Brad Mrsa For CDC Meeting Oct. 20 2009

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74. Redesign Strategies to Reduce MRSA: Community Collaboratives Using Positive Deviance and Lean”, Invited Talk, Eliminating Hospital Acquired Infections Grantees Meetings, CDC, Atlanta, GA, October 19-21, 2009.

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Brad Mrsa For CDC Meeting Oct. 20 2009

  1. 1. Redesigning Hospital Care to Reduce MRSA : Collaboratives Using Positive Deviance, & Lean<br />HAI Elimination Grantee Meeting, CDC, Oct 20, 2009<br />Brad Doebbeling, MD, MScDirector, IU Center for Health Services Research, HSR Director, Regenstrief Institute, <br />Senior Scientist, VA HSR&D Center of Excellence<br />Med. Dept. Professor of Health Services Research, IU School of Medicine, Indianapolis, IN <br />
  2. 2. Acknowledgements<br /><ul><li>Funding from AHRQ
  3. 3. Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria HHSA2902006000131 (Completed)
  4. 4. Healthcare Associated Infections (HAI) Initiative Assessment Program HHSA290200600013I (Current)
  5. 5. Implementing and Improving the Integration of Decision Support into Outpatient Clinical WorkflowHSA2902006000131(Current)
  6. 6. Funding from AHRQ and CDC
  7. 7. Testing Spread and Implementation of Novel MRSA-Reducing Practices HHSA290200600013 (Current)
  8. 8. Thanks to our collaborators, partners, providers, patients!</li></li></ul><li>Reservoir for the Spread of Antibiotic Resistant Pathogens<br />Colonized patients, NOT just infected patients, can transmit <br />AR pathogens to healthcare workers and other patients.<br /><ul><li>Clinical Cultures +
  9. 9. History of MRSA</li></ul>Unidentified Colonized Patients<br />
  10. 10. Efficacy of Preventive Interventions<br /><ul><li>Large body of consistent evidence that control is highly cost effective (Gould 2006)
  11. 11. Organizational Change initiatives (Lean, PD) effective reductions of MRSA 50-85% (Pittsburg, Indy, RWJ Beta 2008-9)
  12. 12. Active interventions to eliminate MRSA transmission shown to save money and lives (van Rijen & Kluytmans, 2009)
  13. 13. Innovative approaches to engage hospital staff to intervene and improve healthcare processes effective in reducing MRSA (Cooper 2005)
  14. 14. External pressure on hospitals to implement universal active MRSA surveillance.  Several states and the VA mandated screening (Graham, 2007)</li></li></ul><li>Regional Collaboratives- <br /><ul><li>Indianapolis has unique health information exchange (RHIO)
  15. 15. Indiana Network for Patient Care (INPC)
  16. 16. Includes nearly all of the healthcare systems in Indianapolis
  17. 17. Spans >95% of all of the inpatient care in the city, expanding regionally.  
  18. 18. The five competing health care systems share electronic information with INPC on their patients, to ensure safe and quality health care. </li></li></ul><li>MRSA Phase One<br /><ul><li>AHRQ funded proposal to reduce MRSA in hospitals over 18 months through the ACTION collaborative funding mechanism
  19. 19. Our interventions were based on the Pittsburgh VAMC bundle, using lean, organizational change and informatics (data exchange, reporting):
  20. 20. Conduct active surveillance of all incoming pts. in ICUs
  21. 21. Improve rates of contact isolation
  22. 22. Improve hand hygiene rates
  23. 23. Organizational change
  24. 24. Environmental decontamination</li></li></ul><li>MRSA Phase One<br /><ul><li>Our health care engineers partnered with and trained front-line workers to use lean and positive deviance approaches
  25. 25. Focused on sharing evidence and methods, coaching front-line staff teams to lead instituting systems changes to systematize processes and sustain practices.
  26. 26. Regular measurement and feedback of adherence to enhance adoption.
  27. 27. Weekly huddle of all hospital teams to identify barriers & facilitators, review and reinforce progress, share best practices, strategize about spread and solutions.
