Overview of STOP-BSI Program (Text Version)

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On September 15, 2009, Peter Pronovost made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.5 MB).  

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Slide 1

Overview of STOP-BSI Program Peter Pronovost, MD, PhD

Quality and Safety Reseach Group

Slide 2

Black and white picture of a baby playing on the beach.

Slide 3

Graph of wrong-site Surgeries Reviewed by Year

Slide 4

Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average

• How smart am I
• How hard do I work
• How kind am I
• How tall am I
• How good is the quality of care we provide

Slide 5

Image depicting Regulatory, Scientifically Sound, Local Wisdom/Market, and Feasible in a quad image with a red x in between Regulatory and Feasible.

Slide 6

Goals

• To work to eliminate central line associated blood stream infections (CLABSI); state mean < 1/10000 catheter days, median 0
• To improve safety culture
• To learn from one defect per month

Slide 7

Project Organization

• Partner with HRET, MHA, JHU, State Hospital Associations
• State wide effort coordinated by Hospital Association
• Use collaborative model (2 face to face meetings, monthly calls)
• Standardized data collection tools and evidence
• Local ICU modification of how to implement interventions

Slide 8

Safety Score Card Keystone ICU Safety Dashboard

	2004	2006
How often did we harm (BSI)	2.8/1000	0
How often do we do what we should	66%	95%
How often did we learn from mistakes*	100s	100s
Have we created a safe culture % Needs improvement in
Safety climate	84%	43%
Teamwork climate*	82%	42%

CUSP is intervention to improve these

Slide 9

Improving Care

CUSP	Translating Evidence Into Practice (TRiP)
1. Educate staff on science of safety	1. Summarize the evidence in a checklist
2. Identify defects	2. Identify local barriers to implementation
3. Assign executive to adopt unit	3. Measure performance
4. Learn from one defect per quarter	4. Ensure all patients get the evidence
5. Implement teamwork tools

Slide 10

Intervention to Eliminate CLABSI

Slide 11

A flow chart of the Translating Evidence into Practice is shown.

Pronovost BMJ 2008

Slide 12

Evidence-based Behaviors to Prevent CLABSI

• Remove Unnecessary Lines
• Wash Hands Prior to Procedure
• Use Maximal Barrier Precautions
• Clean Skin with Chlorhexidine
• Avoid Femoral Lines

MMWR. 2002;51:RR-10

Slide 13

Identify Barriers

• Ask staff about knowledge
  • Use team check up tool
• Ask staff what is difficult about doing these behaviors
• Walk the process of staff placing a central line
• Observe staff placing central line

Slide 14

Ensure Patients Reliably Receive Evidence

	Senior Leaders	Team Leaders	Staff
Engage	How does this make the world a better place?
Educate	What do we need to do?
Execute	What keeps me from doing it? How can we do it with my resources and culture?
Evaluate	How do we know we improved safety?

Pronovost: Health Services Research 2006

Slide 15

Ideas for ensuring patients receive the interventions: the 4Es

• Engage: stories, show baseline data
• Educate staff on evidence
• Execute
  • Standardize: Create line cart
  • Create independent checks: Create BSI checklist
  • Empower nurses to stop takeoff
  • Learn from mistakes: review infections
• Evaluate
  • Feedback performance
  • View infections as defects

Slide 16

Pre CUSP Work

• Create an ICU team
  • Nurse, physician administrator, others
  • Assign a team leader
• Measure Culture in the ICU
  (discuss with hospital association leader)
• Work with hospital quality leader to have a senior executive assigned to ICU team

Slide 17

Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture

1. Educate staff on science of safety
   http://www.safercare.net
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools

Pronovost J, Patient Safety, 2005

Slide 18

Identify Defects

• Review error reports, liability claims, sentinel events
  or M and M conference
• Ask staff how will the next patient be harmed

Slide 19

Prioritize Defects

• List all defects
• Discuss with staff what are the three greatest risks

Slide 20

Executive Partnership

• Executive should become a member of ICU team
• Executive should meet monthly with ICU team
• Executive should review defects, ensure ICU team has resources to reduce risks, and how team accountable for improving risks and central line associated blood steam infection.

Slide 21

Learning from Mistakes

• What happened?
• Why did it happen (system lenses)
• What could you do to reduce risk
• How to you know risk was reduced
  • Create policy / process / procedure
  • Ensure staff know policy
  • Evaluate if policy is used correctly

Pronovost 2005 JCJQI

Slide 22

Teamwork Tools

• Call list
• Daily Goals
• AM briefing
• Shadowing
• Culture check up
• TEAMSTepps

Pronovost JCC, JCJQI

Slide 23

Can We Do this

Slide 24

Safety Score Card Keystone ICU Safety Dashboard

	2004	2006
How often did we harm (BSI)	2.8/1000	0
How often do we do what we should	66%	95%
How often did we learn from mistakes*	100s	100s
Have we created a safe culture % Needs improvement in
Safety climate	84%	43%
Teamwork climate*	82%	42%

CUSP is intervention to improve these

Slide 25

CRBSI Rate Summary Data

An image of the CRBSI Rate Summary Data table is shown.

Slide 26

CRBSI Rate Over Time

An image of a diagram of Median and Mean CRBSI rate over time is shown.

Slide 27

VAP Rate Over Time

An image of a diagram of Median and Mean VAP Rate Over Time is shown.

Slide 28

Michigan ICU Safety Climate Improvement

Pre-CUSP (2004): 87%

Post-CUSP (2006): 47%

* "Needs Improvement" - Safety Climate Score <60%

Slide 29

How Healthy Is Our Culture?

Safety Attitudes Questionaire Domain Scores

An image of a graph showing 6 of 7 domains have shown statistically significant improvements since 2006.

Slide 30

Michigan ICU Safety Climate Score Distributions

Two images of of diagrams are shown. The first diagram is of ICU safety climate score distributions. The second is a diagram is of the percent reporting good safety climate in 2004.

Slide 31

#5. "Medical Errors Are Handled Appropriately In This ICU."

An image of the percent of respondents within an ICU that agree.

Slide 32

#4."I Would Feel Safe Being Treated Here As A Patient."

An image of the percent of respondents within an ICU that agree

Slide 33

Focus and Execute

Picture of a urinale.

Slide 34

Black and white picture of a baby playing on the beach.

Slide 35

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.

Slide 36

References

• Translating Evidence into Practice
• Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: A model for large scale knowledge translation. BMJ. 2008; 337:a1714.
• Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM. 2006; 355(26):2725-2732.
• Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in michigan. J Crit Care. 2008; 23(2):207-221.

Slide 37

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, 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.