C Diff Powerpoint Session 3 140722 - IHI...Session 1: Update on Transfusion Safety August 19, 2014 Begins at 3:00 PM EST Diane Jacobson, MPH, CPHQ Timothy Hannon, MD, MBA Rishi Sikka,

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IHI ExpeditionExpedition: Appropriate Use of Blood Products

Session 1: Update on Transfusion Safety

August 19, 2014

Begins at 3:00 PM EST

Diane Jacobson, MPH, CPHQTimothy Hannon, MD, MBARishi Sikka, M.D

Terina Keller, Project Office Assistant,

Institute for Healthcare Improvement (IHI),

assists in programming activities for

expeditions, maintaining Passport

memberships, as well as other projects and

collaboratives throughout IHI. Terina is

currently in the Co-Operative Education

Program at Northeastern University in

Boston, MA, where she majors in Sociology

with a minor in Health Science. Terina plans

to earn her MPH once finished with

undergrad and work on issues dealing with

social determinants of health around the

country and abroad.

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific

purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

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Expedition Support

All sessions are recorded

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Listserv address for session communications:

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– To add colleagues, email us at [email protected]

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Where are you joining from?

Expedition Director14

Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread Initiative. She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.

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Today’s Agenda15

Ground Rules & Introductions

Pre-program Survey Results

Update on Transfusion Safety

IHI’s Model for Improvement

Action Period Assignment

Ground Rules16

We learn from one another – “All teach, all learn”

Why reinvent the wheel? – Steal shamelessly

This is a transparent learning environment – Share

openly

All ideas/feedback are welcome and encouraged!

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Expedition Objectives

At the end of this Expedition, participants will be able to:

List the quality, economic, and risk management issues

driving the need for safer blood use.

Discuss the pathway required for successful implementation

of evidence-based transfusion guidelines.

Develop three to five key performance indicators for effective

Transfusion Safety Committee oversight

Identify the essential elements of a sustainable Transfusion

Safety Program.

Describe issues of transfusion safety at the bedside and

strategies to improve transfusion administration safety.

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Schedule of Calls

Session 1 – Update on Transfusion Safety

Date: Tuesday, August 19, 3:00-4:30 PM ET

Session 2 – Transfusion Safety Program Infrastructure: Implementing Transfusion GuidelinesDate: Tuesday, September 2, 3:00-4:00 PM ET

Session 3 – Transfusion Safety Program Infrastructure: Measures of Clinical EffectivenessDate: Tuesday, September 16, 3:00-4:00 PM ET

Session 4 – Transfusion Safety Program Infrastructure: Critical Role of Leadership

Date: Tuesday, September 30, 3:00-4:00 PM ET

Session 5 – Nursing at the Bedside: Transfusion Administration SafetyDate: Tuesday, October 14, 3:00-4:00 PM ET

Session 6 – Best Practices: Communication and Awareness StrategiesDate: Tuesday, October 28, 3:00-4:00 PM ET

Session 7 – Putting it All Together: Building a Sustainable Program

Date: Tuesday, November 11, 3:00-4:00 PM ET

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Pre-work Assignment

Complete the Expedition: Use of Blood Products Pre-

Survey

Complete the IHI Open School Course QI 102: The

Model For Improvement: Your Engine for Change

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Pre-Program Survey Results

Diane Jacobsen, MPH, CPHQ

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Survey Results:What roles will be represented on your team participating in the Expedition?

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Survey Results:Degree to which each intervention related to Blood Product use is currently in

place/practice

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Survey Results: Barriers to ensuring appropriate use of blood products in your organization

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Physician/provider related- Lack of physician involvement in the blood management process- Lack of consensus between physicians about appropriate circumstances for blood product usage- Inappropriate orders/use of blood products

Leadership Support/Commitment - Lack of consensus among Hospital Leadership with respect to goals.- Lack of effective leadership accountability, transparency, education

Education-related- Lack of knowledge of current evidence based practice- Lack of electronic guidelines/guidance and support

Lack of transfusion committee oversight- Lack of a system to monitor/regulate blood product usage. - Lack of consistent, ongoing evaluation methods to determine appropriate use of blood products between providers.

