SPS Talk

We Heard You: Top Ten Network Questions on CLABSI Prevention

In the newest episode of SPS Talk, we hear from the CLABSI work stream co-leads Marjorie McCaskey, DNP, RN-BC, CPHQ, Clinical Outcomes and Quality Adviser for Nursing and Director of Nursing Professional Development at Children’s of Alabama, and Dr. Elizabeth Mack, Professor of Pediatrics, Division Director of Pediatric Critical Care, University Faculty Ombuds, and Medical Director of GME Quality and Safety at the Medical University of South Carolina. Listen as they discuss the network’s top ten CLABSI prevention questions such as:

• How should we compare ourselves to other hospitals?
• What happens when your clinicians don’t agree with the IP’s CLABSI call? Does everyone call CLABSIs the same?
• What happens when we can’t get CHG wipes, when families refuse CHG treatment, or when we have a shortage of products?

These are only three of the ten questions so make sure to tune in for more information on CLABSI prevention.

If you have any questions on the CLABSI work stream, the discussion, or the upcoming SPS Learning Session, please reach out to ochsps@cchmc.org. 

The Safety Journey: Leaders Building and Sustaining Momentum

We encourage you to listen to this 8-minute podcast with Dr. Amrit Gill, the Patient Safety Officer for Cleveland Clinic Children’s. On this podcast, Dr. Gill highlighted the important role of physicians in keeping the safety momentum moving forward. One way that she recommends doing this is by celebrating successes. Additionally, she encouraged physician leaders to see challenges and setbacks as a learning opportunity by sharing lessons learned. She shared the role of physician leaders in closing the loop with staff by talking about how they are working to resolve issues from past safety rounds as well as assigning owners to new problems.  Additionally, she remarked that there is immense power in storytelling—these stories motivate and re-energize the listeners to continue to work towards making things safer. She encouraged physicians to set goals and make plans so that we can “together keep our patients safe.”

SPS Call for Innovations: An Inspiring Patient Safety Story

We encourage you to listen to this 7-minute podcast with Dr. Claudia Hoyen, Director of Pediatric Innovation and Medical Director, Peds Infection Control, UH/Rainbow Babies & Children’s Hospital. In our drive to eliminate serious harm in children’s hospitals, we know we have to find new solutions, and as part of this effort, SPS has launched a new innovations program. On this podcast, Dr. Hoyen, a co-leader for this new program, shared innovation work that is being done at her hospital. At Rainbow, they’ve been working hard to reduce CLABSIs. After many huddles, the hospital found that the lines of their patients who had GI issues had somehow become compromised and ended in places where they didn’t belong. Following this realization, Dr. Hoyen met a couple who had just formed a company called CareAline. The couple invented CareAline wraps, wraps that can be safely tucked away when the central line is not in use, out of a direct need for their child who was a patient at Rainbow. The success of the wraps inspired many, and Rainbow has successfully instituted them as part of their bundle. Importantly, in the last year and a half since instituting the wraps, the hospital has seen no additional infections due to a line being in a place it didn’t belong.

SPS Network members, we hope this inspiring innovation story encourages you to submit an innovation proposal to SPS. Please check out the announcements section of the SPS SharePoint homepage for additional information.

Children’s Hospitals Overcoming System-Level Barriers by Leading the Way and Aligning: Physicians Play an Important Role

We encourage you to listen to this 11-minute podcast with Dr. Leslie Jurecko, Vice President for Quality, Safety, and Experience at Spectrum Health, a nonprofit health system with 15 hospitals, a physician group, and health plan in Michigan. Dr. Jurecko is also a practicing Pediatric Hospitalist at Helen DeVos Children’s Hospital, which is the children’s hospital within the larger Spectrum System. In this podcast, Dr. Jurecko provides concepts to reflect on and engagement strategies you can utilize to align your children’s hospital with the larger system and yet still create great improvement work at the local level. For your children’s hospital within a system to get to the ideal state, she shared that “hard work and improved outcomes locally will pave your future to easier success in the larger system.” Listen to this podcast today to learn specific strategies you can use to overcome common barriers that children’s hospitals within systems face!

The Physicians' Role in Driving Engagement on a Safety Survey

If you missed our podcast with Dr. Rahul Shah, Vice President, Chief Quality and Safety Officer, Children’s National Medical Center, we encourage you to listen to it today! On the podcast, Dr. Shah shared his thoughts about the physicians’ role in driving engagement on a safety survey.

