tag:blogger.com,1999:blog-32053362.post598017848959612920..comments2024-03-29T06:37:18.029-04:00Comments on Not Running a Hospital: Central line infection reportPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger31125tag:blogger.com,1999:blog-32053362.post-10594796231558391512008-08-21T18:22:00.000-04:002008-08-21T18:22:00.000-04:00No, the control limits just tell you "when" your p...No, the control limits just tell you "when" your process rendered an odd effect. You still need to look at the real situation to find out what might have caused it. If your control limits show you a periodicity, then you look for a periodic activity. If there is no periodicity, then you look for the singular event cause. Sometimes you can have periodicity with singular events imposed.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-45219872316457117452008-04-23T22:10:00.000-04:002008-04-23T22:10:00.000-04:00Why do people who are good at statistics keep tryi...Why do people who are good at statistics keep trying to provide advice on this? And on whom I should hire? This is not a statistics issue. We view every infection as a potential learning event and investigate its root cause. We don't need to calculate control limits for that.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-51408488887405959992008-04-23T20:37:00.000-04:002008-04-23T20:37:00.000-04:00Wow, months later. I stumbled on this because I wa...Wow, months later. I stumbled on this because I wanted to see why someone was using an upper control limit that I thought was way to "small" for the job. <BR/>I'm in healthcare as an analyst. We use control charts all the time. <BR/>Control charts are a way to apply bell curve statistics to events that happen over time. <BR/>With central line infections, first you establish your 'best practices' to prevent illnesses. And I try to find a statistic of how many of these infections are found in the non-hospitalized population (as a rate). <BR/>In your case, since your ideal is zero, you will show an Upper Control Limit (UCL) on your chart but no lower. You would probably also want to show your 1s and 2s lines as well. In a rough way, the 1s is one standard deviation above your average. Your 2s is two STDs, and UCL is 3s. Approximately. To have anything outside one standard deviation is slightly odd, outside two is odder, and three is becoming improbable. So, if something jumps three at once, it's a shock. On the other hand, something sneaking up with seven events through two levels is also something to check on. That's why it's best to buy a book, because there will be probably a dozen rules of activities that you might want to watch out for. And because you can "tighten" up your limits in certain ways so that they are not so classically a bell curve. <BR/>Here's the wikipedia address for control charts. http://en.wikipedia.org/wiki/Control_chart<BR/>and then I have a book (at home) called "Variations" which covers the subject well. <BR/>Also, a CEO should have an executive consultant, the highest level of analyst in a medical organization. Very likely the charts you are seeing from your doctors and nurses are being made by lower level analyst.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-78564949340828246982007-10-28T11:38:00.000-04:002007-10-28T11:38:00.000-04:00Absolutely on target. We do just as you say.Absolutely on target. We do just as you say.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-73883755946361915162007-10-28T10:16:00.000-04:002007-10-28T10:16:00.000-04:00If you will accept a voice from manufacturing, met...If you will accept a voice from manufacturing, meticulous attention to quality metrics is sensible but failure to incorporate best practices into the strategy reduces the likelihood of signifiant progress. Process controls are only helpful if the process is a good one. I don't see any mention of best practices, including technology (antibiotic catheters, chlorhexidine skin scrub, etc.), that actually reduce infection. The exercise can be as academic as you choose to make it but ultimately, the best outcome will probably result from selecting the right tools then scrupulously applying them.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-14806977996688135562007-05-25T08:14:00.000-04:002007-05-25T08:14:00.000-04:00Thanks, Paul, for your helpful followup. I know a ...Thanks, Paul, for your helpful followup. I know a lot of administrators who would not have bothered to follow up, so my respect for you is increasing even more!<BR/> As for using root cause analysis, my comments above against it presupposed that you did RCA's on all such rare, but "predictable" events (by predictable, I mean that a certain incidence of complications of any procedure is predictable). If you did so, you would be doing a huge number of RCA's. But if you have specifically selected out central line infections for RCA's, to send the message that you really, really want this to be zero, then that is managerially appropriate. Sorry I misunderstood what you were doing.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-81686677771608524162007-05-24T12:00:00.000-04:002007-05-24T12:00:00.000-04:00you lack understanding of the system of profound k...you lack understanding of the system of profound knowledge (not an insult) just read the two books I noted above and you'll join our side. but your QC chief is the man good job.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-9822288474287436482007-05-24T09:20:00.000-04:002007-05-24T09:20:00.000-04:00To reply to the statistical geeks out there, a not...To reply to the statistical geeks out there, a note from our Quality Control chief:<BR/><BR/>"We analyzed the data and established an “upper control limit” as defined by statistical process control methodology. There is no lower confidence limit shown because it would be zero. What this basically says is that if our rate during any one quarter in FY06 jumped above 5.7 per thousand patient days, we should not attribute it to a “special cause” but is likely due to random variation. Likewise, we cannot declare any one quarter decrease as significant improvement because getting even to zero for any one quarter would also be within the realm of random variation. For this type of data, SPC is more likely to be helpful for analysis over an extended period (i.e. a year or more) to say whether the gradual decrease in rates we are seeing is because we made a significant impact, or just good luck."