Using Performance Using Performance Improvement Improvement

toto Improve Patient OutcomesImprove Patient Outcomes

Denise Murphy RN, MPH, CICDenise Murphy RN, MPH, CICVice President, Quality and Patient Vice President, Quality and Patient Safety, Main Line Health SystemSafety, Main Line Health System

September 2009September 2009

Performance ImprovementPerformance Improvement

• Performance ImprovementPerformance Improvement is the process of designing is the process of designing or selecting or selecting interventionsinterventions which may include training which may include training directed toward a change in behavior, typically on the job. directed toward a change in behavior, typically on the job.

• PI is a systematic process of discovering and analyzing PI is a systematic process of discovering and analyzing human performance gaps, planning for future human performance gaps, planning for future improvements in human performance, designing and improvements in human performance, designing and developing cost-effective and ethically-justifiable developing cost-effective and ethically-justifiable interventions to close performance gaps, implementing interventions to close performance gaps, implementing the interventions, and evaluating the financial and non-the interventions, and evaluating the financial and non-financial results.financial results.

Performance Improvement: Performance Improvement: Art or Science?Art or Science?

• PDCA/PDSAPDCA/PDSA• Six Sigma: DMAICSix Sigma: DMAIC• Toyota Production System (TPS) “Lean” Toyota Production System (TPS) “Lean”

Engineering: Get the waste out!Engineering: Get the waste out!• Lean Six Sigma – the hybrid (Lean on the DMAIC Lean Six Sigma – the hybrid (Lean on the DMAIC

framework)framework)• General Electric’s Express WorkoutGeneral Electric’s Express Workout• These approaches to PI are nothing without These approaches to PI are nothing without

Change Mgt!Change Mgt!

Bottom line…Improvement work in health care is Bottom line…Improvement work in health care is getting much more analytical and based on getting much more analytical and based on

scientific and scientific and

mathematical principles!mathematical principles!

Change ManagementChange Management• Change managementChange management is the practice of administering is the practice of administering

changes with the help of tested methods and techniques in changes with the help of tested methods and techniques in order to avoid new errors and minimize the impact of order to avoid new errors and minimize the impact of changes on an organization and individuals.changes on an organization and individuals.

• Change management is a systematic approach to dealing Change management is a systematic approach to dealing with change, and has at least three distinct components: with change, and has at least three distinct components:

– adapting to change,adapting to change,– controlling change, andcontrolling change, and– effecting changeeffecting change..

• A A proactiveproactive approach to dealing with change is at the core approach to dealing with change is at the core

of all three aspects. of all three aspects.

• Change Management is the Change Management is the process, tools and process, tools and techniquestechniques needed to needed to – manage the people side of change processes, manage the people side of change processes, – to achieve expected outcomes to achieve expected outcomes – and to realize the change effectively… and to realize the change effectively…

Change ManagementChange Management

AROUND THE LARGER ORGANIZATION

WITHIN THE TEAM

WITHIN THE SELF

Source: The Change Management Toolbook: Introductionhttp://www.change-management –toolbook.com

Human Factors EngineeringHuman Factors Engineering

• Human Factors EngineeringHuman Factors Engineering is based on sciences of is based on sciences of physics and ergonomics and is essentially the study physics and ergonomics and is essentially the study of man with his/her tools in the system of man with his/her tools in the system (environment) in which they live or work. (environment) in which they live or work.

• HFE is a multi-faceted discipline that generates HFE is a multi-faceted discipline that generates information about human requirements and information about human requirements and capabilities, and applies it to the design and capabilities, and applies it to the design and acquisition of complex systems. acquisition of complex systems.

• Human factors engineering provides the opportunity Human factors engineering provides the opportunity to: to: (1) develop or improve all human interfaces with the (1) develop or improve all human interfaces with the system; system; (2) optimize human / product performance during system (2) optimize human / product performance during system operation, maintenance, and support; operation, maintenance, and support; (3) make economical decisions on personnel resources, (3) make economical decisions on personnel resources, skills, training, and costs. skills, training, and costs.

Human Factors EngineeringHuman Factors Engineering

Photo source: Barnes-Jewish Hospital, Laurie Wolf, Human Factors Engineer

GOOD OR POOR GOOD OR POOR ENGINEERING DESIGN?ENGINEERING DESIGN?

Implementation Science or Implementation Science or thethe Art of ExecutionArt of Execution

1- Maintain focus on the “vital few” goals1- Maintain focus on the “vital few” goals Keep strategic plan simple, communicate goals oftenKeep strategic plan simple, communicate goals often Employees Employees must be clear about their rolesmust be clear about their roles in achieving the in achieving the

most critical 80% of the planmost critical 80% of the plan

2- Develop tracking systems that facilitate problem 2- Develop tracking systems that facilitate problem solvingsolving Set metrics; use charts, graphics and other tracking tools for Set metrics; use charts, graphics and other tracking tools for

planning and execution planning and execution The right measures make expectations clearThe right measures make expectations clear Each key success factor must have only one ownerEach key success factor must have only one owner Conduct RCA* to drill down and uncover barriers to successConduct RCA* to drill down and uncover barriers to success

3- Set up formal reviews3- Set up formal reviews Conduct “toll gate” or milestone reviewsConduct “toll gate” or milestone reviews Be specific about meeting structures, frequency, and Be specific about meeting structures, frequency, and

agendasagendas Personnel and resources needed should be at top of the Personnel and resources needed should be at top of the

agenda!agenda!Root Cause Analysis

Implementation Science or the Implementation Science or the Art of ExecutionArt of Execution

““If you’ve got the right people in the right roles and If you’ve got the right people in the right roles and are still not executing, then look at your are still not executing, then look at your

resources” resources”

Tim Stratman, CEO RRD DirectTim Stratman, CEO RRD Direct

““The most creative, visionary strategic planning is useless if it The most creative, visionary strategic planning is useless if it isn’t translated into action. Think simplicity, clarity, focus…isn’t translated into action. Think simplicity, clarity, focus…

and review your progress relentlessly.” and review your progress relentlessly.”

Melissa RaffoniMelissa Raffoni

Source: Three Keys to Effective Execution, Melissa RaffoniSource: Three Keys to Effective Execution, Melissa Raffoni

Harvard Business School Publishing Corporation, 2003Harvard Business School Publishing Corporation, 2003

Key Messages for Infection Key Messages for Infection PreventionistsPreventionists

• We are doing good things in infection We are doing good things in infection prevention and control; need more prevention and control; need more consistencyconsistency

• This is a time of transition for the professionThis is a time of transition for the profession Consumer awareness and expectationsConsumer awareness and expectations Legislative, governmental mandates Legislative, governmental mandates MDROs, emerging diseases, global MDROs, emerging diseases, global

transmissiontransmission • Customers and payers demand proactive Customers and payers demand proactive

programs – must focus on programs – must focus on PREVENTIONPREVENTION

Source: Denise Murphy and Ruth Carrico. Am J Infect Control 2008: 36:232-40

Key messages continuedKey messages continued

• Many programs getting to zero and Many programs getting to zero and sustaining! sustaining!

• Sustainment goes beyond education and Sustainment goes beyond education and training or other traditional interventions training or other traditional interventions

• Need a systems model that can design or Need a systems model that can design or engineer prevention into patient engineer prevention into patient carecare……an Infection Prevention Systeman Infection Prevention System

Source: Denise Murphy and Ruth Carrico. Am J Infect Control 2008: 36:232-40

What is a SYSTEM?What is a SYSTEM?

