Two years ago, Marcia Cristina da Silva, MD, MSc, wondered how to build a culture of safety at her hospital. Da Silva is a neurosurgeon and coordinator of the Patient Safety Committee at Hospital João XXIII in Belo Horizonte, the capital of the state of Minas Gerais in southeastern Brazil. João XXIII is a 434-bed public hospital specializing in trauma care.
After hearing about the Ministry of Health-sponsored Colaborativa Saúde em Nossas Mãos (Health in Our Hands Collaborative) at IHI’s Latin America Forum on Quality and Safety in Healthcare in 2017, da Silva decided to apply for her hospital to join the patient safety collaborative. She saw it as a unique opportunity to improve care at her hospital, learning from IHI experts and Brazilian quality improvement (QI) specialists involved in the collaborative.
Da Silva recognized her organization had opportunities for improvement. Ventilator-associated pneumonia (VAP) was a critical adverse event at her institution. In 2017, for example, 185 patients admitted to the adult intensive care unit (ICU) were diagnosed with VAP. Da Silva and the project team decided to target VAP to reduce harm to their already vulnerable trauma patients.
They soon realized that there were many opportunities for improvement within the VAP prevention bundle. One of the elements of the bundle is routine oral hygiene, which plays an important role in reducing VAP. The team recognized that João XXIII’s oral hygiene process was not standardized and happened in an inconsistent manner. Based on what they took away from the Latin America Forum about collective learning, “all teach, all learn,” and advice from the local specialists who had completed an IHI QI professional development program in Brazil, they knew the importance of engaging a lot of different patient care providers. Their first step was to put together a diverse team of staff members to help improve the many tasks. They made sure everyone involved in patient care was represented as they co-designed their new oral hygiene process. They brought together nurses, nurse technicians, dentists, ICU doctors, physical therapists, and others.
Don’t Fear Honest Critics
To ensure they got information that was useful to their process of continuous improvement, while organizing the team the ICU nurse coordinator decided it would be a good idea to engage people she knew would provide honest feedback. Da Silva remembers, “She made sure she invited nurse technicians who were engaged and interested but had a more defiant attitude.” Based on her observations of their personalities and working styles, she believed they wouldn’t hesitate to share problems they saw in the design process. “She knew they would be brutally honest,” says da Silva, but the team knew nurse technicians’ insights would be invaluable.
With input from their staff, the team started running a series of PDSA cycles. Initially, they tested performing oral care on patient three times a day, as recommended by the collaborative. They started with only two patients and kept running small tests of change. “We tested it during the day, at different shifts, and then on the weekends,” da Silva recalls. “At the end of each cycle, staff members would give the team feedback on the process, suggesting changes to incorporate and adapt as they learned.”
After running a number of PDSA cycles, they learned from staff feedback that performing oral hygiene three times a day wasn’t working well because of how nursing shifts were scheduled. They changed the routine to twice a day and continued testing. They gradually expanded to a larger group of patients. “We wanted to make sure that every member of the staff involved in the process had enough time to learn, adapt, and suggest,” says da Silva.
Dentists trained the nurses and others involved in administering the new routine. They provided instruction, gave feedback, and answered questions.
At one point during the project, da Silva’s team decided to increase the number of patients receiving the new standardized oral hygiene process to 10 patients. Nurses and nurse technicians caring for those patients were one more time trained and oriented about the new routine. After about 3 weeks, they were surprised to learn that some patients who were not part of the original 10 were also receiving the new oral care routine.
When they asked the team why this happened, their answers surprised them. Says da Silva, “They told us it didn’t feel right to them that only some patients were receiving what the hospital had deemed as standard best practices.” For da Silva and her team, this was an aha moment. “This showed us that staff members were not only engaged and committed to the new process,” da Silva says, “they also understood the importance of quality improvement and the impact it could have on the health of our patients.”
This commitment and understanding translated into rapid improvement. By December of 2018, they reduced VAP infections by 47 percent, surpassing their original goal of a 30 percent reduction by June of 2019.
Angelo Lima is an IHI Project Coordinator.