Survey Results: What we’re most proud of to support appropriate use of blood products

Physician initiation of joining the IHI Blood Product

expedition

Created a team to develop a hospital Blood

Management Program and influence a system-wide

effort

Hired a transfusion safety officer

E-learning program for mandatory education for all staff

involved in the administration of blood products

Multidisciplinary approach to problem solving to ensure

safety and quality in the use of blood products

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Survey Results: What we’re hoping to learn about appropriate use of Blood Products

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Current practice guidelines and ways to implement within our system

How to engage the stakeholders in building an effective transfusion safety

New strategies so we can reach far and deep to the clinicians to improve blood product management, quality and safety of patient care.

Key measures and innovative ways to support staff at the bedside to do the right thing.

Tools to improve different aspects of blood transfusion activity in my hospital.

Faculty26

Timothy Hannon, MD, MBA, is a board certified anesthesiologist who serves as medical director of the St. Vincent Indianapolis Blood Management Program, a forward thinking program which he designed and implemented with great success. Since its establishment in 2001, the blood management program has reduced hospital transfusions by over 30%, resulting in annual savings of over 7000 units of blood products and cost savings that exceed $4,000,000 per year. The program has also substantially improved quality of care and increased patient safety, becoming a model for innovative quality improvement. Dr. Hannon is also the Founder and CMO of Strategic Healthcare Group LLC, a health care consulting group that is the national leader in safe, efficient and effective blood management solutions.

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FacultyRishi Sikka, M.D, As Senior Vice President of Clinical Transformation at Advocate Health Care, Dr. Sikka has system level responsibility for pharmacy, critical care, quality, safety, clinical effectiveness and business intelligence/”big data.” He also serves on the board of Advocate Physician Partners, the clinically integrated network with 4,000 physicians serving 550,000 attributable lives. He continues to practice emergency medicine and is a clinical associate professor in the Department of Emergency Medicine at the University of Illinois-Chicago, School of Medicine. Dr. Sikka’s career has spanned a variety of leadership roles in fields including media, technology start-ups, hospital administration, managed care and big data. His time included roles at Advocate Christ Medical Center, Oak Lawn, IL; Boston Medical Center, Boston, MA; Medco Health Solutions, Franklin Lakes, NJ; Health Benchmarks, Woodland Hills, CA (acquired by IMS); Praxeon, Cambridge, MA (a Boston health technology start-up); Prudential Health Care, Atlanta, GA; and KTTC-NBC, Rochester, MN. Dr. Sikka received his medical degree from Mayo Medical School in Rochester, MN. His internship in internal medicine was completed at St. Vincent's Hospital, New York, NY and his residency in emergency medicine at Boston Medical Center, Boston, MA. He received his bachelor of science in economics from the Wharton School at the University of Pennsylvania, Philadelphia, PA. Dr. Sikka is the recipient of the 2013 Chicago Health Executives Community Leadership Award and was recognized in 2011 Crain’s Chicago Business as a Top 40 under 40.

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Tim Hannon, MD, MBA

Rishi Sikka, MD

IHI Appropriate Blood Use

Introduction to

Transfusion

Safety

© 2014 Tim Hannon, MD. All rights reserved.

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Agenda

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Brief Overview of Blood Management &

Transfusion Safety

A High Reliability Approach to Transfusion

Safety

General Approach to Program

Implementation

Advocate Health Care Transfusion Safety

Program Case Study- Dr. Sikka

Q & A

Session I wrap up

www.BloodManagement.comBloodManagement.com

Why is Blood Use an Issue?

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• Blood is a precious and scarce community resource

• According to the 2010 HCUP survey, blood

transfusions are the most commonly employed

procedure for hospital inpatients1

• Scientific evidence over the last decade has

consistently shown transfusions to be less

beneficial and more harmful• Clinical trials in high risk patients (critical care,

cardiac surgery, orthopedics, gi bleed)2-5 show no

benefit of liberal transfusion therapy and a tendency

towards harm

• A growing list of non-infectious risks of transfusion

have been identified, including lung injury, volume

overload, renal injury, multisystem organ failure and

immunosuppression6

1 Available at: http://www.hcup-us.ahrq.gov2 Hébert et al- NEJM 1999;340(6)

3 Hajjar- JAMA 2010;304(14)4 Carson et al- NEJM 2011;365(26)

5 Villaneuva- NEJM 2013;368(1)6 Gilliss- Anesth 2011;115(3)


http://www.bloodmanagement.com/

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Evidence Based Transfusion Practice

1 Hébert et al, NEJM 1999;340(6)2 Blajchman, Transfusion 2005:45

“A restrictive strategy of red cell transfusions is at least as effective as and possibly superior to a liberal strategy in critically ill patients, with the possible exception of patients with

acute myocardial infarction or unstable angina.”1

Ranked as the #1 landmark study that has changed the practice of

transfusion medicine2 but how many physicians are familiar with it?

