NoCVA Hospital Engagement Network
CLABSI Collaborative
Orientation Webinar #3
Learning from Defects
August 28, 2012
Jan Mangun, MT(ASCP), MSA, CPHRM
Executive Director, Quality and Patient Safety
Virginia Hospital and Healthcare Association
Shelby Lassiter, RN, BSN, CPHQ, CIC
North Carolina Quality Center
Partnership for Patients Goals
• By the end of 2013, preventable hospital acquired
conditions would be reduced by 40%, compared to
2010
Adverse Drug Events
CLABSI
OB Adverse Events
SSI’s
VAP
CAUTI
Falls
Pressure Ulcers
VTE
• By the end of 2013, 30-day hospital readmissions
would be reduced by 20%, compared to 2010
The CLABSI Collaborative is designed to impact the
CLABSI Reduction P4P goal
2
Objectives
Participants will be able to:
1. Describe how defect analysis is a foundational element of
CUSP.
2. Define “defect.”
3. Describe at least two concepts about why defects occur.
4. Describe the five steps in analyzing a CLABSI as a defect and
discuss techniques related to each.
What is a Defect ?
Defect:
• Any clinical or operational event or situation that you
would not want to happen again. May include events that
you believe actually caused harm or put patients at risk
for significant harm.
Johns Hopkins’s “Learning from Defects” tool. Appendix 6 of On the
CUSP: Stop BSI toolkit at http://www.onthecuspstophai.org/on-thecuspstop-bsi/ Accessed 8/24/12
Definitions
Defect Analysis:
-the process of analyzing a defect to determine its root
cause.
Defect Prevention:
-the process of addressing root causes of defects to
prevent their future occurrence.
Lanier K. Experiences In Root Cause Analysis and Defect Prevention
Methods. Presentation publically available at
http://www.dtic.mil/ndia/2004cmmi/CMMIT5Tue/Root_CauseAnalysis.pdf
Accessed April 2010.
The Five Steps of CUSP
1. Educate on the Science of Safety (7/31/12
webinar)
2. Identify defects (today)
3. Engage leadership (now and future)
4. Continue to learn from defects (today)
5. Teamwork and communication (now and future)
CUSP Step 2: Identifying
Defects
• Through reports – HAI (CLABSI) reports from Infection
Prevention and staff, med error reports, incident reports,
etc.
• Patient and family feedback
• Gemba walks
• Unit monitors
• Staff feedback, sharing information in a psychologically
friendly environment, asking, “How will the next patient
be harmed?”
• Reporting of “near misses”
http://www.onthecuspstophai.org/on-the-cuspstop-bsi/toolkits-and-resources/#cusp
CUSP Step 4: Learning from
Defects
1. What happened?
2. Why did it happen?
3. How will you reduce the likelihood of it happening
again?
4. How will you know the risk is reduced?
5. With whom should you share the learning?
It’s All About Prevention
Learning from defects:
•Reduces the likelihood of the event reoccurring and causing harm.
•May occur in two important areas:
o System design
o Human behavior
•Provides structure and consistency.
•Allows learning from common cause and special variations.
•Allows prevention further “upstream” from the untoward outcome
(CLABSI) to make care even safer.
Why is this Important?
• Reimbursement systems are being reengineered to reward
the best performers (no margin, no mission, no salary, no
job…)
• Growing transparency of outcomes – public reporting
• Defects are expensive in many ways…
• Excellence in care - learning from each defect is the best
way to prevent it from reoccurring.
• The Golden Rule-it’s what we’d want done for us or the
person we love most!
Background Concepts
1. Normalized deviance:
• Long-term phenomenon in which individuals or teams
repeatedly accept a lower standard of performance
 lower standard becomes the “norm.”
• Deviation from SOP becomes routine practice and is
“normalized.”
 becomes acceptable
 may no longer even be recognized as deviation. (Just Culture
“behavioral drift”, at-risk behavior)
• Allowed because we get away with it…most of the time…
Normalized Deviance in Real
Life
• I (Shelby) have three rescue dogs, all my furry children that I love dearly.
