Building a Multidisciplinary Team
Loretta Litz Fauerbach, MS, CIC
Fauerbach & Associates – Global Infection Prevention Services
March6, 2013
Taking Quality to the Next Level
Kentucky Hospital Association Annual Quality Conference and
Hospital Engagement Network Convening
Louisville, Kentucky
LLF Teams 2013
Objectives
• To identify key elements of teamwork
• To discuss training needs for team building
• To demonstrate similarities in approach from
aviation to healthcare
• To demonstrate the success of teams in
improving outcomes and patient safety
Why Teamwork & Communications
Matter?
• Better patient outcomes
• Higher patient satisfaction
• Lower malpractice claims
LLF Teams 2013
The Downside
From 1995 to 2005, ineffective communication
was identified as a root cause for nearly twothirds of all sentinel events reported to the Joint
Commission on Accreditation of Healthcare
Organizations, a statistic supported by analyses
of closed malpractice claims. An estimated 1.74
billion dollars in malpractice claims are
associated with ambulatory
care settings….
www.pathwaysforpatientsafety.org ©2008 Health Research & Educational Trust, Institute for Safe Medication Practices,
and Medical Group Management Association 6
Working as a Team | Pathways for Patient Safety™
Miracle on the Hudson
Lessons for Healthcare Industry
• Practice Makes Perfect
• Measure Proficiency Over
Time
• Team work is essential
• Cross-monitoring: An
essential element of
teamwork
• Crew Resource
Management is modeled by
TeamSTEPPS
LLF Teams 2013
• Every healthcare team
member’s safety input
should be heard
• Simulation –based
techniques help improve
outcomes
• Healthcare leaders need to
invest in people like aviation
has do
www.npsf.org
Porto G. “Miracle on the Hudson” Key Safety
Lessons for the Healthcare Industry.”. 2009; Vol
12/Issue 3: 2-4.
The TeamSTEPPS Program
Agency for Healthcare
Research and Quality
(AHRQ) website:
http://www.ahrq.gov/team
stepps
LLF Teams 2013
Department of Defense
Patient Safety Program
website:
• http://dodpatientsafety.us
uhs.mil/teamstepps
Teamwork- What’s in it for you?
• Creates Common
Purpose
• Brings about
Improvement
• Mechanism for change
• Produces expanded
influence
• Improves
communication
LLF Teams 2013
• Increase Professional
satisfaction
• Contributes to Joy of
Work
The Science of Forming a Team
• Review the Aim
• Consider the system (s) that relates to the AIM
• Select team members familiar with all the
different parts of the process
• Obtain executive sponsor who is responsible
for the teams success
LLF Team 2013
Examples of Team Membership
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Clinical Leader
Technical Expertise
Day-to-Day Leadership
Project Sponsor
Staff
Think outside the box
LLF Team 2013
Model for Improvement*
Fundamental Questions that Guide
Improvement Teams
1. What are we trying to accomplish?
2. How will we know if a change is an
improvement?
3. What changes can we make that will result in
improvement?
* IHI- How to Guide: Project Joints, 2012
LLF Teams 2013
The Plan-Do-Study-Act (PDSA) Cycle
Plan
Do
Patient
Act
LLF Teams 2013
Study
Infusing Fun Into Quality And Safety Initiatives
• Leadership can set the tone
• Staff Generated Ideas
– Got to have a Gimmick!
– Rewards for progress
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– Music themes
• WHO –
• APIC • The jingle was recorded at a
local studio,
• a concept for a music video
• “Get Your Clean On” was born
in early May 2010. (See the
music video on the
Nursing2012 iPad app.)
Pizza Party
Breakfast
Candy Bars
Certificates
Thank You Notes
Enlist the help of
Marketing/PR
•
Foulk KC, Tocydlowski P, Snow T, et al. “INSPIRING
CHANGE Infusing fun into quality and safety initiatives”
Nursing2012 November: 14-16. www.Nursing2012.com
– Contests
– Poster Designs
– Got In the Act LLF Teams 2013
A Neurosurgical Multidisciplinary
Infection Prevention Team:
Adverse Event Review and
Assessment to Reduce Class I Surgical
Site Infections (SSI)
THE PATHWAY TO PREVENTION
LLF Teams 2013
Infection Prevention Performance
Improvement Team Members
• Champion: Neurosurgery (NSG) Chairman
• NSG Department: faculty, residents, fellows, ARNPs, nurses
and other members
• OR NSG Team: Scrubs, Circulators, RN leader, OR Patient
Safety Nurses, OR Management
• NSG Nursing Units and Nursing Specialists: SICU, 82NS,
65MS
• Anesthesiology: NSG Anesthesiology Team, QA
Anesthesiologist/Educator
• Support Departments: PI Educator, Decision Support
Services, Central Sterile Supply, Facilities, Environmental
Services, Pharmacy and Hospital Administration
• IP&C Team: Infection Prevention & Control Department (IP &
Director) plus Hospital Epidemiologist
LLF Teams 2013
Strategies of the Neurosurgery
Infection Prevention Team
 Employed Adverse Event Trigger Strategy
 Every Monday IPC notified NSG Chair of potential
cases
 Investigation and Data Collection related to
procedure and team members
 NSG Team reported infections to IP
 Each case reviewed with all participants at meeting
2x’s a month initially then once a month
LLF Teams 2013
Strategies of the Neurosurgery
Infection Prevention Team
 Root Cause Analysis discussion concerning each case was
done
 Evaluation of Practice, including surgical and unit procedures
and OR setting
 OR observational studies performed by IP with feedback to
team and staff
 Education – every meeting addressed a “hot topic”
 Development of Checklist for Common Practice
LLF Team 2013
Surveillance & Data Trending
• SSIs detected through reporting of infections
from the NSG Team as well as by routine
surveillance methodology used by the IPC
Department.