Integrated collection of facilities, parts, equipment, Integrated collection of facilities, parts, equipment, materials, technology, personnel and/or techniques which materials, technology, personnel and/or techniques which make an organized whole capable of supporting some make an organized whole capable of supporting some purpose or function.purpose or function.

The basics...The basics...

Interaction of elements Interaction of elements Conversion processes Conversion processes Structure Structure Purpose and goals and functionPurpose and goals and function Inputs or resources Inputs or resources Outputs Outputs Environment Environment AttributesAttributes Management, agents, and decision makersManagement, agents, and decision makers

Source: The practice of Ergonomics: Reflections on a Profession by David Meister

Components of All SystemsComponents of All Systems

BasicBasic Functions of a System Functions of a System

Modified from: Mc Cormick, EJ and Sanders, MS.

Human Factors in Engineering and Design. New York: McGraw-Hill Book Company, 1982.

SensingRec’d info that

pt. needs constant I&O monitoring

Information(Input you)

Info processedObtain MD order, decide to insert

foley catheter now

Action functionsInsert foley; record I&O

OutputPatient output info used for tx decisions

Information storage (EMR)

Output becomes feedback creating new Input

ThroughputI&O monitored via foley; medication

adjusted based on this info

What does a COMPLEX ADAPTIVE SYSTEM look like?What does a COMPLEX ADAPTIVE SYSTEM look like?

SOURCE: Carayon, P., Hundt, A., Alvarado, C., et al.(2006) Work system design for patient safety: SOURCE: Carayon, P., Hundt, A., Alvarado, C., et al.(2006) Work system design for patient safety: SEIPS model. Qual and Safety in Health Care;15(supp 1):50-58. SEIPS model. Qual and Safety in Health Care;15(supp 1):50-58. (SEIPS = System Engineering Initiative for Patient Safety)(SEIPS = System Engineering Initiative for Patient Safety)

If people are not totally predictable, what can we build in to make processes

(therefore, outcomes…..) more reliable?

SimplificationSimplification StandardizationStandardization AutomationAutomation RedundancyRedundancy Recovery methods/strategiesRecovery methods/strategies Visual queuesVisual queues Right resources, roles, responsibilitiesRight resources, roles, responsibilities Autonomy/empowermentAutonomy/empowerment Supportive cultureSupportive culture

Potential Model for Prevention of Potential Model for Prevention of CLABSI Using a System FrameworkCLABSI Using a System Framework

Barnes-Jewish Hospital’s Value Stream Barnes-Jewish Hospital’s Value Stream Analysis – using principles of LEAN Analysis – using principles of LEAN engineering aligned with a Six Sigma engineering aligned with a Six Sigma DMAIC (define, measure, analyze, DMAIC (define, measure, analyze, improve, control) framework to improve, control) framework to

map out, map out, analyze, analyze, redesignredesign and sustain and sustain

a more efficient, defect-free experience for a more efficient, defect-free experience for the patient with a central line …and to the patient with a central line …and to eliminate CLABSIeliminate CLABSI

LEAN APPENDIXLEAN APPENDIX

Principles of Lean Systems Principles of Lean Systems EngineeringEngineering

VALUEVALUE: Exactly what customers are willing to pay for: Exactly what customers are willing to pay for

VALUE STREAMVALUE STREAM: ...is “everything that goes into” : ...is “everything that goes into” creating and delivering value to the customer. creating and delivering value to the customer. These are the steps/actions/processes that deliver These are the steps/actions/processes that deliver value.value.

FLOWFLOW: Flow challenges us to reorganize the Value : Flow challenges us to reorganize the Value Stream to be continuous… one by one, non-stop, Stream to be continuous… one by one, non-stop, minimal waste.minimal waste.

PULLPULL: Pull challenges us to only respond “on demand” : Pull challenges us to only respond “on demand” to our downstream customers. to our downstream customers.

PERFECTIONPERFECTION: Perfection challenges us to also create : Perfection challenges us to also create compelling quality (“defect free”) while also compelling quality (“defect free”) while also reducing cost (“lowest cost”).reducing cost (“lowest cost”).

Source: Adapted from Simpler Business Systems, Indiana, USA

Basic Elements of Lean Basic Elements of Lean

FlowFlow: : The continuous creation or delivery of value The continuous creation or delivery of value without interruptionwithout interruption

5S5S: : A complete system for workplace organization, A complete system for workplace organization, including the process for sustainmentincluding the process for sustainment

Visual ManagementVisual Management: : Using visual signals for more Using visual signals for more effective communicationeffective communication

PullPull: : Working or producing to downstream demand Working or producing to downstream demand onlyonly

Standard WorkStandard Work: : Identifying the “best practice” and Identifying the “best practice” and standardizing to it, stabilizing the process standardizing to it, stabilizing the process (predictability)(predictability)

1 by 11 by 1: : Reducing batch size to one whenever Reducing batch size to one whenever possible to support flowpossible to support flow

Zero DefectsZero Defects: : Not sending product or service to Not sending product or service to downstream customer (internal or external) downstream customer (internal or external) without meeting all requirementswithout meeting all requirements

What is the What is the Value Stream Analysis Process?Value Stream Analysis Process?

A combination of Lean tools and techniques to: A combination of Lean tools and techniques to: – Analyze a processAnalyze a process– Prescribe a plan, with timeline and Prescribe a plan, with timeline and

assignments, for transforming the processassignments, for transforming the process– Achieve breakthrough resultsAchieve breakthrough results

Deliverables of a Deliverables of a Value Stream Analysis Event (4 Value Stream Analysis Event (4

days)days)

Three Value Stream MapsThree Value Stream Maps– Current StateCurrent State:: A clear picture of how it is today A clear picture of how it is today– Ideal StateIdeal State:: What we envision long range (perfect?) What we envision long range (perfect?)– Future State:Future State: What we will look like in 6-12 monthsWhat we will look like in 6-12 months

Key VS performance improvement indicators (metrics)Key VS performance improvement indicators (metrics)

Detailed action plan of Rapid Improvement Events Detailed action plan of Rapid Improvement Events (RIEs), PI projects, and Just-Do-Its (JDI)(RIEs), PI projects, and Just-Do-Its (JDI)

Flow cell - “the fundamental building block of Lean”Flow cell - “the fundamental building block of Lean”

Visual Visual ManagementManagement

(a completely transparent (a completely transparent process is what enables a flow process is what enables a flow

cell to operate)cell to operate)

1-piece 1-piece FlowFlow

PullPull

Standard Standard WorkWork

5S5S• StraightenStraighten• SortSort• ShineShine• StandardizeStandardize• SustainSustain

On Demand:• Produce to downstream request only

• Work fluctuates w/demand• Perfect handoffs- one way to

request- one way to receive

Defect Free:• No asking, no

searching, no clarifying• Can tell normal vs. abnormal at a glance• Abnormal conditions trigger immediate action

One by One:• Batch size of one

• Most direct path• Each item “flows” through the cell without stopping

Source: Simpler Business Systems

Lowest Cost:• Best way known today

• Pace to Takt Time• Same way for all staff• Everyone sees, knows and understands

