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Challenge 2A-Hand Hygiene
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Commitment
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UCI Health
Challenge 2A-Hand Hygiene
Contact Info
Name: William Wilson, MD
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive S. , Building 54, Suite 5400
Orange, CA 92868 US
Participants:
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Linda Dickey,Sr. Director, Pt. Safety, Quality & Infection Prevention
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Challenge 2A-Hand Hygiene
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• Developed an electronic application in partnership with APIC, GoJo, HQI/HRET to track hand hygiene. This app allows UCI to provide real time feedback and data with unit specific compliance by job role, by the WHO 5 Moments, by discipline. It also enables us to feedback where our misses are with more specificity such as misses before gloving, after gloving, between a task, after contact with environment, poor technique, etc…
• Data is collected by name in our Operating Room areas. This is posted in their workrooms to provide full transparency, as well as shared at the physician committees and followed up by their leadership. For areas outside the OR, physician teams and program directors receive unit specific data delineated by Attending, Resident/Fellow, and Medical Students with an expectation for each lead to provide follow up and improvement.
• Implemented a more robust observation network that covers the entire span of the hospital and higher risk ambulatory areas, and includes all job roles. The observers cannot be part of this team unless they complete a formal, in person, didactic and training course. They also must commit to at least one year minimally. This provides us with standardized observation definitions and standardized observers. There is a specialized team that has been incorporated into this group that acts as our inter-rater reliability validators. Their data can be separated and used when there are any discrepancies noted.
• UCI is in the process of changing out all of our hand gels and soaps to a more superior product line. After a lengthy trial with front line staff, their feedback helped decide on our new products. By installing products that are more skin friendly and staff approved, we hope to increase frequency and compliance through higher staff satisfaction.
• In addition to being included in individual unit goals, hand hygiene has been our organization wide goal for 2 consecutive years now which sends a very clear and very strong message across the UCI campus that our senior leadership is in full support as to it’s importance and holds us all accountable for improvement.
Commitment Timeline
January 1-December 31, 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Calculation will be included in APSS #1
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Challenge #14: Preventing Falls
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Commitment
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UCI Health
Challenge #14: Preventing Falls
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Participants:
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Linda Dickey,Sr. Director-Quality, Pt Safety & Infection Prevention
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
Challenge #14: Preventing Falls
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
We have periodical Assessment of our existing fall prevention program, including tools, interventions, and outcomes. We have been modifying our program based on evidence provided by research and trends from analyzing our own data.
Employees have Computer based training as well as selected events are shared with and presented at the unit practice council and the division council.
We have been debriefing falls for the last 7-8 years, where the team immediately meet after a fall and use a form to guide staff in the debrief process.
Falls data are collected and analyzed by the Falls Prevention PI team every month (ACA).
Recommendations are made based on the outcomes and findings of the ACA.
Fall Prevention PT team is a multidisciplinary lead by a clinical nurse specialist, and nursing director. Members are: nurse managers, staff nurses, nursing AIDs, Physical therapy, MD, and Risk management.
Each unit has a fall champion whose goal is to monitor fall trends and provide education as needed. One of our champions conducted a survey where she interviewed all patients at risk for falls to know if they knew why they are at risk for falls and what do they need to do to prevent a fall and injury. Based on that survey we modified our education to teach back method.
We based our intervention on our analysis of the trends and any specific findings.
A nurse, a manager or a designated person will present the falls of their unit to the PI team and a discussion will take place on what was done and how to improve conditions for patients. One of the mandatory interventions is for staff to be within arm reach of the patient who is deemed at risk during the critical times (toileting, ambulation, and transfer).
Video monitoring, bed alarms, gait belts, Posey alarms, non-slip cushions, and more tools are available for staff to utilize to protect patients based on their unique situation and plan of care.
Post fall algorithms identify post fall assessment, and monitoring required by staff.
Falls data are reported to CALNOC and NDNQI and results are shared with staff and managers.
Commitment Timeline
Actions are already underway on these items and will be implemented throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The calculation for lives saved will be incorporated into APSS #1.
