I'd like to welcome everyone to today's
AHRQ Fall and Pressure Ulcer Prevention Learning Network webinar.
We've joined them this month, and we have a very special guest speaker who will
be talking about strategies for sustaining change.
This is a particularly relevant topic for all of you, as you've now spent more
than a year crafting, implementing, and fine-tuning your fall and pressure ulcer
prevention interventions as part of this AHRQ initiative.
Although we have a few people that are still logging on, we're going to go ahead
and get started on time so that we don't lose any valuable time for our later
questions and discussion.
This slide just shows the agenda for today's webinar.
We're going to quickly walk through some housekeeping items, and then we're also
going to review our upcoming webinar schedule, and then we're going to dive into
our feature presentation, which is being led by Pat Posa.
Just a few housekeeping items…we've reserved a little bit of time, 10-15
minutes, at the end of this presentation for questions and discussion; and we
hope you'll participate in that discussion.
Feel free to submit questions that you have for Pat using the Chat panel
throughout this presentation, and please make sure if you do use the Chat panel
or the Q&A panel that you direct it to "All Participants and Panelists"
…actually, just to "All Participants."
Now, everyone is currently on mute until we reach the question
and discussion section.
At that time, we will unmute the lines; and if you'd like to ask a question
during that time, please raise your hand using the hand tool,
or you can simply chime in if other people are not speaking.
Also note that at that time, please do try to keep background noise to a minimum.
Turn down the volume on your computer if you haven't already done so, especially
if you've joined by the telephone, so that there's none of that interference
noise that we often hear.
Also, please make sure that you do not put your line on hold at that point in
time because we will be able to hear any hold music that you have.
This slide just shows the webinars that we have coming up for both the Fall and
the Pressure Ulcer Prevention Learning Networks.
For our Fall Prevention hospital cohort, we're going to be hearing from
Cait Walsh in November; and she's going to be talking about
teaching critical thinking skills for fall risk assessments.
Then in December, we have another guest speaker, Susan Mascioli,
who will be talking about her institution's Lean Six Sigma process
for reducing falls.
For our Pressure Ulcer Prevention hospital cohort, in November we will be
hearing from Karen Zulkowski on the topic of pressure ulcer prevention
measurement and using data to tell a story.
We are still at this time developing the schedule for the upcoming webinars
in the first part of the next year.
Now I'd like to actually welcome our guest presenter today, Pat Posa.
Pat is a System Performance Improvement Leader
at St. Joseph Mercy Health System.
She's held various roles in healthcare in her 31-plus years of practice,
including serving as a critical care staff nurse, a manager, an educator,
and a director of nursing and administrator
of an outpatient multi-specialty primary care clinic.
Her role is to oversee quality and patient safety in critical care areas for
four hospitals, and implementation of a program to manage severe sepsis and
septic shock throughout each of the hospitals.
In 2015, Pat was named a Michigan Health
and Hospital Association Keystone Center Senior Fellow.
In that capacity, she supported the planning and development of interventions to
improve patient safety and the quality of care delivered in Michigan hospitals.
Excellence in clinical practice is her passion, and she has been involved in
many programs that aim to achieve that.
Pat has also published many articles in both clinical and quality journals, and
she lectures extensively nationally on various critical care and quality topics.
Today we're pleased to have her join us
to talk about issues related to sustainment.
At this time, I'm going to pass it over to you, Pat.
Great, well, thank you for having me, Michelle.
I'm really excited to be with you guys today and talking about sustainability,
which is often the elephant in the room
in how do we get this to continue to work.
So what is sustainment?
It's really about holding the gains and evolving as required – so you're not
staying stagnant, but you're definitely not going back to the old way.
Over the next 30-plus minutes – and we're going to leave lots of time for your
questions – I'm going to talk about some key elements of sustainability,
the key components of sustainable change, and some of the common barriers
and how to address them.
When should we begin to worry about sustaining the gains?
I know you guys have been involved in this project for a while, but thinking
about sustainability needs to happen throughout the project.
If you've followed the toolkit that has been provided in the format, you have
put in some key components of sustainable change.
You don't want to just focus on sustainability at the very end of the project,
the last month, because that's often too late to make any changes
so that you can maximize the potential.
So think about it in terms of baking a cake.