What is Value \ What is NotWhat is Value \ What is Not

Value-adding:Value-adding:– ANY ACTIVITY THAT PHYSICALLY CHANGES THE ANY ACTIVITY THAT PHYSICALLY CHANGES THE

MATERIAL BEING WORK ON MATERIAL BEING WORK ON ANDAND INCREASES IT’S INCREASES IT’S VALUEVALUE

Non-value adding:Non-value adding:– ANY ACTIVITY THAT TAKES TIME, MATERIAL, OR ANY ACTIVITY THAT TAKES TIME, MATERIAL, OR

SPACE BUT DOES NOT PHYSICALLY CHANGE THE SPACE BUT DOES NOT PHYSICALLY CHANGE THE MATERIAL MATERIAL OROR INCREASE IT’S VALUE INCREASE IT’S VALUE

Every activity required to move an item through a value stream falls into one of these two categories

Source: Simpler Business Systems

The 8 Operational The 8 Operational WastesWastes

DEFECTS:DEFECTS: (Wrong info. / Rework / Inaccurate information) (Wrong info. / Rework / Inaccurate information) Medication errors; misdiagnosis; wrong patient or Medication errors; misdiagnosis; wrong patient or procedureprocedure

OVERPRODUCTION:OVERPRODUCTION: (Duplication / Extra information) (Duplication / Extra information) admitting patients early for staff convenience; blood admitting patients early for staff convenience; blood draws/tests/treatment done early, pre-op chart prep 90 draws/tests/treatment done early, pre-op chart prep 90 days outdays out

WAITING/DELAYS:WAITING/DELAYS: (Patients / Providers / Material) ER staff (Patients / Providers / Material) ER staff waiting for admission; MDs waiting for test results; staff waiting for admission; MDs waiting for test results; staff waiting for prescriptions/orders/transport/cleaningwaiting for prescriptions/orders/transport/cleaning

NEGLECT OF HUMAN TALENTNEGLECT OF HUMAN TALENT: (Unused Skills / Injuries / Unsafe : (Unused Skills / Injuries / Unsafe Environment / Disrespect) Scrub Techs used as retractor Environment / Disrespect) Scrub Techs used as retractor holders; RNs kept from direct patient care holders; RNs kept from direct patient care

The 8 Operational The 8 Operational WastesWastes (continued) (continued)

TRANSPORTATION:TRANSPORTATION: (Transactions / Transfer Moving) patients, (Transactions / Transfer Moving) patients, meds, specimens, lab work, equipmentmeds, specimens, lab work, equipment

INVENTORY:INVENTORY: (Incomplete / Piles) Dictation waiting for transcription; (Incomplete / Piles) Dictation waiting for transcription; Medical supplies; Specimens awaiting analysis; Patients waiting Medical supplies; Specimens awaiting analysis; Patients waiting for tests, treatment or dischargefor tests, treatment or discharge

MOTION:MOTION: (Finding Information / Double entry) Looking for missing (Finding Information / Double entry) Looking for missing supplies, forms, patients; equipment not within reachsupplies, forms, patients; equipment not within reach

EXCESS PROCESSINGEXCESS PROCESSING: (Extra Steps / Quality Checks / : (Extra Steps / Quality Checks / Workarounds / Inspection / Oversight) Asking patients the same Workarounds / Inspection / Oversight) Asking patients the same information multiple times; completing unnecessary forms/tests; information multiple times; completing unnecessary forms/tests; Triage; verifying ordersTriage; verifying orders

VALUE STREAM MAPPINGVALUE STREAM MAPPINGValuable?Valuable?

– Is the output of the process what the customer wants and needs?Is the output of the process what the customer wants and needs?– Are there items missing that can add value to the customer in Are there items missing that can add value to the customer in

the current process?the current process?– Are there items that are making the process more efficient but Are there items that are making the process more efficient but

not creating value?not creating value?Capable?Capable?

– Can each step be performed the same way with the same result Can each step be performed the same way with the same result every time? every time?

– Is the result satisfactory from the standpoint of the customer?Is the result satisfactory from the standpoint of the customer?– Can the steps be executed in similar locations with the same Can the steps be executed in similar locations with the same

output every time?output every time?Available?Available?

– Can each step be performed every time it needs to be Can each step be performed every time it needs to be performed?performed?

– Can each step be performed in the cycle time required?Can each step be performed in the cycle time required?

Is the current state...Is the current state...

Adequate?Adequate?Is there enough capacity to perform each step without waiting?Is there enough capacity to perform each step without waiting?

Can the process accommodate changes to operating conditions Can the process accommodate changes to operating conditions and still meet customer requirements?and still meet customer requirements?

Can the process produce similar quality outputs across a range Can the process produce similar quality outputs across a range of operating conditions? (Robust)of operating conditions? (Robust)

Flow?Flow?Do all the steps in the process occur in tight sequence or with Do all the steps in the process occur in tight sequence or with little waiting?little waiting?

Pull?Pull?Does the downstream step signal when a process should Does the downstream step signal when a process should occur?occur?

Level?Level? Is demand leveled so that unnecessary variation is removed Is demand leveled so that unnecessary variation is removed

from the flow?from the flow?

Is the current state…Is the current state…

Ideal and Future StateIdeal and Future State

• Built knowing the current state and its weaknesses Built knowing the current state and its weaknesses and with clarity around the end goal (outcomes)and with clarity around the end goal (outcomes)

• Built as if there were no barriers – in time, human Built as if there were no barriers – in time, human factors, organizational constraints, cultural issues, factors, organizational constraints, cultural issues, resources, competencies, equipment, technology….resources, competencies, equipment, technology….

• Ideal: a reliable, dependable and nearly-perfect Ideal: a reliable, dependable and nearly-perfect system (maybe after years of work)system (maybe after years of work)

• Future State: what can be accomplished toward the Future State: what can be accomplished toward the ideal state in the next 12 months (& keep resetting)ideal state in the next 12 months (& keep resetting)

Gap AnalysisGap Analysis

GAPGAPCurrent Current

StateStateFuture Future StateState

Action PlansAction Plans

Events Projects Do-Its

EVENT TOPIC EVENT TOPICPRO-JECT

PRO-JECT

ACTIONITEM

EVENT TOPIC EVENT TOPICPRO-JECT

PRO-JECT

ACTIONITEM

EVENT TOPIC EVENT TOPICPRO-JECT

ACTIONITEM

ACTIONITEM

ACTIONITEM

EVENTTOPIC

May Jun Jul Aug Sep Oct

Do-

Its

P

roje

cts

Eve

nts EVENT

TOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

EVENTTOPIC

PROJECT

PROJECT

PROJECT

PROJECT PROJECT

PROJECT

ACTION ITEM

ACTION ITEM

ACTION ITEM

ACTION ITEM

ACTION ITEM

ACTION ITEM

ACTION ITEM

Sort the action items

Develop an action plan

Brainstormed Ideas

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

ACTIONIDEA

Brainstorm Solutions

Executive Champion/Sponsor: Denise Murphy; Physician Champions: Richard Bach, MD (CCU) and David Warren, MD(HEIP);Process Owner/Team Leader: Amy Richmond, Manager, Infection Prevention

Central Line Insertion & Central Line Insertion & CareCare

Value Stream AnalysisValue Stream AnalysisFebruary 25-27, 2008February 25-27, 2008

ScopeScope

The scope of this Value Stream Analysis will include the The scope of this Value Stream Analysis will include the central central line insertion, access & care processesline insertion, access & care processes

