Project overview (Immersion Call 1)

1. Project overview (Immersion Call 1) Peter J. Pronovost MD, PhD. Johns Hopkins University School of Medicine Quality and Safety Research Group

2. Immersion call Schedule

3. Learning Objectives • To delineate the goals of Cardiac Surgery CER Project • To describe the project organization • To define the interventions • To outline the planned learning sessions • To identify who to call for help

6. Project Organization • Multi-site Project coordinated by Quality and Safety Research Group with collaboration from SCAF • Learning collaborative model (e.g., multisite participation, 2 face-to-face meetings, monthly calls) • Standardized data collection tools and evidence • Local unit modification of how to implement interventions

7. Improving Care CUSP CLABSI Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines 1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools www.safercare.net

8. Pronovost, Berenholtz, Needham BMJ 2008

9. CRBSI Rate Over Time

10. Impact of Statewide Quality Improvement Initiative on Hospital Mortality Lipitz: BMJ 2011

11. Michigan ICU Safety ClimateImprovement * “Needs Improvement” - Safety Climate Score <60%

13. On the CUSP: STOP BSI Preliminary data

14. Lessons Learned • Technical Work • Work for which there is known science • Evidence and Measures • Adaptive work • Work for which there is no science • Requires changes in values attitudes belief • Need to get both technical and adaptive work right • Adaptive work is usually why programs falter

16. Project Goals • Primary Goal: Reduce mortality and length of stay of cardiovascular surgical patients in a cohort of hospitals across the United States. • Secondary Goals: • Reduce / Eliminate Surgical Site Infection rates • Reduce / Eliminate Central line Infection rates to <1/1000 catheter days. • Reduce / Eliminate Ventilator Associated Infection rates in the ICU. • Reduce handoff errors at patient transition points • Implement a unit based safety program to address defects at the local level • Improve patient safety culture in the CVOR, CVICU and Inpatient floor

18. Measure IMPROVE CUSP Comprehensive Unit based Safety program (TRiP) Translating Evidence Into Practice Have We Created a Safe Culture? How Do We know We Learn from Mistakes? How Often Do we Harm? Are Patient Outcomes Improving? Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence www.onthecuspstophai.org

19. Ensure Patients Reliably Receive Evidence Pronovost: Health Services Research 2006

20. Major Intervention Areas • CLABSI • VAP • SSI • CUSP • Cross-unit integration • (For selected sites) Handoffs and Transitions of care

21. Specific Aims • AIM 1: To implement and evaluate the impact of a patient safety program on surgical site infection (SSI) rates and operating room (OR) safety culture in a cohort of cardiac ORs. •  AIM 2: To implement and evaluate the impact of a patient safety program on rates of central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and safety culture in a cohort of cardiovascular surgical intensive care units (CVICUs) • AIM 3: To improve the safety of transitions of care/hand-offs from the cardiac OR to the cardiovascular ICU (CVICU), from the CVICU to the surgical inpatient floor, and from the surgical inpatient floor to hospital discharge. • AIM 4: To facilitate and improve teamwork, communication, and coordination across the three clinical areas/units.

22. OR Measures IMPROVE CUSP Comprehensive Unit based Safety program AIMS Have We Created a Safe Culture? How Do We know We Learn from Mistakes? How Often Do we Harm? Are Patient Outcomes Improving? Surgical Site infection reduction Central Line Associated Blood Stream Infections Improve unit culture Ensure all patients get the evidence Briefing/Debriefing Morning Huddle Learning from defect Hand-off tools Shadowing another provider

23. ICU Measures IMPROVE CUSP Comprehensive Unit based Safety program AIMS Have We Created a Safe Culture? How Do We know We Learn from Mistakes? How Often Do we Harm? Are Patient Outcomes Improving? Surgical Site infection reduction continued Central Line Associated Blood Stream Infections Reduction Ventilator- Associated Pneumonia reduction Improve unit culture Ensure all patients get the evidence Daily Goals Conducting a Morning Briefing Shadowing another provider Learning from defect Observing Rounds

24. CV Inpatient Floor Measures IMPROVE CUSP Comprehensive Unit based Safety program AIMS Have We Created a Safe Culture? How Do We know We Learn from Mistakes? How Often Do we Harm? Are Patient Outcomes Improving? Surgical Site infection reduction continued Central Line Associated Blood Stream Infections continued Improve transitions in care Improve unit culture Ensure all patients get the evidence Daily Goals Shadowing another provider Learning from defect Hand-off tools Identifying who is on call

25. Action Items • Send us key contact person and ID • Start to form interdisciplinary team in each area • eview content of website at www.safercare.net • Toolkits • Slidesets • Manuals • Project Management Checklists • Pre-Implementation Checklist • CEO/ Senior Leader Checklist • Infection Preventionist Checklist

26. To Get Help • Email David Thompson DNSc, RN for study related questions. dthomps1@jhmi.edu • Talk to your team leader

27. References Measuring Safety • Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199. • Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699. • Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

28. References Measuring Safety • Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199. • Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699. • Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

29. References • Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40. • Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75. • Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337. • Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68. • Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.