Dr. Shah shared how his hospital used a safety attitude questionnaire to drive physician engagement. Dr. Shah highlighted the importance of line item authority of physicians, understanding the data, and executive engagement and accountability. His hope is that this podcast will help you move a little closer to engaging physicians in safety culture surveys.

Storytelling: A Leadership Competency for Safety

In this 12-minute podcast, Dr. Lennox Huang, the Chief Medical Officer and Vice President for Medical and Academic Affairs at The Hospital for Sick Children, shares how storytelling is a leadership competency—a way of sharing knowledge, moving people, and moving culture. He emphasizes, “Storytelling is so much more than conveying information and facts; it’s also about conveying emotion and showing people how much you care about things.”

Dr. Huang shares the importance of having a bit of structure for a story to resonate with an audience. He encourages the storyteller to give the audience a sense of who the story is about, the emotion around the story, the impact that story had on the characters, and to conclude with a lesson or reason for telling the story. He concludes the podcast by encouraging listeners to “use your stories to help improve safety at your institution and at others as well.”

The Physicians' Role in Reporting Near Miss and Adverse Events

If you missed our podcast with Dr. Dan Hyman, Chief Medical & Patient Safety Officer, Children’s Hospital Colorado,  we encourage you to listen to it today. During the 5-minute podcast, Dr. Dan Hyman shared his thoughts about the physicians’ role in reporting near miss and adverse events.

Dr. Hyman shared that there are a number of reasons that people, including but not only medical staff members, don’t report near miss and adverse events. However, he shared that each of us has the opportunity to encourage more active use of our incident reporting system. Dr. Hyman encourages physicians to test setting a goal for themselves and their residents to increase the number of incident reports they file.

Reducing Unplanned Extubations: Physicians Driving Change

In this 10-minute podcast, Drs. Neal Maynord (Assistant Professor of Pediatrics and Director of Quality for Critical Care Medicine at Monroe Carell Jr. Children’s Hospital at Vanderbilt) and Kristin Melton (Associate Professor of Pediatrics and a practicing neonatologist at Cincinnati Children’s, where she serves as the Associate Medical Director for the NICU and the Fellowship Director) share how they have helped drive change as physicians and lessons they have learned from colleagues across the country. Dr. Maynord highlighted the importance of enforcing with staff that unplanned extubations matter. He noted, “They are harmful, they are avoidable, and they are expensive.” Dr. Melton shared, “Physicians can play a significant role in helping the team understand why we care.”

Dr. Melton emphasized the importance of a multidisciplinary team approach for UE prevention, and the physician plays an important role in engaging that multidisciplinary team. Dr. Maynard encouraged physicians to be involved, be encouraging, and help co-lead RCAs and the educational processes that are needed to maintain this kind of work.

Importantly, Dr. Melton concluded, “We’ve seen in our data that hospitals that have been working on this continue to show improvement, and one of the ways they are showing improvement is going back to the basics and making sure that they are really doing the right thing every time and that we’re reinforcing to our staff that they’re doing things well.”

Reference: Roddy DJ, Spaeder MC, Pastor W, Stockwell DC, Klugman D. "Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay." Pediatr Crit Care Med. 2015 Jul;16(6):572-5.

The Physicians' Role in Promoting a Safe Culture

If you missed our podcast with Dr. Bridget Norton, we encourage you to listen to it today. During the 4-minute podcast, Dr. Norton, Chief Medical Quality Officer, Children’s Hospital & Medical Center (Omaha), shared her thoughts about the physicians’ role in promoting a safe culture at her hospital.

Dr. Norton discussed the ways her hospital found to build physician engagement when tackling the culture aspects of the SPS plan and then use that physician engagement to help them get buy-in from the rest of their staff.

Ultimately, this physician engagement resulted in the hospital having a significant reduction in their serious safety events.

The Important Role Physicians Play in Error Prevention Training

In this 8-minute podcast, Dr. Diane Heatley, a pediatric otolaryngologist and the Medical Director of UW Health - American Family Children’s Hospital, shares that by the time her hospital within a system was a year into their SPS journey, it became clear that they wouldn’t be successful with their HAC work unless they also started to get a handle on their culture.

Her team attended error prevention training and reassembled the SPS course into something that they thought would resonate at home. As a result of focus group feedback, the hospital asked physicians to co-lead the course and found all of the hospital’s physicians were supportive of the concept of working on the hospital’s safety culture. Not only was it easy for the hospital to find willing and interested individuals, involving physicians in the training made the safety message so much stronger.