  28. 28. Collaboration teleconferences</li></li></ul><li>Lean Tools<br />Define the Problem<br />Project Charter<br />Baseline Current Processes<br />Process Map<br />Check sheet<br />Process Observation Worksheet<br />Identify <br />Operational Barriers<br />Spaghetti Diagram<br />Develop<br />Future State Process<br />Lean Tools<br />Process Control<br />Strategy<br />Process Control Plan<br />
  29. 29. An Operational Citywide Electronic Infection Control Network: Results from 1st Year<br /><ul><li>Infection control is a regional problem, requiring a coordinated effort
  30. 30. Created a citywide electronic notification system to prospectively track all known patients with MRSA
  31. 31. Currently track 17,000 patients with a history of MRSA infection or colonization across Indianapolis.
  32. 32. Since May 2007, delivered 2698 admission alerts on patients with a history of MRSA, 19 percent based on data from another institution.
  33. 33. 20 infection control providers (ICPs) spanning 16 hospital </li></ul>Kho, Lemmon, Dexter, Doebbeling AMIA 2008<br />
  34. 34.
  35. 35.
  36. 36.
  37. 37. MRSA Phase One Results<br /><ul><li>Significant improvement in process measure adherence to 80->95%
  38. 38. Pre and post intervention results for first three hospitals mean of 60% reduction on study units over 9-12 months
  39. 39. ~ 20% reduction MRSA infections hospital wide
  40. 40. Reduction in level of MRSA among S. aureus (4th hospital)
  41. 41. Reduction in associated BSIs and UTIs (4th hospital)
  42. 42. Presented at Academy Health, AHRQ and AMIA 2008, 2009</li></li></ul><li>MRSA Phase Two<br />Spreading the successful intervention of Phase One to more units in Indianapolis<br />Recruited 4 Indy and 3 other hospital systems <br />University Health Network, Toronto, Ontario<br />St. Patrick’s Health, Missoula, Montana<br />Maine Medical System, Providence, Maine<br />Training and Coaching Using Experienced Integrated Positive Deviance with Lean Coaches<br />
  43. 43. MRSA Phase Two<br /><ul><li>What is Positive Deviance?
  44. 44. Technique to engage front line staff in owning & improving processes and sustaining change
  45. 45. Based on identification of practices of used by ‘positively deviant’ staff/departments
  46. 46. Critical for staff involvement/buy-in</li></li></ul><li>Integrated Lean/PD approach<br />Define the Problem<br />Baseline Current Processes<br />Discovery<br />Identify <br />Operational Barriers<br />Dialogues<br />Develop<br />Future State Process<br />Action<br />Process Control<br />Strategy<br />
  47. 47. Discovery and Action Dialogues <br />Informal meetings held with front line staff to discuss the current status of the process<br />Incorporate as much front line staff as possible<br />The goal is to ‘discover’ the issues and potential solutions and then take ‘action’ as rapidly as possible.<br />It is easier to “act your way into a new way of thinking”than to “think your way into a new way to acting”<br />
  48. 48. MRSA Phase Two<br />What’s different in Phase Two besides spread to new systems?<br />Learning Collaborative: Teams from hospitals connect with teams from other hospitals employing the MRSA Intervention Bundle to foster learning and innovation.<br />More extensive activities to train interdisciplinary teams within each of the participating health systems.<br />
  49. 49. MRSA Phase Two- Challenges<br /><ul><li>Leadership engagement critical in times of financial and H1N1 challenges
  50. 50. Data collection for research rigor may be too intensive for most community hospitals
  51. 51. Hospitals need and desire regular feedback on impact of interventions
  52. 52. Need a better electronic data collection infrastructure relating to displaying intervention success (outcome data)
  53. 53. Need better solutions to support long-distance collaboration, coaching, mentoring
  54. 54. Need new mechanisms for academic achievement, paper writing, publishing of redesign papers, new journals, new toolkits</li></li></ul><li>MRSA Phase Two – Lessons Learned<br />System redesign approach of training, consultation and coaching front-line staff seems to be strong, sustained approach<br />Importance of buy-in from highest institutional levels crucial<br />Enthusiasm builds from within because redesign teams own it!<br />Informatics tool helpful in identifying great cross-over of MRSA patients in hospitals<br />
  55. 55. Conclusions from other recent AHRQ Work<br />Hospital Acquired Infections Collaboratory has identified many important barriers, facilitators and positive deviant practices to reduce HAIs!<br />Usability assessments, including enthnographic observation, structured interviews and usability testing of prototypes valuable for improving CDS!--see Haggstrom et al, Saleem et al at AMIA 2009<br />