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Challenge #1: Improving Safety Culture
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Commitment
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UCI Health
Challenge #1: Improving Safety Culture
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Participants:
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Linda l Dickey,Sr. Director, Pt. Safety, Quality & Infection Prevention
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Challenge #1: Improving Safety Culture
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
UC Irvine Health is targeting 4 overall strategies for improvement of our culture of safety:
--Implementing TeamSTEPPS
--Implementing our Just Culture policy
--Using an internally developed measurement tool ("Crosswalk " document) to monitor safety & quality metrics; multiple improvement efforts are underway related to these metrics
--Participating in the PSMF Zero Lives by 2020 Campaign
Specific actions include:
1) Rolled out a Campaign to change Culture from current state to a Culture of Safety 2) Conducted a Culture of Safety Survey 3) Used Results from the Culture of Safety Survey to develop a message to hospital stakeholders, and to inform corrective actions to make the hospital safer, and make the safety culture more robust. 4) Have developed multidisciplinary teams composed of MDs, RNs, Quality Experts, Pharmacists, Lab medicine, Radiology, Respiratory therapy, and other ancillary stakeholders, to review our safety data, and have asked these teams to develop corrective measures in their domains to improve safety and quality. We meet with these teams every 4-6 weeks to track improvements in safety and quality metrics. 5) Developed a TeamSTEPPS training program and began teaching this work. 6) Developed a Just Culture Algorithm for dealing with errors when they occur to increase reporting and increase the ability to make systems changes, rather than individual blame. 7) Developed a balanced scorecard (one for inpatient and one for ambulatory) that is now shared at Managers Forum, Director's Council, Medical Executive Committee to align all stakeholders on our institutional goal of Zero Harm to patients (especially by 2020). 8) We have a daily review of 100% of IRs that occurred in hospital within the prior 24 hours (72 hours for the Monday review). 9) We have a robust RCA and ACA review process of all IRs that come in or other systems errors that are reported to our critical event management team (CEMT). 10) Began a daily operations huddle that includes representatives for all hospital stakeholders - we lead off this meeting with requests for safety concerns. 11) we do 100% mortality review of all expired patients to search for safety factors.
Commitment Timeline
1) Jan 15, 2017 - began Roll out on Campaign to change Culture from current state to a Culture of Safety (Zero Harm by 2020) 2) May 2017 - Conducted a Culture of Safety Survey 3) July/Aug 2017 - Used Results from the (May 2017) Culture of Safety Survey to develop a message to hospital stakeholders, and to inform corrective actions to make the hospital safer, and make the safety culture more robust. We are in the process of rollng this message out to stakeholders - should be complete by December 2017. 4) Jan 15, 2017 - developed multidisciplinary teams composed of MDs, RNs, Quality Experts, Pharmacists, Lab medicine, Radiology, Respiratory therapy, and other ancillary stakeholders, to review our safety data, and have asked these teams to compose corrective measures in their domains to improve safety and quality. We meet with these teams every 4-6 weeks to track improvements in safety and quality metrics. On going. Note last year our Vizient Hospital Quality Scorecard was 51 of 107 AMC hospitals in 2016; our rank increased to 34 of 107 hospitals in the recently announced rankings (Sept 15, 2017). 5) Began developing TeamSTEPPS training program in fall of 2017; after revising material based on survey feedback, teaching began spring 2018 and will be implemented to all departments.
6) Approximately 3 years ago began work on a Just Culture Algorithm and Policy. We completed this work in July, 2017 and have now begun training. We presented the work to medical staff in July, and presented to Managers Forum September 27, 2017. We will now roll this education out to rank and file front line stakeholders. Roll-out is led by 2 MD Champions, and 2 Nurse Champions - the CMO & CNO are also supporting this work. The goal will be to increase reporting (tracked by monthly IR tallies) and increase the ability to make systems changes, rather than individual blame (we conducted a pre-introduction survey), we will send out a post training survey once the education is completed - likely in March/April 2018. 7) June 2017 we developed a balanced scorecard (one for inpatient and one for ambulatory). These were refined monthly, and now deployed. The scorecards are available on line, and have also been shared at Managers Forum, Director's Council, Medical Executive Committee, and other venues to align all stakeholders on our institutional goal of Zero Harm to patients (especially by 2020). Execution complete. 8) Aug. 2014 started a daily review of 100% of IRs that occurred in hoslpital within the preceeding 24 hours (72 hours for the Monday review).We have improved the process over time, and now have a stable, mature process. We have more IRs submitted than any other of the 5 University of California Hospital systems. 9) We have a robust RCA and ACA review process of all IRs that come in or other systems errors that are reported to our critical event mangement team (CEMT). We revised the system in July 2015, and then again in July 2016, and have once again improved processes as of August , 2017 and are having a 2018 Kaisen event to again revise our RCA/ACA process for continued improvement. 10) March, 2017 Began a daily operations huddle that includes representatives for all hospital stakeholders - we lead off this meeting with requests for Safety concerns. This process allows for immediate conveyance of safety concerns and rapid correction by stakeholder on site. 11) July, 2013 began 100% mortality review of all expired patients to search for safety factors. We have bolstered the program in July 2017. This work has allowed focus on correction of safety concern that have led to patient deaths.
