SPSP Fellowship Project Charter by nyut545e2

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									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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