Getting Better at Getting Better
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VPH Workshop Accelerates Changes
A quarterly
newsletter
from the
Office of the
Chief Quality
& Patient
Safety Officer
IN THIS ISSUE
VPH Workshop
Accelerates
Change
Letters From
the CQO
Chasing Zero
Premiere
Pillar Goals in
Practice:
Reduce the
Number of HAIs
Exemplars of
Quality &
Patient Safety:
Stories From
the Field
I
n June, Vanderbilt Psychiatric Hospital
(VPH) leaders held a four-day Rapid
Process Improvement Workshop (RPIW)
focused on strengthening and streamlining
handover processes. The Joint Commission
has mandated a standardized patient
handover process since 2006, yet many
handover methods remain scattered and
unfocused, compromising patient safety. VPH
leaders Stephan Heckers, MD, department
Chair; Avni Cirpili, RN, MSN, Chief Nursing
Officer; and Harsh Trivedi, MD, Executive
Medical Director and Chief of Staff,
championed the RPIW team’s efforts to
organize and execute a large-scale redesign of
the handover processes. This was the first
RPIW at VUMC, applying Lean methodology
to patient care practices.
The goal of the workshop was to develop a
Psychiatry Transition Bundle: a set of
Workshop participants gathered for a final
report on their results.
standardized checklists to identify key
information that must be provided when a
patient is changing treatment locations or
treatment providers. The multidisciplinary
RPIW team reviewed current processes from
(Continued on page 2)
Letters from the CQO
Hello, and welcome to the inaugural issue of
our quarterly newsletter, Getting Better at
Getting Better. We’ll use this space to
provide an in-depth view of the people at
Vanderbilt who are driving the work of quality
improvement. As we connect the quality
efforts across the clinical enterprise we
increasingly leverage one another’s hard work,
energy, and enthusiasm for providing the very
best and safest care for our patients.
Each edition of our newsletter will explore
the range of improvement work from the
frontline of care to
more foundational
changes. We hope
that you are inspired
by these stories, and
that you’ll let us
know when you
have something to
share.
Thank you for reading,
Julie Morath
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(Continued from page 1)
the point of a referral for inpatient
admission through to the point of
transition to outpatient status.
The team found multiple opportunities for
improvement and standardization to
enhance patient safety and the quality of
care. Examples include the patient
admission process, face-to-face information
exchange, and reliable physician sign-off.
Workshop participants organized in three
groups, each tasked with a distinct phase of
the Transition Bundle.
Quality
We relentlessly pursue
and measure ourselves
against the highest
quality performance in all
areas, from patient care
to scholarship.
GETTING
The Admissions Team developed a
strategic plan to implement a streamlined
admission process to decrease patient wait
time and minimize patient handovers via a
“one-stop” process. The Unit Team
studied patient flow from the moment of
transition from the VPH admitting service
onto an inpatient unit, to address the lack
of standard workflows and communication
methods across disciplines (MD, RN, Social
Worker) and practice sites (Vanderbilt
University Hospital, Monroe Carrell, Jr.
Children’s Hospital at Vanderbilt, the
Emergency Department [ED], etc.). The
Discharge Process Team created a plan to
implement a multidisciplinary treatment
team meeting, improve documentation of
the treatment plan, and integrate with both
the Discharge Wizard and Team Summary.
Implementation of the process changes
began in July, with the transition to a onestop admissions process for patients
referred to VPH from the ED. The process
change streamlines the patient’s intake and
transfer to the VPH unit, bypassing checkin with the Psychiatry Respond team.
Process changes cut four hours
from the average wait time
between referral and arrival on
the VPH unit.
Patients admitted from non-ED areas still
use Respond, but their wait time has been
significantly decreased through streamlining
the Respond processes and changes to the
physical layout. A total of seven tools were
created in the RPIW and will be implemented in the coming months.
Chasing Zero Premiere
The documentary film Chasing Zero:
Winning the War on Healthcare Harm,
premiered on the Discovery Channel on