Our improvement activity is ongoing throughout the year.
Impact Details Lives Lost in Last Calendar Year: 551 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 57 Methodology for Determining Lives Saved:
UCI Health has established an internal mortality goal based on our overall mortality. Based on the overall as the population for calculating mortality rates/lives saved, UC Irvine Health has used data from Vizient to calculate lives saved for 2018 (57).
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Preventing CLABSI
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Commitment
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UCI Health
Preventing CLABSI
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Preventing CLABSI
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
- Use a standardized process, including a checklist for central line insertion
- Use a standardized kit and process for central line dressing changes
- Use chlorhexadine (CHG) for patient bathing
- Use a systematic process to daily access the central line insertion site and need for removal
- Develop and implement use of materials to promote peer to peer hand hygiene accountability
CLABSI core improvement team is in place. CLABSI cases provided to unit manager and Medical Director for review. "1,2,3… Count w/Me" continuing in 2018. OC Shield Project housewide - CDC public healthcare initiative targeting reduction of MDROs across the healthcare continuum through decolonization with CHG bathing and nasal iodophor for all adult ICU and contact isolation patients. Nursing educators providing support with the central line care best practices with roving cart education ongoing. Central line rounds conducted on outlier units focusing on insertion site and dressing appearance. CLISA is being transitioned into Epic.
Commitment Timeline
Improvements underway and ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Preventing CDI
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Commitment
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UCI Health
Preventing CDI
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium Difficile Infection (CDI)
Commitment Name:
Preventing CDI
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
PCR vs Toxin EIA testing validation in progress. Swabbing test validation (vs stool specimen); in progress. Clinician notification of inappropriate override C.diff orders in progress. Continued focus on hand hygiene compliance and environmental cleaning. Transitioning best practices into Epic to notify MDs of CDI ordering protocol.
Commitment Timeline
All improvements underway and will be continued into 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Preventing SSI-Colon Surgery
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Commitment
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UCI Health
Preventing SSI-Colon Surgery
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical Site Infections (SSI)
Commitment Name:
Preventing SSI-Colon Surgery
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Ongoing outcomes review and preventive measures implementation with Colorectal and General Surgery Chiefs. Reporting division and surgeon-specific data. Maintaining high compliance with pre-op CHG bathing. Standardization of alcohol-CHG containing skin prep use for colorectal patients. Issuing standardized patient wound care discharge education and transfer instructions. Implementation of mechanical bowel prep and oral ABs administration for elective colorectal resection cases. Revision of surgical prophylactic protocol in collaboration with the Antibiotic Stewardship Committee. A multidisciplinary Task Force with Colorectal Chief, CMO, Anesthesia, EIP and Quality Improvement. Task Force is looking into pre-op patient preparation (bowel prep with low residue diet and oral antibiotics), intra-op (increasing FiO2 to 80%), discharge measures (ostomy education, surgical site infection patient education).
Commitment Timeline
Actions have commenced and will continue throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Preventing SSI-Abdominal Hysterectomy
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Commitment
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UCI Health
Preventing SSI-Abdominal Hysterectomy
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical Site Infections (SSI)
Commitment Name:
Preventing SSI-Abdominal Hysterectomy
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Ongoing outcomes review and preventive measures implementation with GYN ONC Chief. Reporting surgeon-specific data. Re-enforcement of pre-op, intra-op measures, post-op care and discharge care practices: maintaining high GYN patient pre-op CHG bathing compliance. Standardization of alcohol-CHG containing skin prep use for GYN patients. Implementation of timely re-dosing of intra-op prophylactic surgical antibiotic with Anesthesia and Surgeon, include re-dosing assessment based on estimated case duration into Timeout process, and timing reminders for Anesthesia. Engage OBGYN department into additional measures to reduce the risk of surgical site infection: (1) development/implementation of standardized wound care discharge instructions; transfer instructions for GYN ONC patients; (2) development of criteria for application and use of negative pressure wound therapy (PICO dressing), patient PICO dressing discharge care instructions.