You have all these ingredients and you put them in just so,
and you time it correctly, cook it correctly;
but if you don't worry about sustainability throughout,
waiting till the end is going to be too late to make any change.
So it's important to ensure that you've done all the things from the beginning
in order to achieve the best outcomes.
You've had a pretty extensive journey so far, and this is from your toolkit.
Your journey included assessing readiness, managing change,
implementing practices, redoing those best practices and then implementing them,
measuring and used a lot of tools throughout the whole process.
Now you're moving on to sustainability.
All of these steps in your journey
are all components to good, sustainable change.
What do we mean by sustaining change?
Change needs to be so integrated into your organizational work,
into your processes and routines, that it's no longer thought of as separate.
This is just how we do it here.
So that is key.
This can't be considered, oh, it's the flavor of the month;
and we're going to work on falls.
And once the AHRQ group is done, then we'll go back to business as usual.
That's not sustaining change.
So we're going to talk about the Top 10 components to ensure that you have
sustainability in the process change and programs that you've implemented over
the course of the last year.
We are all striving to become high-reliability organizations.
So what does that mean?
It means that we provide consistent performance at high levels of safety over a
long period of time, and that's very hard to achieve.
Three main components of highly reliable organizations is that they possess a
collective mindfulness, understanding that even small failures in safety
protocols, deviations from processes, can lead to catastrophic or adverse events
if they don't take action to solve the problem so that they have an overzealous
look and worry about failure in everything that they do.
The second key component is that they eliminate deficiencies in their processes
through powerful practice improvement tools.
So you've been educated on a lot of those as well.
Then the third and one of the key factors is creating an organizational culture
that focuses on safety, so you're constantly aware of the possibility of failure.
As Michelle talked about in my introduction, I've been part of the MHA Keystone
ICU Project since it began with AHRQ funding and Dr. Pronovost from Hopkins.
And that was the key difference…is really putting in worrying about
safety culture and changing your culture to ensure that it will support safety
and it will support change.
"One of the most common leadership mistakes is to expect technical solutions to
solve adaptive problems."
So I'm clinical; my background is a critical care nurse.
There are lots of evidence-based practices that we put into place every day, and
those are technical solutions to solve…if I want to improve the outcome of
someone who is on a ventilator, I need to do certain things.
But without changing the culture and worrying about the adaptive components of
change, I'm not going to create sustainable change.
So understanding that there's technical work that needs to be done…so in this
group, your technical work has been all of the fall and pressure ulcer
prevention strategies you've put in place.
You've put in place risk assessments using validated instruments; you've created
tailored care plans based on that risk – not just generalized across everyone
but tailored based on that risk; and then consistently carrying out those
specific individualized care plans based on that patient's risks.
So some of the technical works lends itself to reminders and using checklists
and standardizing practices and protocols, and that's all important.
But if you don't combine it with the adaptive piece…and adaptive work is work
that shapes the values, attitudes, and beliefs and values of a clinician
so that they consistently perform tasks the way they should.
For example, in the critical care environment, we had certain beliefs.
It was part of our culture that our patients would get pneumonia on the
ventilator and they would get central line bloodstream infections…
that they're just really sick and these things happen.
Until we began to work on our culture and changed people's attitudes and beliefs
that these events are preventable and that we need to work to prevent them, we
were not going to be successful in putting in these interventions because people
are going to say, "Well, why should I do this?
It's inevitable that this will happen."
So this adaptive work and a lot of what you guys did
in your sections related to managing change,
improving the safety culture on the unit are key because you need to have that,
along with the technical interventions, in order to have sustainable change.
Here are the Top 10 strategies to ensure that you have sustainable change.
We'll walk through each of these, and then after that
we'll talk about common barriers.
The first strategy is to engage leaders,
and I know this was part of your journey.
Why do you need to engage leaders?
Because if your leadership is not supportive of what you are doing and feels the
value and can structure and hold people accountable, you're not going to get
this to continue long term.
So how do you engage leaders?
Well, you have to answer the question: What's in it for me?
Why should I worry about this; why is this important?
And one of the best ways to do that is through patient stories of harm;
but also, they're looking at what drives them besides just general good care
and the best for our patients is scorecards, both financial and clinical,
quality scorecards.
So talking to them in their language and sharing how important these outcomes
are is significant…so cost avoidance estimation, patient throughput,
turnover reduction, overall decrease in patient harm.
