim (or objective) • Data • Evidence • PDSA or process (small steps of change) • Team (including patients and carers) (Bernard Crump) AIM NEEDS • Priority • How will we tell if its improving ? • Absolute level of performance (agree locally) • DATE • Some is not a number…..soon is not a time • Segment • But stretch goals/aims Central Line Infections The problem • Anecdotes of CRBSIs • Not enough evidence • Lack of guidance for doctors and nurses • No idea of complication rate until a recent study Study Showed • Over a 6 month period 75 CVCs were inserted in ICU. 11 proved positive for bloodstream infection translating to an infection rate of 14.6% • Lines inserted in the radiology department have an infection rate of “up to 18%” • 2 CVCs were inserted in patients in theatre and one of these developed a bloodstream infection Mission Statement • Within 6 months there will be no central venous access device infections at this hospital Feedback • To encourage • To guide • To teach • Listen and learn from everyone “All teach, all learn” Feedback • Encourage • Pareto chart probably incorrect- based on consensus opinion • Email Everyone • Failure to segment • Large test of change • Good to copy other guideline and change- one thing in one place wont work with another • Aim is good BUT:- 5 Times - WHY ? • Ask why 5 times • Need more knowledge - don’t assume one cause or solution The Five Whys ? Repeatedly ask the question ‘why?' (5 - rule of thumb) - peel away the layers of an issue, just like the layers of an onion, Can lead you to the root cause of a problem. May need > or < 5 times to get to origin of a problem. The key is to avoid assumptions and logic traps and encourage the team to keep drilling down to the real root cause. The Five Whys ? When does it work best?: Quickly identifies source of an issue or problem - focus resources on correct areas Tackles true cause not symptom How to use it: Write down specific problem- formalizes problem – describe accurately. Helps team focus on same problem focus on improvement 100 90 80 focus on differences 70 focus on “worst” 60 50 40 30 20 10 0 A B C UCL CCB1 GRI ICU Length of Stay (days) LCL Process Avg 16 Daily Goals & VAP 14 Prevention bundle start 12 10 Days 8 6 4 2 0 Ja 3 Ja 4 Ja 5 Ja 6 Ja 7 Ja 8 9 03 04 05 06 07 08 09 l-0 l-0 l-0 l-0 l-0 l-0 l-0 n- n- n- n- n- n- n- Ju Ju Ju Ju Ju Ju Ju Ja 7 Spreadly Sins (RC Lloyd and associates IHI) 1) Start with large pilots 2) Find one person willing to do it all 3) Use vigilance and hard work 4) If a pilot works - spread the pilot unchanged 5) Make the person and team who drove the pilot responsible for system wise spread 6) Look at process and outcome measures on a quarterly basis 7) Expect early marked improvement without attention to process reliability All 5 components 100% of bundle implemented 90% Checklist & documentation 80% 70% Hand Hygiene, Gown, Hat&mask 60% Used chlor-prep 50% Checklist & graph on trolley stick 40% Checklist E-mail trainees Full body drape used 30% Avoided femoral route, or valid exclusion Example 1 • Patient late in theatre, it caused a delay. Why? There was a long wait for a trolley. Why? A replacement trolley had to be found. Why? The original trolley's safety rail was worn and had eventually broken. Why? It had not been regularly checked for wear. Why? • The root cause - there is no equipment maintenance schedule. Example 1 • Root cause - No equipment maintenance schedule. • Setting up proper maintenance schedule ensures patients should never again be late due to faulty equipment. • Reduces delays and improves flow. • If simply repair the trolley or do a one- off safety rail check, the problem may happen again sometime in the future The Five Whys ? Use brainstorming to ask why the problem occurs then, write the answer down. If this answer doesn't identify the source of the problem, ask ‘why?' again and write that answer down Loop back to step three until the team agrees that they have identified the problem's root cause. Again, this may take fewer or more than five ‘whys?'
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