Commitment Timeline
Actions are underway and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Preventing CAUTI
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Commitment
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UCI Health
Preventing CAUTI
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
Preventing CAUTI
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
New suction canisters are now in-house to measure strict output for urine. Purewick device launched. Working with nursing students to perform potential observations for compliance with care (CDC CAUTI bundle). EMR work underway re: daily device necessity.
Commitment Timeline
Actions underway and ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Improving Medication Harm Errors
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Commitment
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UCI Health
Improving Medication Harm Errors
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication Errors
Commitment Name:
Improving Medication Harm Errors
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
A Medication Safety Team is in place. All medication errors are reviewed for trends, severity of harm and actions for improvement. Opioid use is under review with the intent to reduce use as appropriate and to prevent ADEs related to opioid use.
Commitment Timeline
Actions for this challenge are underway and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
ADEs will be calculated based on incident reporting system data Jan-Dec 2018. Mortality calculation is included in APSS #1.
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Antimicrobial Stewardship
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Commitment
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UCI Health
Antimicrobial Stewardship
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial Stewardship – The Role of Pharmacy & the Microbiology Lab in Patient Safety
Commitment Name:
Antimicrobial Stewardship
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
An Antimicrobial Stewardship Program is established at UC Irvine Health. Implementing Vancomycin pharmacokinetic dosing per Pharmacy for patient safety. IV to PO conversions are being monitored on a monthly basis.
Commitment Timeline
Improvement actions are underway and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Adverse Drug Events will be limited to IV Vancomycin incidents only. Lives spared harm will be calculated at the end of the measurement year. Overall mortality calculation is included in APSS #1.
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Preventing Insulin-Induced Hypoglycemia
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Commitment
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UCI Health
Preventing Insulin-Induced Hypoglycemia
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3C - Improving the Prevention of Severe Hypoglycemia
Commitment Name:
Preventing Insulin-Induced Hypoglycemia
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Multiple multi-disciplinary teams have been established to address this challenge. Events are reviewed and categorized as preventable vs non-preventable. Aim is to reduce preventable hypoglycemia among all patients (not just those associated with insulin). Insulin order sets have been developed to reduce occurrence of insulin-associated hypoglycemia. NPO order sets are in place and periodic re-education/reinforcement of use is ongoing. A hyperkalemia order set is also available for use.
Commitment Timeline
Actions are underway and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Preventable events are tracked; events for 2017 will be compared to 2018 (by percent).
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Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events
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Commitment
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UCI Health
Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric Adverse Drug Events
Commitment Name:
Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Newborn and Pediatric adverse drug events and medication errors are reviewed monthly with a multi-disciplinary team. Aim is to decrease preventable errors and ADEs. Actions underway include:
-The SQIS Incident Reporting system is utilized to report ADEs for analysis, trending and performance improvement
-eMAR and barcoding for medication administration has been implemented
-Standardized order sets are established which include pharmaceutical administration
-CPOE has long been in place at UC Irvine Health; mechanisms for medication reconciliation, allergy checking, interaction and dose range checking with alerts exist in Epic
-Pharmacist rounding, including double-check processes has been implemented for newborn and pediatric patients
-Nurses review the MAR during their standardized hand-off process
-Smart drug infusion pumps are utilized, with drug libraries appropriate to the population served
-The EMR provides support for weight-based prescribing, compounding dispensing and administration, although further refinement would be beneficial in this area
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Commitment Timeline
Actions are underway and will be implemented throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
See APSS #1 for calculation of lives saved.
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Preventing Failure to Rescue
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Commitment
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UCI Health
Preventing Failure to Rescue
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for Opioid-induced Respiratory Depression
Commitment Name:
Preventing Failure to Rescue
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Narcotic naïve patients are monitored by pulse oximetry. All patient harm & death associated with opioids are reviewed. All units have the capability for continuous pulse oximetry use and may be monitored as ordered/needed. Monitoring is standard of care for first 24 hours for patients on PCA. A physician (Dr. Shah) has been identified as the organizational champion to evaluate and improve narcotic use. Pt education will be provided to all patients through the EMR when narcotics are prescribed at discharge. Ranges of patient tolerance for narcotics have been developed for physician ordering guidance. Theraputic duplication prevention is in place. Bag volumes for IV narcotics will be reduced in the future. Standardized all narcotic drug dosages in the Pyxis.