So the leaders need to be aligned to the improvement efforts.
I know in our prevention of harm in our facilities and through the state of
Michigan, we had an Executive Sponsor for each of those key programs.
That Executive Sponsor or Senior Leader really is critical to breaking down
barriers, helping problem solve, and then holding accountable the team to
getting the outcomes that they set forth to achieve.
Engaging leaders in the hospital in general, where senior executives walk and
round on the unit and talk to frontline staff, is another key strategy to
sustaining change.
So that leadership support is usually vice president or higher; sometimes in
large organizations they even have director-level to ensure that each unit gets
someone to pay attention to them.
They're rounding on the units; and these executives might not be clinical, so
you need to help prepare them to be comfortable
and support them as they're rounding.
But it's really talking to frontline staff because frontline staff know what's
safe and what's not safe and where their concerns are
because they work in these processes every day,
and some of the processes might be broken.
Some examples of what happens on rounds are asking the staff how the next
patient might be harmed in the unit; what barriers do you have that are in place
that prevent you from providing the best care for patients;
how's your teamwork…
all of the things that are important to a positive safety culture.
I know in our organization we have – and I'll show you an example of it –
we have learning boards, or huddle boards, where we display current metrics.
These are out in the hallways; patients, families, whatever can see them.
We huddle each shift to have a safety huddle talking about what's working,
what's not, where are our goals for the unit, and getting input from the staff.
So engaging your leaders when they're rounding by talking at the learning board
is a great strategy.
So key thing…leaders need to be engaged.
Having an Executive Sponsor for your falls and Pressure Ulcer Program
is vitally important.
They can support it and make sure that it's part of report cards, et cetera,
holding people accountable…but also breaking down barriers
and then engaging with frontline staff.
So the Executive Sponsor of a falls group might be when they're rounding on the
units, they might be asking questions specific to what's working with falls;
when was the last time someone fell; and what did you guys find was the cause,
and what are the barriers from you making this work in your unit?
The next three items I've grouped together.
It's really about having a multidisciplinary group that you've put together to
do this work continue on, having local physician and nurse champions, and then
making sure that you have frontline staff involved
so you can tap into their wisdom.
Your falls or pressure ulcer prevention groups that have done this change over
the last year…what are your plans to keep that going?
There are some things that can be merged into an existing group,
or this group continues to meet.
If you haven't been able to impact a significant amount of your falls and reach
the outcomes, then that group might need to continue to meet.
Otherwise, you might be able to merge it into another group, an existing group.
So maybe in your organization you have a group that looks at hospital-acquired
injury, and you could combine falls and pressure ulcer into that group.
So you want to have a place for this team or for this work to be continued
because it doesn't end; you have to continue to refine and measure how things
are going and tweak and new literature comes out, et cetera.
So part of your sustainability plan is what's going to happen to this group as
the project winds down…continue to meet or merge to an existing group.
Make sure that the work of this group…if you continue as a separate fall or
pressure ulcer prevention group, you have to make sure that you're linked within
your quality structure in your group and that your quality structure is asking
for outcomes or reports.
At my organization, we have a Quality and Safety Committee that's made up of
director-level and above.
Each of the key priorities in the hospital have to present their work:
what have they achieved over the last year,
what are their goals for the next year, and what are issues and barriers
that the executives might be able to assist in breaking down.
The other important piece as you transition from this falls or pressure ulcer
prevention group is within that group or as it merges with an existing group,
you need to continue to have clearly-defined goals
and action plans going forward.
So that's not something that ends.
Yes, you created your implementation plans when you worked over this past year;
but that needs to continue because as you measure,
you're going to find issues and barriers.
Maybe some of the prevention strategies haven't stuck yet, and so you're going
to have to begin to tweak things to understand why they didn't stick
and begin to tweak it so it can stick.
New literature might come out on different strategies;
you want to be able to continue to improve.
So it's important that your team continues to redefine goals
and develop action plans.
Again, its goals should be aligned with the organizational goals of preventing
harm, be part of the dashboard.
I know we report skins involved on our dash board
and so it's in front of everybody.
It's talked about at our executive huddle every day,
so that's a way to keep it going.
Your teams, either in the merged group or the individual group, again
should include local champions…at a minimum, a nurse and physician that can
continue to carry this work on.