A Multicenter, Randomized Controlled Clinical Trial of

Transfusion Requirements in Critical Care (TRICC)1



1

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1Kim-Shapiro- Transfusion 2011;51(4)2 Hovav- Transfusion 1999; 39

Physical Properties of Stored Blood

Vasoconstriction

and microvascular

occlusion

Platelet adhesion

and aggregation

2

3

Interleukins,

TNF

Cytokines cause

inflammation &

immunosuppression


3Grimshaw- Transfusion 2011;51(4)



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Transfusion- Related Adverse Effects

1 Goodnough- CritCare Med 2003;31(12S)2 Utter- Transfusion 2006;463 Rana- Transfusion 2006;464 Li- Transfusion 2011;51(2)

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Infectious Complications

– Viral transmission

– bacterial contamination of platelets* (1:3000)

– nvCJD, West Nile, Chagas, Babesiosis, Chikungunya

Noninfectious Hazards of Transfusion

– Febrile and allergic reactions 1- 2%

– Hemolytic transfusion reactions

• Mistransfusion* (clerical error) incidence 1:14:000-16,000

– TA- Microchimerism (50% of trauma pts @ discharge/ 30% @ 1 year)2, TA- graft vs. host disease

– SIRS, TRIO, TRAKI, TRAGI

– TRALI* (1:10,000), TACO*(1:16- 1:350)3,4

– TRIM*

Infectious and Noninfectious Risks of Transfusion

* Leading

causes of

morbidity

and

mortality


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Evidence of circulatory overload within 6 hours of a transfusion1

Increase in CVP and PCWP

BNP may help distinguish from TRALI

Incidence 1%- 8% (FFP and RBC)1,2,3

Mortality 1- 3%1,2

Increased mortality rate (OR=3.2)

Increased LOS by 4 days (ICU)

Risk Factors1,2,3

Extremes of age

Positive fluid balance (OR=9.4/L)

Renal dysfunction (CRF OR=27)

History of CHF (OR=6.6)

Amount of blood given (OR=1.11/ unit)

Higher rates of transfusion (> 170 mL/hr)


Transfusion Associated Circulatory Overload (TACO)

1 Alam, TransMedRev 20132 Murphy, AmJMed 2013


3 Li, Trans 2011;51(2)

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Transfusion Related Immunomodulation (TRIM)

• Immune system response to foreign tissue1

• Upregulation of humoral immunity-antibody production/ alloimmunization

• Downregulation of cellular immunity

• Decreases in NK cell and macrophage activity

• Activation of T-suppressor cells (anergy)

• Immune system “overload” leads to adverse effects2

• 3- 10 fold increase in postoperative infections and VAP3 in transfused patients leading to increased LOS and costs

• Increased 5 year mortality in CABG4, increased cancer recurrence in some studies

• Effect has been known and well-documented for years

1 Triulzi, Transfusion 1992;322 Blumberg, Transfusion 2005;45(S)

3 Shorr, CurrOpinCritCare 2005;114 Engoren, AnnThorSurg 2002;74


Transfusion Dose Response for Adverse Effects

1 Bernard et al, JAmCollSurg 2009;2082 Ferraris et al, ATS 20113 Ferraris et al, Arch Surg 2012;147(1)

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Surgical Outcomes and Transfusion of Minimal Amounts

of Blood in the Operating Room3

Each unit of RBC

transfused results in:

• 4% increase in

wound complications

• 1.5 day LOS

• 0.9% increase in

mortality 3



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© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved. 37

Transmittable Disease

IMPROVE OXYGEN DELIVERY

PREVENT ORSTOP BLEEDING

IMPROVED WOUND HEALING

IMPROVED REHABILITATION

Transfusion Benefit vs. Risk 1998


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Transfusion Benefit vs. Risk 2014

© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved.