Commitment Timeline
Actions are underway and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives expected to save is calculated under Challenge #1.
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Improvement of Patient Blood Management
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Commitment
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UCI Health
Improvement of Patient Blood Management
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient Blood Management
Commitment Name:
Improvement of Patient Blood Management
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Blood Utilization Committee in place with ongoing monitoring of metrics--currently awaiting Epic data for continuity. Data analysis will focus on blood utilization to target interventions specific to the needs of patient populations. Multiple protocols/algorythms and guidelines are in place to address the recommendations noted in the PSMF materials.
Commitment Timeline
Improvement actions are underway and will be ongoing throughout 2018 to include data analytic work to support intervention efforts.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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APSS #6 Improving Hand Off Communications
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Commitment
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UCI Health
APSS #6 Improving Hand Off Communications
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
APSS #6 Improving Hand Off Communications
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Hand-off policy in place that meets the requirement of the Joint Commission. Current process in place uses the SBAR structure for hand-off communications. The SNUG Committee is also addressing standardization of hand-off through the EMR.
Commitment Timeline
Actions are underway and will be continued throughout 2018 (calendar year).
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Improving Neonatal Oxygen Targeting
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Commitment
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UCI Health
Improving Neonatal Oxygen Targeting
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7A - Optimal Neonatal Oxygen Targeting
Commitment Name:
Improving Neonatal Oxygen Targeting
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. Clear policy outlining oxygen management and including pulse oximeter saturation targets for preterm infants
2. All new hires receive education about oxygen management and target sat monitoring
3. Histograms are printed daily (for those infants on oxygen and at risk for ROP) and reviewed by the medical team to note those infants spending time in pulse oximeter ranges outside of the target range for their gestational age
4. Pulse oximetry targets are evaluated and modified as new literature is published
5. Oxygen blenders are used in all delivery rooms and anytime we are using oxygen (as appropriate); heated humidifiers are also used.
Commitment Timeline
January 1 through December 31, 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Methodology for calculation of lives saved will be submitted under APSS #1.
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Improving Detection of Critical Congenital Heart Disease
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Commitment
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UCI Health
Improving Detection of Critical Congenital Heart Disease
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7B - Failure to Detect Critical Congenital Heart Disease (CCHD) in Newborns
Commitment Name:
Improving Detection of Critical Congenital Heart Disease
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
A policy in place to screen all newborns for critical congenital heart disease based on nationally recognized criteria and California state requirement. An annual report is sent to the California Dept. of Public Health and CA Children's Services.
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Safer Airway Management
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Commitment
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UCI Health
Safer Airway Management
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
Commitment Name:
Safer Airway Management
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
A voluntary reporting system: Tracking of all perioperative incident reports relative to Anesthesia with improvement/intervention. that allows for reporting of airway events, patient harm (e.g. dental damage), or unexpected difficult airway events, and ongoing evaluation for trends that allows for reporting of airway events, patient harm (e.g. dental damage), or unexpected difficult airway events
• Through the house-wide Incident Reporting System: Tracking of non-perioperative incident reports relative to Anesthesia airway management during Code Blue or airway emergencies
• Sedation Database: Tracking, trending airway complications during sedation procedures throughout the organization
• Acute Response Committee Project: Improvement of dashboard and datamining and benchmarking for causes of code blue and rapid responses and outcomes
• Developing a Difficult Airway algorithm, which will include:
o Early Identification of all patients at risk for a difficult airway/ airway compromise
o Patient designation (e.g. bracelet) and indication in the EMR of difficult airway Early evaluation by Anesthesiology and Advance Airway management practitioners to Develop an airway management plan/intervention and prevent complications with difficult airways
o Plan includes availability of standardized difficult airway carts located in all critical care units
• Simulation training, particularly with trauma scenarios
• Difficult airway management annual education requirement for Anesthesia Residents in Advance airway management techniques
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year 3 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The methodology used in APSS #1 to calculate housewide mortality will be used to incorporate this APSS.