  56. 56. HAI: Barriers & Challenges to Infection Prevention at the Point of Care<br />AHRQ Hospital Acquired Infections Collaborative<br />July 13 and 14th, 2009<br />Brad Doebbeling, Chris Kiess & Shawn Hoke<br />AHRQ HAI Coordinating Ctr.<br />Regenstrief Institute, Indianapolis<br />Indiana University School of Medicine<br />
  57. 57. Key Barriers<br /><ul><li>Problems when leadership support is MIA, naivete’ about resource requirements
  58. 58. Challenges of unanticipated change (turnover of residents, champions in units, nursing staffing, redesign of units, new information system)
  59. 59. Demonstrating cost effectiveness, limited additional funds
  60. 60. Competing priorities, level of required documentation in daily work
  61. 61. Use and documentation of bundle variables inconsistent- Real time data collection, burden of reporting
  62. 62. Availability of time, staff and effective approaches for training
  63. 63. Need to convince professionals EBPs are beneficial to them and their patients—given limited time
  64. 64. Mix of hospitals (large, small) and unique challenges (surveillance) of a small rural community, non-profit hospital
  65. 65. Evolve guidelines based on developing evidence.
  66. 66. Time, persistence and structured communication needed for practice/culture change to take hold.
  67. 67. Involving key stakeholders (unit champions, front-line) integrating into the unit</li></li></ul><li>Key Facilitators<br /><ul><li>Teamwork Crucial (the leader isn’t always in the front (bicycle racing team))
  68. 68. Mechanism to provide staff with strong evidence-base
  69. 69. Communicate expectations and require accountability
  70. 70. Do what works locally—ability to adapt to local context
  71. 71. Promise of providing back data one of greatest motivators.
  72. 72. Strong physician and nurse leadership and champions
  73. 73. IT develops an electronic checklist (data warehouse) to allow data queries and feedback compliance on process measures
  74. 74. Top executives make rounds and solve problems
  75. 75. Mandatory state reporting (NHSN) and changes in CMS reimbursement
  76. 76. Leadership support results in sufficient time for front-line staff to improve processes, change systems and achieve success
  77. 77. Communication, involvement of front-line staff imperative
  78. 78. celebrating the successes</li></li></ul><li>Lessons Learned/“Positive Deviants”<br /><ul><li>Developing implementation plans, audit tools, assess sustained translation of prevention interventions in clinical practice.
  79. 79. Identify current practices, opportunities and action plans for improvement
  80. 80. Utilize strengths of individuals to motivate and sustain changes in behaviors—nurses really want to train younger nurses and mentor
  81. 81. Need to use strength and experiences of champions key to implementing and sustaining changes over time
  82. 82. Use multiple venues to raise awareness and reinforce practice (start with medical leadership, then staff, getting board involved, posting BSI rates in bathrooms)
  83. 83. Compare performance in a meaningful way
  84. 84. Start small (at unit level, make it work, easy success begets success, then spread)
  85. 85. Collect limited data that is most relevant to showing impact of interventions
  86. 86. Data collection needs to have face validity with clinicians and be timely</li></ul>Lessons Learned/“Positive Deviants<br />”<br />
  87. 87. Lessons Learned/“Positive Deviants”<br /><ul><li> Program for nurses in TRIP, reviewing evidence, coaching TRIP project, write a manuscript (Titler)
  88. 88. Once physician (ICU) unit leadership adopts goals to be the best in hand hygiene for the hospital—strong driver of change
  89. 89. Regularly (daily) measuring and feeding back hand hygiene at unit level really reinforces adherence
  90. 90. Nurses encouraged by manager and ICU directors to “call out” non-adherence and teasing/cajoling low adherence providers
  91. 91. Advanced Practice Institute provides training in implementing EBP, critique of CPGs, and hospital-specific action plans
  92. 92. IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) for data queries and feedback compliance to units
  93. 93. After eliminating BSIs for a year in intervention unit, then every subsequent BSI is reviewed and discussed by an interdisciplinary team
  94. 94. Integrating checklists into work rounds, electronic systems is effective
  95. 95. Multiple champions, staff engagement helps overcome turnover in project leadership</li>

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