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39

Focus on Overutilization


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“Since physicians want to practice evidence-based medicine and do what’s

right during their interactions with individual patients, the work group

emphasized the importance of having the infrastructure and support tools

that help physicians make the best decisions and to document why they

were made.”

“The work group pointed out that more guidelines are not the answer, since

there are many excellent trials and guidelines available that are not being

followed. To make sustainable progress in the use of blood and blood

components, changing behaviors when supporting data are available is the

best solution.”



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42




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44© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved.

Transfusion and Risk Management



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Transfusion Economics

Hannon, Gjerde.

Economics of

Transfusions. In:

Perioperative Blood

Management ( 2005)

Blood Costs

$ 220

$ 660

$ 1220

$ 2100*

Labor

Overhead

Adverse Effects

Transfusion Costs

*2010$ costs



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Quality Outcomes Resources Costs

Qualit

y

Cos

t

Healthcare Quality and Costs




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Transfusion Appropriateness

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• In spite of the growing evidence for more thoughtful

& conservative blood use, blood utilization is far

from optimal1

• There is wide variation in transfusion practice

between hospitals and among physicians at the

same hospital2

• Published studies and Strategic Healthcare Group

audits demonstrate that 30-70% of transfusions are

inappropriate or unnecessary3

• Transfusion appropriateness in many hospitals is

essentially a “coin toss” decision

• Physicians typically lack formal training in

transfusion medicine and are often unfamiliar with

the current indications and dosing for blood

component therapy4

1Boucher, Hannon- Pharmacotherapy 2007;27(10)2Bennett-Guerrero- JAMA 2010;304

3Friedman et al- ArchPatholLabMed 2006;1304 Dzik- Transfusion 2003;43



• Blood transfusions are one of the most

common treatments within our hospitals

• Evidence-based transfusion guidance has

become more conservative because of a

significant shift in transfusion benefits and

risks

• In spite of this evidence, transfusion practice

remains less than optimal

• Unnecessary transfusions waste precious

resources and cause avoidable harm

• As such, the medical decision to transfuse

is a critical component of patient safety


Appropriate Blood Use and Patient Safety



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Introduction to Transfusion Safety

A High Reliability

Approach to

Transfusion Safety



501 Dzik, Transfusion 2003;43

Shifting the Focus From Blood Center to Hospital: A

Vein-to-Vein Transfusion Safety Chain

Bedside ID/

administration

Medical decision

to transfuse

Monitor &

evaluate

Transfusion Safety

From Blood Safety to Transfusion Safety

Safe transfusion therapy depends upon an interconnected series of

processes that begin with the donor and ends with the patient.1

“Unsafe at Any Speed: Dangerous

Focal Points in the Transfusion Process”1

Recruit

Donor screening

Collect & prepare

Infectious disease

tests

Blood Safety

Pre-transfusion testing Issue/

transport

1




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Primary prevention of transfusions

Transfusion Safety is a

multidisciplinary, multimodality

patient safety initiative designed to improve

blood utilization and reduce avoidable harm.

Roadmap for Transfusion Safety

1 Dzik, Transfusion 2003;432 Reason, 19903 Hannon, AAOS Comp Orth Rev 2009

“Unsafe at Any

Speed:

Dangerous

Focal Points in

the Transfusion

Process”1

2

Blood Management Best Practices

3



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• Avoiding unnecessary transfusions!

• “Meaningful use” of evidence-based transfusion guidelines

• Single unit transfusions (RBC)

• Should be the standard of care for non-bleeding patients

• Reducing transfusion rates

• Specify transfusion rates as mL/hr, not “transfuse over X hours”

• <120mL/h on an infusion pump for patients at high risk (positive fluid balance, history of CHF, history of CRI)

• Splitting units and/ or preemptive diuretics (high risk patients)

• Lasix should not be used to “squeeze in” questionable transfusions

• “Critical Nurse Supervision”1- vigilant monitoring by nursing is key

• Encouraging/ enforcing transfusion guidelines (“stop the line”)

• Careful monitoring for first 15 minutes

• Intermittent monitoring every 30- 60 minutes for duration of infusion

• Use of continuous pulse oximetry?

