# Presentation: 035235

## Improving Care Through Technical & Adaptive Work

- Chris Goeschel RN MPA
- Director, Patient Safety &Quality Initiatives
- JHU Quality & Safety Research Group
- cgoesch1@jhmi.edu

## Central Mandate

- Local Wisdom

- Scientifically Sound

- Feasible

**X**

## The Johns Hopkins Comprehensive Unit-based Safety Program

- Evaluate culture of safety
- Educate staff on science of safety
- Identify defects
- Assign executive to adopt unit
- Learn from one defect per month and implement teamwork tools
- Evaluate culture
**www.safetyresearch.jhu.edu**

**Pronovost J Patient Safety 2005**

**Notes:**
CUSP

## Creating Reliable Healthcare

- Identify interventions associated with improved outcomes in specified population
- Select strongest interventions, convert to behaviors
- Develop measures (either process or outcome)
- Ensure patients receive the intervention

## Preventing 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

## Technical Challenges

- Can be solved with existing science or technology
- Issues or challenges for which there is “an answer”
- Amenable to centralized development

## Slide 7

## Adaptive Challenges

- Require a change of values, attitudes or beliefs
- Local...........respecting the wisdom of the front line worker

## How do we need to learn?

**How do we need to learn?**

**Notes:**
Point when improve technical, what is left to improve like aviation when planes are in air.        Where is variation among you.    SSI not likely technical     

## Leading Change

**Leading Change**

|  | Executive Leaders | Team Leaders | Staff |
| --- | --- | --- | --- |
| Engage
adaptive | How Do I Make the World a Better Place?
How do I create an organization that is safe for patients and rewarding for staff?
How does this strategy fit our mission?  | How Do I Make the World a Better Place?
How do I create a unit that is safe for patients and rewarding for staff?
How do  I touch their hearts? | How Do I Make the World a Better Place?
Do I believe I can change the world, starting with my unit?
Can I help make my unit safer for patients and a better place to work?  |
| Educate
technical | What Do I Need to Know?
What is the business case?
How do I engage the Board and Medical Staff?
How can I monitor progress?  | What Do I Need to Know?
What is the evidence?
Do I have executive and medical staff support? 
Are there tools to help me develop a plan? | What Do I Need to Know?
Why is this change important?
How are patient outcomes likely to improve?
How does my daily work need to change?
Where do I go for support? |
| Execute
adaptive |  What Do I Need to Do?
Do the Board and Medical Staff support the plan and have the skills and vision to implement?
How do I know the team has sufficient resources, incentives and organizational support? 
  | What Do I Need to Do?
Do the Staff Know the plan and do they have the skills and commitment to implement? 
Have we tailored this to our environment? | What Do I Need to Do?
Can I be a better team member and team leader?
How can I share what I know to make care better?
Am I learning from defects?  |
| Evaluate
technical | How Will I Know I Made a Difference?
Have resources been allocated to collect and use safety data?
Is the work climate better?
Are patients safer?
How do I know? | How Will I Know I Made a Difference?
Have I created a system for data collection, unit level reporting, and using data to improve?
Is the work climate better?
Are patients safer?
How do I know? | How Will I Know I Made a Difference?
What is our unit level report card?
Is the unit a better place to work? 
 Is teamwork better?
Are patients safer?
How do I know? |
|  |  |  | © Quality and Safety Research Group, Johns Hopkins University    |

## Collaborative Participants

- Agree to use common methods for improvement
- Data reporting and analysis, central
- Collaborative learning
- Training, support, coaching from the collaborative sponsor & faculty
- Benchmarking

## Key Concepts

- The purpose of data is to help understand, control, and improve processes and systems
- Measurement for learning and testing, not for judgment
- Must measure to improve

## Safety Measures

- How often do we harm patients?
- BSI and VAP
- How often do we do what we should?
- Vent bundle
- How often do we learn from defects?
- Learn from one per month
- How well do we improve culture?
- SAQ

**Notes:**
Culture tell e bay story.   

## 80% Reduction in BSI in One Year

| Time period | Median CRBSI rate | Incidence rate ratio |
| --- | --- | --- |
| Baseline | 2.8 | 1 |
| Peri intervention | 1.7 | 0.53 |
| 0-3 months | 0 | 0.33 |
| 4-6 months | 0 | 0.31 |
| 7-9 months | 0 | 0.2 |

- 433 prevented infections 108 deaths

## Lessons Learned

- Need to get technical and adaptive work right
- Centralized measurement, local ownership

## Lessons Learned

- Technical lessons
- Link culture and specific outcomes
- How have you used your SAQ and clinical results?
- Data quality control
- Does your project team include and respect expertise of technical and adaptive experts ?  (Infection control, education, QI, organizational development etc?)

## Lessons Learned

- Adaptive lessons
- Commit that harm is untenable; make harm visible
- What does this look like in your clinical area?
- Ohana
- How have you shared what you are learning with other teams in the collaborative?
- Local modification of execution
- Have you adapted the implementation in light of your organizational culture?

## Important Research Questions

- How can we improve quality improvement?
- Will public reporting change focus from doing good to looking good ?
- What degree of evidence is required to develop a process measure?
- How will we know we made a difference?

## Can We Cross the Chasm ?

- Science demands rigor
- Patients deserve reliability
- We are capable ~
- Do we have the courage?

## Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.”
						Margaret Meade

- 						Margaret Meade