“For the surveillance 3P, we came up with the phrase: Protect me. That phrase characterized the team’s aspiration to move from a passive data collection and reporting process to proactively protecting our patients, staff and community.”
- Celeste Derheimer, RN
(Editor’s note: This is the first of two installments on the visionary power of 3Ps.)
One of the most important moments in modern health care history came in 1999 when the Institute of Medicine issued its report, To Err is Human: Building a Safer Health System. It shocked the nation with its portrayal of the injuries and deaths patients suffered as a result of medical errors. In the decade and a half since the report was published, health systems nationwide have worked assiduously to reduce harm to patients.
Virginia Mason has been in the forefront of this movement. When Jeremy Hunt, secretary of state for health in the United Kingdom, sought to find the safest methods for protecting patients in his country, he traveled to Seattle to announce that the National Health System would adopt the Virginia Mason approach to patient safety.
“Virginia Mason is one of the safest hospitals in the world and perhaps the safest in the world,” he said.
What sets Virginia Mason apart in terms of safety? An essential element is process; applying the methods and tools of the Virginia Mason Production System to eliminate defects that harm patients. Hundreds of kaizen events have been held through the years to identify and eliminate defects in the system that could lead to patient harm. The Virginia Mason Patient Safety Alert system empowers every employee to “stop the line,” if they believe any patient is in any danger at any time.
A key part of the process is major improvement events, such as 3Ps (Production, Preparation, Process). In fact, 3Ps serve as an instructive window into Virginia Mason’s improvement efforts. A 3P targeting health care associated infections (including catheter-associated urinary tract infections and central line infections) reveals a good deal about the Virginia Mason process.
Celeste Derheimer, RN
Celeste Derheimer, RN, is a faculty member at the Virginia Mason Institute and was a team member for a 3P focused on a “surveillance process for infection prevention.” Celeste notes that the 3P process helps create a vision for sustained improvement in a particular area.
“A 3P helps get all the right people in same room,” she says. In this particular case, it brought together a team of approximately two dozen clinicians, data experts, lab technicians and executives (along with an outside facilitator to help guide the week-long process).
Often, 3Ps are characterized as a way to blow up an existing space or process and create something new. Thus, when teams initially gather to begin the work, there is a sense both of excitement and anxiety; excitement at the prospect of being able to do something great; anxiety in the face of a huge challenge.
A fundamental key to understanding the nature and power of a 3P is recognizing that it is the beginning of an improvement process that will require a series of additional kaizen events to achieve the vision outlined in the original 3P. In fact, an essential part of the 3P Celeste worked on was developing a kaizen plan to provide the structure needed to achieve the vision.
To set the stage for the 3P, a session was first held in April 2011 to create a vision for the work on infections:
Our infection surveillance program will systematically provide easily understood, timely, and actionable information that empowers patients, staff, and the organization to improve safety, quality of care, and outcomes across the continuum.
The 3P event itself began in January 2012 “with the goal of identifying the model for a highly reliable surveillance process and information flow at Virginia Mason and development of a 12-18 month kaizen plan to implement the vision.”
“One of the first things that is standard in a 3P is finding a word or two to signify the rallying cry of the 3P,” she says. “Using the vision we created for what surveillance at Virginia Mason would look like, we came up with the phrase, ‘protect me.’ That characterized the team’s aspiration for this 3P; to move from a passive data collection and reporting process to proactively protecting our patients, staff and community.
“Next, we broke up into three different teams of about eight people on each team, and each team was a mix of physicians, other clinicians and administrators. Each team selected examples from other disciplines that could help guide safety improvements.
“We start out with exercises that push you to think beyond your first few ideas. For example, we said, ‘Think about seven ways in nature how nature protects. [An example might be the way in which emperor penguins identify hazards and work together as portrayed the film, March of the Penguins.] What protective mechanisms in nature might apply to this model? That takes you out of your current way of thinking.”
There is homework after the first day. Each team was asked to gather information on three different industries – weather, computer viruses and air traffic control. Derheimer says, “We asked the teams to think about how the concepts from those industries create a model for a surveillance system. Each team created a model and then we incorporated ideas from the teams into one model.”
“It is a very creative process and the teams came up with imaginative and very exciting models,” she says.
Prevent, detect, analyze, respond
The final report for the 3P noted “the breakthrough concept was the move from responsibility resting with one department to a shared ownership model at the center with the unifying theme of ‘protect me’ at the heart. Patients, staff, family and community are equal partners in the processes of prevention, detection, analysis and response.”
The 3P and subsequent kaizen events focused on finding solutions in concert with workers at the frontlines. For example, the equipment frontline workers use – and the protective clothing they wear – are critical safety factors. The 3P revealed a sense of frustration among nurses and others at the frontlines concerning the use of safety equipment and clothing.
“The staff kept telling us `we don’t know what to wear when,’” Derheimer recalls.
And no wonder. There were 60 pages of guidelines for protective clothing and equipment. That was condensed to 10 pages, but it was still too confusing – and not available where team members needed them. The innovation was a one page list of precaution principles that actually helped teams clearly understand what was required.
The guidelines got very specific, says Derheimer: “When you have a patient with C-diff you have to be sure to use the right-hand hygiene approach. When you are in this area of a patient room you need to use this equipment. We now have a one page, color-coded guide, hanging outside every patient room that puts the four key items staff need to know (as identified by them) for each type of transmission-based precaution right where they need it; not in some policy book or web page.”
Additionally, the team saw early on that the gowns used had two key defects: People were not tying them in the back and there was a gap between the sleeve of the gown and the glove. “We had a fashion show, and we asked different departments to trial new options that helped us select one self-tie in the back with a thumb-connection that keeps the gown from sliding away from a glove. The staff know what they need to do the work; they voted and we listened – and selected the gown they identified,” Derheimer says.
A key measure is the number of months where there are zero catheter-associated infections. In 2012, there were no infection-free months. In 2013, however, eight months were infection free. Through May, three months have been infection free in 2014.
Another key measure centers on central line infects. Since December 2012, there have been zero such infections within the hospital.
“We tracked the use of personal protective equipment,” says Derheimer, “and since January 2012 our results have improved from 72 percent compliance among the staff to 93 percent compliance.”
The 3P model (see photo) was represented by puzzle pieces with a frame around it, consisting of prevent/detect/analyze/respond. “The middle is shared ownership with the ‘protect me’ concept right at the center,’’ says Derheimer.
“Our hypothesis out of all this was that the process would be sub-optimized if any piece was missing,” she says. “We were thinking very high level with the 3P. Then, you move from the very theoretical to practical application of the kaizen plan to help you develop the process and discipline needed to implement the vision.”