And frontline staff, maybe they're not able to attend every meeting; but you
need to have the ability to tap into their wisdom.
As you're continuing to meet, executives and leadership need to support people
attending meetings, collecting data, and other activities as well.
This is often where people stall and fall off…is, oh, we're in a budget crunch,
all the meetings get canceled; or, I have some short staffing issues on a unit
and I can't send someone; or I didn't budget for people attending meetings and
they should be paid for it.
So as you move into budget your next year, make sure that you're budgeting to be
able to engage frontline staff and support them attending meetings.
If you support them, they're going to see that, okay, this is valuable;
they're allowing me to move from my workplace to be a part of this group.
So it sends the right message,
and that's often one of the barriers that people face…
that it's not supported that these meetings occur by leadership
and that I'm reimbursed for them or I'm given the time to be able to attend them.
So the fifth strategy is to learn from your defects or learn from your errors.
So when you have a fall or a pressure ulcer, why did it happen?
This is in – remember in talking about highly-reliable organizations,
one of the key components of that is creating a positive culture of safety.
And that is recognizing the inevitability of errors and proactively seeking to
identify latent threats and then resolve that.
We can learn a lot more from our errors than from our successes.
Vil Pareto tells us, "Give me a fruitful error anytime, full of seeds,
bursting with its own corrections.
You can keep your sterile truth to yourself."
So you get a lot of valuable information when you study your failures.
You pick up hidden causes, trends,
and you'll be able to identify how to reduce the risk.
So it's important to learn from your failures.
So post fall or post pressure ulcer, you should be performing as a routine
either a root cause analysis or we used a shortened tool, similar to root cause
analysis, but this came out of Johns Hopkins; and it's called
"Learn from a Defect."
It's very similar to the root cause analysis,
and the root cause analysis in your toolkit is very robust and specific
for both falls and pressure ulcers.
You're really answering the questions what happened, why did it happen;
and you're not looking at what people did something wrong,
but what went wrong in our process?
Then once you identify what that root cause is or that issue that you believe
led to the fall, then what are you going to do
to reduce the risk of it re-occurring?
I know we do post fall and post skin huddles; and the post fall huddle we'll do
right there after the patient falls because we want to make sure that we prevent
them from falling on the next shift.
So it's important to do it in a timely fashion, and using the learning from a
defect tool has allowed us to do that.
We script it similar to what you see in the root cause analysis.
You're looking to see was the risk assessment done appropriately and timely,
and were the appropriate interventions put in place and carried out
based on that patient's risk?
So lots to learn from that, and then you need to take that information back to
your team and say, "Okay, these were the last pressure ulcers
or these were the last falls, root cause analysis on them.
Okay, let's trend this; let's look to see what's wrong and where we have
opportunities in our process."
Combining this along with your outcome data and
your other process data that you should be collecting ongoing
will give you a good way to decide where do we need to focus our efforts next?
Okay, 6 and 7…as you're putting in these new processes,
you've implemented new tools.
Maybe you weren't using some specific risk identification tools.
Maybe there were certain prevention strategies based on that risk that you
hadn't been doing before.
So you want to ensure that it happens with every patient every time
based on their risk, and so that can occur through standardization.
Then how do you ensure that it's focused on each day?
How do you include it into that patient's daily goals?
How do you make it visible to all the members of the team that this person might
be at risk and talk about it every day?
So here are just some tools that help you to integrate the prevention practices
into the usual care of patients.
So if you do interdisciplinary rounds throughout your hospital…
multidisciplinary, where you have docs, nurses, maybe case managers,
maybe in an area where you have a lot of wounds and issues your wound care
specialist might be on those rounds…are those rounds scripted to where each of
the people participating in the rounds will review certain things?
I gave you an example here on the right side of the screen.
In our ICU; this is the rounding script that the nurses use
as they're part of interdisciplinary rounds.
It includes key interventions that we want to ensure
each of our ICU patients have.
So you can see on the second page, we look at skin;
we look at the different lines; and we don't have as many falls in the ICU,
so it's not called out on that script.
But skin, we look to identify if that patient is at risk and do we have all the
right things in place based on that patient's risk level?
So it's important to have those independent redundancies so that you can ensure
that those practice are integrated into just everything you do.
