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Thursday, December 19 2013. Sepsis and Defect Analysis. Roger Resar , Senior Fellow, IHI. Session Objectives. Learn a methodology that surfaces and scopes improvements in a complex process design (sepsis) Learn how to engage both the leadership and frontline in a ground up improvement work - PowerPoint PPT Presentation
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Sepsis and Defect Analysis
Roger Resar, Senior Fellow, IHI
Thursday, December 19 2013
Session ObjectivesLearn a methodology that surfaces and scopes improvements in a complex process design (sepsis)
Learn how to engage both the leadership and frontline in a ground up improvement work
Develop the skill to utilize minimal (data, persons, time and meetings) resources
P2
Assumptions I have MadeYou have formed a team
A protocol has been designed by the team for implementation of the bundle guidelines in the affected departments
Some early testing has been started
P3
Sepsis 3 Hour BundleMeasure Lactate levelObtain blood cultures prior to administration of antibioticsAdminister broad-spectrum antibioticsAdminister 30mL/Kg crystalloid for hypotension or lactate >4
P4
Sepsis Bundle 6 HourApply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP)>65 mm HgIn the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate> 4 mmol/L (36mg/dL):
Measure central venous pressureMeasure central venous oxygen saturation
• Remeasure lactate if initial lactate was elevated
P5
Facts of DesignComplex protocols require the design of multiple processes
Processes need to be designed by the frontline that will be using the process or little chance of success let alone sustaining the process will be enjoyed
Process design needs to have clearly articulated standard work (who, when, where, what, how and with what)
P6
Team and the DyadThe team sets the overall goals and designs a protocol based on science (what we want to do and accomplish)
The frontline designs the standard work of how are we going to actually accomplish this while still doing everything else they have to do
It means rethinking the role of the frontline as a resource to actually do the design rather than a passive group that will bid the teams demands
P7
Frontline Structured
Conversation
FrontlineDefects
Clinical Non-clinical
CollectData
Suggest Strategies
Identify
Defects
Frontline Engagement
Small TestsLeadingToProjectSuccess
Frontline Defect Driven Project Design
Surface Defects
Scope Defects Validate
Select specific
work
Design Strategy
Finish Project
Actions
DesignBenefits
Timeline 90 min 2 Days 1 day 60 min 60 min 30 days
FrontlineEngagement
LeadershipEngagement
FrontlineEngagement
Tester Engagement
FrontlineEngagement
DesignBasics of theActions
ConversationSpecificMethodology
Anchoring Questions
Frontline Feedback
Align work
Gauge Capacity
ArticulateImplications
Study the next defect
Y/N FrontlineData Collection
Determinefrequency
DefineBoundaries
Determine Simplemeasures
Frontline Input
SmallTests
Frontline Defect Driven Project Design
R Resar
The Conversation with the FrontlineOrganize the visit to the unit beforehand
SPECIFIC DUTIESSelect a mix of frontline staff (6-8)Select a small “leadership” team (From the Sepsis workgroup)Arrange for at 60 minutes of conversationArrange for a location on the unit for the conversation
11
The Conversation with the FrontlineSTEP 1
DESIRED OUTCOMECross-section of staff working on the unitEnough time for all staff to have an opportunity to talkA location where interruptions are minimized
The Conversation with the FrontlineSTEP 2
Have each of the participants describe how they see their role in the protocol
SPECIFIC DUTIESEstablish a non-threatening atmosphereLimit this part of the conversation to the first 10-15 minutesPurpose of this portion is to understand the work and work environment
13
The Conversation with the FrontlineSTEP 2
DESIRED OUTCOMETrust from the frontline staff this is not about assessing personal work performanceParticipants who are willing to talk about the work, how they do it, and how they add value to the processes being designed
The Conversation with the FrontlineSTEP 3
Assess using “anchoring questions”
SPECIFIC DUTIESUse questions like: How does our protocol fit your work day? Tell us about how it worked the last time? Were you happy about the results of using the protocol? Use these questions to learn about both clinical and non-clinical situationsCenter questions around identified defects where actual harm discussions are avoided but potential of harm is presentSteer discussion away from solutions
15
The Conversation with the FrontlineSTEP 3
DESIRED OUTCOMEFind a specific example of a defect around which you can anchor subsequent questions about frequency, type of patient involved, previous attempts to fix, or what might happen with your day if it were resolvedKeep the discussion to a completely non-threatening, blame-free environment to allow for maximal information sharingKeep a simple record of the defects surfaced for further discussion at the team level
16
The Conversation with the FrontlineSTEP 4
DESIRED OUTCOMEGenerate a list of defects that the frontline has surfacedAchieve buy-in from the frontline for possible actionAchieve buy-in from the questioning team as to the need for action
Surface Defects
Scope Defects Validate
Select specific
work
Design Strategy
Finish Project
Actions
DesignBenefits
Timeline 90 min 2 Days 1 day 60 min 60 min 30 days
FrontlineEngagement
LeadershipEngagement
FrontlineEngagement
Tester Engagement
FrontlineEngagement
DesignBasics of theActions
ConversationSpecificMethodology
Anchoring Questions
Frontline Feedback
Align work
Gauge Capacity
ArticulateImplications
Study the next defect
Y/N FrontlineData Collection
Determinefrequency
DefineBoundaries
Determine Simplemeasures
Frontline Input
SmallTests
Frontline Defect Driven Project Design
R Resar
18
Scoping the Projects
Team needs to decide if this is within the abilities of a Dyad to solve
Team needs to give specific direction to the Dyad in regards to methodology for design of that part of the process
19
Properly ScopedThe Dyad will feel comfortable working on this particular defect in the design because the new design is integral with the current work they do
The solution for the defect will easily be designed within a few weeks (max 30 days)
Multiple designs for multiple defects can be taking place at the same time
Surface Defects
Scope Defects Validate
Select specific
work
Design Strategy
Finish Project
Actions
DesignBenefits
Timeline 90 min 2 Days 1 day 60 min 60 min 30 days
FrontlineEngagement
LeadershipEngagement
FrontlineEngagement
Tester Engagement
FrontlineEngagement
DesignBasics of theActions
ConversationSpecificMethodology
Anchoring Questions
Frontline Feedback
Align work
Gauge Capacity
ArticulateImplications
Study the next defect
Y/N FrontlineData Collection
Determinefrequency
DefineBoundaries
Determine Simplemeasures
Frontline Input
SmallTests
Frontline Defect Driven Project Design
R Resar
21
AdvantagesProjects are accomplished by a dyad
No team meetings
No training other than JIT
No data collection other than pencil and paper
Creates enthusiasm for improvement
