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Case Study 3: Reducing Infection and Mortality Rates in a Pediatric Intensive Care Unit Note:

the following is an adaptation of a case study from Children's Hospital in Cincinnati. Some of the specialized language of health care has been removed to increase understanding for all readers. Children's Hospital Medical Center in Cincinnati has used the Model for Improvement for a number of years to guide improvement work. It was decided in 2005 to take lessons learned from the Institute for Healthcare Improvement's (IHI) 100K Lives campaign (adult focus) and apply these changes to reduce infection and mortality rates for children in the Pediatric Intensive Care Unit (PICU). The PICU cared for 1,982 patients in 2007, with an average daily census of21.5. It began this decade with mortality rates that were average for PICUs of their size and patient mix. They were not satisfied with the status quo and sought to improve the outcome for these vulnerable patients. They targeted the infections that were key contributors to PICU mortality. An analysis of their 2005 data found that ventilator-associated pneumonia (VAP) and catheter-associated blood stream infection (CA-BSI) cases represented the highest reasons for mortality. What Are We Trying to Accomplish? • Decrease the rate of VAP in the PICU by 50 percent (from a baseline of 5.6 per 1,000 ventilator days) and sustain this level of performance for at least two quarters • Decrease the rate of CA-BSIs in the PICU to less than or equal to 1.0 per 1,000 central line days by June 2007 In our effort to reduce VAP rates, an internal improvement collaborative was organized among our three critical care units: PICU, cardiac critical care unit, and neonatal intensive care units. Unit physician and nurse leaders along with lead respiratory therapists from each ICU made up the team. Our CA-BSI project was carried out via an improvement collaborative with physician and nurse representation from several parts of the organization, including our three intensive care units (among them the PICU), our hematology-oncology service, our operating room and anesthesia services, and one of our gastroenterology floors. How Will We Know That a Change Is an Improvement? We used four key measures to track our progress. They are described in Table 12.1 and appear in the graphs near the end of the study. Table 12.1. Measurements, Definition, Baseline, and Goals for the Project. What Changes Can We Make That Will Result in Improvement? VAP We adapted the adult ventilator care bundle developed for IHI's 100K lives campaign for use in our pediatric intensive care population. This bundle of changes included several specific changes that were proven to be effective in other health care organizations in earlier improvement efforts and offered as a proven practice to members of IHI. CA-BSI Our organization has also been involved in multiple efforts to reduce CA-BSI rates over the past several years, including involvement in a 2003 collaborative with ten other local hospitals. We began by implementing small PDSA tests of change around specific bundle elements for both insertion and maintenance bundles that have proven successful in reducing infection rates in other collaboratives. Supporting Changes In addition to the focus on the two bundles of changes to affect both VAP and CA-BSI, we found it necessary to add additional changes to impart the necessary structure to sustain the improvements. Table 12.2 describes these changes for both VAP and CA-BSI. Table 12.2. Additional Changes to Support the Adherence to Bundles. Here is a description of one series of PDSA Cycles used to adapt, test, and implement these changes: Plan: Having developed a draft pediatric ventilatory care bundle, we determined that compliance with the bundle components needed to be tracked to ensure compliance by ICU staff. The team developed a draft monitoring tool and developed a process whereby one respiratory therapist (RT) and one registered nurse (RN) would test the tool for one month. Do: The team developed a checklist to assess the extent to which the components of the pediatric ventilatory care bundle were carried out-—The first draft of this checklist was tested by one respiratory therapist and one RN on selected day shifts for one month. Study: The team assessed the extent to which the checklists were completed, as well as the compliance indicated. On the basis of feedback from the RN and RT, the team determined that it made more sense for the RT to complete the checklist than the RN. The RT had more direct involvement with the bundle components. However, the team also determined that because many of the bundle components involved collaboration between the RT and RN, the RT had to engage the RN in conversation regarding bundle compliance. The team determined that small wording and formatting changes would lead to a more user-friendly tool. Act: Having determined that the checklist was a viable way to assess compliance with the bundle components, the team decided to test a slightly revised version on a larger scale—with more patients and on additional shifts. Through subsequent PDSAs, the team: • Tested the monitoring tool on various shifts • Tested the tool with additional caregivers • Made additional revisions to the tool (including adding a space to note issues and challenges, and adding notes regarding contraindications to implementing the bundle components with particular patients) Implementation After numerous PDSAs to adapt the changes, the items included on the compliance form were eventually added to RN and RT flowsheets. The Social Impact of Change As with any attempt to transform deeply entrenched care processes with the goal of dramatically improving outcomes, this work was not without challenges. Here are examples of the challenges that we faced, along with our methods for overcoming them. As these challenges were overcome, our belief that the changes we had tested would lead to improvement was bolstered. Challenge: Convincing clinical colleagues to adapt changes that did not have substantial evidence in the pediatric population. Solutions: Shared improving rate data with colleagues as it became available. Challenge: An initial reticence to share outcomes data with the broader organization, as well as patients and families. Solutions: Shared improving rate data with colleagues as it became available. Staff became eager to show off results of excellent