– From the decision to insert a central venous line to line From the decision to insert a central venous line to line removalremoval

Note: Process mapping for PICC lines and dialysis catheters Note: Process mapping for PICC lines and dialysis catheters was done prior to VSA and information incorporated into was done prior to VSA and information incorporated into VSA VSA

Reasons for ActionReasons for Action

BJH ICUs BJH ICUs – 2007 - 66 catheter-associated BSIs (CLABSI) identified 2007 - 66 catheter-associated BSIs (CLABSI) identified – 2007 – 2.2 CA-BSI/1000 catheter days (SIR 0.53)2007 – 2.2 CA-BSI/1000 catheter days (SIR 0.53)

BJH Non-ICU areas BJH Non-ICU areas – CLABSI rates vary from 4 to 9 per 1000 catheter days CLABSI rates vary from 4 to 9 per 1000 catheter days – Compared to non-ICU rates of 1.5 in med/surg and 2.1 in Compared to non-ICU rates of 1.5 in med/surg and 2.1 in

general medicine published in the 2006 NHSN reportgeneral medicine published in the 2006 NHSN report

CLABSI attributable mortality rate = 15% (#10 BJH pts in 2007)CLABSI attributable mortality rate = 15% (#10 BJH pts in 2007)

Bloodstream infections cost an excess of $36,000 and excess Bloodstream infections cost an excess of $36,000 and excess LOS = 12 daysLOS = 12 days

CLABSI is publicly reported and CMS no longer pays excess CLABSI is publicly reported and CMS no longer pays excess costscosts

RIGHT THING TO DO FOR PATIENT SAFETY!!RIGHT THING TO DO FOR PATIENT SAFETY!!

Identify the OpportunityIdentify the OpportunityICU Central Line Associated Bloodstream Infection Rates

2000 to 2007

0

1

2

3

4

5

6

7

8

9

2000 2001 2002 2003 2004 2005 2006 2007

BSI Rate (per 1000 Line Days)

62

97

81

95

103

101

64

84

Source: Barnes Jewish Hospital Epidemiology and Infection Prevention Department

Identify Current Success to Build Identify Current Success to Build UponUpon

Central Line Associated Bloodstream Infection RatesCardiothoracic ICU

2001 to 2007

0

1

2

3

4

5

6

2001 2002 2003 2004 2005 2006 2007

BSI Rate (per 1000 Line Days)

20

11

4

2

16

12

0

Source: Barnes Jewish Hospital Epidemiology and Infection Prevention Department

Initial StateInitial State CLABSIStandardized Infection Ratios with LOWER TARGETS

December 2006 - November 2007

0.00

0.650.65

0.24

0.84

0.94

0.53

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

104ICU 56ICU 82CCU 83ICU 84ICU 89ICU Overall

Source: Barnes Jewish Hospital Epidemiology and Infection Prevention Department

1.0 = NHSN POOLED MEAN FOR THAT TYPE OF ICU1.0 = NHSN POOLED MEAN FOR THAT TYPE OF ICU

Initial StateInitial State

Criteria for meeting all recommendations;

Site disinfected with CHG and air dried Full drape was used

Inserter did the following: practiced HH,

Barnes Jewish Hospital Epidemiology Infection Prevention

Central Line Insertion and Dressing Scorecard

Proper PPE (Sterile gown, gloves mask and cap)Maintained a sterile field

90%

82CCU 91% 94% 94% 94% 66% 79% 96% 15% 83% 83% 83ICU 84% 100% 100% 100% 98% 98% 98% 48% NC 84%

* Is not required to meet all recommendations, NC = Not Collected by the Unit

Unit Inserter

HH Inserter

Sterile gown

Inserter Mask

Inserter Cap used

Site

air dried Drape used

Dated

*

maintained

104ICU 90% 90% 90% 90% 100% 90% 100% NC 90%

CHG Compliance w/allRecommendations

Sterile field Dressing

> 90%

80 - 90%

< 80%

Solution Approach for this EventSolution Approach for this Event

Process Mapping Process Mapping – Current: VA vs. Non-VACurrent: VA vs. Non-VA– Future: VA vs Non-VAFuture: VA vs Non-VA– IdealIdeal

Gemba WalkGemba Walk

Solution Approach for this EventSolution Approach for this Event

Voice of the CustomerVoice of the CustomerIdentified WastesIdentified WastesAffinity DiagramAffinity DiagramImpact MatrixImpact MatrixFlow CellFlow Cell

Current State Process MapCurrent State Process Map

Decision to insertDecision to insertPreparation for insertionPreparation for insertionInsertion of CVCInsertion of CVCMaintenance of CVCMaintenance of CVCDiscontinuation of CVCDiscontinuation of CVC

CURRENT STATECURRENT STATE

Decision To Insert

Prep for

Procedure

Insertion of Central Line

Care &

Maint.

Line Removal

Start IV support/line?

RN to page MD

NoWait

MD to assess

peripheralsWait

Choose MD

Communicate with person insert ingline

Walk and

Search

WaitFind and

communicate with staff

Order for CL

Wait: process order

Patient

EducationLOC

Patient signs paper consent

Wait: MD arrival

Evaluate

patient

condition

Wait: Labs

Transport patient

Wait: staff

arrival

Gather

supplies

Environ-mental

prep

Patient prep

Wait: ultrasnd supplies

MD prep

Patient Prep and Drape

Dry Time

MD prep:

anesthesiaLocal onset

Insertion“ TIME

OUT” & local

Secure dressing

ChestXRay

Verificat-ion

ChestXRay

Read

Use or

Not Use?

Document-ation

Checklist

Document-ation

MD/RN

Monitor patient

and site

Initial Dressing Applied (RN)

Document-ation (RN)

Chest X-Ray

Wait: Xray

Wati: results

Wait for orders

Use of Line (lab draw, flush, med infusion)

Wait

Daily

observation (dressing, cath)

Dressing changes

Infustion management

Decision for lineRemoval ?

Transport to IVR Wait

Assemble equipment

New line placement Wait

RN Discontinues

Line

Document, assess,

placement, removal

Future StateFuture State

– Elimination of CLABSIs by 2010Elimination of CLABSIs by 2010

– ICU CLABSI SIR of 0.38 for 2008 ICU CLABSI SIR of 0.38 for 2008 (no more than #30 CLABSI; 13 in 2009) (no more than #30 CLABSI; 13 in 2009)

– >95% Compliance with CVC insertion and >95% Compliance with CVC insertion and dressing change recommendationsdressing change recommendations

– Identify and evaluate complications related Identify and evaluate complications related to CVC insertion (other than infection) to CVC insertion (other than infection)

Current State to Future StateCurrent State to Future State

Decision to

Insert

Prep for

Procedure

Insertion of

Centra l

L ine

Care &

M aint.

L ine

Rem oval

Start IV

support/

line?