1 Alam, TransMedRev 2013

Using a High Reliability Approach to Reduce TACO




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General Approach

to Program

Implementation



Philosophy

• Physicians and nurses want to do the right thing, but they

“don’t know what they don’t know”

• Initial and ongoing education, training and awareness

are essential program elements

• Competency and credentialing should be a

requirement for both physicians and nurses

• Physicians and nurses don’t willingly harm patients!

• Program must continually be framed as a patient

safety initiative

• Emphasis on patient safety drives a sense of urgency

and helps to prioritize the program efforts

Methodology

• Evidence based, patient centered, data driven & systems

oriented

• E4 Process Improvement Methodology

• Evaluate, Educate, Engage, Empower


General Approach to Healthcare Quality Improvement



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Ongoing Selection, Prioritization and Implementation of Projects

Clinician Education

Physician, Nursing, Mid-Levels

Education , Training and Awareness in Support of

Evidence-Based Transfusion Guidelines and Program Goals

Transfusion Safety Committee

Review of Structure and Function

Transfusion Guideline Development

Development of Key Performance Metrics

Expansion of Membership

Phase I:Leading

Change,

Mobilizing

Commitment,

Developing

Capabilities

Phase II:Changing

Systems &

Structures,

Monitoring,

Hardwiring

Audit and Feedback of Transfusion Ordering

Practices

Audit and Feedback of Transfusion Administration

Safety

Monitoring and Improvement of Key Performance Metrics

Ongoing Education, Training

& Awareness

Process Improvement in High Blood Use

Specialties


Transfusion Safety Program Implementation



Case Study:

Advocate Health

Care

Transfusion Safety

Program




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Questions?57

Raise your hand

Use the Chat

Rishi Sikka, MDSenior VP, Clinical Transformation

Advocate Health Care

Safety First Case Study in Implementing Transfusion Guidelines

August 2014

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Discussion Topics • Who is Advocate?

• Why blood product transfusions?

• Leading to safety – leveraging High Reliability Values in change management

• Results

• Closing thoughts…Lessons Learned

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A Little about Advocate…• Largest integrated healthcare system in Illinois:

– 3000 + beds (12 acute care facilities)

– 250 sites of care

– Largest integrated children’s network

– Largest emergency and Level I trauma network

• Expenditures for blood in 2011: $26 million dollars– Over 28,000 patients transfused annually

• Physicians on staff: 6300

• Nurses on staff: 10,000

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Emerging Issue • By the end of 2011, leadership at

Advocate had watched our use of blood products increase every year

– Was our transfusion practice evidence based?

– What was the impact of non-evidence based use of blood products on patients?

– What could be done to improve our use of blood products?

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Our Issues• If we want to improve practice, how do we:

– Change the consensus about what safe blood product use is?

– Do this across an integrated health system?

– How do we measure multiple dimensions of change?

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Our Values: High Reliability • These organizations perform

dangerous, complex tasks every day in unforgiving environments

• Manage to do so safely – almost all the time – without hurting anyone, or failing operationally

• Share five characteristics or organizational values

• We leveraged these values in our rollout plan

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Sensitivity to operations

Reluctance to simplify

Preoccupation with failure

Deference to expertise

Resilience

Values Count… • Defer to expertise

– It’s all about the evidence

– Decision making and project selection were entrusted to physician, blood bank, and nursing experts in transfusion therapy

• Sensitivity to operations– Communications and support focused on direct care

clinicians

– Messaging and tools were developed to support adoption

Sensitivity to operations

Reluctance to simplify

Preoccupation with failure

Deference to expertise

Resilience

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“Why” before “How”

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• You can ruin a perfectly good idea with bad implementation

– Do not expect physicians to adopt new practices without a good reason

– Integrate the evidence into clinical work flow

– Select projects that drive that integration

– Measure

Improve Each Process Step

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Pre-transfusion testing

Medical Decision to Transfuse

Dispense the correct product from the Blood

Bank

Safe Administration at the bedside

• Switched the system to smaller specimen tubes to prevent iatrogenic anemia

• Developed evidence-based transfusion guidelines

– Impact - a shared medical consensus on safe blood product use

– Deployed CPOE order sets that embed guidelines into blood product ordering

– Deployed an aggressive communication campaign with the safety message

• System and site Transfusion Safety Committees to own the transfusion process

• Developed a measurement system to track progress and put it on line for Advocate clinicians to view

