Hi. We're going to talk today about, Building Momentum. I think we last talked about developing a quality improvement initiative. And here we're talking about the capacity for patient and safety and quality to be improved and expanded, and the way we do that is we take something that was successful at the local level, and we can either move it across the organization, we can move it state wide, we can move it national and international. So, we're really going to talk about how we go about doing that. Taking a local initiative and moving forward. So our objectives today are really to look at some of the things that we needed to do as we moved from local to some more national quality improvement initiatives. The other thing is that we want to talk a little bit about the implementation science that's behind this, that have led to our success, and our continued success because after we were able to do this once we were able to do this numerous time with lots and lots of different quality improvement projects. And we really want to take a chance to look at the intervention itself, and take apart the intervention and teach you how you go about doing the same thing within your own organization. So the background for building momentum, clearly if you've seen this before. We talked about the CLABSI program at Johns Hopkins and in the late 1990s to the early 2003. Is It took us really five years to get a handle on infections that were a rate of anywhere from 10-20 per 1000 catheter days. And all of the different adaptive work that we had to do in order to meet the needs of our ICU providers at the local level through that program, not only did we develop translating evidence through practice, but we also developed the comprehensive units-based safety program which was our method to address some of the adaptive programs that we had here. And in this opportunity, we're going to talk about how we took our local initiative from two ICU at Johns Hopkins that were very successful, into the whole state of Michigan and we called that the Michigan Keystone project. And, what was really exciting about that was that we asked for all comers from the ICU. So we had a 108 ICU that actually signed up to participate at the end of the program, which was two years. We had 103 ICU that were able to provide us data consistently, and those were the ones that were included in this initiative. So it was implementing both the trip model for the CLABSI prevention. It was also implementing the 5 step CUSP program although I believe it was six. We also started with looking at the daily goals for them because that is one of the CUSP tools that we found to add to a lot of success. And then, leading the change within those organizations, why we did it in a collaborative effort? So we would fly out to Michigan and we would have face to face meetings with all of the partners so we would have physicians and nurses from each of the hospitals and then, we had to find other ways in order to keep them connected and educate them from long distance. So really you're going to learn from steps from the very beginning until the end of the program after watching this video. So here's where we were at Johns Hopkins, and as you can see it took us a long time, what we were hoping to do with Michigan because we had felt that we had worked out all of the problems that we had had on getting system change, or culture change within the organization was really utilizing each one of these steps. So we had to include each one of these different components into the work. And we're going to be going over how we did that? And how we provided the support at the local level for the Michigan Keystone Hospital Association and for the 108 participants that were there. So everything that you see here that we did to eliminate CLABSI within Johns Hopkins ICU, were the things that we were going to do. And we showed a lot of promise with those. So epidemiology of CLABSI at the time we were looking at a pretty significant problem. So we had already shown at Johns Hopkins that this was definitely a preventable harm. It was an infection that did need to happen, by placing the line appropriately, and by maintaining the line appropriately. We were able to reduce the annual CLABSI rates, we were able to reduce the mortality rate, and we were also able to reduce the cost. And at the end of this I think you'll be very surprised to see that we spend up to $29,000 per patient for each one of these CLABSI infections. How much money we were able to save statewide, and then later we took this nationally. So this, as you've probably seen before is the Armstrong institute Model to Improve Care. It starts with the translating evidence into practice, and because a little bit of time went by between when we began working with Johns Hopkins, and when we moved to Michigan, there was still another literature search that was done. And the level for insertion of evidence really didn't change. So it was those five pieces that I'm going to be talking about, which is wash your hands before any procedure. It was where you choose to put your line. And that was to avoid the femoral site to use for barrier precautions, which was a study that was done that showed with forbearer cautions we reduce infections by two to three fold. It was also removing lines as quickly as possible. And the way we did that was we had to find a method in order to remind providers every day that this put the patients at risk. And then lastly, how do we address the adaptive change? And that adaptive work came through the comprehensive unit safety program, which to date has been the only program that has been shown to improve both safety and teamwork culture across the board, whether you use the safety attitude's questionnaire, or whether to use the hospital survey on patient safety which was developed by the Agency for Healthcare Research and Quality. So some of the finer points of designing safer systems was very important and this comes to us from the science of safety, and a lot of this work has done way before health care providers became involved in patient safety. Other risk averse industries and high reliable organizations have focused on this many more years at least two decades longer than we have. And the first one is that standardizing care was especially beneficial because you made sure that patients were getting the evidence every time. When we did an analysis that looked at all types of care patients presenting to the E.R. depending on where they were getting care about 10 to about 60 percent of patients actually got evidence based care. So standardizing care was something that we found would enable us to make sure that all patients all comers coming into the hospital would be getting the care that they needed that was supported by the evidence that were shown to reduce preventable harm. The other thing that we wanted to look at was, how do we go about making sure that we're doing this safely, and that is by creating independent checks. I gave an example of insulin, where many nurses look at each other's insulin vial, and we look at the insulin syringes that are coming out of them. But a truly independent check, where we focus on preventing harm is where we look at every step of the process. So a nurse or a physician that would be doing an independent check would be a second set of eyes to walk through the whole process. So not only would you be looking at the MAR to see what the prescribed dose would be he'd be looking at the glucometer to see what the reading was. And then you would be looking at both the vial and the syringe and leaving the vial and the syringe together so that you could see that the syringe of insulin actually came out of that vial. And that would be an independent check. When you confirmed all three of those areas not only the physician order but the glucometer. And then what was drawn up. And then like other high reliable organizations was learning from defects and this is really about focusing on what we don't want to have happen in hospitals. And when we got started with our work we really found that there was under reporting in fact the literature supported that about 40-90 some percent of adverse events were not reported. If you don't report something there is no way that we can address how to fix it. So that was something that we also had to address. So looking at how often the frequency of reporting, and then learning from the defects not just fixing one aspect, but looking at all the system factors that were responsible. And then addressing each one of those. So unlike a root cause analysis where you might have 10 different things that were identified to eliminate that problem we would want to implement everything that we identified from the learning from defect tool. And that's one of the cost tools that we've used. And really this comes down to understanding the technical work which is the processes of care that are based on the evidence and the adaptive work that we use in order to train our providers and get them to have buy in to support this work that we're doing. And here is the trip model as you can see it is quite extensive. The very beginning provides us with the literature review to support the evidence that we're doing, and all the way down to the implementation, which begins with the last square which begins with engage. How do you engage your participants? So from that, summarize the evidence makes sure that everybody has the evidence make sure that we have included that in all of our tools that we're using to implement. And we want to make sure that everybody that enters the hospital receives the evidence, when they get a central line placed.