Purposeful hourly rounding…if you're rounding on your high-risk patients,
you should have certain things that you're looking for on those rounds.
If this patient is a fall risk, you would want to assess,
based on their risk level, do they have all the right interventions in place?
Leader roundings…we have managers on each of the units round on the patients
at least once during their stay, if not daily; and they are looking for these
practices being in place…so another check.
Huddles…below, on the left-hand side of the screen, is an example of a huddle
board where we have certain clinical metrics/quality metrics at the top where we
talk about them every day.
Those change based on whether or not we achieve them.
Then the staff can give input; on the bottom right is where the staff can give
input on why we didn't meet a metric or where some of their barriers are.
Using different types of checklists, including this in your handoffs, are all
ways to ensure that these new practices get reinforced and integrated into the
usual care of patients.
Checklists aren't the end-all be-all.
If you don't have a positive safety culture, then having a checklist that if I
don't do something on the checklist but I can't tell anybody about it, no one
will respond to it, then your checklist isn't going to help you.
So you have to combine it with having that positive safety culture,
where people feel comfortable speaking up, they're encouraged to speak up,
and the team communicates well with each other.
But checklists are important because – and I don't remember the quote,
but frontline nursing staff does so many tasks in an eight-hour shift
that it's easy to forget certain things.
Stress and fatigue can compromise our cognitive function,
so making checklists are important.
It doesn't mean that you're not knowledgeable,
that you're not an expert practitioner.
If we learn from our colleagues in other fields,
such as aviation and aeronautics, they use checklists.
It doesn't matter if you're a pilot and you've flown and have 10,000 hours;
you're still completing the same checklist because we understand human factors
and how the brain works.
It's hard to remember long lists of things, and so checklists are very helpful.
8 and 9 in the Top 10 strategies are talking about
what are you going to measure;
how are you going to track your prevention practices;
and then what are you going to do with the data, both your outcome data…
so what your pressure ulcer rate is, as well as what your fall rate is.
But then those process measures…
how often are you assessing fall risk appropriately?
How often based on that risk, if a specific intervention should be implemented
based on that patient's risk, is it being done?
So it's important to set up a regularly-scheduled
process metric data collection process.
You should be collecting outcome data, and that's important;
but it's really that process data.
So you put in this change; you're doing a new prevention practice.
You have to see if it's being done.
It's great to learn if a fall happened or a pressure ulcer that,
oh, we didn't do these three things…as you do you're root cause analysis
or you're learning from that defect.
But you want to know up front in a broad brush,
if we set up the new practice to be done when this risk level is identified,
you've got to go out and look to see if it's being done.
So along with collecting your process data, looking at your outcome data
and the information from your defects, that's where you're going to identify
where your opportunities are to continue to hardwire your practice.
And that data is key; the data will help your team identify next steps
where the issues are.
But you need to share that data;
along with sharing it with your Improvement Team,
it needs to be shared with the frontline staff and help them understand it
and talk to them on why.
If you're not getting the processes done the way you think they should be done,
then that frontline staff is going to help you determine why.
Then leadership…it's important to keep them in the loop on progress
as well as barriers.
Remember, the leaders are there to help us break down those barriers that we
might be facing.
The final thing is to continue to train new staff
in the evidence-based practices.
So you've put all this work in; you've changed new processes.
How are you going to make sure when you onboard new clinicians…
nurses, nursing assistants, physicians…to these new practices?
You've got to incorporate it into orientation for all disciplines.
An important thing to remember is even if you're on the right track,
you'll get run over if you just sit there.
So the change that you made, you need to continue to look at it
and continue to see what other changes might be necessary.
As your patient population might change, the evidence comes out
and shares some additional things.
So you can't just sit there.
What are some common barriers to sustainability?
These are the Top 5: competing priorities, staff buy-in,
challenges to patient engagement, difficulty implementing changes consistently,
and resistance to spread.
You want to anticipate these barriers, and your team should begin to talk about
them if you haven't already.
There are always going to be competing priorities…people, the whole world stops
when you update your electronic medical record, right?
But you need to not have that happen or recognize but have some things in place
to continue working on.
Maybe if you have a big thing that's happening in the organization that's going
to take people's time, realize that but still understand that we have these five
things that need to continue.
How do we make them continue?