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Challenge 8B: Preventing Unplanned Extubations
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Commitment
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UCI Health
Challenge 8B: Preventing Unplanned Extubations
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned Extubations
Commitment Name:
Challenge 8B: Preventing Unplanned Extubations
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Unplanned extubations have been tracked in the Neonatal ICU (NICU) since 2008. This is reported to the unit for tracking and intervention. Interventions have included elimination of inline suctioning, standardized ET tube holder, bedside safety practices such as two providers for high risk procedures such as suctioning, linen change, chest X-ray.
A nursing project focused on unplanned extubations in the NICU population--findings indicated standardized roles and communication would be valuable; subsequent implementation of these practices has occurred.
Housewide, a standardized ET tube holder has also been implemented, with isolated exceptions. Investigation is underway to determine if an EMR core data set from Epic is available for analysis and performance improvement. Data on unplanned extubations are also entered into our incident reporting system for review by Respiratory Care for trends. A difficult airway algorithm is in development to identify patients with known difficult airways. This year 15 additional ventilators were purchased with wave form capnography.
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Overall mortality calculation is included in APSS #1.
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APSS #9 Preventing Sepsis
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Commitment
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UCI Health
APSS #9 Preventing Sepsis
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
APSS #9 Preventing Sepsis
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The focus of our efforts through the Sepsis Committee is to increase compliance with current evidence-based guidelines. A dashboard has been created for tracking of compliance with the sepsis bundle elements. Data and non-complaint cases are disseminated to physician leads and sepsis committee for review and to identify opportunities for improvement. Case information and education is discussed and provided as needed to physicians, nurses and pharmacists. Additionally, information related to processes and protocols, current guidelines, IT system upgrades, chart addenda, coding changes/corrections and corrective improvement actions are discussed at the Sepsis Team meeting as needed.
Electronic workflows to facilitate best practice and appropriate, timely treatment have been previously implemented and are being refined due to transition to a new EMR. An order set for sepsis care is also being embedded into the new EMR. A nurse-driven sepsis screening system has been implemented for early identification of potential sepsis cases and use of a care algorythm.
Sepsis is monitored by hospital leadership through the organizational crosswalk for progress accountability.
Commitment Timeline
Actions are in place and will be ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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APSS #10 Ensuring Optimal Resuscitation
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Commitment
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UCI Health
APSS #10 Ensuring Optimal Resuscitation
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest
Commitment Name:
APSS #10 Ensuring Optimal Resuscitation
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Simulation training on a routine basis focused on acute response and advanced resuscitation.
Acute Response Committee responsible for data analysis and improvement development; based on findings, policies have been revised and workflows amended. Outcome data is presented to QSOC (quality leadership committee) for oversight and support as needed. A difficult airway algorythm has been developed; evaluation and periodic revision of acute airway carts has occurred based on findings from reported incidents.
Commitment Timeline
Timeline for this challenge is January-December 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Preventing Postpartum Hemorrhage
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Commitment
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UCI Health
Preventing Postpartum Hemorrhage
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11A - Postpartum Hemorrhage (PPH)
Commitment Name:
Preventing Postpartum Hemorrhage
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
UCI Health uses the CMQCC Toolkit for Prevention & Management of Post-Partum Hemmorhage. Risk is assessed on admission (low, medium & high); based on risk assessment, protocols and plans are followed and are revised based on patient need. For example, anticipated need for uterotonics, blood product needs or potential use of RIP protocol. There is also a formalized family support system for patients that experience a stage 3 hemmorhage. UCI has completed all 16 elements of the toolkit.
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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APSS # 11B Optimizing Management of Pre-eclampsia
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Commitment
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UCI Health
APSS # 11B Optimizing Management of Pre-eclampsia
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11B - Severe Hypertension in Pregnancy and Postpartum
Commitment Name:
APSS # 11B Optimizing Management of Pre-eclampsia
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
In 2016 UCI Health participated in the CMQCC Pre-eclampsia toolkit. Full implementation took 18 months. Based on that initiative, current care utilizes standardized algorythms for care of patients with new onset new hypertension preeclampsia. Other elements include policy & procedure, staff & physician education and a standard approach to managing patients with this condition. Simulation training has been developed & is ongoing.
