Welcome to the

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• Welcome to the
• NQF Safe Practices for Better Healthcare Webinar
• Preventing CLABS Infections Safe Patients,
  Smart Hospitals
• (Safe Practice 21)
• Hosted by TMIT

To join the online webinar, go to
www.safetyleaders.org Online Access Password
Webinar1 (case-sensitive)
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Welcome
Charles Denham, MD Chairman, TMIT Co-chairman,
NQF Safe Practices Consensus Committee Chairman,
Leapfrog Safe Practices Program Safe Practices
Webinar March 18, 2010
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Panelists
Peter Pronovost
Kathy Warye
Charles Denham
Charles Denham Welcome and Safe Practices
Overview Kathy Warye APIC Resources for
Targeting Zero HAIs Peter Pronovost Safe
Patients, Smart Hospitals
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Panelists
Patti ORegan
Melinda Sawyer
Deborah Hobson
Deborah Hobson Melinda Sawyer Clinical
Pearls for Nursing to Eliminate CLABSIs Patti
ORegan The Role of the Patient Advocate
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Disclosure Statement
The following panelists certify
that unless otherwise noted below, each presenter provided full disclosure information, does not intend to discuss an unapproved/investigative use of a commercial product/device, and has no significant financial relationship(s) to disclose. If unapproved uses of products are discussed, presenters are expected to disclose this to participants.

• Charles Denham Chairman, TMIT education grant
  (CareFusion) and co-production with Discovery
  Channel
• Peter Pronovost Grants, AHRQ, NPSA (Reducing
  CLABSI), honoraria from hospitals and healthcare
  systems (speaking on quality and safety),
  co-authored book Safe Patients, Smart Hospitals
• Kathy Warye Employed by Association for
  Professionals in Infection Control and
  Epidemiology (APIC)
• Deborah Hobson, Melinda Sawyer, and Patti ORegan
  have no relevant financial interests in this
• presentation

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The Role of the Patient Advocate

• Patti ORegan, ARNP, ANP, NP-C, PMHNP-BC
• Nurse practitioner, Port Richey, FL
• Founding member, TMIT Patient Advocate Panel
• Safe Practices Webinar
• March 18, 2010

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Safe Practice Overview
Charles Denham, MD Chairman, TMIT Co-chairman,
NQF Safe Practices Consensus Committee Chairman,
Leapfrog Safe Practices Program Safe Practices
Webinar March 18, 2010
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Harmonization The Quality Choir
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The Patient Our Conductor
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2010 NQF Safe Practices for Better Healthcare A
Consensus Report

• 34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness

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History of NQF Safe Practices for Better
Healthcare

• 2010 Final Report
• Format Structure Preserved
• Problem Statement and Implementation Guide
  Thoroughly Updated
• Minor Specification Changes
• Updated References
• Corrections and Clarifications
• Care Setting Clarification Using CMS
  Classification
• Measures Section Updated Thoroughly with
  NQF-Endorsed and Other Practical Measures for
  Consideration
• Soft Copy Document Hyperlinks
• Crosswalk Tables
• Glossary

• 2009 Final Report
• From 30 to 34 practices
• Culture Practice Elements Broken Up into 4
  Practices
• 2 Practices Discontinued
• 4 Medication Management Practices Combined into 1
• 2 Communication Practices Combined into 1
• 8 New Practices Added
• CMS Care Settings Defined
• Patient and Family Involvement Section Added

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2003, 2006, and 2009 Update Versions
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2010 NQF Report
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Culture

• CHAPTER 2 Creating and Sustaining a Culture of
  Patient Safety (Separated into Practices
• Leadership Structures and Systems
• Culture Measurement, Feedback, and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards

Culture Meas., FB., and Interv.
Structures and Systems
ID and Mitigation Risk and Hazards
Team Training and Team Interv.
Consent Disclosure

Consent and Disclosure

• CHAPTER 3 Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver

Informed Consent
Life-Sustaining Treatment
Disclosure
Care of Caregiver
Workforce

• CHAPTER 4 Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care

2010 NQF Report
Nursing Workforce
ICU Care
Direct Caregivers

• CHAPTER 5 Information Management and Continuity
  of Care
• Patient Care Information
• Order Read-Back and Abbreviations
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
  including CPOE

Information Management and Continuity of Care
Read-Back Abbrev.
Patient Care Info.
CPOE
Discharge System
Labeling Studies
Medication Management

• CHAPTER 6 Medication Management
• Medication Reconciliation
• Pharmacist Leadership Role Including High-Alert
  Med. and Unit-Dose Standardized Medication
  Labeling and Packaging

Med. Recon.
Pharmacist Systems Leadership High-Alert, Std.
Labeling/Pkg., and Unit-Dose