RN to page M DNo

Wait

M D

assessm ent o f

periphria ls

Wait Choose M D

Com m unicate

with person to

insert line

Walk and Search

Wait

Find and

com m unicate

with sta ff

Order for CLWait:

process

order

Patient

EducationLOC

Patient sign

paper consent

Wait: M D

arriva l

Evaluate patient

condition

Wait:

Labs

Transport

patient

Wait: sta ff

arriva l

Gather

supplies

Environm enta l

prepPatient prep

Wait:

u ltrasnd

supplies

M D prepPatient Prep

and DrapeDry Tim e

M D prep: anesthesia

Local onset

Insertion TIM E OUT & loca l

Secure dressing

CXRay VerificationCXRay

ReadUse or

Not Use?Docum entation

ChecklistDocum entation

M D/RN

M onitor patient

and site

In itia l Dressing

Applied (RN)

Docum entation

(RN)Chest X-Ray

Wait:

rad io logy

Wati:

resu lts

Wait for

orders

Use of L ine (lab draw,

flush, m ed

in fusion)

Wait

Daily

observation (dressing, cath)

Dressing

changes

Infustion

m anagem ent

dec for line

rem oval

Transport to

IVRWait

Assem ble

equipm ent

New line

p lacem entWait

RN Discontinue

L ine

Docum ent,

assess,

p lacem ent, rem oval

Current State

Future StateDecision to

Insert

Prep for Procedure

Insertion of Central

LIne

Care & Maint

Line

Removal

Start Daily access Call MD CommunicateMD place

orders

MD get ready (review labs, get consent, det. location)

Room Set-upPrepare pt &

meds

Drape & prep patients(gown,

skin prep)

Time out & Local Anes.

Insert CVC & secure line

MD clean site

& apply dressing

Chest X-ray and read

Interprete &

order Use/No Use

Move pt Clean up room

monitor pt & site

Discuss continued need

change dressing

DocumentInfusion

managment

Clinical

decision for line removal

Assess need

for alternative access & insert

Aquire supplies

for removalRemove Line

Apply dressing & compress &

pt educ about site

Document

6 fewer steps

11 fewer steps

7 fewer steps…

53 % fewer steps

Gap Gap AnalysisAnalysis• Lack of RN competency with Lack of RN competency with

peripheral sticks peripheral sticks • Lack of dedicated vascular Lack of dedicated vascular

access expertsaccess experts Lack of Lack of

communication/command communication/command centercenter

• Lack of standard algorithms: Lack of standard algorithms: initial/daily screening, decision initial/daily screening, decision to insert, decision to removeto insert, decision to remove

• Lack of staff to assist provider Lack of staff to assist provider with insertionwith insertion Central line insertion Central line insertion

requires an appropriately requires an appropriately trained assistanttrained assistant

• Lack of standard work (SW) for Lack of standard work (SW) for line insertion/careline insertion/care No SW for preparation/set up No SW for preparation/set up

and break down and break down No procedure checklist for No procedure checklist for

line insertionline insertion No SW for documentation of No SW for documentation of

line insertion, care and line insertion, care and maintenancemaintenance

• Supplies/Equipment not Supplies/Equipment not available as neededavailable as needed Kits not standardized to Kits not standardized to

contain what is neededcontain what is needed Supplies not available at Supplies not available at

point of carepoint of care Equipment (e.g. ultrasound) Equipment (e.g. ultrasound)

not readily availablenot readily available

Gap AnalysisGap Analysis• Lack of transparency regarding Lack of transparency regarding

competency of provider to insert competency of provider to insert central linescentral lines

• Lack of core central line Lack of core central line competencies for floor staffcompetencies for floor staff

• Lack of standardized central line Lack of standardized central line educationeducation Patients – only given post Patients – only given post

procedureprocedure StaffStaff

• Lack of standard Lack of standard environment for line environment for line placement (e.g. procedure placement (e.g. procedure room vs. pt room)room vs. pt room)

• Lack of technology to Lack of technology to support the central line support the central line processprocess Transparency re Transparency re

insertion, maintenance insertion, maintenance & care (e.g. auto-& care (e.g. auto-population of task lists)population of task lists)

Lack of ability for rapid Lack of ability for rapid read of verification x-rayread of verification x-ray

Solution Solution ApproachApproach

• Just Do ItsJust Do Its – Problem/Gap: Problem/Gap:

Standard full barrier drape not available Standard full barrier drape not available in all patient care areas for CVC in all patient care areas for CVC insertioninsertion Full drapes available at point of careFull drapes available at point of care

Events Projects Do-Its

EVENT TOPIC EVENT TOPICPRO-JECT

PRO-JECT

ACTIONITEM

EVENT TOPIC EVENT TOPICPRO-JECT

PRO-JECT

ACTIONITEM

EVENT TOPIC EVENT TOPICPRO-JECT

ACTIONITEM

ACTIONITEM

ACTIONITEM

– Problem/Gap: Varying staff skill levels placing peripheral IVsProblem/Gap: Varying staff skill levels placing peripheral IVs

– Initial State: Initial State: Multiple attempts – patient discomfort/dissatisfactionMultiple attempts – patient discomfort/dissatisfaction Excessive utilization of central linesExcessive utilization of central lines Medication delaysMedication delays

– Future State: Increased staff skill levels in placing Future State: Increased staff skill levels in placing peripheral IVs; Develop and implement plan for peripheral IVs; Develop and implement plan for multidisciplinary training to include “simulation” trainingmultidisciplinary training to include “simulation” training

– Metric: Decreased CVC utilization ratesMetric: Decreased CVC utilization rates

Performance Improvement Project #1Performance Improvement Project #1

Central Line Utilization Ratio

Medicine Wards

January 2007 - Present

0.20

0.22

0.24

0.26

0.28

0.30

0.32

0.34

0.36

0.38

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2007 2008

Central Line Utilization Ratio NHSNSource: Barnes Jewish Hospital Epidemiology and Infection Prevention Department

Central Line Utilization Ratio

Surgical Wards

Jan 2007 - Present

0.20

0.22

0.24

0.26

0.28

0.30

0.32

0.34

0.36

0.38

0.40

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2007 2008

Central Line Utilization RatioSource: Barnes Jewish Hospital Epidemiology and Infection Prevention Department *Benchmark not available

– Problem/Gap: Lack of standardized educational material for Problem/Gap: Lack of standardized educational material for patients requiring central linespatients requiring central lines

– Initial State: Initial State: There is no standardized patient educational material There is no standardized patient educational material

pre-procedure pre-procedure Although post-procedure material exists, there is no Although post-procedure material exists, there is no

standardization for disseminating to patientsstandardization for disseminating to patients

– Future State: Future State: Create roles for patient and families relative to insertion Create roles for patient and families relative to insertion

and care of central linesand care of central lines Create standardized educational materials and Create standardized educational materials and

standardized process for dissemination to patientstandardized process for dissemination to patient

Performance Improvement Project #2Performance Improvement Project #2

Rapid Improvement Event #1Rapid Improvement Event #1

– Problem/Gap: No standardized process for determining when to Problem/Gap: No standardized process for determining when to insert or remove a central lineinsert or remove a central line Over utilization of central linesOver utilization of central lines Increased risk for complications including BSIsIncreased risk for complications including BSIs

– Initial State: Fragmented process throughout the hospital, Initial State: Fragmented process throughout the hospital, causing inconsistency and variation in the evaluation processcausing inconsistency and variation in the evaluation process

– Future State: Future State: Standardized tool (e.g. algorithm) to predict the optimal Standardized tool (e.g. algorithm) to predict the optimal

vascular access mode for a patientvascular access mode for a patient Consistent, reliable process that will provide appropriate Consistent, reliable process that will provide appropriate

vascular access utilization and monitoringvascular access utilization and monitoring– Metric: 90% utilization of standardized tool to predict optimal Metric: 90% utilization of standardized tool to predict optimal

vascular access mode for patients throughout hospitalization; vascular access mode for patients throughout hospitalization; decrease femoral line utilizationdecrease femoral line utilization