• Class I SSI and procedure-specific SSI rates
were calculated on a quarterly basis.
• Reported to IPC Committee, NSG team,
Surgical Committee and Operations Committee
of the Medical Staff and through the quality
committee structure.
LLF Teams 2013
Risk Factors Analyzed for Class 1 NSG SSI
Name
Medical Record Number
Admission Date
Discharge Date
Diagnosis
Attending Physician
Resident Physician
Operation Performed
OR Date
Time of Surgery
Post-operative Unit
Culture Date
Organism
Source of Culture
# of Days from OR to Culture Date
Location Prior to OR
OR Room Number
OR Personnel
Choice of Pre-operative Antibiotics
Timing of Pre-operative Antibiotics
Dosage of Pre-operative Antibiotics
ASA Score
Patient’s Sex
Patient’s Age
Patient’s Race
Hair Removal
Body Mass Index
Re-dosing of Antibiotics
Risk Index
Re-admissions
LLF Teams 2013
Education of the Team
Based on Observational Studies
• Hand hygiene -Implemented Alcohol Hand Rub in OR
for non-scrubbed care
• Monitored and reported variances from good surgical
practice
• Maintain 2 feet for sterile field
• Handling of medications – established new protocol and
taught aseptic management of vials and fluids
• Empowerment of staff
• Initiated Patient Safety Advocate Nurses who rounded
for compliance
• Foley catheter management
• Pre-operative bathing
LLF Teams 2013
Building Trust
• Respect
• Videos
– The Enforcer
• Empowerment of
– WHO Hand Hygiene
Everyone
Dance
• Chair taught by example
• Humor
• Surgeon Specific Rates
• Open and honest
communication
Equipment and Device Reps
• Educate through REPtrax
• Must use laser pointer to indicate placement or
device selection
• Must use hospital provided scrubs labeled Sales or
Technical Rep
• Instruments and devices must be brought in the night
before procedure for processing
• No Flashing - IUSS
LLF Teams 2013
Process & Practice Improvements
• Improved classification with implementation of a mandatory
classification field
• Developed & implemented checklist and improved
consistency in following recommended practices
• MRSA screening has identified about 8% of their elective
surgical patients are MRSA positive. Noted that more
patients had infections with MSSA
• NSG staff screened for MRSA/MSSA- no MRSA
isolated, 4 MSSA identified and decolonized. No
linkage to cases.
• Implemented pre-op screening for MRSA/MSSA
and decolonization
LLF Teams 2013
Process & Practice Improvements
• Improved consistency of Pre-op Showering with CHG
• Improved Management of medications, vials and fluids
• Created signage to make sure vial tops were
scrubbed with alcohol before each entry
• Improving OR environment (new carts, more storage,
on-going monitoring by 2 OR patient safety nurses, no
personal items in the OR room)
• NSG to report infections to IP
LLF Teams 2013
Process & Practice Improvements
• Education for Anesthesiology, OR team and Patient Care
Unit staff
• Pre-Op Antibiotics (ABX) Prophylaxis
• Changed ABX prophylaxis to Kefzol from
Vancomycin based on literature review, if
Vancomycin is used Kefzol is still needed,
unless allergic
• DC ABX at 24 hours according to SCIP
LLF Teams 2013
Lessons Learned
• A collaborative effort between the hospital IPC team, the
Neurosurgical Department, Operating Room and other
services strengthen the surveillance and prevention systems
for surgical site infections.
• The increase in reporting of infections strengthened the
surveillance systems of the IPC Department allowing for more
accurate infection rates for all surgical services.
• Measures for NSG SSI prevention are multi-factorial.
• Deeming every SSI an adverse event trigger can lead to improved
outcomes.