<BR/><BR/>So does this mean we still should not strive for zero? No way. Does it mean we should not investigate each infection for root causes? No. Does it mean that I still view variation as troublesome? Yes, managerially, even if no, statistically.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-52221475040517176362007-05-24T06:36:00.000-04:002007-05-24T06:36:00.000-04:00I work in quality control in a large hospital. We...I work in quality control in a large hospital. We use statistical process control to look at our data. Basically, it is a way to draw confidence intervals around a data trend and decide whether the trend is meaningful or a random fluke. SPC works great for large number, but most things that we track -- like your central line cases -- are not that amenable to making conclusions on the basis of SPC. You would have to wait forever before you did anything about anything.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-83890284123380452892007-05-23T08:24:00.000-04:002007-05-23T08:24:00.000-04:00Lets start our own deming pi blog!Lets start our own deming pi blog!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-8964284459812106492007-05-22T15:53:00.000-04:002007-05-22T15:53:00.000-04:00Hey anon 8:47;No, I don't run a hospital; I just h...Hey anon 8:47;<BR/>No, I don't run a hospital; I just have fun sitting home and giving everyone else my advice! (: But yeah, Deming was part of my PI "education" and he was great. I did run a hospital lab once; arriving when it was in a state of total collapse due to the wrong chem analyzers, a failed LIS implementation, failed administrative leadership, angry clinicians, state threatening to withdraw Medicare reimbursement, etc. One learns PI fast under those circumstances. Must have been similar to when they appointed Paul CEO of a failed merger, although I wasn't aware of that one at the time.<BR/>Love, anon. (:Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-60800761735193727212007-05-22T08:47:00.000-04:002007-05-22T08:47:00.000-04:00hey anonymous do u run a hospital? i want to work...hey anonymous do u run a hospital? i want to work for you. Love, ananymous. We'll make it a 100% deming hospital.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-33119091675387978952007-05-21T18:49:00.000-04:002007-05-21T18:49:00.000-04:00Dear SWC,Don't worry. Not even close to a war. T...Dear SWC,<BR/><BR/>Don't worry. Not even close to a war. Thanks for your kind words.<BR/><BR/>But, I am not boasting about these numbers. Pls go back to several other posts as to the reason I am posting these and others. For example, http://runningahospital.blogspot.com/2007/02/we-saved-one-persons-life-can-we-keep.html.<BR/><BR/>But, especially read this one. http://runningahospital.blogspot.com/2007/03/these-things-happen.html.<BR/><BR/>Here's the pertinent excerpt: "One way to encourage organizational improvement is to publicize the results of your program. I have done that below for our hospital, and I have made the suggestion that others in the city could do the same. As I noted, I did not make the suggestion for competitive purposes -- after all, I don't know if our numbers are better or worse than those of other hospitals -- but because public exposure of all our efforts will drive all of us to do better. Also, it will build, rather than erode, public confidence in the academic medical centers in our city."<BR/><BR/>Anon,<BR/><BR/>We are intensely focusing on these cases because we want to make sure we are understanding what is systemic and what is not. There are so few cases that it is worth spending time on each one. But, btw, a central line infection is serious. A very large percentage of them result in death. That is why we are shooting for a "zero" standard.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-91768820945984999162007-05-21T17:50:00.000-04:002007-05-21T17:50:00.000-04:00Well, then, perhaps you could do it (discuss signi...Well, then, perhaps you could do it (discuss significance) for readers of this blog, if not the public; otherwise why publish it? Is your process considered to be in control, or not? (I am guessing yes from your numbers) Also, just my opinion, it seems that treating every central line infection as a sentinel event with the formal process of root cause analysis consumes a lot of resources. I know sentinel events are defined as having caused harm, or with high potential to cause harm, to a patient, but I think most hospitals reserve them for really severe incidents like wrong medication or wrong patient ID, etc. Or am I out of date? You all must perform a huge number of RCA;s, or have a truncated process for doing so with less severe incidents?<BR/> BTW, don't worry; I don't think any of your readers doubt your training or brainpower.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-15156955822689329512007-05-21T17:36:00.000-04:002007-05-21T17:36:00.000-04:00I'm sorry, I didn't meant to start a war by mentio...I'm sorry, I didn't meant to start a war by mentioning SPC charts...<BR/><BR/>I think your site's great and your position affords you a lot of insight, and it's so great to read your blog because I've so rarely heard senior management talk candidly about issues. <BR/><BR/>Which brought me to my second question about IHI and their work. I've heard Don Berwick speak and he's great, and I've read tons and tons of stuff about his work in papers and such. Commitment to quality is personal, as he, Paul Bataldan, and so many others have said, and obviously you think that too since you boast about your numbers on your personal blog.