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Challenge 11C: Preventing Unnecessary C-Sections
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Commitment
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UCI Health
Challenge 11C: Preventing Unnecessary C-Sections
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Challenge 11C: Preventing Unnecessary C-Sections
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• Looked into every NTSV case 2016-17. Found that most inductions were medically indicated (only 1 or 2 elective inductions), NTSV C/S were primarily for Cat II tracing remote from delivery and Arrest of Descent (2nd stage labor arrest). Every failed induction met the new recommended criteria (i.e. 12-18 hours, ruptured on pitocin) and all labor arrests followed the ACOG recommendations (e.g. 1st stage: 6 hours ruptured on pitocin with inadequate contractions or 4 hours with adequate contractions; 2nd stage: 3-4 hours of pushing depending on epidural and parity).
• Actions
o FHR tracings:
Perinatal Quality Foundation Exam by all MDs/RNs Standardizing NICHD terminology and strip interpretation
Cat II FHR tracing algorithm implemented
o 2nd Stage labor:
2nd stage evidenced-based labor algorithms implemented
Peanut balls to facilitate labor management and vaginal delivery
Labor management classes for RNs
OVD education for MDs
• Grand Rounds
• Resident lectures
o Grand Rounds reviewing all this information last Fall
o Individualized score cards
o Monthly newsletters with stats
- Perinatal in situ simulation
- Track, monitor and report metrics monthly at OB Quality and Safety and Grand Rounds, annually at QSOC
- Implementation of standard induction scheduling
- Offer VBAC as an option with a success rate higher than the UC System and the California Maternal Data Center
Commitment Timeline
These actions are underway and will continue throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
This calculation will be included in APSS #1.
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Preventing VTE
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Commitment
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UCI Health
Preventing VTE
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous Thromboembolism (VTE)
Commitment Name:
Preventing VTE
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1) Development of VTE Risk Report is underway and will be monitored for patients that were at Moderate to High Risk and have no orders for mechanical or pharmacological prophylaxis, physicians and nursing were contacted to provide appropriate VTE prophylaxis. For patients that were Moderate to High Risk and only receiving mechanical prophylaxis, nursing was audited to assure they are receiving administration and documentation of Sequential Compression Devices (SCDs). For patients with no VTE Risk Assessment the physicians were contacted to have the VTE Risk assessment completed. 2) All PSI 12 post-operative PEs and DVTs are reviewed with an Attending – Dr. Alpesh Amin. Any concern for potentially preventable VTEs, the Attending is contacted and a review was requested. Reviewed HAC VTEs monthly with Anticoagulation Steering Committee and Chair, determining potentially preventable and non-preventable VTEs, and identifying opportunities to improve patient care. 3.) Findings from PSI review are escalated to CEMT for reporting and support if necessary. 4.) Trauma service has changed Enoxaparin dosing now based on weight, and evaluating with anti-Xa levels and adjusting dosing accordingly. 5.) Algorithm and policy developed for ultrasound and CTA to identify high risk patients on admission. Review by specific services pending. 6.) Trauma developed a DVT/VTE prophylaxis algorithm to determine appropriate treatment.
Commitment Timeline
Improvement work is underway and ongoing throughout 2018 (January-December 2018)
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Challenge 12B-Preventing Air Embolism
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Commitment
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UCI Health
Challenge 12B-Preventing Air Embolism
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12B - Air Embolism
Commitment Name:
Challenge 12B-Preventing Air Embolism
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
In the Operating room the following measures are currently adopted in certain high risk situations and are part of the workflow:
A) Central lines:
For all central lines inserted in the OR, ports not in use are covered with claves that have valves to avoid air entrapment from improperly capped stopcocks.
It is not customary to use air filters on all central lines.
B) Massive Transfusion devises
They are equipped with technology to prevent air embolism, stop infusion and alarm if the reservoir is below a certain level
C) Patients wiith intracardiac shunts
Meticulous deairing of all IV injection ports and stopcocks
(Air traps are not routinely used in all patients)
D) High risk surgery
Sitting craniotomy is a very high risk procedure- we use precordial doppler for monitoring this rare surgical position. Setting alarms to detect drop in etCO2. Aspiration of an atriocaval junction double lumen catheter distal port is our next check to confirm the diagnosis in the 60 degree sitting position.
Prone or supine positioning (and C-Section) are moderate risk procedures and usually drop in etCO2 is used for monitoring. If the surgeon mentions that there would be high risk due to opening of venous sinuses then a catheter placed in the deep right atrial position for air aspiration in case air embolism does occur. In general it is often less practical to use for monitoring in these cases. Rarely we use TEE, but more for diagnostic rather than monitoring purposes.