• Observational studies, education, and a multidisciplinary IP effort
enhances awareness and results in improved outcomes.
• Administrative and physician leadership support of improvement
activities are key to success.
LLF Teams 2013
"Staging the OR for Success"
 If Operating Room was on HGTV program,
“Flip this House”
Would you buy this OR?
Let’s all get ready for success
LLF Teams 2013
"Staging the OR for Success"
• Remove all trash after each procedure
• Place alcohol gel in substerile room and in OR room
– perform hand hygiene prior to working with patient
– contact with patients devices, inserting or
– Handling a foley catheter and other activities
• Maintain the anesthesiology cart in proper order and protect
supplies
• No storage on the floor – limits ability to clean, increases chance
of contamination and clutters the floor of an already crowded
room.
• Supplies in the OR should be protected from contamination and
only be for the current case
• Cleaning schedules for lead aprons established and enforced.
Stop and look objectively to make sure OR is ready for next case
LLF Teams 2013
Last Name
First Name
MR#
Admit Date Discharge Date
Diagnosis
Attending
Surgical
Resident
OR Date
Post-op Unit
Cx Date
Source
Organism
<5 days (Y/N) Wt/Ht BMI
Surgeon
OR to Cx (# of
days)
T>T (mins) Risk Index
ASA>2
Operation
Performed
> 30 days
(Y/N)
NNIS Cut
Time (mins)
Room Start
Date
Patient Sex
Patient Race Patient
Birthdate
Patient Status AdjustedType Room Start
Description
Time
Room
Med. Records
Number
Patient Age Hair Removal
(Years)
Room End Patient Account
Time
Number
Room
Elapsed
Service
Name
Location prior OR date
to OR
Time Before
Proc End
Incision
Dose
Proc Start
Case Number Case Date
ABX
Re-dose
LLF Teams 2013
ABX Time
Eliminating Ventriculostomy Infection
Study (ELVIS)
Reducing Ventriculostomy-Related Infections to Near Zero: The
Eliminating Ventriculostomy Infection Study
Authors: Rahman, Maryam; Whiting, Jobyna H.; Fauerbach,
Loretta L.; Archibald, Lennox; Friedman, William A.
Source: Joint Commission Journal on Quality and Patient Safety,
Volume 38, Number 10, October 2012 , pp. 459-464(6)
Publisher: Joint Commission Resources
LLF Teams 2013
ELVIS Task Force
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Neurosurgery
Critical Care Medicine
Infectious Disease
Infection Prevention & Control,
Quality Assurance,
Nursing,
Pharmacy
The Elvis Task Force Met At Regular Intervals To Identify
Systematic Issues That Could Be Improved To Reduce
The Risk Of Infection.
LLF Teams 2013
Critical Steps for Improvement
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Performed FMEA
Developed Insertion Checklist
Re position bed
Trained observer
Inserter must simulate practice and also
demonstrate competency
• Supplies including antimicrobial catheter,
sterile gowns etc
LLF Teams 2013
Ventriculostomy Infection Rate
()
LLF Team 2013
HHS Partners
in Prevention
Award, 2012
Critical Care
Society and
the ACCN
• 4E Surgical Intensive Care Unit
– 20 different surgical specialties
including abdominal transplant
services
– New Unit – New Goal
• NO CLABSI
– Manager, Clinical Specialist,
Medical Director and IP&C
Partnership
LLF Teams 2013
The Pathway to CLA-BSI Prevention
Unit Activity for New ICU
• Performance Improvement
Group
• Daily/Shift Rounding for
Compliance
• Communication with IP
– RCA for each potential infection
• Involved Clinical Specialist ,
Nurse Manager, and Medical
Director
• On the CUSP – joined 1 year
after unit opened
• Education, monitoring and
feedback
LLF Teams 2013
ICU Improvement Team and CVL
Complication Prevention Team
• Active Participation in
Hospital wide improvement
teams
• Supply Chain and assuring
right supplies
• Adoption of the CVL
Prevention Bundle
• Horizontal Approach to
Infection Prevention
• Monitoring of all CLA-BSIs
CLA - Blood Stream Infection
4E
11/1/2009 - 5/31/2012
LLF Teams 2013
Best Practice Bundles Implemented
Education & Training
 Healthcare providers
 Educational modules
 Lectures
 Videos
 Simulation Labs
 Medical Staff
 Nursing Staff
 On the CUSP

Hand Hygiene
 Compliance with proper hand hygiene is
everyone’s responsibility
 Use waterless Alcohol-based products
or wash hands if visibly soiled with
CHG containing soap
 Perform hand hygiene before and after:
 palpating site
 inserting
 replacing
Patient and Family Education related to CVL  accessing
Prevention Strategies
 repairing or
 changing dressing
Daily bathing of patients with CHG
Aseptic technique during insertion and care
 If aseptic technique during insertion cannot
be ensured, replace all catheters as soon as
possible
 Use CHG/Alcohol combo to prep sites and
for dressing changes
Daily review of CVLs for clinical necessity
Daily unit rounds by clinical leader and/or
nurse manager to assess compliance with
practices in prevention bundle
LLF Teams 2013
Best Practice Bundles Implemented, continued
Catheter insertion, site care, and dressing
regimens made easy by kits, trays and carts
Selection and replacement of intravascular
catheters to use lowest risk
No routine replacement of CVLs.
