How will you know that your changes as intended are being faithfully implemented on the wards? Where are the bottlenecks? What steps can be taken to make the new clinical processes you have implemented function more reliably? To learn more about spread, view the SSC webcasts
on spread topics.
The Model for Improvement will be used in concert with enhancing reliability, an active approach to clinical process improvement that embeds steps to prevent, identify, and mitigate failures directly into the process itself. Reliability is a scientific method that evaluates, calculates, and improves the overall reliability of a complex system. It is a goal of consistently producing appropriate outcomes and preventing adverse events. The Enhancing Reliability methodology has three levels, as described below.
1. Stabilization (Prevention):
It is impossible to sustain improvement of a chaotic process. In general, any process that fails 1 time in 10 (functions less than 90 percent of the time as intended) is chaotic and unreliable. Efforts to stabilize the system prevent failures. The first step in stabilizing a process is the establishment of a standardized approach. Therefore, a standardized protocol customized to your institution will be necessary to implement the sepsis bundle.
Next, measure the baseline reliability of the clinical processes you have created in your protocol. These are process measures. Each process being measured can be improved individually.
In the event that standardization is already in place but a particular process is functioning at less than 90 percent reliability, more work is necessary to stabilize that process. Some examples include building decision aids and reminders into the system and making the desired action the default strategy rather than an option.
2. Redundancy (Identification):
Once a process functions reliably 90 percent of the time or better, it is reasonable to pursue improvement in the next PDSA cycle toward the next threshold of reliability - 1 failure per every 100 opportunities, or 99 percent reliability. Redundancy of procedures helps to achieve this goal by identifying more instances when the process should be applied.
No effort to pursue this level of improvement in the course of a PDSA cycle should be undertaken for an unstable process. This is so because redundant efforts are, by definition, resource intensive. Implementing a redundant procedure in an unstable system is wasteful.
Effective redundancy steps function independently of the normal mechanism that triggers use of the clinical process. For example, the laboratory may have a procedure to contact physicians directly for routine labs that suggest acidosis, such as very low bicarbonate levels, which may indicate sepsis. A successful redundancy step may bring the number of missed cases below 10 percent and advance the process toward a 1 percent failure rate.
3. Failure Modes Analysis (Mitigation):
Once sufficient recovery of cases can be established to approach better than 90 percent reliability, further steps involve identifying the causes of failure and mitigating their effect.
Specific impediments to the functioning of reliable processes will be identified in the course of implementation. These represent failure modes that need to be eliminated or in some other way circumvented in subsequent PDSA cycles.
The particular impediment detected will drive your team to create a new level of customization to prevent further failures and to achieve increasingly reliable processes.