care. Challenge: Perception among staff that improvement activities were adding to already substantial clinical care for very ill patients. Solutions: Shared improving rate data with colleagues as it became available demonstrated that changes actually led to enhanced efficiency. Challenge: In collaborative improvement efforts with other units, reticence among these units to test changes suggested by the PICU with “their” population. Solutions: Allowed other units to adapt changes to their own environment and devise tests of change that were acceptable to their staff. Summary of Results The improvement activities presented in this case study helped us achieve the outcomes described in Table 12.3. Table 12.3. Summary of Measurement Results Compared to Baseline and Goals. We have also achieved important improvements in efficiency: • Mean hospital length of stay for VAP patients was 26.5 ± 13.1 days compared to 17.8 ± 4.7 days for non-VAP patients • Mean hospital attributable costs for VAP patients were $156,110 ± $80,688 compared to $104,953 ± $59,191 costs for non-VAP patients The use of run charts with control limits has helped us identify the points at which improvement in our outcomes is likely to be significant and not due to special causes in our system. For both VAP and CA-BSI, we saw a significant shift in the average PICU rate following the launch of the improvement initiatives: For VAP, a shift in the PICU average rate from 5.6 per 1,000 ventilator days to .50 per 1,000 line days occurred in April 2006. For CA-BSI, a shift in the PICU average rate from 3.1 per 1,000 ventilator days to 2.8 per 1,000 line days occurred in October 2006. Figure 12.7 shows the control charts and run charts that were used to monitor progress of the changes tested and implemented for the PICU. Lessons Learned That Can Be Spread to Others Here are specific lessons learned from our effort that would benefit other hospitals: Figure 12.7. Family Of Measures For PICU Improvement Effort. • An intensive focus on reduction of infections in pediatric intensive care units can result in substantial and sustained improvement. The reductions in morbidity, family stress, and cost are real and measurable, as are improvements in family and staff satisfaction, and staff retention. • Engaging frontline caregivers from the beginning of these projects helped ensure that the interventions reflected the practicalities and realities of daily care and also helped ensure their buy-in and enthusiasm for this work. • Embedding the improvements into routine clinical care is essential. Building the work into daily routines instead of layering it on as “extra” work promoted efficiency and caregiver buy-in. Examples of this are adding the bundle components to RN flowsheets and making discussion of central line issues part of daily PICU rounds. • Adult “bundles” of changes can be adapted to the pediatric setting with few modifications, leading to dramatic results. • Once initial success in reducing infection rates is achieved, it is essential to continue random chart audits to review compliance with bundle components. Success could potentially lead to complacency with new care processes, so the knowledge that the care being provided may be audited can increase the likelihood of compliance by staff members. • Celebrate successes! When the PICU reached milestones (such as one hundred days or six months) for the time between infections, staff appreciated celebrating with a party and cake. • The use of real-time case notification and immediate analysis of causes was one of the best ways to identify compliance issues with the bundles, patient factors that might require additional interventions, and steps to be taken toavoid similar cases in the future. The staff now “huddle” at the bedside to discuss cases and learn from the results of the analysis. • Staff previously untapped for improvement work, such as respiratory therapists involved with our VAP reduction work, were extremely effective change agents for improvement projects in the intensive care setting thanks to their real day-to-day ownership of and experience with the clinical care processes. • Implementing bundles aimed at reducing infection rates can be accelerated by the involvement of multiple units within the hospital. This leads to cross-fertilization of ideas and economies of scale in terms of financial, human, and improvement resources and ensures that patients in different parts of the organization benefit from the best possible care. • There is likely to be a strong business case for a variety of improved outcomes in the PICU, as our analysis of our VAP improvement work demonstrates. Case Study 4: Improving Safety at a Manufacturing Plant A manufacturing plant that produced cabinets experienced a number of unprofitable years. Lack of standardized and optimized processes resulted in poor performance in safety, productivity, claims, and quality. Customers were unhappy due todelays in shipments and product defects. Because there was no formal system to make improvements, poor performance persisted. Facing the possibility of a plant closure and the loss of jobs, leaders of the parent organization set an objective to improve performance in the key measures of the plant: safety, on-time deliveries, productivity, and quality. This case study is focused on the work at the plant that began in 2006 to improve safety. A new management team was given leadership of the plant at the end of 2005. They established objectives for key plant measures. For safety, the management team established objectives to reduce lost time accidents and OSHA recordable injuries by 50 percent in both 2006 and 2007. To achieve these objectives, the management team needed to make safety a priority, so they immediately instituted a support structure to foster effective changes: • Improvement in safety measures was imbedded in all managers’ goals. • Safety was made an agenda item at all management meetings. • A multidisciplinary safety team was formed. Engineers, managers, supervisors, and hourly workers from production and representatives from maintenance were members of the team. Meetings were held regularly to discuss safety issues and improvement strategies. The management team also took steps to ensure the responsibility for safety did not reside just with them or members of the safety team. • All supervisors, leads, and hourly workers were given safety training. Leads are staff who work on the line but are also