– Problem: Lack of standard work (SW) Problem: Lack of standard work (SW) Preparation, Insertion (Provider & Assistant), Care, Removal, Preparation, Insertion (Provider & Assistant), Care, Removal,

DocumentationDocumentation– Initial State: Poor compliance with current policies, lack of CVC training Initial State: Poor compliance with current policies, lack of CVC training

for non-ICU stafffor non-ICU staff– Future State: Future State:

Insertion checklistInsertion checklist Standardized documentationStandardized documentation Std. work for prep, insertion, care, removal, documentation Std. work for prep, insertion, care, removal, documentation Visual queues to alert staff about line maintenance process steps Visual queues to alert staff about line maintenance process steps A model that empowers staff (in all roles) to A model that empowers staff (in all roles) to STOP THE LINESTOP THE LINE when when

they see non-compliance with infection prevention measures they see non-compliance with infection prevention measures Engineering/administrative controls that will eliminate steps, build in Engineering/administrative controls that will eliminate steps, build in

“mistake-proofing” at each critical step in line insertion process “mistake-proofing” at each critical step in line insertion process– Metric: 95% compliance with insertion checklistMetric: 95% compliance with insertion checklist

Rapid Improvement Event #2Rapid Improvement Event #2

Problem: Lack of standard work (SW)Problem: Lack of standard work (SW) Supplies/EquipmentSupplies/Equipment

• CVC KitsCVC Kits• CartsCarts

– Initial State: Initial State: Disorganization of supplies Disorganization of supplies Supplies not available at point of care Supplies not available at point of care An abundance of wasted motion & time An abundance of wasted motion & time

looking for equipment and supplies looking for equipment and supplies– Future State: Standard CVC supply kits Future State: Standard CVC supply kits

and procedure carts available at point of care and procedure carts available at point of care– Metric: 100% standardized CVC supplies and equipment in Metric: 100% standardized CVC supplies and equipment in

all areas where CVC insertion is performed (cart)all areas where CVC insertion is performed (cart)

Rapid Improvement Events 3, 4Rapid Improvement Events 3, 4

– Problem/Gap: Lack of coordinated Problem/Gap: Lack of coordinated approach to entire spectrum of approach to entire spectrum of vascular access (peripheral and vascular access (peripheral and central line)central line)

– Initial State: No standardized Initial State: No standardized approach; everyone works in silos, approach; everyone works in silos, doing their own thingdoing their own thing

– Future State: Vascular Access Future State: Vascular Access Coordinating Center with identified Coordinating Center with identified experts/best practice/standard work experts/best practice/standard work algorithmsalgorithms

– Metric: Decreased CVC UtilizationMetric: Decreased CVC Utilization

Rapid Improvement Event # 5Rapid Improvement Event # 5

Decision Process for Vascular Access Decision Process for Vascular Access

Rapid Improvement Event #1Rapid Improvement Event #1

April 14-17, 2008April 14-17, 2008

ScopeScope

• Initial assessment for necessity of a central line Initial assessment for necessity of a central line • Daily assessment for line necessityDaily assessment for line necessity

Reasons why line is neededReasons why line is needed When should a line be continued and/or discontinuedWhen should a line be continued and/or discontinued

Reasons for ActionReasons for Action

• No standardized process to decide whether to No standardized process to decide whether to insert a central line or not insert a central line or not

• The lack of standardization produces unnecessary The lack of standardization produces unnecessary procedures and increases risk for complications, procedures and increases risk for complications, including BSI including BSI

• Patient dissatisfactionPatient dissatisfaction

Initial StateInitial State• Throughout the Throughout the

hospital the hospital the decision to insert decision to insert an IV access an IV access varies varies

• Initial assessment Initial assessment of line necessity or of line necessity or line type does not line type does not always meet the always meet the patient’s needpatient’s need

Red dot = waste/non-value added stepGreen dot = value added step

Initial StateInitial StateMetricMetric BaselineBaseline

Peripheral IV Attempts Peripheral IV Attempts 33%33%

((>> 3 attempts) 3 attempts)

n = 21n = 21

% of Staff Able to % of Staff Able to Verbalize Knowledge of Verbalize Knowledge of Procedure Team and Procedure Team and (PICC) Vasc Access Team(PICC) Vasc Access Team

Proc 33%Proc 33%

PICC 87%PICC 87%

# Central Line/PICC # Central Line/PICC Lines:Lines:

RemovedRemoved

Wait time to removeWait time to remove

PICC lines placed PICC lines placed urgently@ DC urgently@ DC

3-5 per wk/unit3-5 per wk/unit

½ hr – 3 hrs½ hr – 3 hrs

13%13%

# of Communication # of Communication Steps – Decision to InsertSteps – Decision to Insert

3 - 223 - 22

Future StateFuture State• To develop a tool that To develop a tool that

will predict the optimal will predict the optimal vascular access device vascular access device for each patientfor each patient Standardized methodology will Standardized methodology will

be utilized for line placement be utilized for line placement decisions decisions

Urgent requests at discharge Urgent requests at discharge for PICC lines and Hohns will for PICC lines and Hohns will be decreasedbe decreased

• To have a consistent To have a consistent and reliable process and reliable process throughout the hospital throughout the hospital that will provide that will provide appropriate vascular appropriate vascular access utilization and access utilization and monitoringmonitoring

Gap AnalysisGap Analysis• Vascular Access CompetencyVascular Access Competency

– Multiple “sticks”Multiple “sticks”– Lack of trust in skill levelLack of trust in skill level– No reliable back up availableNo reliable back up available

• Lack of standard work-variation floor - floorLack of standard work-variation floor - floor– Determining appropriate vascular accessDetermining appropriate vascular access– Daily assessment of access statusDaily assessment of access status– Line RemovalLine Removal

• Lack of transparencyLack of transparency– No cues that patient has PICC or central line No cues that patient has PICC or central line

for discharge planning for discharge planning– No cues for line maintenanceNo cues for line maintenance

• Lack of knowledgeLack of knowledge– Procedure teamProcedure team– Method of ordering a PICC/contacting Vascular Method of ordering a PICC/contacting Vascular

Access ServicesAccess Services– Line Care and Line RemovalLine Care and Line Removal

• Standard WorkStandard Work– Algorithm and Daily Assessment ToolAlgorithm and Daily Assessment Tool– Line RemovalLine Removal– Line MaintenanceLine Maintenance

• Transparency & Visual CuesTransparency & Visual Cues– Compass – electronic documentation/task listsCompass – electronic documentation/task lists– EMTEK – IV flushEMTEK – IV flush

• Communication PlanCommunication Plan– Vascular Access & Procedure TeamsVascular Access & Procedure Teams– RolloutRollout

Rapid ExperimentsRapid Experiments• Problem:Problem:

– Variation in process for determining appropriate IV access Variation in process for determining appropriate IV access • Experiment:Experiment:

– Developed a tool to assist in determining appropriate Developed a tool to assist in determining appropriate access, type, and ongoing necessity of lineaccess, type, and ongoing necessity of line

