Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System Workshop Summary (2009) / Chapter Skim
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5 Case Study Vanderbilt's Journey Toward System-Supported Practice--William W. Stead
5 Case Study Vanderbilt's Journey Toward System-Supported Practice--William W. Stead
Pages 69-80
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From page 69... ...
. In expert-based practice, experts are supposed to bring knowledge and technical skills, assimilate data, make wise decisions, and do what This chapter is based on the author's presentation and responses to questions during a plenary session of the NAE-IOM workshop on Harnessing Operational Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System on June 11, 2008.
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From page 70... ...
In comparison, the idea behind system-supported practice focuses on the system's performance; teams of people, a well defined process, and information technology tools work in concert to produce desired results consistently. People bring compassion and judgment, the process brings simplification and standardization, and information technology reduces dependence on memory and forces action when needed.
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From page 71... ...
In this instance, the focus was on intensive care units. Executives, medical, and nursing leadership from each unit, subject-matter experts, and key support personnel came together for an intensive day of crossenterprise design.
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From page 72... ...
Stress-ulcer prophylaxis Yes No Contraindications Nurse given Sedation mgmt target RASS Pt at or Is patient Pt meets 3. DVT Prophylaxis Continue Pass SBT Goal directed and above target Y agitated or N criteria for Yes No Contraindications to monitor ?
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From page 73... ...
Defining the system and outlining differences between evidence and standard practices are key aspects in the development of system-supported practice. The second aspect of system-supported practice is closed-loop control, which means the output of the system feeds back directly to change TABLE 5-1 Standard Practice Table for Stress-Ulcer Prophylaxis VUMC Practice Standard: Gastric Access Gross Blood Y N H2 blocker per tube Y Y Proton pump inhibitor per tube N N H2 blocker IV or TPN N Y Proton pump inhibitor IV
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From page 74... ...
When the thermostat senses the temperature is falling below the control limit, it calls for heat, the furnace turns on, the temperature rises, and the thermostat approaches the upper-control limit and turns off the heat. Because it keeps a record of its immediate past performance, if it overshoots the next time, the thermostat turns off a little earlier until the temperature is within the control limits.
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From page 75... ...
Figure 5-5 shows a model for adapting the practice for closed-loop control. However, health care situations are often too complex for an end-toend plan at the level of detail for an order or a prescription.
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From page 76... ...
Objectives Process Steps Measures Minimize time on • Avoid over-sedation • Risk-adjusted time on mechanical ventilation • Wean as rapidly as mechanical ventilation possible • Unplanned extubation rate •➢ Failed extubation rate Minimize complications • Pneumonia prophylaxis • Incidence per 1,000 ➢ • Stress-ulcer prophylaxis ventilator days ➢ • DVT prophylaxis Source: Stead et al., 2008. Reprinted with permission of the American Clinical and Climatological Association.
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From page 77... ...
TABLE 5-4 Ventilator Management Tier 3 Plans Objectives Process Steps Measures Stress-ulcer prophylaxis • + tube – blood => • Use or non-use of Pepcid 20 mg PT order set q12 hr • Tube +/ • + tube + blood => • TPN +/ Prevacid 30 mg PT • Drug order q24 hr • Administration record • – tube – blood => Pepcid 40 mg /c TPN q24 hr ➢ • – tube + blood => Pepcid 20 mg IV q12 hr Source: Stead et al., 2008. Reprinted with permission of the American Clinical and Climatological Association.
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From page 78... ...
The approach at Vanderbilt is measurement-driven based on agreement TABLE 5-5 Rapid Iterative Cycles in the System-Supported Approach Phase Goal # People Duration Initiation Focus 2–4 1–2 hrs Pre-work Approach 6–10 2–6 wks Design shop Agreement 30–60 1–2 days Development Components 10–20 3–12 wks Pilot System 30–100 2–6 wks Rollout Dissemination > 100 4–6 wks Improvements Performance > 100 Continuous
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From page 79... ...
The important thing is to focus on what must be improved rather than on external measures; use measurement-driven, iterative cycles to create self-correction and sustained improvements; use a common fact base to encourage agreement; set a target of 100 percent performance for the set of practices appropriate to a patient; and combine people, processes, and technology to achieve desired results. Another factor critical to the success of this initiative is that the institution and the support staff must approach the project with a collective will for process improvement.
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