However, I put one of them, Bindi Sue, in a life-threatening situation one day. I
was practicing normalized deviance: any dog owner knows that allowing your
dog to ride in a motor vehicle with their head out the window is asking for
disaster. I did it because Bindi loved it. One day, we were riding in my SUV
with the windows rolled down and when I made a left-hand turn, it pitched
Bindi out of the back window into a busy intersection. After a trip to the vet,
she was officially deemed OK but I could have easily killed my beloved Bindi.
• Now as you listened to this story, what were you thinking? “Gosh, I’ve done
the same thing.” or “How stupid can you be? Didn’t you know better?” or “I
remember when I did something like that…” It got you to thinking about
situations you may have been in that could have resulted in a pet’s or child’s
harm maybe. My telling my story helps others to realize that we all do things
we may know are not the best practice. But, we get away with it, most of the
time.
What are some deviances you’ve
normalized?
• Speeding?
• Leaving written passwords in clear view around
your computer?
• Not getting your dryer vent cleaned routinely?
• What are some other things?
CLABSI “SUV Rides”
• Inconsistent hand hygiene practices?
• Not disinfecting access ports “swabbing the hub” on IV
when entering for medication administration or not
swabbing for at least 15 seconds?
• Not “CUSS’ing” when a provider is not following proper
central line insertion bundle protocols or you see a peer
breech central line maintenance standards?
• What are some others?
Excuses to Deviate
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“The rule(s) is stupid”
Rule or reason for it is unknown
New technology
Complexity of work
Rule does not apply to this patient
“Rule(s) doesn’t apply to me”
“I know a better way”
Healthcare worker is not the one at risk
Competing priorities:
o Cost and time,
o Culture (politics, hierarchy, lack of communication openness, etc.)
• “It won’t hurt anything this one time…”
Background Concept 2: Errors in
Complex Systems
• When dealing with complex systems, such as healthcare, we have both
sharp end and blunt end factors.
• The “sharp end” refers to the personnel or parts of the health care system
in direct contact with patients. Personnel operating at the sharp end may
literally be holding a scalpel (eg, an orthopedist who operates on the
wrong leg) or figuratively be administering any kind of therapy (eg, a nurse
inserting a Foley) or performing any aspect of Foley care. This is where
active failures can occur.
• The blunt end refers to the background of policies, administrative
priorities, process designs, etc. where decisions are made that impact the
sharp end “downstream.” This is where latent failures occur and most
often where the root cause of an active failure may be found.
Active Failures
• Active failures: failures that occur at the point of contact
between a human and some aspect of a larger system
(e.g., a human-machine interface).
o readily apparent (e.g., pushing an incorrect button, not
following sterile technique to change a CL dressing)
o involve someone at the frontline or “sharp end”.
Latent Failures
• Latent Failures: less apparent failures of organization
or system/process design that contribute to the
occurrence of errors or allowed them to cause harm to
patients.
o Occurrences are at the “blunt end” but may result in
active failures on the “sharp end.”
o AKA: “Accidents waiting to happen.”
Reason JT. Human Error. New York, NY: Cambridge University Press;
1990.
Background Concept 3: Timing
of Analysis
Analysis of a defect should occur as
soon as possible after the defect is
recognized.
The best light is often that from a burning bridge…
~Don Henley
The best learning from a defect occurs before the “light goes
out.”
Two important terms:
• Gemba walk: A Japanese term used in Lean methodology
that means, “the real place.” In a business sense, it refers to
the place where value is created.
o observation where the work is actually carried out, such as
on the nursing unit,
learn both what the actual problems are and the best solutions
for those problems.
o activity that takes management to the point of care to find
ground truth
• Ground truth: Information that is collected on location and
used to compare reality to perception.