April 24th. The film, which includes footage
shot at VUMC, was produced by the Quaid
Foundation and the Texas Medical Institute
of Technology (TMIT). Actor Dennis
Quaid and his wife, Kimberly Quaid, were
inspired to create the Foundation following
their personal experience with near-fatal
medication errors that affected their
newborn twins in 2007. The documentary
centers on the stories of families who have
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experienced harm in the healthcare
system, and the professionals who are
working to prevent medical events from
happening.
Chasing Zero is the first of a series of
patient safety documentaries produced by
TMIT. Future installments, one of which
will prominently feature VUMC, will
provide “arc to action” stories to inspire
leaders.
The film may be viewed online at http://
discoveryhealthcme.discovery.com/zero/
zero.html.
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Pillar Goals In Practice: Reduce the Number of HAIs
Editor’s note: We’ll use this space to feature a different Quality Pillar Goal in each issue, along with some notable
progress in the ongoing work supporting that Goal. We begin the series with the Goal of Reducing HealthcareAssociated Infections (HAIs).
Goal Definition: VUMC has set a goal of zero preventable hospital-acquired infections. Efforts to prevent HAIs
successfully reached the 2010 Pillar Goal of achieving a target Standardized Infection Ratio (SIR) of 1.26, which reflects
the ratio of Observed HAIs to Expected values from the National Healthcare Safety Network. The 2011 Pillar Goal is
more ambitious: to reach an SIR of 1.11. Types of infections, location and source, as well as compliance with best
practices to reduce transmission of infections are tracked. Here are some encouraging signs in ongoing efforts to
prevent central line-associated blood stream infections (CLABSI), a key component of HAI.
CLABSI Prevention Efforts Gain
Traction in FY2010
A
s of January 2010, VUMC’s CLABSI rates
continued to be reported higher than our
peers’. In response, a BSI Prevention Bundle (of
interventions) was introduced, with standard
practices to manage central lines and minimize
line days throughout the ICUs. Multiple teams
throughout the Medical Center were focusing on
CLABSI, and Neonatal Intensive Care Units
(NICU) at MCJCHV and Stahlman joined the
Tennessee Initiative for Perinatal Quality Care
(TIPQC) CLABSI reduction project. The Pediatric
ICU (PICU) began using Event Analysis to review
each BSI occurrence.
VUMC leadership reached out to external
experts through membership in the Tennessee
Center for Patient Safety Collaborative on BSI.
Peter Pronovost, MD, from Johns Hopkins
Hospital visited as an external consultant, and a
team of quality leaders from VUMC made a site
visit to Cincinnati Children’s Medical Center to
learn from their success.
Through diligent work, the NICU’s efforts to
prevent CLABSI produced results, achieving 100
consecutive days with no infections by March 31st.
Contributing to their success were practice
changes and vigilance, including hand hygiene,
maximum barrier precautions while inserting
central lines, two-person line-insertion technique,
and monitoring to discontinue central lines as
soon as possible to do so. The NICU also began
publically posting the number of days without
CLABSI, to serve as a visual reminder of the
staff’s ownership of infection prevention. To build
on these successBedside tools
es, unit leaders
Safer line
access
helped spread
their safety
practices to other
areas: Elevate
boards were
established in each
ICU to count the
days between
infections and
NICU reaches 100 days
without CLABSI
provide visible
NICU staff post quality indicators at
performance feedback on
the unit.
the nurses station.
A comprehensive plan is set in motion
In April, a housewide approach to reduce CLABSI
was adopted and implementation initiated, with a
focus on embedding standard expectations for
line practices. Housewide efforts were made to
assess, plan, and implement specific interventions
(Continued on page 4)
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Reduce the Number of HAIs
(Continued from page 3)
to prevent CLABSI. These include preventing contamination of blood cultures, and standardization and reinforcement of evidence-based best practices during line
insertion, maintenance, and discontinuance.
Infection Prevention During Line Insertion:

