15. Bundles

Summary

A ‘bundle’, derived from the concept that IHI has introduced for this (see here), is a group of precautionary steps with approximate time and space characteristics that, when executed collectively and reliably, has an enhanced effect on patient outcomes. The bundle is based on the hypothesis that when care processes are grouped into simple bundles, caregivers are more likely to implement them by making fundamental changes in how the work is done. When the care processes are evidence based, subsequent outcomes will improve.The bundle is illustrated with an example to clarify the principle.

Application of the ‘bundle’ appears to be an effective method in reaching a set objective. This is partly due to the fact that one intervention from the bundle helps to remind the care provider of the other interventions from the bundle, so that they are less often forgotten than if they had been implemented separately. If the bundle is not implemented in a patient (e.g. one of the interventions is nevertheless forgotten), this information is analysed and used to redesign the process, where possible, to improve the chance of a successful application of the bundle.

The goal oriented nature of the bundle also appears to demand development of the teamwork necessary to improve reliability; care providers together ensure that the bundle is applied completely. IHI: ‘While most hospitals likely follow some of these steps some of the time, few if any ICUs complete them all of the time. The bundle provides a "forcing function" for teamwork, and this teamwork has led to outstanding results’.

A potential disadvantage is that a limited number of interventions can be ‘bundled’ and measured as one intervention for its application. This means that choices have to be made about which interventions are considered to be critical in reducing the complication, which means that other important interventions may receive less attention.