Sepsis and Defect Analysis Roger Resar, Senior Fellow, IHI Thursday, December 19 2013.

Sepsis and Defect Analysis

Roger Resar, Senior Fellow, IHI

Thursday, December 19 2013

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

Develop the skill to utilize minimal (data, persons, time and meetings) resources

P2

Assumptions I have Made

You 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 Bundle

Measure Lactate level

Obtain blood cultures prior to administration of antibiotics

Administer broad-spectrum antibiotics

Administer 30mL/Kg crystalloid for hypotension or lactate >4

P4

Sepsis Bundle 6 Hour

Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP)>65 mm Hg

In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate> 4 mmol/L (36mg/dL):

Measure central venous pressure

Measure central venous oxygen saturation

• Remeasure lactate if initial lactate was elevated

P5

Facts of Design

Complex 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 Dyad

The 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


R Resar

The Conversation with the Frontline

Organize 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 conversation

Arrange for a location on the unit for the conversation

11


STEP 1DESIRED OUTCOME

Cross-section of staff working on the unit

Enough time for all staff to have an opportunity to talk

A location where interruptions are minimized


STEP 2Have each of the participants describe how they see their role in the protocol

SPECIFIC DUTIESEstablish a non-threatening atmosphere

Limit this part of the conversation to the first 10-15 minutes

Purpose of this portion is to understand the work and work environment

13



Trust from the frontline staff this is not about assessing personal work performance

Participants who are willing to talk about the work, how they do it, and how they add value to the processes being designed


STEP 3Assess 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 situations

Center questions around identified defects where actual harm discussions are avoided but potential of harm is present

Steer discussion away from solutions

15



Find 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 resolved

Keep the discussion to a completely non-threatening, blame-free environment to allow for maximal information sharing

Keep a simple record of the defects surfaced for further discussion at the team level

16



Generate a list of defects that the frontline has surfaced

Achieve buy-in from the frontline for possible action

Achieve buy-in from the questioning team as to the need for action

Surface Defects


Select specific

work

Design Strategy

Finish Project

Actions

DesignBenefits


FrontlineEngagement


FrontlineEngagement

Tester Engagement

FrontlineEngagement



Anchoring Questions

Frontline Feedback

Align work

Gauge Capacity




Determinefrequency

DefineBoundaries


Frontline Input

SmallTests


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 Scoped

The 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


Select specific

work

Design Strategy

Finish Project

Actions

DesignBenefits


FrontlineEngagement


FrontlineEngagement

Tester Engagement

FrontlineEngagement



Anchoring Questions

Frontline Feedback

Align work

Gauge Capacity




Determinefrequency

DefineBoundaries


Frontline Input

SmallTests


R Resar

21

Advantages

Projects 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

Sepsis and Defect Analysis Roger Resar, Senior Fellow, IHI Thursday, December 19 2013.

Documents

Transcript of Sepsis and Defect Analysis Roger Resar, Senior Fellow, IHI Thursday, December 19 2013.