cross-trained to fill in at other positions. One result of the training was that each morning when the group huddled to discuss issues for that day, safety was included. • Maintenance issues with safety implications were given priority. • Three engineers were hired and dedicated part of their time to eliminating hazardous conditions as sources of injuries. The management team instituted benchmarking within and outside the company to identify best practices, ongoing safety audits to identify hazardous conditions and unsafe behaviors and the analysis of all safety events. Informed by this information, the safety team summarized the problems producing poor safety outcomes. This summary, referred to as a driver diagram, is shown in Figure 12.8. In the driver diagram, the safety team also included areas for improvement to address the problems. Figure 12.8. Driver Diagram Of Safety Problems and Areas for Improvement. The management team established an organized system of improvement to address the safety problems identified. They set goals; dedicated resources to developing, testing, and implementing changes; and established time to review progress. To focus the work, they developed a charter for the safety team for their improvement efforts in 2006. Seen in the box “Charter for Improving Safety at a Manufacturing Plant,” it answers the question “What are we trying to accomplish?” Charter for Improving Safety at a Manufacturing Plant PDSA Cycles for Testing a Change Cycle 1: Plexiglas Guards Plan Objective: Test the use of a Plexiglas guard installed on equipment with rotating shaft for sanding and cutting Questions: Would a Plexiglas guard prevent workers from lifting the guard to perform cutting or sanding and thus reduce lacerations? Why? Predictions: This unsafe behavior will be greatly reduced once workers can see through the Plexiglas guard to perform the work. The old guards did not allow a clear view of the work area. Keeping the guard down when cutting or sanding will reduce lacerations. Who, what, where, when: Maintenance will install a Plexiglas guard on one machine. Two operators on the day shift will perform sanding and cutting operations with the guard on Monday. The operators will be asked to comment on the ease of performing the operations with the guard. Do Test was carried out as planned. Study Both operators commented that the Plexiglas guard did not hinder their work and saw no reason not to keep it down. They believed it would greatly reduce the number of lacerations that occur when cutting and sanding is performed with the guards up. Act Thanks to the success of the test, plans were made to install the Plexiglas guards on all equipment with rotating shafts. Before the guards were installed, a few workers on the evening shift were asked to perform cutting and sanding with the Plexiglas guard. Cycle 2 and Cycle 3 In cycle 2, two workers on the evening shift were asked to perform cutting and sanding with the Plexiglas guard. Results were similar to cycle 1. In cycle 3, guards were installed throughout the plant on equipment with rotating shafts. Data collection included compliance with keeping the guards down, satisfaction of the operators with use of the guards, and the number of lacerations that occurred during sanding and cutting operations. Installation of Plexiglas guards addressed a hazardous condition. To achieve the full impact on improved safety, worker compliance with using the new guards was still required. The management team understood they needed to balance a “blame free” environment with individual accountability. They would always place the initial focus on making timely changes to have an impact on hazardous conditions. If a hazardous condition existed and resulted in an unsafe behavior, a worker would not be disciplined. Once the hazardous condition was eliminated and a policy for safe behavior established, workers would be disciplined for not following the policy. This Progressive Discipline System is described next. Cycles to test and implement the system began in parallel with the cycles to test the Plexiglas guards. Progressive Discipline System • Hazardous condition identified (for example, guards difficult to see through, resulting in workers lifting guards) • No discipline for unsafe operation or injury until hazardous condition addressed • Priority given to a physical change to correct the hazardous condition (such as Plexiglas guards) • Policy on safe behavior established if not already existing (Plexiglas guard must remain down when working) • Policy enforced with violations, with or without injury, resulting in discipline Cycle 1: Progressive Discipline System The Progressive Discipline System was reviewed with supervisors, leads, and hourly workers. They requested that short but formal training sessions be conducted prior to a policy being enforced. The safety team was given responsibility for this. Cycle 2 The safety team developed a short training session on the use of the Plexiglas guard. The session was tested with a few workers and some minor clarifications made. The session was then required for all workers who use equipment with rotating shafts. Cycle 3 To formally implement the Progressive Discipline System, the safety team documented the system and shared it with all staff at scheduled meetings. Discussion of the system was included as part of orientation for new staff. The safety team kept and reviewed data on those disciplined, the unsafe behavior, and comments from both the lead and the staff member disciplined. They used this information to ensure the system was functioning as designed. Other Areas of Improvement 1 Lifting procedures. To reduce the number of strains from lifting, training on lifting was conducted. Weight limits were also established for workers. For example, two men were needed to lift anything weighing over fifty pounds. This and other lifting procedures were tested and adherence monitored. After some minor changes to the procedures, a policy was developed that spelled out the lifting procedures at the plant. Once the policy was agreed on, lifting procedures became part of the progressive discipline system. • Use of forklifts. A worker, whose work station was within an aisle used by forklifts, was hit by a forklift and injured. Neither the worker nor the driver was disciplined for the existence of this hazardous condition. But from the incident, the management team chose to include guidance in the safety charter that work areas and