This is where having leadership support is so important because they're going to
be able to allocate people's time and help people identify and break down some
of those competing barriers.
One of the questions people ask is: Data…how long do I collect the data, and
what type of data do I collect?
If you look at improvement science and you talk about it, your sustainment
period is your control period in the world of Six Sigma.
So you have to have some key process and outcome metrics that you watch on a
regular basis; and if they move out of control, you have set some triggers up to
be able to say, okay, we need to take a deeper dive in.
So if you are consistently assessing your processes and you have great
compliance with them, you can decrease the frequency of collecting that data.
So instead of collecting it monthly, maybe you go to every other month.
If it continues to have been hardwired and you're getting great outcomes and the
process metrics are showing 95%-98% compliance, then you can move to quarterly.
But once you take your eye completely off the ball, that's when drift happens;
and the gains that you had made can often decrease.
So pick key metrics, both process and outcomes,
and continue to collect that data.
Staff buy-in and engagement…if you've followed the process that has been
outlined in this program where you have identified your key stakeholders,
you've engaged leaders, you have frontline staff involved in this work…
they're the people that will assist you in getting the buy-in.
And by bringing data to the staff and having them help problem solve and
listening to them, that's also going to help with buy-in.
Oftentimes, you might have open units, travelers, rotating staff,
lots of turnover; and it's important there to ensure
that they have adequate training.
That's tough; but just like you're incorporating this into your orientation and
onboarding processes, if you know you have a lot of other staff coming in,
floats into the unit, you need to define a way to either match them up with a
staff person on that unit to go over key practices or make sure
that they do some training prior to coming.
It's really about changing the attitude that this is not a project; this is just
how we will care for our patients and how we ensure that we can prevent harm.
And it's really having that frontline staff participating and working on that
adaptive piece of change, that cultural change, that you're going to gain the
greatest success in your staff buy-in and engagement.
We want to involve patients and families in all the work that we do,
and there are challenges to patient engagement.
Oftentimes, families don't know what their role is when their loved one is in
the hospital; and the patients don't know what their role is.
People speak in a different language in the hospital, and so they're confused.
Maybe they've had bad experiences in the past with another loved one or even
themselves, and so they have mistrust.
So those are often the issues when related to patient engagement,
and how do you resolve those?
Well, it's about inviting them in.
A lot of organizations around the country have
Patient and Family Advisory Councils.
So maybe on your fall and pressure ulcer meeting, you put in a family member
that had a fall or a patient that had a fall because they can give you a
perspective that you're not going to gain from anyone else.
Ensure that there is good communication amongst patients.
Have you invited patients and families into your interdisciplinary rounds?
What is the communication between the healthcare team and the family?
Do you use other tools, like whiteboards, in the room that has the names of the
caregivers, as well as what the plan is for the day and a place maybe for
patients and families to write questions?
So there are lots of strategies to help engage families…
especially throughout the whole process, as well as during the discharge phase.
We could talk hours on other strategies to engage patients and families;
and we're running out of time, so we won't today.
Another barrier is how do I get this done consistently?
Usually that's a result of competing priorities.
You haven't gotten the staff to buy into that this way is the right way.
So do you not have champions in place?
Because hearing it from their coworker might be helpful…
a physician hearing it from a physician coworker,
a nurse hearing it from a nurse…
have they not seen the data, do they not know the evidence,
have you not gone back an shown that in the experience of other hospitals
as well as in this hospital,
when we put this in place we see better outcomes.
So the frontline staff – this is all part of that staff buy-in and engagement --
if they're involved in the process, understand the process, everyone can't be
involved in everything; but if you have those champions and then you bring this
information out to the units and have discussions there,
you're going to get the staff to support it.
Implementing change consistently is also about hardwiring it,
changing that culture from we just do this because
"this is the project of the month" or "this is just how we do it here."
Putting in those independent redundancies, the checklists,
incorporating this into handoffs between staff as well as into
interdisciplinary rounds are all important ways to ensure that the change
gets implemented consistently.
Your EMR can either be your friend, or it can delay things significantly;
this is where your executive can help.
If you have a specific change that you need to put in your EMR,
and it's critical to you guys achieving the outcome that you want to achieve,
then that's where your executive is there to help you.
If not, you might have to do some interim step
before it gets placed into the EMR.