Drill downs/ root cause analysis for each
identified CLABSI done by clinical leader,
infection preventionist, medical director and
unit staff who have recently cared for patient
Manager, Clinical Coordinator, Medical
Director, Staff and IP all had
CLA-BSI Prevention included in their
goals and performance evaluation
Stabilization CVLs through securement
device and dressing improvements
IV mixtures and processing fluids through
IV tubing and bags being in date and
clean pharmacy
labeled with color coded day specific
labels
Surveillance performed using NHNS
Monitor all insertions using the CVL
definitions for CLABSI
Insertion Checklist.
Feedback to providers including nurse
 Checklists reviewed by
manager, medical director, CVL Team
manager/clinical leader
champion, ICU Improvement Committee;
Infection Prevention & Control Committee,  Sent to Quality for scanning into
database
Unit performance improvement teams,
 Compliance tracking and trending
administration and MHA/Care Counts
Database for “On the Cusp”.
LLF Teams 2013
Project – Multidisciplinary Task Force
A MULTI-DISCIPLINARY TEAM TACKLES
STANDARDIZATION OF ENDOSCOPE
PRACTICES IN A TERTIARY CARE SETTING:
FINDING COMMON GROUND
LLF Team 2013
Improve Patient Safety through Scope
Management
• To review standards and practices for scope
care and sterilization to standardize cleaning
and processing
• To standardize departmental practices related
to the management of scopes based on AAMI,
CDC and other professional organizations
recommendations
• To assure compliance with recommended
practices
LLF Team 2013
Is This Device Ready to Be Used ?
How do you know?
There is a new, simple way!
“READY TO USE”
• Do you know if a piece of equipment/device has completed
the cleaning/high level disinfection/sterilization required
for that piece of equipment?
• To eliminate confusion, when you have completed the
appropriate processing requirement for that specific device
per protocols (cleaning/high level disinfection/sterilization),
Please label devices or bags they are placed in
with the “READY TO USE” tags.
Stakeholders
• Anesthesia
• All Central Sterile Processing
Areas
• Respiratory Therapy /
Pulmonary Lab
• Infection Prevention &
Control staff
• OR Sterile Processing
• Surgical Services (FSC, CSC,
NT)
• Heart Station
• ICUs
• ED
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Biomedical Engineering
Zone Mechanic
Patient Safety Officer
Champion – Vice President,
Finance and Supply Chain
• Co-chairs: South Tower OR
Manager and Infection
Prevention & Control
Director
• Team won CEO Patient
Safety Award
LLF Teams 2013
LLF Teams 2013
Standards for Practice
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AAMI
CDC Guidelines
SHEA- Multi-societal Endoscope Standards
SGNA-Society of Gastroenterology Nurses and Associates
APIC
Literature
Infection Prevention & Control Hospital Policies
Departmental Policies and Procedures
LLF Team 2013
Key Elements
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Pre-Clean at Point of Use
Leak Testing
Manual Clean
High Level Disinfection /
Sterilization
• Based on Spaulding
classification
– Critical
– Semi-Critical
– Non-Critical
• Ready To Use –New Tag
LLF Teams 2013
• Flush scope with enzymatic
cleaner
• Store vertically to promote
drying.
• Use transport bags marked
contaminated
• with identical stickers.
• Do not transport scopes in red
bags.
• Use identical clean-storage
and labeling
• practices across departments
• Flush with alcohol after
processing
Team Results
• Documents to assist with standardization
were developed:
– Development Of Practice Standards And
Checklists For Compliance
– Complete Inventory Of Scopes
– Common Logs And Training
– Standardization Of Supplies
– Ready To Use Tag
LLF Team 2013
Lessons Learned
• Standardization creates opportunities for
cost savings, better practice monitoring, and
competency training.
• Individual scope manufacturer’s
recommendations must be followed.
• Compliance with practice recommendations
and monitoring is improved through
standardization.
LLF Team 2013
Team Diversity
• Recognize differences
• Celebrate uniqueness of each individual
• Understand cultural and ethnic diversity
LLF Team 2013
Celebrate Success
Teamwork & Communications make
life better!
LLF Team 2013
LLF Team 2013
WHO Hand Hygiene Dance
http://vigigerme.org/videos/