• CHAPTER 7 Hospital-Associated Infections
• Hand Hygiene
• Influenza Prevention
• Central Venous Catheter-Related Blood Stream
  Infection Prevention
• Surgical-Site Infection Prevention
• Care of the Ventilated Patient and VAP
• MDRO Prevention
• UTI Prevention

Healthcare-Associated Infections
Central V. Cath. BSI Prevention
Hand Hygiene
Influenza Prevention
VAP Prevention
Sx-Site Inf. Prevention
MDRO Prevention
UTI Prevention

• CHAPTER 8
• Wrong-Site, Wrong-Procedure, Wrong-Person Surgery
  Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
• Organ Donation
• Glycemic Control
• Falls Prevention
• Pediatric Imaging

Condition-, Site-, and Risk-Specific Practices
Wrong-site Sx Prevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
Contrast Media Use
Falls Prevention
Organ Donation
Glycemic Control
Pediatric Imaging
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LEADERSHIP STRUCTURES and SYSTEMS
Patients and Community
Leadership Structures and Systems
Culture Measurement, Feedback, and Intervention
Teamwork Training and Skill Building
Identification and Mitigation of Risks and
Hazards
NQF 34 Safe Practices
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HAI Guidelines
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APIC Resources for Targeting Zero HAIs
Kathy L. Warye Chief Executive Officer,
Association for Professionals in Infection
Control and Epidemiology (APIC) Safe Practices
Webinar March 18, 2010
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The Association for Professionals in Infection
Control Epidemiology

• Mission To improve health and patient safety
  by reducing the risks of infection and related
  adverse outcomes
• Global leader in infection prevention
• Over 13,000 members worldwide, responsible for
  infection prevention and hospital epidemiology in
  a variety of healthcare settings
• Cores services
• Education, practice guidance, research,
  communications and public policy

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• Developing and Validating Clinical Best-Practices
  
• APIC works with 28 healthcare organizations to
  facilitate consensus on practice recommendations.
  
• Ensures that the development of standards and
  guidelines are evidence-based.

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Targeting Zero

• Setting the theoretical goal of elimination of
  HAIs
• An expectation that IPC measures will be applied
  consistently
• A safe environment for healthcare workers,
  empowered to
  hold each other accountable
• Systems and administrative support that provide
  the necessary foundation
• Transparency and continuous learning
• Prompt investigation of HAIs
• Real-time data to front line staff to drive
  improvement
• Zero tolerance for unsafe behaviors and practices
  that put patients and healthcare workers at risk

APIC 2008 Targeting Zero Position Statement
www.apic.org
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Targeting Zero CRBSI/CLAB Resources

• Online Course Elimination of Catheter-Related
  Bloodstream Infections
• Part of APIC ANYWHERE Online Course Offerings,
  delivered via Healthstream
• Helps healthcare workers recognize the role they
  play in the transmission and prevention of
  CR-BSIs
• Participants are provided with resources and
  checklists to assist in developing prevention
  strategies
• Eliminating Catheter-Related Complications
  Toolkit
• CNE-certified, features video demonstration of
  proper catheter insertion, check-lists for
  insertion and maintenance, additional learning
  modules and discussion of the cultural attributes
  of reaching zero CR-BSIs.
• Guide to the Elimination of Catheter-Related
  Bloodstream Infections
• Provides step-by-step guidance to facilitate the
  bedside implementation of relevant clinical
  evidence and best practices for eliminating
  CR-BSIs
• Webinars
• Strategies to Prevent Catheter-Related
  Bloodstream Infections
• Access Site and Hub Disinfection The Missing
  Link in the CR-BSI Prevention Bundle

Visit www.apic.org/guidelines to access the CDC
Guidelines for CR-BSIs, and more.
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Safe Patients, Smart Hospitals
Peter J. Pronovost, MD, PhD, FCCM Professor,
Johns Hopkins University School of
Medicine(Departments of Anesthesiology and
Critical Care Medicine, and Surgery), Bloomberg
School of Public Health (Department of Health
Policy and Management), and School of
Nursing Medical Director, Center for Innovation
in Quality Patient Care Safe Practices
Webinar March 18, 2010
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A National Program to Eliminate CLABSI Peter
Pronovost, MD, PhD
Safe Patients, Smart Hospitals
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Regulatory
x
Scientifically Sound
Feasible
Local Wisdom/Market
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IMPROVE
Measure
How Often Do we Harm? Are Patient Outcomes
Improving?
Have We Created a Safe Culture? How Do We know We
Learn from Mistakes?
www.safercare.net
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Pronovost BMJ 2008
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Checklist to Prevent CLABSI

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

MMWR 200251RR-10
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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

