C8 Patient safety work in a Danish Clinical Microsystem

Transkript

1 C8 Patient safety work in a Danish Clinical Microsystem Gry Rosenmai Mette Børgesen Christian von Plessen Participants today Name Country Rahm Magnus Sweden Andersen Camilla Denmark Brandrud Aleidis Skard Norway Hultgren Kyle USA Hørlück Jessen Elisabeth Denmark Kallestrup Ragnhild Denmark Liss Ingrid Sweden Lukkari Liisa Finland Marjamäki-Kekki Minna Finland Pedersen Inge Denmark Petersson Mats Sweden Poulstrup Arne Denmark Reneflot Thoresen Tone Norway Røsbjørgen Mette Norway Ursin Grau Tine Denmark von Bülow Lene Denmark Munch Børgesen Mette Denmark Rosenmai Gry Denmark von Plessen Christian Norway 1

2 2

3 Patient Harm Hillerød d Skader pr liggedøgn jan 10-a feb 10-a mar 10-a apr 10-a maj 10-a jun 10-a jul 10-a aug 10-a sep 10-a okt 10-a nov 10-a dec 10-a Reduction of patient harm by 30% Reduction of mortality by 15%

4 Participants today Name Country Role Rahm Magnus Sweden Facilitator Andersen Camilla Denmark Improvement Advisor Brandrud Aleidis Skard Norway Improvement Advisor Hultgren Kyle USA Improvement Advisor Hørlück Jessen Elisabeth Denmark Improvement Advisor Kallestrup Ragnhild Denmark Improvement Advisor Liss Ingrid Sweden Improvement Advisor Lukkari Liisa Finland Improvement Advisor Marjamäki-Kekki Minna Finland Improvement Advisor Pedersen Inge Denmark Improvement Advisor Petersson Mats Sweden Improvement Advisor Poulstrup Arne Denmark Improvement Advisor Reneflot Thoresen Tone Norway Improvement Advisor Røsbjørgen Mette Norway Improvement Advisor Ursin Grau Tine Denmark Improvement Advisor von Bülow Lene Denmark Improvement Advisor Munch Børgesen Mette Denmark Presenter Rosenmai Gry Denmark Presenter von Plessen Christian Norway Presenter Agenda Aims Team Patients and bundles Processes Results Summary 4

5 Agenda Aims Team Patients and bundles Processes Results Summary Our team 4 specialists i pulmonary medicine 8 interns 18 nurses 8 nurse assistants 1 secretary Physiotherapist Pharmacist 5

6 Agenda Aims Team Do microsystems in your organisations have explicit aims? Is the team complete? Patients and bundles Processes Results Summary Agenda Aims Team Patients and bundles Processes Results Summary 6

7 Some data: our patients Afsnit N Alder Mænd Gange (median) (%) overfl Antal Afsnit AK Insulin Opioider Antal abx Cytostatika Syst. Steroider SAG IV med Ilt Afsnit Sår Haft fald Faldrisiko Afsnit Skopier 3 dgn Op minor 3 dgn Op major 3 dgn Spinalpkt 3 dgn Respirator 3 dgn PVK CVK Dræn KAD NIV Sonde ernæring Nedsat bevidsthesion Angst Sprog snakke hørsel syn > 1dgn Konfu- Kan ikke Nedsat Nedsat Immobil Immunsuppr. IVernæring Isolation Christian 0 von Plessen 12 1 Hillerød Elements PVK-pakke 1. Relevant indikation for PVK foreligger før anlæggelse 2. Daglig vurdering af indikation for PVK 3. Daglig vurdering af rødme, ømhed eller hævelse 4. Seponering af PVK, der er løbet s.c. eller rødme/ømhed/hævelse 5. Seponering af PVK, der har siddet > 72 timer 7

8 Indicators PVK pakke Agenda Aims Team Patients and bundles Processes Results Summary 8

9 Huddle Our huddles: 05 minutes daily 30 minutes daily 30 minutes weekly Meeting place 9

10 Model for improvement Mål Mål for målet Ændring som vi tester for at opnå målet A S P D Registration form Dato: Daglig sikkerhedsscreening Lungemedicinsk afsnit Registreret af: Gry Antal i alt i 0633 i dag Antal med relevant og aktuel indikation i dag Antal fjernede inden < 72 timer i dag Antal ptt. med risiko for tryksår i 0633 Antal ptt. med risiko for tryksår revurderet i dag PVK KAD CVK Tryksår Sæt en streg "I" per "slange" eller "0" hvis der er ingen! Eksempel: = 5 "slanger" 10

11 Harm logbook 11

12 Agenda Aims Team Patients and bundles Processes Which safety problems do your microsystems work on? Ideas for good tools? Results Summary Days since the last... CATH UTI Pressure Ulcer 62 CVL-infection 47 PVL-infection

13 0633 Andel PVK med relevant aktuel indikation % days measured: Nov Dec Jan Feb Måned 13

14 Agenda Aims Team Patients and bundles Processes Results What/how would you measure? Summary Agenda Aims Team Patients and bundles Processes Results Summary 14

15 Elements prototype clinical team Clinical bundles Define aim White boards: patients, staff, quality (measures) Data used in routine work Huddles: patients, staff, quality Tools Leadership PDSA Roles: leader, registrar, clinician.. Elements prototype clinical team Clinical bundles White boards: patients, staff, quality (measures) Define aim Patients involvement Data used in routine work Huddles: patients, staff, quality Tools Leadership PDSA Roles: leader, registrar, clinician.. 15

16 Hvilke foran drin gers kali vær k- sætes fora tska befo rbed ringe r? Hvad ønsk er vi atopnå? Hvordanvedvi, at en forandri ng eren forbedring? A P S D Journey Period 1 Establish team meetings for improvement work? Period 2 Measure events and use measurements to in cr e as e aw ar en e ss of in fe ct ion s and pres sure ulcers Period 3 Reduce inf ections and pressure ulcers 1. Meetings start on time. 2. S taff satisfied with meetings 1. Process measures regularly updated 2. Outcome measures used during patient huddles 1. Number of days between infections/pressure ulcers increasing 2. Learning from cases of infections/pressure ulcers 1. H old meetings on Mondays 0930am 2. U se of 4-fields whiteboard for QI-huddles 3. R eschedule to Tuesdays H old meetings next to quality white board (QO-board) 5. D efine roles during team meetings 1. Leader asks for measures patient huddles 2. D ata presented on QI-white board as run charts 3. D ata presented in spreadsheet next to QI-board 4. D ays since last infection posted on QI-board 5. R esults discussed during patient huddles at 1.30pm 1. Short root cause analyses during patient huddles Impl ement regular meetings 5 interventions tested Tes t/ im pl ement sy st em of measures 4 interventions tested so far Working on it. Learning/Questions? Using most ly qualit at ive dat a to evaluate in period 1 Anything can j ust implement without testing? Learning/Questions? S tart ing t o focus in patient relevant measures Learning in team starts Start using PDSA test forms! Upper limit for number of checks on our checklists? Learning/Questions? Hard to see im provements with rare events Come visit! 16