Other things that impact your ability to change consistently
is insufficient education and training
and people not believing this is the best practice,
and so we've talked about strategies to help with that.
A lot of times if you've targeted one specific unit for the work,
you want to spread it to other units;
and you can meet resistance when trying to spread that change.
And it's really about -- the key component to any change is
have you involved the key stakeholders.
When you're going to another unit, even though it's a different unit in the same
hospital, their culture might be different; their patient population might be
different; some of their processes might be a little different.
So you can't necessarily slap something on that worked in one unit
and have it completely work in another area.
We're in the midst of taking a progressive mobility program that we have done in
our ICU for a number of years and spreading it hospital wide.
In order to spread that change, we're not going to just say,
"Okay, you guys do the stuff we've done in the ICU."
We're going to, again, look at the literature.
We're going to adapt the tools that had worked in the ICU,
but use the frontline staff and the leadership in the non-ICU areas
to adapt the program to meet the different patient needs
and the different processes that units might have.
These are the Top 10 strategies
for fall and pressure ulcer prevention sustainment.
You can take these to your team and use this as a checklist…
do we have all of these components in place?
Part of your sustainment plan would be, okay, if we don't,
how are we going to do that?
Then the barriers I discussed, are they barriers in your facility; and if so,
what are some of the things I can do to overcome those barriers?
Lots of different references…and we have about 10 minutes for questions.
Thank you so much, Pat.
That was a really nice presentation.
I'd like to open it up.
Deidra, you can go ahead and take folks off mute
so that we can have some questions.
I see a hand up…Barb, go ahead.
Thank you, Pat, that was perfect…wonderful…especially the examples and how you
took what you did and you applied it to our particular projects.
I'm one of the QI specialists working with five of the hospitals
on the falls prevention.
One of the things you mentioned in the beginning was collective mindfulness.
That's one of the things we are seeing as a success in many of the
hospitals…that increase in awareness by the staff.
So I know that you keep it up through education
and making sure the new staff are oriented to it; but could you address –
you did some time in this, but I'd like you to reinforce
how the folks that we're working with, the contacts, can keep that awareness up,
keep that collective mindfulness going.
That's the end of my question.
Barb, great question, and it's really about how are you integrating it
into your practices.
Some of this is the structure that you have within your organization.
We, like many other organizations, have standardized interdisciplinary rounds
throughout the hospital.
So collective mindfulness in the script in those rounds talks about
preventing harm, and so it gets brought up there.
We have safety huddles; throughout every shift, every unit does a safety huddle.
And you can see here on the left-hand side at the bottom,
it was seven days from the last skin injury.
That's where the collective mindfulness comes.
These aren't just sheets of paper in your office, Barb;
these are things that hit the frontline staff.
Your frontline staff knows when the last fall was…should know,
should know when the last skin injury is and why
and what are we going to do differently.
So some of those structures that you need to put in place
will help reinforce and help you achieve that collective mindfulness.
One follow-up question because we've talked about these,
and I love the way this brings it together.
When you were talking about the leader rounds,
you mentioned that the huddles occur once a shift.
Do the leaders attend those huddles every shift…and at what level of leadership?
We have unit-based huddles that occur each shift;
and then we have an executive hospital-wide safety huddle,
and anyone can attend that.
That's at the same time every day, 10:45 a.m.
Then each unit has defined their time that works best in their process.
The unit managers attend the huddles, and then directors and above
will attend on a regular basis.
So maybe it's once a month or the executive team that kind of owns that unit or
does safety rounds on that unit, they'll attend the huddles once a month when
they're doing safety rounds.
That's great, thank you.
You're welcome.
Other questions or comments for Pat?
Again, feel free to raise your hand or chime in.
[Pause for responses]
While we're waiting for some of our participants to maybe
think about a question that they'd like to ask,
I'm wondering what your thoughts are, Pat,
on whether or not we rely too much on champions.
With all the staff turnover, are there any strategies
for sort of dealing with that?
If we're relying on champions to help communicate and then they leave,
then the effort may potentially fall apart.
I guess I'm just wondering your thoughts on the role of champions
and how much to rely on champions.
Well, I think champions are important because it's someone from…you know,
you have the physician and the nurse champions are key to these.
So you have someone in a like discipline being able to look at it from their
perspective and then talk to people in that discipline.
Just like anything else, you need a succession plan for champions.