Real-time, unit-level data showing compliance with
the insertion bundle was disseminated.

A pilot study of a Line Cart to standardize and
improve ease of access to supplies during insertion
began in the MICU and Neuro ICU, with housewide
implementation to follow.

Other possible drivers for infection were studied,
and key stakeholders developed guidelines to
address potential risks.
Infection Prevention During Line Maintenance:

Comprehensive line maintenance guidelines were
developed, with consensus regarding strict hubaccess practice.

An Enhanced Education Program was introduced,
and unit-based displays with best practice reminders.
Ongoing Infection Monitoring:

Real-time, unit-level key indicators such as device
days, assessment of site, and assessment of need
entered development.

Unit-based analytic tools to track HAI were studied,
to identify specific areas of concern and customize
rapid intervention when infections develop.
Reducing False Positives:

An ongoing problem regarding contamination of
blood cultures, which hampers accurate infection
monitoring and can lead to morbidity in patients, was
addressed, with prevention measures being piloted
in the adult ED. To date, the number of contaminat-
ed specimens in the ED has been reduced by more
than 50% since the intervention of new prevention
measures.
VUMC issued Standards for Non-emergent Insertion and
Management of Central Venous Catheters (CVCs), and
began to monitor compliance with each element of
insertion, care, access, and discontinuance. Visual cues to
reinforce the standards were distributed, and all
members of the CVC care team were empowered and
obligated to identify and correct any deviation or
potential deviation from the standards. New house staff
were trained to follow the standards, and a “Boot Camp”
on line insertion was repeated for current staff and unit
champions. Nursing staff received the same basic training,
with an annual review in the future.
Strict adherence to standard
practice during line insertion,
maintenance, and
discontinuance is critical in
reducing CLABSI.
Monitoring Performance
In August, quality staff conducted a review of 15 months
of CLABSI occurrences in the adult ICUs, to identify
vulnerabilities in the care processes that may lead to
infections. Specific attention was devoted to accurately
capturing all central lines in place at the time of each
CLABSI, as well as assessment of the time between line
insertion and infection. Of the 165 infections studied,
73% occurred in patients with only one central line in
place at the time of the CLABSI. More of the infections
(Continued on page 5)
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Reduce the Number of HAIs
Seeing Results
(Continued from page 4)
appeared to be the result of maintenance practice (44%)
than insertion practice (25%), given the length of time
between insertion and CLABSI infection. The review
revealed that line insertion in the ED was not a primary
contributor to the CLABSI rates, as was previously
thought.
Quality staff began creating processes to capture
infection data in near real-time for review by Infection
Preventionists, using the Vanderbilt Infection Prevention
Electronic Resource (VIPER). Building on the PICU’s
efforts to conduct an Event Analysis for each CLABSI
occurrence, a standardized Event Analysis tool entered
development. The Tool is to be used in each instance of
infection, to aid in the identification of trends and inform
practice. Additional review and analysis is to be expanded
to non-ICU areas, as the changes related to eliminating
CLABSI take hold and are successful.
Quality improvement efforts in FY2010 resulted in
significant reduction in CLABSI, with a fiscal year-end
standardized infection ratio (SIR) below 1.0 (the Centers
for Disease Control and Prevention benchmark) as of
July 2010. Quality leaders and staff are energized to attain
even greater reductions in the current fiscal year. While
setbacks will continue to occur, it is anticipated these and
other efforts over time will strengthen the infection
prevention safety net as we continue Chasing Zero.
HAIs At A Glance:
CLABSI - 0.34, lowest SIR to date in October 2010
VAP - SIR continues to decline, within Target goal
CAUTI - SIR is 0.51, within Reach goal
SSI - Reductions in nearly all procedures tracked
Hand Hygiene - Year’s efforts achieve gains to 80%,
on the way to >95% compliance
- Tom Talbot, MD, Chief Hospital Epidemiologist
Fiscal year 2010 CLABSI performance
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Exemplars of Quality & Patient Safety:
Stories From the Field
Editor’s note: This section is devoted to highlighting individuals on the frontline of care who
are putting Quality and Safety into their practice.
Patient and Family Engagement
Improves Hand Hygiene
compliance from June through September
2010.
The efforts to improve hand hygiene at
VUMC include measures to engage patients
and families as part of the Infection Prevention safety net. There are signs that this
practice is taking hold; in a recent example,
an ICU patient’s family was present when a
caregiver from another unit arrived for a
routine treatment. The family noticed that
the caregiver had not washed his hands, and
asked that he please do so before beginning
the treatment. The caregiver thanked them
for the reminder, washed his hands, and
proceeded with the treatment.
Clinic manager Pat Covington, RN,
credits the staff’s engagement, and their
willingness to ask other caregivers to
wash their hands. Clinic leadership
performed a human factors assessment,
installing hand hygiene stations outside of
clinic rooms where previously sinks had
been exclusively in-room. The commitment of physician leaders was another
key factor, with Attendings serving as role
models for the 80 residents who work in
the clinic each week. In the end, she says,
“There were no heroic measures, just a
heightened awareness and cultural
expectation,” that drove performance.
Lessons From a Top Performer
The Adult Primary Care Clinic on the 7th
floor of Medical Center East has had
remarkable success with their campaign to
improve hand hygiene, achieving 100%
Do you have an Exemplar story to share?
Send it to amie.hollis@vanderbilt.edu.
VUMC is dedicated to
achieving the Institutes of
Medicine’s Six Aims for
Changing the Health Care
System:
Safe, Timely,
Effective, Efficient,
Equitable, and
Patient-Centered care.
GETTING
About Us
The work of Quality and Patient Safety at
Vanderbilt University Medical Center is
centered upon Accountability, Clinical
Effectiveness, Reliable Systems, and
Compliance with Best Evidence Practices
and Standards. Our mission is to bring
together the individuals, departments, and
services dedicated to improving the quality
and safety of the clinical care provided at
Vanderbilt, using rigorous data analysis and
building upon lessons learned at VUMC
and peer organizations.
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If you have a question, concern, or
comment regarding healthcare quality and
patient safety, please contact the office of
Julie Morath, RN, MS, Chief Quality and
Patient Safety Officer.
Contact us at:
Vanderbilt University Medical Center
Quality & Patient Safety
2135 Blakemore Ave.
Nashville, TN 37212
615.322.2560