forklift aisles should be clearly separated. As part of the improvement work, all work stations near forklift aisles were relocated. Forklift aisles were clearly marked and walking lanes indicated. The new layout was tested over a short time period. Once agreement was reached to make the layout permanent, a policy was developed for safe driving of forklifts and safe behavior of workers. Use of forklifts became part of the progressive discipline system. Summary of Results The plant achieved its aim for 2006 to reduce lost time accidents and OSHA recordable injures by 50 percent. The improvement continued through 2007. Although a 50 percent reduction in lost time accidents was not achieved from 2006 to 2007, the overall reduction from 2005 to 2007 exceeded the strategic goal. The number of staff who needed first aid and the number of near misses also decreased. The data are shown in Table 12.4. Table 12.4. Summary of Results. Leadership is essential to improve safety and other system measures. Leaders both at the parent organization and at the plant committed to improve the plant's poor safety record. Strategic objectives focused on safety were established, and improvement in the safety measures was imbedded in management goals. Thanks to the actions of leaders, everyone understood that safety was a priority. Maintenance, for example, began prioritizing issues with safety implications. Appropriate structures should be established to facilitate the improvement of safety. A multidisciplinary safety team was formed at the plant to manage the improvement work. Both management meetings and daily huddles conducted by staff included formal agenda items on safety. The management team established policies for safe behavior. All staff should be involved in making improvements. The safety team developed a driver diagram to document knowledge of problems affecting safety outcomes. The team reviewed data to determine the initial areas of focus. Supervisors, leads, and hourly workers all had input into developing changes. The time of hourly workers was used efficiently by bringing them together in twenty-minute huddles, with supervisors and leads filling in on the line as needed. Engineers supplied technical input. Leads ensured that tests were carried out as planned. To improve safety, there should be a balance of system improvement and individual accountability for unsafe behavior. The progressive discipline system was developed at the plant to achieve this balance. A policy for safe behavior was enforced only after hazardous conditions were eliminated. Policies were reviewed and approved by supervisors, leads, and hourly workers. Once the policy was in place, individuals were disciplined for unsafe behaviors. Case Study 5: Improving the Credentialing Process at CareOregon CareOregon is a not-for-profit organization that is committed to improving and protecting the health of low-income and vulnerable Oregonians. One area CareOregon identified for improvement was workflow between the credentialing and provider services departments. The credentialing department is responsible for ensuring the quality of the health care facilities and medical providers contracted with CareOregon. Provider services manages the contracts, relationships, and system data for health care facilities and providers that participate with the health plan. The aim for improvement identified was the method by which each department identified and communicated the credentialing status of providers. Background The current process involved seven people in the two departments. They tracked multiple calls to providers in a complicated, time-consuming spreadsheet, which when printed was more than five feet wide. Each department functions independently, using its own reports and access to information. The system dominated decisions and actions, while relationships suffered. Sponsors from both departments identified key staff who had intimate knowledge of the process. During a two-day workshop, the team was introduced to the Model for Improvement. Chapter Fourteen has an example of the agenda that was used to get the team going (under “Getting Started”). During the workshop, relationship awareness theory was explored with a method called the Strengths Deployment Inventory (SDI), which was a critical factor in helping team members understand each other's differences and create a foundation for building trust in a historically low-trust situation. The team used the Model for Improvement charter to create a picture of the three questions with the addition of change concepts, which were identified by the team for generating ideas to test. Questions generated by the team were grouped into the initial cycles and prioritized for learning. Figure 12.9 describes the tree diagram to summarize the approach to the project. During a twelve-week period, the team met weekly, running concurrent PDSA Cycles by subgrouping members of the team to “divide and conquer PDSA Cycles.” The team created a flow diagram of the credentialing process; it is presented in Figure 12.10. Assumptions were tested and team members learned each other's processes by cross-training, discovering missing information (available to only one department but presumed available to both) which caused individuals to personalize and misinterpret actions. The most important cycle was to test the elimination of the five-foot-wide spreadsheet, as shown in Figure 12.11. Summary of Results At the conclusion of the team project, the entire five-foot-wide spreadsheet was eliminated. The project team included eight members, two sponsors, and three ad hoc members for developing and testing this change. The process is now done as a daily task by one credentialing administrative assistant and one provider information specialist rather than seven persons. The streamlined process eliminates work duplication and improves the clarity of communication processes, documentation, and integration of processes. Figure 12.12 shows the impact of these changes on the control charts kept by the two people involved before and after the changes. Most important, the interdepartmental relationship has grown to have greater respect and trust. New issues and processes are now openly discussed and identified for additional improvement opportunities. Figure 12.9. Model for Improvement in a Tree Diagram. Figure 12.10. Flow Diagram for Credentialing Request Process. Figure 12.11. PDSA Cycle No. 4: Test Elimination of Tracking Spreadsheet.