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The Benefit of Projects• Forces diverse groups to come together

• Drives discussion and debate about improvement

• Creates a shared goal and understanding of what patients need

• The shared understanding translates into shared consensus between clinicians and across sites of care

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The Power of Consensus…

As a nurse began her pre-transfusion patient assessment she noted that thepatient’s clinical condition did not ‘look like she was less than 7.0.’ She contactedthe physician; he agreed that a re-check was in order. The new lab values indicatedthat a transfusion was not needed, and the physician canceled the order for thetransfusion.

The nurse – physician teamwork, and the awareness of the evidence-base forsafe transfusion avoided a transfusion for this patient.

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Our Safety Message

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Distill the safety message into a single idea thatcan be used in patient care

RBC Use/1000 Adj Patient Days

Our Results • Since 2011, RBC usage has

declined by: – 49% at the Level I Trauma

sites,

– 44% at all other Advocate sites

• Component use decreased:– Level I

• Platelets = 11% Decrease

• Plasma = 42% Decrease

– Level II • Platelets = 20% Decrease

• Plasma = 27% Decrease

70

**Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma

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Blood Product Units Saved• RBC’s = 39,642

• Platelets = 3,036

• Plasma = 6,703

• Cryo = 1,918

• Total Resource conservation = 51,299 units

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Clinical Impact• Health Outcomes for Advocate Patients

– 1,797 complications avoided

– 67,369 inpatient days avoided

– 98,809 Nursing hours repurposed

– 404 Lives saved

Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma

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Stewardship• In 2011, Advocate spent over $26 million

dollars on blood products

• In 2013, we spent $17.5 million dollars for the same purpose

• The bottom line – we are able to repurpose over $8.5 million dollars into improved patient care

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Final Thoughts…• Start with ‘why’

– Make the link between medical decision making and patient safety

• Communicate the message everywhere

• Improve your whole process, from medical decision-making to administration

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Questions?75

Raise your hand

Use the Chat

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,

Norman, C. L., & Provost, L. P. The Improvement Guide:

A Practical Approach to Enhancing Organizational

Performance. San Francisco, CA: Jossey-Bass, 1996.

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Plan• Compose aim

• Pose questions/predictions

• Create action plan to carry

out cycle (who, what, when,

where)

• Plan for data collection

DoStudy

Act

• Carry out the test and

collect data

• Document what occurred

• Begin analysis of data

• Complete data analysis

• Compare to predictions

• Summarize learning

• Decide changes to make

• Arrange next cycle

77

Why Test?

Increase the belief that the change will result in

improvement

Predict how much improvement can be

expected from the change

Learn how to adapt the change to conditions in

the local environment

Evaluate costs and side-effects of the change

Minimize resistance upon implementation

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Repeated Use of the PDSA Cycle79

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range of conditions Spread

Multiple PDSA Cycle Ramps

Transfusion

Administration

Safety

Communication

and Awareness

Strategies

Engaging with

Leadership

80

Implementing

Transfusion

Guidelines

8/18/2014

41

Action Period Assignment

Read “Blood Management: A Primer for Clinicians”

Construct a three year trend chart for your facility noting

percentage change for:

– Blood utilization by product (RBC, platelets, plasma,

cryoprecipitate) and annual blood purchase costs|

– Randomly ask clinical staff if they are familiar with your hospital

transfusion guidelines and if they can list the three leading risks

of blood products

Come prepared to share what you learned………..

81

Questions?82

Raise your hand

Use the Chat

8/18/2014

42

Expedition Communications

Listserv for session communications:

[email protected]

– To add colleagues, email us at [email protected]

– Pose questions, share resources, discuss barriers or successes

83

Next Session

Session 2: Transitions to and from the acute care,

long term care and rehabilitation settings

Tuesday, September 2, 3:00 PM – 4:00 PM ET

Faculty: Timothy Hannon MD

84


Documents

C Diff Powerpoint Session 3 140722 - IHI...Session 1: Update on Transfusion Safety August 19, 2014 Begins at 3:00 PM EST Diane Jacobson, MPH, CPHQ Timothy Hannon, MD, MBA Rishi Sikka,