Tips on Learning from each Defect
• Use some type of standard investigation tool
• Utilize a multidisciplinary team (Unit CUSP Team)
• Investigate details prior to meeting
• Build on Current Process. (“mini-RCA”, a “deep dive” etc.)
• Don’t be afraid to really challenge practice and
traditional ways of thinking!
• Environment of psychological safety is critical.
Basic steps in the “L-from-D” Process
1. What happened?
2. Why did it happen?
3. How will you reduce the likelihood of it happening
again?
4. How will you know the risk is reduced?
5. With whom should you share the learning?
Case Study
•44 y.o. female w/ colon CA admitted to your med/surg ICU on
7/12/12 with diarrhea and severe dehydration.
•She is S/P partial colectomy and has a colostomy.
•She was in process of completing her 3rd round of chemotherapy
prior to admission.
•CL inserted 7/12 in Rt. subclavian for hydration and to monitor
CVP.
•On 7/19, she became hypothermic w/a temp of 957F and
hypotensive.
•BC Gram stain + for gram negative rods. BCs + for E. coli on 7/20.
•CXR - for pneumonia. Other cultures −.
Step 1: What Happened?
• Use a standard event investigation format. (See CLABSI Event
Report template as an example).
• Tool should be easy to use.
• No perfect tool so use what works but include information to assess
for active and latent errors.
• Must establish a chronological order of events and data related to the
event.
• Usually requires some research and gemba walks.
• One person should not do all the research or gemba walks.
(Science of Safety principle: Teams make wise decisions when there is
diverse and independent input.)
Example of an Event
Investigation Tool
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Patient: JJ
MR No: 29292999
Admit Date: 7/12/12
Diagnosis:. Colon cancer, receiving 3rd round of chemo, has colonoscopy s/p
partial colectomy
Infection Date: 7/19/12
Criteria: Hypotension, hypothermia, +BC
Organism: E. coli
CVC Insertion Info
Date CVC Removed: 7/20/12
Insertion Site: Rt subclavian Type of Line: TLC
Was insertion bundle used and were all elements complied with when CVC
inserted?
YES__X__ NO_____ If NO, explain:
Who Inserted: Dr. McSwain, intensivist
Patient Information and CVC Care Practices
1 Patient’s location/room number(s) 3415
What have we learned from Event
Report Tool?
1. E. coli grown in blood from BC done 7 days after admission
and 7 days after CL was inserted.
2. Patient was immunocompromised with leukopenia (WBC 2
on
adm.)
3. Patient was having severe diarrhea
4. Pool nurse staffing used more than desired
Step 1: Example
Additional information needed:
•How is environmental room cleaning done? How often?
•What is our patient hygiene like, including hand hygiene?
•What is compliance to “scrub the hub” since the educational
push? Has it fallen off?
•What is our true hand hygiene compliance rate?
•How was the diarrhea managed?
Additional Learning…
• Direct patient-contact environmental surfaces are not cleaned in
occupied beds by EVS.
• Unit staff use bath basins to give bed baths; they rinse basins after
use and allow to dry. UM saw one pool RN giving a bath from the
sink during one gemba. UM did a lit review on IPH.
• Diarrhea management was difficult w/many spills onto bed and
patient. No WOCN on staff at hospital to help. They used the
largest colostomy bags the hospital stocked.
• UM enlisted a hospital volunteer to do “secret shopping”
observations w/hand hygiene and scrub the hub X 1 wk. He found
HH at 52% and scrub the hub at 80%. (HH % driven by nonnurses)
Step 2: Why Did It Happen?
1. Review events from event report with unit CUSP team
2. Identify any gaps
3. For each gap identified, ask “Why?” and then for each
reason generated, ask “Why?” at least four more times or
until the group feels the root cause has been found. (Keep
pushing to the 5 “Whys” to ensure root cause is determined
and latent failures are recognized if present.)
Further research/lit review may be necessary to gather ground
truth, determine why it happened, and if there were any gaps with
best practice. This is another time when gemba walks, staff and/or
patient interviews, and literature reviews may be indicated.