Case Study 5: Improving the Credentialing Process at CareOregon

CareOregon is a not-for-profit organization that is committed to improving and protecting the health of low-income and vulnerable Oregonians. One area CareOregon identified for improvement was workflow between the credentialing and provider services departments. The credentialing department is responsible for ensuring the quality of the health care facilities and medical providers contracted with CareOregon. Provider services manages the contracts, relationships, and system data for health care facilities and providers that participate with the health plan. The aim for improvement identified was the method by which each department identified and communicated the credentialing status of providers.

Background

The current process involved seven people in the two departments. They tracked multiple calls to providers in a complicated, time-consuming spreadsheet, which when printed was more than five feet wide. Each department functions independently, using its own reports and access to information. The system dominated decisions and actions, while relationships suffered. Sponsors from both departments identified key staff who had intimate knowledge of the process. During a two-day workshop, the team was introduced to the Model for Improvement. Chapter Fourteen has an example of the agenda that was used to get the team going (under “Getting Started”). During the workshop, relationship awareness theory was explored with a method called the Strengths Deployment Inventory (SDI), which was a critical factor in helping team members understand each other's differences and create a foundation for building trust in a historically low-trust situation.

The team used the Model for Improvement charter to create a picture of the three questions with the addition of change concepts, which were identified by the team for generating ideas to test. Questions generated by the team were grouped into the initial cycles and prioritized for learning. Figure 12.9 describes the tree diagram to summarize the approach to the project.

During a twelve-week period, the team met weekly, running concurrent PDSA Cycles by subgrouping members of the team to “divide and conquer PDSA Cycles.” The team created a flow diagram of the credentialing process; it is presented in Figure 12.10.

Assumptions were tested and team members learned each other's processes by cross-training, discovering missing information (available to only one department but presumed available to both) which caused individuals to personalize and misinterpret actions. The most important cycle was to test the elimination of the five-foot-wide spreadsheet, as shown in Figure 12.11.

Summary of Results

At the conclusion of the team project, the entire five-foot-wide spreadsheet was eliminated. The project team included eight members, two sponsors, and three ad hoc members for developing and testing this change. The process is now done as a daily task by one credentialing administrative assistant and one provider information specialist rather than seven persons. The streamlined process eliminates work duplication and improves the clarity of communication processes, documentation, and integration of processes. Figure 12.12 shows the impact of these changes on the control charts kept by the two people involved before and after the changes.

Most important, the interdepartmental relationship has grown to have greater respect and trust. New issues and processes are now openly discussed and identified for additional improvement opportunities.

Figure 12.9. Model for Improvement in a Tree Diagram.