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Changing the way we do business: a four cornerstone approach to reducing health care acquired infections
Quality Form 2012
March 8, 2012Dr. Elizabeth Bryce, Linda Dempster, Dr. Jennifer Grant & Deb DanielAdvisor: Shane Busby
Outline
• Current situation• Where we want to be• Four Cornerstones Approach to reduce HAIs• Self-sustaining proposal• The return on investment • Metrics• Where we are today
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Current Situation
• Environmental issues: clutter, hoarding, poorly maintained and cleaned equipment, poor separation clean and dirty, no assigned personnel for mobile equipment.
• Antimicrobial use: no new antibiotics on horizon, emerging resistance in gram negative rods, lack of monitored policies and protocols, accountability re: prescribing practices lacking.
Not delivering best value
Typical ward clutter in a 6-foot wide hallway
Not enough space in combination with staff hoarding behaviour
Mixing clean and dirty
The Everyday Reality
No routine maintenance
No routine cleaning for all wheeled equipment
Where we want to be
Centralized Equipment & Clean On-unit Equipment Storage
Clean Supply & Soiled Utility Rooms
Buckets, Microfiber and PPE Holders
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Colour-coded Microfiber cloths
New PPE holders to get
items off of floor
Appropriate use of Antibiotics
• Evidence- based• Transforming the way
antimicrobials are prescribed and used in clinical practice
• Enhancing research and education
• Patients receive “the right antimicrobials, right dose, when they need them.”
Four Cornerstones to Reducing HAIs
The Proposal – LGH, RH and VGH
1. Implement an environmental program to improve equipment and surface cleanliness
2. Establish a VCH antimicrobial stewardship program to ensure appropriate, cost effective antibiotic use
3. Implementation of a risk-managed approach to the isolation of vancomycin-resistant enterococcus (VRE) once the environmental and antimicrobial stewardship programs are underway
4. Be self-sustaining by end of year 2
Vancouver Coastal Health Strategic Framework
Lens People First
Vision We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation.
Mission We are committed to supporting healthy lives in healthy communities with our partners through care, education and research.
Values Service Integrity Sustainability
Drivers Patient/Community Focus Engaged Team Operational Excellence Financial Sustainability
Goa
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ctiv
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Provide the best quality of care.
Promote better health for our communities.
Optimize our workforce and prepare for the future.
Use our resources efficiently to sustain a viable health care system.
Use a standardized, rigorous process to accelerate the creation and broad use of evidenced-based protocols in all clinical areas and programs.
Develop a regional program for Mental Health and Addiction and Cardiac Sciences to improve quality of care.
Build a regional medication
reconciliation system across the continuum.
Reduce health inequities in the
populations we serve through focused improvements in core public health programs.
Build on VCH integration
strategies to support implementation of the MoHS directive to deliver integrated primary care, home and community care and community mental health services.
Enhance workforce utilization and match staffing to clinical volumes and patient acuity.
Recruit and retain the best
people by fosteringa culture of excellence, recognition and respect.
Buildorganizational capacity by strengthening leadership and management competencies.
Embed LEAN thinking at all levels
to fulfill objectives and to deliver quality outcomes.
Develop and implement best
practices in care management to reduce unnecessary days of stay.
Deliver administrative and support efficiencies through the shared services organization and consolidation.
Respond to provincial patient-centered funding model.
Develop service agreements with funders and service providers.
Develop and implement a strategy to secure increased capital funding.
Continue our commitment to “Green Care” alternatives by reducing waste and our carbon footprint.
Respond to provincial patient-
centered funding model.
Develop service agreements with
funders and service providers.
Develop and implement a strategy
to secure increased capital funding.
Continue our commitment to
“Green Care” alternatives by reducing waste and our carbon footprint.
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Proposal Elements• Environmental Program
– Centralized, Cleaning Storage and Maintenance – Cleaning of wheeled equipment by Equipment Aides– Centralized Ordering and Delivery by Material Porters– Microfiber, Coloured Buckets, Clean/Dirty Tags, Bar Coding– New PPE Carriers
• Antimicrobial Stewardship– Antimicrobial utilization Committees– Education– Clinical Pathways and algorithms– Lab based messaging and integration with pharmacy– Prior approval programs
Cost of the Proposal
• Two-year funding commitment $3.7M for the environmental and stewardship programs
• Demonstration of sustainability and self-funding by end of year 2
• Commitment to reinvest “savings” back into the program
Return on Investment• Implementation of the two new pillars FIRST
• Change to a risk-managed approach for managing VRE
• Use the $ from the VRE risk managed approach to continue funding the cornerstones
The rationale behind the VRE Risk Management Approach
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Overal l Infection Colonization
Current situation with VRE
But few VRE cases are infections
Return on InvestmentA. Risk managed approach for VRE: Stop routine
admission and isolation screening except for a) Bone Marrow and Solid Organ Transplant, Dialysis and ICU patients and b) patients with diarrhea and/or with Clostridium difficile and VRE (55% of our patients)
B. Antimicrobial Savings through Stewardship
C. Decreased Equipment and Supply Costs
Equipment/Supplies/Cleaning: $ 894,650Antimicrobials: $ 636,000Lab: $ 62,000Total Cost Avoidance: $1,592,650
Eliminating the VRE ManagementBurden with the New Cornerstone Approach
• PPE Supply Savings– Decrease use of PPE supplies used on isolated VRE pts
• Laundry Savings– Decrease use of laundered gowns and curtains
• Cleaning Savings– Decrease VRE isolation terminal cleaning
• Wasted Supply Savings– Decrease hoarding of isolation supplies on isolated
VRE pts
Eliminating the VRE ManagementBurden with the New Cornerstone Approach
• Equipment Savings– Equipment inventories across 3 sites– Change to centralized purchasing and based on need– Sharing – change management!
• Abx Savings– Based on conservative estimate of 5% reduction– Used UHN model
• Lab Savings– Decreased use of lab supplies
Baseline Metrics Method of Tracking Progresscompared to baseline
∀ Incidence of VRE, MRSA and C.difficile
∀ Number of VRE patients isolated annually
∀ Impact on Equipment and Supplies
∀ Antimicrobial drug usage
Standardized surveillance to monitor cases of VRE, C.difficile and MRSA exists
Monitoring of VRE isolation flag
Decrease in equipment costsDecrease in isolation gowns and suppliesDecreased turnaround time (TAT) for equipment repairs
Decrease in Defined Daily DosesDecrease in antibiotic expenditures (excluding antifungals and antiviral agents)Increased sensitivity profile for selected gram negative pathogens
This proposal…
• Is fundamental to quality patient care• Will decrease HAIs and antimicrobial resistance• Will prevent spread of resistant organisms• Will be self-sustaining• Will significantly improve patient flow & productivity• Will produce savings from reduced waste for
equipment and supplies• Will produce a safer, cleaner, healthier environment• Will require change management and a culture shift
Where are we now?
• We presented to SET in early February• SET approved the concept• Waiting on funding approval• We are in the planning stages
– Renovations committee– Abx committee– Cleaning and product committee
• Starting small initiatives
