Eliminating Patient Harm and Reducing Readmissions

Cohort 1 Coaching CallMarch 5 2014Facilitators:Lisa CarhuffKathy McGowanJoyce ReidLearn. Act. Improve. Spread.Keep the Drum Beat Going.WELCOME and Introductions2

Learn. Act. Improve. Spread.Keep the Drum Beat Going.Sense of UrgencySome is not a number; soon is not a time.Don Berwick 100Klives Campaign

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#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Key ConceptsCulture of Safety Promoted from the Top Ownership at Point of Care Engaging patients in redesign

4#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Model for improvement5

Learn. Act. Improve. Spread.Keep the Drum Beat Going.The Cohort ChallengeMarch to the Goal Keeping the Beat

Topics CAUTI and Falls without InjuryRapid Cycle ImprovementParticipation guidelinesBaseline Data

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#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Best Practices: CAUTIInsert catheters only for appropriate indications using evidence based criteria including in the OR and ED. Daily assessment of catheter necessity and meeting criteria included in bedside report Leave catheters in place only as long as needed. Use nurse driven protocols for catheter removal Facilitation of nurse/patient/family communication during report, rounding and interactionsIncrease communication with nurse and physicians related to catheter continuation Automatic removal orders after surgery Ensure that only properly trained persons insert and maintain catheters. Perform staff competency assessment related to urinary catheter insertion and maintenance Insert catheters using aseptic technique and sterile equipment (acute care setting)Maintain a closed drainage systemMaintain unobstructed urine flowPerform proper hand hygiene and use Standard (or appropriate isolation) Precautions

#Learn. Act. Improve. Spread.Keep the Drum Beat Going.7Sharing Best Practices: CAUTIJane Chesser, RN, CIC Infection Control DirectorMemorial Hospital and Manor

8#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Falls with Injury: Definition Clarification Clarification NDNQI Falls definitionInjury Level When the initial fall report is written by the nursing staff, the extent of injury may not yet be known. Hospitals have 24 hours to determine the injury level, e.g., when you are awaiting diagnostic test results or consultation reports. This is a required data element and you should report Falls with Injury through NOVI monthly based on the following guidelines: Nonepatient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury Minorresulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion Moderateresulted in suturing, application of steri-strips/skin glue, splinting, or muscle/joint strain Majorresulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with any type of fracture regardless of treatment or patients who have coagulopathy who receive blood products as a result of a fall Deaththe patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)

9#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Sharing Best Practices: Fall PreventionSelina Baskins, RNQuality CoordinatorNorthridge Medical Center

#Learn. Act. Improve. Spread.Keep the Drum Beat Going.10Northridge Medical Center

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#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Sharing Best Practices: Fall PreventionErica FishellSylvan Grove

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Team Innovations in Professional Practice Award2014

Recognizing Excellence in Improving Patient Safety and Quality Purpose: To recognize front line staff teams who have improved safe patient care and reduced harm through innovation and operationalization of practices, processes and through collaboration with multidisciplinary teams.

Goal: To promote front line staff engagement and leadership in patient safety and quality improvements to move to zero harm through collaboration with multidisciplinary teams in a rapid cycle.

Eligibility: Multidisciplinary hospital teams, led by front line staff, who has achieved an innovation in process/practice improvement that has led to significant reduction in Safety Across the Board or increased engagement of patients/family in care.

Application due: April 21, 2014 by noon

13#Learn. Act. Improve. Spread.Keep the Drum Beat Going.Data Submission March 15:

NOVI SurveyINRFalls with injuryGlycemic ControlOpioids NEW!!EED if applicableInfection (if not submitting via NHSN)

14#Learn. Act. Improve. Spread.Keep the Drum Beat Going.EVALUATIONRemember Complete the evaluation for todays Cohort 1 Coaching Call!Link posted on Agenda15

#Learn. Act. Improve. Spread.Keep the Drum Beat Going.