– Tool will be integrated into Eclipsys/Compass (CPOE)Tool will be integrated into Eclipsys/Compass (CPOE)– Incorporated a daily assessment tool for line type and Incorporated a daily assessment tool for line type and

necessitynecessity• Expected Impact:Expected Impact:

– Decrease BSIDecrease BSI– Decrease LOSDecrease LOS– Increase in patient and staff satisfaction Increase in patient and staff satisfaction – Standardized decision process for line placementStandardized decision process for line placement

• Metric: Metric: – Decrease the % of PIV with attempts >2 Decrease the % of PIV with attempts >2 – RN/Resident comfort level w/determining appropriate accessRN/Resident comfort level w/determining appropriate access

Necessity for Necessity for CVC –CVC –

Scoring ToolScoring Tool

Intravenous Access Determination

Patient Name: DOB: Room #

Circle all scores that apply to this patientAbsolute Indications for Central Venous Access (Central Line) Score

Trauma / Code 15TPN 15

Home IV access needed 15Hemodynamic monitoring 15

Vasoactive drugs (i.e.flolan, norepinepherine, epi, Thymocyte) 15Preferred central line medications (immuneglobulin, dopamine, dobutamine) 15Chemotherapy requiring central line (i.e., ARA-C, Vincristine, Adriamycin) 15

Acute hemodialysis needed 15Chronic hemodialysiss access needed 15

Pheresis 15If any of the above criteria apply, STOP: Refer to LIP* for central line none

AssessmentPoor vasculature (0-1 vessel remaining) 2

Current peripheral IV access failed OR Outside hospital access needs to be removed 11-2 attempts at peripheral access failed 1Expert attempt / assessment failed 2Current Central Line failed 5

Unable to use upper extremities (i.e. AV fistula/graft, mastectomy, amputee, thrombosis) 8Obesity (BSA >) 4

Suboptimal current access (i.e. femoral, drainage, EJ catheter, placed emergently). STOP: Reassess need for linenoneTotal Score for Assessment sectionAnticipated Duration3-7 days 28-14 days 42-3 weeks 63-4 weeks 8

Greater than 4 weeks OR discharged with IV 10Total Score for duration section

InfusionsChemotherapy (not requiring central line) 2

Blood products 4Vancomycin, Cipro, Oxacillin, Zosyn for >72 hours 8Total Score for infusion section

Misc. needsEnd stage renal disease,considering hemodialysis. STOP: Refer to LIP possible Renal consult none

Multiple IV medications or incompatibility 6Frequent routine blood draws (q 6 hours or more frequently for >24hours) 2

Combined score for all sections:Comments:

Score of 6 or less = Does not meet criteria for central line or continuation of existing central lineScore of 7 = Discuss need for central line with primary LIP

Score of 8-15 = Central line necessary, collaborate with LIP to obtain order or assess future needs

UrgencyUrgencyDECISION TO

PLACE CENTRAL ACCESS

URGENCY

CRITICAL :LESS THAN 30

MINUTES

URGENT :30 MINUTES TO 4

HOURS

TODAY /ELECTIVE :

4 HOURS +

Team To Place Line

Code Team

Procedure Team

Primary Team

Team To Place Line

Code TeamPrimary

Team

Team To Place Line

CALL COMMAND CENTER :

2 -1112

CHOOSE LINE

TLC

CORDIS

SHEATH

CHOOSE LINE

SHEATH

CORDIS

TLC

Decision to place & type of lineDecision to place & type of lineCENTRAL LINE

HIGH FLOW or LOW FLOW

HIGH FLOW LOW FLOW

LONG TERM PORT VS HICKMAN

PORT HICKMAN PICC TLC HOHN

SHORT TERMPICC vs TLC

vs HOHN

LONG TERMDuraflow vs

Trifusion

SHORT TERMQuinton vs Hemocath

TRIFUSIONDURAFLOW QUINTON HEMOCATH

ContraindicationsRenal: Limits dialysis access.

Poor Vascular Access: Limited access related to clots, Limited Upper extremity Availability.

New Pacer: Pace maker less than three months old.

IndicationsAccess needed for 5 days to 1 year.

Multiple IV drips/Antibiotics greater than 5 days.

Home IV medications.

TPN (IN HOUSE ONLY)

Rapid Rapid ExperimentsExperiments• Problem: Problem:

– Varying knowledge of resources available for central line Varying knowledge of resources available for central line placement placement

– Underutilization of experts for line placementUnderutilization of experts for line placement• Rapid Experiment: Rapid Experiment:

– Screen Saver – Vascular Access and Procedure TeamsScreen Saver – Vascular Access and Procedure Teams– Dissemination of informational flyersDissemination of informational flyers– Placement of flyer on CCTVPlacement of flyer on CCTV– Article in Article in Physician NewsPhysician News

• Impact: Impact: – Increase efficiency of determining appropriate accessIncrease efficiency of determining appropriate access– More time for staff to focus on patient careMore time for staff to focus on patient care– Line placed in timely mannerLine placed in timely manner– Increased patient satisfaction Increased patient satisfaction

• Metric: Metric: – Increased (95%) staff/resident awareness of resources – Increased (95%) staff/resident awareness of resources –

Vascular Access Team and Procedure Team Vascular Access Team and Procedure Team – Monitor # of requests for PICC placement and Procedure TeamMonitor # of requests for PICC placement and Procedure Team

Need a PICC line?

Contact Vascular Access Service

through ADGO (vascular access referral) or x 2-1112:

Everyday 7:30AM – 8PM

Need a central line?

Contact the Procedure Team

Mon - Fri 8AM – 5PM at 294-4853 (also performs paracentesis, thoracentesis, and lumbar

puncture)

Having trouble with venous access…need Having trouble with venous access…need advice?advice?

Rapid Rapid ExperimentsExperiments• Problem: Problem:

– Variation in the line removal processVariation in the line removal process– Delays in patient dischargeDelays in patient discharge

• Rapid Experiment: Rapid Experiment: – Created standard work for line removalCreated standard work for line removal– Created reference pictorialCreated reference pictorial– Identification of available professionals in each Identification of available professionals in each

department to remove lines department to remove lines – Created an education module for the standard process for Created an education module for the standard process for

line removalline removal • Expected Impact: Expected Impact:

– Increase patient satisfaction Increase patient satisfaction – Decrease infectionDecrease infection– Decrease delays in dischargeDecrease delays in discharge– Improve understanding of proper technique for line Improve understanding of proper technique for line

removalremoval• Metric:Metric:

– # Central lines/PICC removed by nursing staff# Central lines/PICC removed by nursing staff

HeparinHeparinMD, ICU RN, PACU MD, ICU RN, PACU RN, ED RN, 7200 RN, RN, ED RN, 7200 RN,

NP, PA, LCNNP, PA, LCN

MDMDArrow Triple Lumen Arrow Triple Lumen CatheterCatheter

HeparinHeparinVIRVIRVIRVIRNeostarNeostar

HeparinHeparinVIRVIRVIRVIRHohnHohn

HeparinHeparinVIRVIRVIRVIRPower HohnPower Hohn

Saline onlySaline onlyVIRVIRVIRVIRGroshong Tunneled Groshong Tunneled CatheterCatheter

HeparinHeparinVIRVIRVIRVIRHickman catheterHickman catheter

FlushFlushWho removesWho removesWho placesWho placesPicturePictureNameName

Barnes-Jewish Hospital Central Line Grid

Confirmed StateConfirmed StateMetricMetric BaselineBaseline Post ExperimentPost Experiment TargetTarget