So if you know someone is going to leave,
then you have to assign or get another champion.
In our improvement work that we do in our ICU,
that same team has met since 2003;
but there are two people on the team that are the same members,
and the champions have changed throughout the years.
I truly do believe champions are important, but you need to ensure that
that champion understands the evidence and understand what their role is
in reinforcing and assessing and talking with staff.
And then it's good to change out champions
or maybe have more than one champion related to a specific issue.
So I don't believe they should go away; I do believe they add a great service
in your sustainability and your staff buy-in,
they are one of the key stakeholders;
and they are carrying that flag every day.
Right, great.
I have a quick question.
This is Dave McMillan from Briar Health North.
We also started in the ICU and rolled out to the rest of the units.
And as we were rolling out to the rest of the units for our CLABSI, just the
different ratios and, like you said, different cultures and things, presented
tremendous roadblocks for us as we were working through that.
We have rolled out housewide now; but one thing that I asked our specialist is
we had to change a lot of our standards and things that we expected from the
floors as we got further away from acute care.
Because acute care, 2 to 1 ratio…by the time we got down to the med/surg and
rehab, we were at 8 to 1, 9 to 1 sometimes on the ratios.
So we had to change expectations.
Is that something you guys also have found as you're rolling out?
Absolutely, and that's where you have to look at the processes.
Now, some of the expectations you don't change, right?
True.
The expectation that a risk assessment is done every shift,
that's standard throughout.
But you are going to have to tweak some of the things.
I'd be cautious that you don't move away from the evidence
because the evidence is the evidence on preventing pressure ulcers and falls.
But again, the frequency, et cetera, based on nurse/patient ratio
might be different.
And then where in their process does it best fit?
So you're right, you have to look at each of the units that you're going to
apply it to and understand what might work, what might not.
This tweaking is a little bit, but it's not as much as you would think.
Like when we did CLABSI and CAUTI preventions and rolled it from the ICUs to
everywhere else, it really wasn't tweaked that much.
The only area that was different was, for example, in CLABSII insertion having
someone in the room during the line insertion;
well, on the floor, that's not going to happen.
The nurse can't be in the room.
So what are you going to do different?
But, it's still important to have someone in the room doing that checklist.
That's an example of what I mean…that you don't want to move away
from what the evidence tells you.
You might just have to find a different person to do it
or do it a little bit differently.
Does that make sense?
Yes, I actually identify with that perfectly because we actually just had to
change some frequencies.
They weren't huge changes; it's just we could probably do a Q4 in the ICU, and
then we did a Q6 on certain floors, and then Q8 was the minimum.
And that was the best practice…was Q8; we just went above best practice for the
other two floors and then stayed with best practice on like the med/surg
and the rehab floor.
So we definitely had a lot of tweaking and different things working with IT.
But as we were rolling out the expectations that we started with, we just had to
be able to adapt to each floor.
So it took a little bit of change on our part to be able to say, okay, let's
look at each one and make the best decision and where it works in…as you said,
that collective mindfulness.
Thank you for sharing, David.
I commend you guys in doing that because it's going to stick, right?
It's going to become a sustainable change because you did that.
Right, because we built it into IT everything.
So the (inaudible), everything goes exactly.
But I will tell you, it took a lot longer than anticipated because of the
resistance to the Q4.
So then we had to sit with each one and kind of go through it and come up with
reasonable guidelines.
Yep, and because you did that, as opposed to just saying, well, this is what
it's going to be…it wouldn't have worked, right?
But you identified it and you discussed and you didn't go away from the
standard, but you were able to tweak it within the recommended standard but set
the expectation reasonable to their process.
Yeah, and it sounds like that involved some engagement of those different
stakeholders within your hospital.
Any other questions?
We are at the top of the hour, so I know a lot of people are going to need to go
off to other activities; but any other questions while we have Pat with us that
anyone would like to ask?
[Pause for responses]
All right, well, thank you again, Pat.
That was an outstanding presentation and, again,
very timely to all the activities
that many of our hospitals are working on right now.
So we want to just thank you again.
And thank you, everyone, for joining us.
If you wouldn't mind, please complete the webinar evaluation
as you exit the webinar.
We will all be talking with you next month.
Thank you again, everyone; the meeting is now adjourned.
Thank you.
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