Step 2: The 5 Why’s – an
Example
Gap: Direct patient-contact environmental surfaces are not
cleaned in occupied beds.
1.Why? EVS policy prohibits.
2.Why? Risk of cleaning chemicals causing respiratory and/or topical
issues with patients.
3.Why? Direct or close contact w/hospital-grade chemicals can be toxic
and patients are already compromised.
4.Why? There are no physical or spatial barriers between the patient and
the surface disinfectants currently used.
5.Why? Not possible, given the physical proximity. Would need to protect
the patient’s entire body and airway.
6.Why? Spray disinfectants are currently the primary type used and thus
are not usable in close proximity to the patient.
Step 3: How can we reduce the
chances of it happening again?
1. Prioritize most important contributing factors.
2. Develop interventions (countermeasures) to defend
against the most important contributing factors.
3. Then, rate each countermeasure on its ability to
mitigate the root cause and on the team’s belief that
the countermeasure will be executed.
4. Make an action plan for 2-5 of the highest scoring
countermeasure.
• Must have many different perspectives.
• Must engage leadership.
Example: Prioritize contributing factors
Importance
to future
events 1
(low) to 5
(high)
Ease of
Resolution 3
=easy, 2 =
fairly easy
1=hard
Total
Score
High bioburden of colonic organisms on
5
environmental surfaces directly in contact
w/patient due to no cleaning of these surfaces
done in occupied beds.
5
1
11
High bioburden of colonic organisms on
environmental surfaces directly in contact
w/patient due to inadequate diarrhea
management processes.
5
2
2
9
Inadequate patient hygiene practices due to
lack of knowledge of current science.
5
5
2
12
Swabbing of CL hubs prior to use is
inconsistent due to perceived time pressures
from lack of staffing
5
5
2
12
Hand hygiene compliance inadequate,
especially in non-unit staff, due to ?
5
5
2
12
Contributing Factors
Importance
to current
event, 1
(low) to 5
(high)
Countermeasures
• Consider safe design principles:
• Standardize – eliminate steps when possible
• Create independent checklists
• Learn when things go wrong (analyze defects)
• Safe designs apply to technical and team work.
• Brainstorm strategies and consider:
1.Ability to mitigate error.
2.Strength of countermeasures to prevent error.
3.Ease of implementation. (Resources and will necessary
to implement.)
Rank Order: Strength of Error Reduction Strategies
7. Forcing functions and constraints
Designed so that errors are virtually impossible or very difficult to make.
Example: removing potassium chloride for injection from all patient care areas.
6. Automation and Computerization
Example: Placing alcohol wipe in each Pyxis drawer with IV medications so wipe issued with each
dose of medication.
Lessons human fallibility by limiting reliance on memory.
5. Standardization and Protocols
Standardizes processes/materials/resources to promote awareness of evidence-based practice
and increase consistency between providers. It makes defect detection possible also.
Example: Standardized CL insertion kit/cart. Standardized CL dressing change kits.
4. Checklists and double-check systems
Example: Checklist to guide central line dressing changes. Requirement for an RN to recalculate
doses of heparin in pediatrics behind pharmacist.
Creates redundancies in system to look for errors
3. Rules and policies
Example: CL maintenance policy based on current science to prevent CL complications such as
infection.
Sets standards and expectations. Helps define what defects are.
2. Education/Information
Education and sharing of information
Example: Staff education on CL maintenance policy.
1. Instructions to be more careful, vigilant.
Admonitions to be more careful to prevent error. This is very traditional in the mental model where
individuals have total control of their actions.
Example: Management counsels an individual to “be more careful” after staff member has made a
med error.
Countermeasures (interventions to reduce the
risk of the defect) to Prevent Inadequate Patient
Hygiene.
Ability to
mitigate the
contributing
factor, 1 (low)
to 5 (high)
Team believes the
countermeasure
will be
implemented and
executed, 1 (low)
to 5 (high)
Strength of
Strategy, 1
(low) to 7
(high)
Total
Score
A. Provide mandatory education to staff on
Interventional Patient Hygiene in the ICU.