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Ensure Patients ReliablyReceive Evidence
  Senior Team Staff
  leaders leaders Staff
Engage How does this make the world a better place? How does this make the world a better place? How does this make the world a better place?
Educate What do we need to do? What do we need to do? What do we need to do?
Execute What keeps me from doing it? What keeps me from doing it? What keeps me from doing it?
Execute How can we do it with my resources and culture? How can we do it with my resources and culture? How can we do it with my resources and culture?
Evaluate How do we know we improved safety? How do we know we improved safety? How do we know we improved safety?
Pronovost Health Services Research 2006
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Ideas for ensuring patients receivethe
interventions the 4Es

• Engage stories, show baseline data
• Educate staff on evidence
• Execute
• Create line cart that contains all needed
  supplies
• Empower nurses to stop takeoff
• Learn from mistakes review all infections as
  defects
• Evaluate
• Feedback performance
• View infections as defects

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Partnership

• To help with 4Es, Partner with
• ICU physician and nurses
• Infection control staff
• Hospital quality and safety leaders
• Nurse educators
• Physician leaders

ICU staff must assume responsibility for reducing
CLABSI
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Comprehensive Unit-based Safety Program (CUSP)
An Intervention to Learn from Mistakes and
Improve Safety Culture

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

Pronovost, J Patient Saf, 2005

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Science of Safety

• Understand system determines performance
• Use strategies to improve system performance
• Standardize
• Create Independent checks for key process
• Learn from Mistakes
• Apply strategies to both technical work and team
  work
• Recognize that teams make wise decisions with
  diverse and independent input

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Learning from Mistakes

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

Pronovost, JCJQI 2005
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Teamwork Tools

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

Pronovost, JCC, JCJQI
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CRBSI Rate Summary Data
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CRBSI Rate Over Time
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VAP Rate Over Time
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Michigan ICU Safety ClimateImprovement
Needs Improvement - Safety Climate Score lt60
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How do we move to level 4? 5?
Level 1 Enroll in program
Level 2 Implement the checklist or bundle but do not collect data on CLABSI, or CLABSI rates remain high
Level 3 Culture change junior nurse can stop a senior physician who does not comply with checklist when placing a catheter and the interaction goes well
Level 4 Profound and Sustained reduction in CLABSI, Improvement in Culture, Joy in work
Level 5 Self sustaining Develop new efforts that are just as effective
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Action Plan

• Join your states effort to eliminate CLABSI
  contact your state hospital association or email
  stopbsi_at_jhmi.edu to find contact person
• Meet with ICU team, infection control staff,
  quality and safety leaders, nurse educators and
  physician champions
• Understand barriers (walk the process)
• Use 4E grid to develop strategy to engage,
  educate, execute and evaluate

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Focus and Execute
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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.

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References

• Translating Evidence into Practice
• Pronovost PJ, Berenholtz SM, Needham DM.
  Translating evidence into practice A model for
  large scale knowledge translation. BMJ. 2008
  337a1714.
• 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.
• Peter J Pronovost, Christine A Goeschel,
  Elizabeth Colantuoni, Sam Watson, Lisa H
  Lubomski, Sean M Berenholtz, David A Thompson,
  David J Sinopoli, Sara Cosgrove, J Bryan Sexton,
  Jill A Marsteller, Robert C Hyzy, Robert Welsh,
  Patricia Posa, Kathy Schumacher, and Dale
  Needham.Sustaining reductions in catheter
  related bloodstream infections in Michigan
  intensive care units observational study. BMJ.
  2010340c309, doi 10.1136/bmj.c309

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References

• Pronovost P, Weast B, Rosenstein B, et al.
  Implementing and validating a comprehensive
  unit-based safety program. J Patient Saf. 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.

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Clinical Pearls for Nursing To Eliminate CLABSIs
Deborah Baugher Hobson, BSN Quality Improvement
Chairperson/Staff Nurse Johns Hopkins Hospital
Surgical Intensive Care Unit Patient Safety
Clinical Specialist, Center for Innovation in
Quality Patient Care
Melinda Sawyer, RN, MSN Patient Safety Officer,
Department of Medicine, The Johns Hopkins
Hospital Senior Clinical Research
Coordinator, The Johns Hopkins University
Quality and Safety Research Group (QSRG) Safe
Practices Webinar, March 18, 2010
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Clinical Pearls for Nursingto Eliminate CLABSIs

• Putting evidence into every day practice
  walking the process
• Empowering the Nurses to stop the process at any
  step with every insertion
• Now that the line is insertedhow do we maintain
  the line to remain infection-free?

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Q A
Peter Pronovost
Kathy Warye(Denise Graham - proxy)
Charles Denham
Patti ORegan
Melinda Sawyer
Deborah Hobson
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The Role of the Patient Advocate

• Patti ORegan, ARNP, ANP, NP-C, PMHNP-BC
• Nurse practitioner, Port Richey, FL
• Founding member, TMIT Patient Advocate Panel
• Safe Practices Webinar
• March 18, 2010

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