Peripheral IV Attempts Peripheral IV Attempts 33%33%

((>> 3 attempts) 3 attempts)

n = 21n = 21

0%0%

% of Staff Able to % of Staff Able to Verbalize Knowledge of Verbalize Knowledge of Procedure Team and Procedure Team and (PICC) Vascular Access (PICC) Vascular Access ServiceService

PICC 87%PICC 87%

Proc 33%Proc 33%

95%95%

# Central Line/PICC # Central Line/PICC Lines:Lines:

RemovedRemoved

Wait time to removeWait time to remove

PICC lines placed PICC lines placed urgently@ DC urgently@ DC

3-5 per wk/unit3-5 per wk/unit

½ hr – 3 hrs½ hr – 3 hrs

13%13%

½ hr½ hr

0%0%

# of Communication # of Communication Steps – Decision to InsertSteps – Decision to Insert

3 - 223 - 22 4-54-5 3 when command 3 when command center implementedcenter implemented

Equipment Equipment neededneeded

Wash handsWash hands

Remove Remove dressingdressing

Clean insertion Clean insertion areaarea

with alcohol stickswith alcohol sticks

and Chloraprepand Chloraprep

PICC LINE REMOVAL EDUCATION FOR STAFF

ETC.

Completion PlanCompletion Plan

Action ItemAction Item Who is Who is ResponsibleResponsible

By WhenBy When

Post screen saverPost screen saver Chad HamptonChad Hampton 4/24/084/24/08

Communication planCommunication plan

(Publications, Meetings)(Publications, Meetings)Jamie GagliarducciJamie Gagliarducci Upon Upon

completion completion of final RIEof final RIE

Place line removal training Place line removal training module on module on PathlorePathlore (intranet)(intranet)

Vicky Ferris, RN Vicky Ferris, RN Angie DixonAngie Dixon

05/16/0805/16/08

Central line removal picturesCentral line removal pictures Melissa Schultz, RNMelissa Schultz, RN

Vicky Ferris, RNVicky Ferris, RN4/24/084/24/08

Rapid Improvement Events #3 & 4Rapid Improvement Events #3 & 4

– Problem: Lack of standard work (SW) Problem: Lack of standard work (SW) Supplies/EquipmentSupplies/Equipment Preparation, Insertion (Provider & Assistant), Care, Preparation, Insertion (Provider & Assistant), Care,

Removal, DocumentationRemoval, Documentation– Initial State: Poor compliance with current policies, Initial State: Poor compliance with current policies,

disorganization of supplies, lack of CL training for non-ICU disorganization of supplies, lack of CL training for non-ICU staffstaff

– Target State: Standard CL supply kits; standardized Target State: Standard CL supply kits; standardized procedure carts on all floors; insertion checklist; procedure carts on all floors; insertion checklist; standardized documentation; SW for prep, insertion, care, standardized documentation; SW for prep, insertion, care, removal, documentation removal, documentation

Confirmed StateConfirmed StateMetricMetric BaselineBaseline PostPost

ExperimentExperimentTargetTarget

Standardized Standardized CL KitsCL Kits

ICU 0%ICU 0%

Nursing Division Nursing Division 0%0%

100%100% 100%100%

POC CL POC CL Supplies – Supplies – Procedure Procedure CartCart

ICU = 100%ICU = 100%

Nursing Division = Nursing Division = 4.5%4.5%

100%100% 100%100%

# Types of CL # Types of CL kitskits

>3>3 11 11

Motion (ft) toMotion (ft) to

Gather SuppliesGather SuppliesNursing Division = Nursing Division =

3810 ft (.72 mi)3810 ft (.72 mi)283 Ft283 Ft Decrease by Decrease by

25%25%

Time to Time to Gather Gather SuppliesSupplies

Nursing Division = Nursing Division =

30-45 min 30-45 min (~.5 (~.5 FTE/year)FTE/year)

2.2 min2.2 min

(8 min to (8 min to restock restock cart)cart)

5 min5 min

# Items to # Items to GatherGather

1717 2 2 Decrease Decrease

by 50%by 50%

Standardized Central Line Kit Standardized Central Line Kit

Needleless caps 3Sterile Saline Flush 3Filtered Needle or straw 1Caps 2Masks with Eye Protection 2Sterile Gowns xl 2Chloraprep 3 ml tinted 1Lidocaine Label 1Full Body Drape 1Needle Driver 1Sterile Towels 4Sterile Pen 1Op Site Dressing 1Suture or Statlock 1Safety Scalpel 1Central Line Insertion Checklist 1Benzoin 1

ORANGE = CVC Supplies/Equip in all store rooms, carts and bins!ORANGE = CVC Supplies/Equip in all store rooms, carts and bins!

Supply Transport OptionsSupply Transport Options

Cart RE-STOCKING procedure-Cart RE-STOCKING procedure-Part of standard work!Part of standard work!

STOP INTERRUPTIONS STOP INTERRUPTIONS DURING CVC DURING CVC

INSERTION!INSERTION!

RIE: Standardized Kits and CVC Carts RIE: Standardized Kits and CVC Carts (Source: Amy Richmond)(Source: Amy Richmond)

Item Current annual cost Estimated annual future cost

CL catheter $14,938 $14,938*

CL Kit $15,732.64 + (single supplies $25.54 ea)

$21,560

CL Carts N/A $39,521.88 Ultrasound N/A $92,000 Cost of CLABSI- $2,088,000 (58 BSIs in 4

PCA over 12 mos) $1,368,000 (38 CLABSIs, 1/3 reduction)

TOTAL $2,118,670 $1,536,019 Savings of $582,651

* Current cost for catheter tray. Cost for catheter minus items placed in new kit to be

determined. Cost will also decrease due to elimination of catheter trays being opened

to remove a single item.

human factors

supplies,“tools”

training

++

tasks

+ +

+ +

+ +

environment

organization, cultureORDERSORDERS

CPOECPOE

information,directives

Steve Cochran, M.D.UBMC

data,information

Need forNeed for CVCCVC++

HC TeamHC Teamalertedalerted

Com

ple

x A

dapti

ve S

yst

em

IP system?IP system?

Who will lead this future IP System?Who will lead this future IP System?

Advanced skills in Advanced skills in facilitation and group process, facilitation and group process, building and leading teamsbuilding and leading teams performance improvement tools and methodsperformance improvement tools and methods change managementchange management

Analytic skills, such as those required to do real-time Analytic skills, such as those required to do real-time point-of-care root cause analysispoint-of-care root cause analysis Refined understanding of systems thinking, complex Refined understanding of systems thinking, complex adaptive adaptive systems/systems approach to problem solvingsystems/systems approach to problem solving Advanced leadership skills: e.g., negotiation, persuasionAdvanced leadership skills: e.g., negotiation, persuasion

Infection Preventionists with...Infection Preventionists with...

Thanks to Amy Richmond, Team Thanks to Amy Richmond, Team Leader; Pat Matt, PI Engineer Leader; Pat Matt, PI Engineer

(Facilitator) and the Teams at Barnes-(Facilitator) and the Teams at Barnes-Jewish Hospital who are committed to Jewish Hospital who are committed to

eliminating HAI.eliminating HAI.

murphyd@mlhs.orgmurphyd@mlhs.org