<BR/><BR/>It's really fascinating how management/leadership can drive better patient care. Your work at BIDMC speaks for itself.<BR/><BR/>-SWCWongMLhttps://www.blogger.com/profile/15507550914792992303noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-6255599487066440672007-05-21T17:13:00.000-04:002007-05-21T17:13:00.000-04:00Guys and/or gals, please relax. I understand this...Guys and/or gals, please relax. I understand this stuff. Really, truly. I just did not know the words you used. Let me say again: My major interest and training in college was statistical analysis and inference.<BR/><BR/>I disagree on this point, "However, it will also help you present these numbers on this blog in a way that's more understandable to people reading them and theoretically trying to use them in deciding where to obtain care. ... Then you could offer a summary as to the significance of your results each time you report them." Public reporting will not be at this level of detail. The general public will not be able to interpet things to this degree.<BR/><BR/>Everyone is currently working through the question of what information would be most helpful to the public. We have some ideas. Stay tuned on that.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-25956135691343195092007-05-21T16:32:00.000-04:002007-05-21T16:32:00.000-04:00Paul;You sound as bewildered as I was some years a...Paul;<BR/><BR/>You sound as bewildered as I was some years ago(as medical director of a hospital laboratory) when I first heard these terms; statistical process control (spc charts for short) and stable vs. unstable process. They are part of the way the performance improvement dept. decides if results are significant or not, and therefore they can just continue to monitor the indicators, or need to take some sort of action. The methods they use are really very interesting and I have the feeling you would get the same "eureka" moment I did once I saw the light. One of the PI people could give you a quick "course" in all of this - even though I have already deduced that one of your best skills as CEO is the ability to delegate and trust your people.<BR/>However, it will also help you present these numbers on this blog in a way that's more understandable to people reading them and theoretically trying to use them in deciding where to obtain care. That's the whole purpose of public outcome reporting, right? Then you could offer a summary as to the significance of your results each time you report them.<BR/>Like some of the anon's above, I had questions about your monthly variability; whether it's significant or not. (For instance, special cause variation might be that resident X is always working when the rate is higher, or whatever.) <BR/>I do have to agree the CEO should be conversant in this stuff, if for no other reason than to impress your staff and the medical staff that you know more than they think. (: No, seriously, because it affects your personal ability to evaluate BIDMC's quality of care.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-64276811188467019792007-05-21T16:16:00.000-04:002007-05-21T16:16:00.000-04:00ok fine read the books anyways *muah*ok fine read the books anyways *muah*Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-30428389046254556402007-05-21T16:00:00.000-04:002007-05-21T16:00:00.000-04:00Yes, they do get training in this.Yes, they do get training in this.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-46502568384394338822007-05-21T15:42:00.000-04:002007-05-21T15:42:00.000-04:00i doubt it! docs and nurses receive no training o...i doubt it! docs and nurses receive no training on this; it is management's responsability to spread the system of profound knowledge.<BR/><BR/>Paul, 2 MUST READ books for u:<BR/><BR/>W. Edwards Deming "The New Economics for Industry and Government"<BR/><BR/>Joiner "Fourth Generation Management"Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-22998970503723201772007-05-21T15:38:00.000-04:002007-05-21T15:38:00.000-04:00Ease up on the jargon, buddy, and speak English. ...Ease up on the jargon, buddy, and speak English. I am actually trained in statistics, and I have never heard the term. But I appreciate the lecture.<BR/><BR/>I am sure, though, that the doctors and nurses here who handle our quality control programs know how to do the kind of analysis you are describing.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-52992456143769568252007-05-21T15:34:00.000-04:002007-05-21T15:34:00.000-04:00scary that a major hospital ceo doesn't know what ...scary that a major hospital ceo doesn't know what a control chart is. it helps you to differentiate between common cause and special cause variation. if you have a stable process, i.e. no special cause variation, only then can you begin process improvement initiatives.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-7428491192657283352007-05-21T14:59:00.000-04:002007-05-21T14:59:00.000-04:00Sorry, I don't know what you mean by that, i.e, st...Sorry, I don't know what you mean by that, i.e, statistical process control charts. I'm sure someone here does, but I have never heard the term.<BR/><BR/>We work closely with IHI on lots of things. 100K Lives program overlaps with some many things we do.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-88507335736045843152007-05-21T14:49:00.000-04:002007-05-21T14:49:00.000-04:00You guys do statistical process control charts to ...You guys do statistical process control charts to analyze data?<BR/><BR/>Could you talk about how the IHI 100K Lives Campaign affected your practice?WongMLhttps://www.blogger.com/profile/15507550914792992303noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-45864192354042762352007-05-21T11:12:00.000-04:002007-05-21T11:12:00.000-04:00Don't have CLI-associated mortality rate here hand...Don't have CLI-associated mortality rate here handy right now. I'll get back to you.Anonymousnoreply@blogger.com