Day 2
Gary Kantor
Discovery Health
1
Process Measure
Compliance with bundles
Bar graphs measure the difference
between different categories (elements
of the bundle)
BEST CARE ALWAYS : COMPLIANCE : CLABSI
Target
Process Measure
Compliance with bundles
Overall compliance to the bundle can
only be as good as the worst element.
BEST CARE ALWAYS : COMPLIANCE : SSI Bundle
Process measures for Central Line Bundle
A line graph is used to measure bundle compliance over time
Process Measure
Compliance with bundles
• What to measure
• How to collect the data
• How to analyse the data
Measuring
Compliance
with bundles
Step 1
Checklists
• help measure
• act as a guide
Checklist for Central Line Insertion
Checklists 
Gary Kantor
Discovery Health
10
Reliability:
Design for Reliability
1:100,000
Level 3
• High Reliability Organisations
Anesthesia-related
deaths
Level 2
1:10,000
• Reliability science, process
redesign, human factors
Level 1
• Intent, vigilance, hard work
1:10
Unassisted humans can’t achieve better than 1:100 reliability
11
Human Error
• If each step in a ten-step process can
be performed with 99% reliability, that
system functions error-free 90% of the
time.
• A similar process with 50 steps
functions error-free only 61% of the time
12
First Officer Jeffrey B.
Skiles (49)
On last leg of first
assignment in the Airbus
A320 since passing the
training course
Captain Chesley "Sully" Sullenberger (57)
Former fighter pilot, safety expert
2 experienced pilots…..who had never
flown together before
13
Hero? …….
14
• The windscreen quickly turned dark brown
and several loud thuds were heard. Both
engines ingested birds and immediately lost
almost all thrust.
• Captain Sullenberger took the controls…
…“my aircraft!”
…while Skiles began going through the threepage emergency procedures checklist in an
attempt to restart the engines.
15
Hero 
Checklist 
Teamwork 
Design 
16
A typical building site:
• Hundreds of workers
• Many subcontractors
• 16 or more different trades
How do you build a skyscraper so it doesn’t fall down?
17
USA serious building failures:
• 20 per year among >100
million buildings
= 0.00002% per year
18
How do you run a busy restaurant?
19
Non-cardiac surgery
3,955 patient in 8 hospitals in 8 cities
Mortality 1.5%  0.8% p=0.003
Inpatient complications 11%  7% p<0.001
Jan 29, 2009
20
• At Johns Hopkins University –
America’s #1 hospital – one or more
simple steps required for central line
insertion were missed 30% of the time
Peter Pronovost
Michigan
21
After checklist implementation (and more)…
Pronovost P. An Intervention to Decrease Catheter-Related
Bloodstream Infections in the ICU. NEJM Dec 2006
22
• Within 3 months infection rate in
Michigan’s ICUs decreased by 66%.
• The typical ICU cut its quarterly
infection rate to zero.
• Michigan’s average ICU outperformed
90% of American ICUs.
• In the first 18 months,1500 lives saved.
23
Sustained improvement !!
Pronovost, P. J et al. BMJ 2010;340:c309
Copyright ©2010 BMJ Publishing Group Ltd.
Checklists (Bundles): 2 Types
1. Applicable to tasks in which
best practice is well understood
2. In situations of
complexity/uncertainty, use
checklists that foster teamwork
and communication
25
26
• What you find, when the checklist is well
made, is ….the checklist gets the dumb
stuff out of the way so you can focus on
the hard stuff”
27
PREVENT CENTRAL LINE INFECTIONS
•
•
•
•
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with subclavian vein as the
preferred site for catheters in adults
• Daily review of line necessity with prompt removal of
unnecessary lines
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30
31
To your planning page add:
1.Your aim
2.The outcome measures
i) Rate = numerator/denominator (describe)
ii) Days between
iii) Welsh Safety calendar
iv) Other
3.A process measure
4.How you will feedback the data every month to
i) The frontline staff
ii) Management
iii) Presentation of your process measure
To your planning page add:
1.Your aim
2. Process Measures (Bundle compliance)
3.The outcome measures
i) Rate = numerator/denominator (describe)
ii) Days between
iii) Welsh Safety calendar
iv) Other
4.How you will feedback the data every month to
i) The frontline staff
ii) Management
Mark with a * areas that you want to strengthen
Using the priority * areas
plan a PDSA to improve or measure
compliance with bundles
• Design or implement a checklist
• How to collect the data (checklist / spot checks)
• How to sample the checklists
• How to analyse the data
• How to display and present the data
• Who to present it too
Select a priority area for improvement
• resolving it will have a big impact
• it is under your control to test a change
• you can start on Monday
Plan a PDSA using the
Model for Improvement
What are we trying
to accomplish?
What can we
change that will
result in an
improvement?
aim
How will we
know that a
change is an
improvement?
change
measurement
PLAN
DO
ACT
STUDY
PROBLEM :
AIM of this change:
Design a PDSA to improve one of the areas with a *
PROBLEM : staff aren’t engaged in the project
AIM
increase awareness through measurement
AIM: use
the
Welsh
Safety
Cross
What
When
Where
Who
How
AIM: the
Welsh Safety
Cross is
completed
Staff know
what it means
Welsh Safety Cross will improve the profile of the project.
Will need to engage staff with colouring it in or they won’t take any
notice
“ All work is a process”
W. E. Deming
Mapping the Process
Process Mapping
• What is a process map?
• Simply put, it is a way of visualizing all the
steps taken to get to the desired outcome.
• Steps are shown in sequence as they are taken
over time
• Helps identify delays and losses, opportunities
for change
Process Mapping Exercise
• As a whole group lets spend the next
few minutes creating a process map for
getting to work in the morning
Process Mapping Exercise
• How can we get there quicker?
Process Maps
• High or low level
• Follow
– patient journey
– staff (eg gathering equipment)
– steps in the protocol
– Equipment procurement
– etc
Leadership support
Insert
Maintain
Measure
Remove
Feedback
Process Mapping Exercise
• Within your groups:
– Choose 1 person and together map a process
they work with (draw the process out)
– Spend time as a group analyzing the process,
asking each of the questions listed above
– Make notations on the map indicating key
learning, important constraints
– Time permitting begin to think about how you
would redesign this process (possibly draw an
idealized map)
Process Map Analysis
• Time – How long?
• Space – Where did the step take
place?
• Human Resources – Who did it?
• Geography – How far is the journey?
• Financial Resources – What is the cost
and to whom?
Process Map Analysis
• How many steps are in the process?
• Examine the order of the steps in the process – are
they ideally placed?
• How many transfers occur in the process?
• Where do delays occur in the process?
• Can you identify known bottlenecks in the process?
Model for Improvement
What are we trying
to accomplish?
What can we
change that will
result in an
improvement?
Aim
How will we
know that a
change is an
improvement?
Change
Measurement
PLAN
DO
ACT
STUDY
Feedback
• How confident are you in your
ability to improve on:
–Teamwork
–Measurement
–Overall progress
Feedback
• How did you find the workshop?
Thank you for
your participation