4
5
2
11
B. Implement protocol for patient hand
4
hygiene before and after meals and after
every use of bathroom/urinal/bedpan/BM. (Pt
education and posted reminders in room.)
4
5
13
C. Revise patient bathing protocol to require
disinfection of bath basins after each bath.
4
3
5
12
D. Revise patient bathing protocol to forbid
using sink as a bath basin.
2
5
5
12
E. Revise patient bathing protocol to include 5
CHG-impregnated bathing on a daily basis in
the ICU.
3
5
13
F. Educate visitors about importance of
3
hand hygiene and have them perform hand
hygiene before entering pt’s room and before
& after physical contact.
3
2
8
Step 4: How will we know the risk
is reduced?
• Assess outcome and process data (CLABSI
rates, compliance to CL maintenance protocols,
monitoring of specific process changes, etc.)
• Talk to staff to get their perspectives.
• Talk to patients/families to get their
perspectives.
• Do gemba walks for direct observation.
• Feedback from patient safety rounds.
Step 5: How do we communicate
our findings and to whom?
• Internal communications
– other areas/people possibly prone to this defect.
– what other people/groups need to know for the purposes of
regulatory compliance, accreditation concerns, risk management.
– what people/groups need to know for closure on the event.
– what other potential defects could occur related to root causes
identified
• External communications
– PSOs
– Others
– Must include input/permission from Risk Management and
Administration
Remember: Learning from Defects
• Can help prevent future errors and prevent human
suffering and death.
• Needs consistent discipline through structured way of
thinking and communicating.
• Highest form of learning is from and by the group
“Teams make wise decisions when there is diverse and
independent input.”
• Purpose of Defects Analysis is to help drive constructive,
open communication.
Questions?
• Thank You
39
Polling Question #1
How well did this Learning activity meet the stated
objectives?
1.Describe how defect analysis is
1. Excellent
a foundational element of CUSP.
2. Good
2.Define “defect.”
3. Fair
3.Describe at least two concepts
about why defects occur.
4. Poor
4.Describe the five steps in
5. N/A
analyzing a CLABSI as a defect
and discuss techniques related
to each.
40
Polling Question #2
Amount of useful information and ideas provided:
Excellent
1. Excellent
2. Good
3. Fair
4. Poor
5. N/A
41
Polling Question #3
Usefulness to my hospital of the information and
ideas provided:
1.
2.
3.
4.
5.
Excellent
Good
Fair
Poor
N/A
42
Polling Question #4
Chance that the information and ideas provided will
improve my effectiveness and results:
43
Timeline
Safety Culture Survey
(baseline)
September 15, 2012
Action Periods
June 2012 – December 2013
Data Collection
Baseline: Jan-June 2012
Begin Monthly July 2012
Refer to data schedule for details
3 Monthly Orientation
Webinars
June 19: Measurement
July 31: Science of Safety
Aug 28: Learning from Defects
Upcoming Webinars
Success Stories
Culture of Safety Survey Results
Quarterly Content Webinars
Beginning December 2012
Learning Session 2
January 30, 2013
44
Next Steps
(September-October)
• Complete AHRQ HSOPS Culture of Safety survey on
selected unit(s) by September 15
• Grant NSHN group rights to NCQC or enter baseline CLABSI
rate data into QDS (Jan-June 2012)
• Begin Data Collection on CL review for necessity
o Enter into QDS
• Conduct Defects Analysis for any CLABSI events on unit
• Upcoming Webinars
o Hospital Success Stories
o Culture of Safety Survey Results
Contact Information
Jan Mangun, MT(ASCP), MSA, CPHRM
Executive Directive, Quality & Patient Safety
jmangun@vhha.org
804-965-1202
Debbie Roddenberry
Assistant Director
droddenberry@vhha.com
804-965-5714