Commitment Timeline
Improvement actions are underway and ongoing throughout 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Calculation will be included as part of APSS #1.
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Improve Access to Acute Psychiatric Beds
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Commitment
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UCI Health
Improve Access to Acute Psychiatric Beds
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Improve Access to Acute Psychiatric Beds
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
We would like to work with Orange County to optimize downstream placement of patients to appropriate lower levels of care. Unfortunately, more low acute IMD beds (e.g. psychiatric SNF) beds are needed in the community; given that these are not available, a backlog of "boarder" patients is an ongoing challenge which compound ED overcrowding. We communicate closely with our county counterparts in the ED re: daily bed availability; therefore, a bed registry wouldn't be useful at this time. An increased number of hospitals in Orange County are dissolving their LPS designation, shunting more involuntarily detained patients to UCI (which often correlates with severe pathology). We have had meetings with the County to discuss the current status of bed availability at UCI. County case workers are assigned to facilitate discharge planning, although they are often not available.
Commitment Timeline
January 1-December 31, 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Lives saved calculation is reflected in APSS #1. Awaiting measurement period results to calculate lives spared harm per formula above.
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Challenge 13B: Optimizing Collaborative Care Planning in Mental Health
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Commitment
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UCI Health
Challenge 13B: Optimizing Collaborative Care Planning in Mental Health
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13B - Collaborative Care Planning in Mental Health
Commitment Name:
Challenge 13B: Optimizing Collaborative Care Planning in Mental Health
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• Provide low barrier ways for staff and patients to collaborate on care planning.
o Collaborative care planning begins on admission with nursing
Unit orientation
Community meeting and goal setting each morning
Group therapy schedules
Goals completion / follow up group daily
o Collaborative care planning continues on admission day with nursing/ SW/CM and MD in rounds
o Improvement opportunity: staff should be in the milieu at all times, only one person at the nurse’s desk.
Improves group attendance, observable patient status and communication on interventions or needs for discharge
• Promote patients to take more of an active role in identification and management of symptoms.
o In California patients have the right of refusal, which gives choice and active participation it can result in the need for Reise hearings for appropriate treatment
o Improvement opportunity: with staff constantly and consistently in the milieu, there is a quicker response to potential escalation where de-escalation can be successful and prn medications given to reduce violent episodes.
Increased awareness and insight on appropriate discharge placement to be communicated to and discussed with interdisciplinary team
Potential decrease LOS
Reduce restraint
Reduce seclusion
• Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others.
o First and foremost the EOC is essential
o Ongoing and consistent treatment team meetings and daily team rounds
o Initiation of constant observation if warranted or 1:1 if actively suicidal
o 15 min safety checks consistently 24/7 with room checks for safety
o Thorough room checks when warranted
o Improvement opportunity: Staff in the milieu heightens awareness, increases patient interaction, improves overall trust and communication
Potential decreased LOS
Decrease violent episodes
Improve patient satisfaction
• Be evaluated with metrics such as Client Satisfaction Surveys, patient lengths of stay, patient readmission rates, Code White frequency, and seclusion room use.
o Press Ganey patient satisfaction surveys
o HBIPs which include:
SA (Drugs Alcohol Tobacco)
Seclusion and Restraint data
Commitment Timeline
These actions are underway and will continue through December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
This calculation will be included in APSS #1
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Challenge #15: Optimizing Nasogastric Feeding and Drainage Tube Placement and Verification
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Commitment
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UCI Health
Challenge #15: Optimizing Nasogastric Feeding and Drainage Tube Placement and Verification
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric Feeding and Drainage Tube Placement and Verification
Commitment Name:
Challenge #15: Optimizing Nasogastric Feeding and Drainage Tube Placement and Verification
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The use of CorTrak for nasoenteric tube placement is in place; this imaging technology allows visualization of tube placement in real time to support appropriate intervention should misplacement occur. All nasoenteric feeding tube insertions are confirmed with X-ray post-placement. There is a "super-user" group who receive specialized training for this placement; insertion of these devices is limited to this group, and annual education occurs.
A random sampling of tracings from CorTrak are reviewed for quality purposes.
If a salem sump drainage tube is converted for short-term feeding, placement is confirmed with X-ray prior to administration of tube feeding.
Commitment Timeline
January-December 2018
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Housewide mortality will be used for this APSS; see APSS #1 for reporting on this metric.
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Challenge 16: Optimizing Person and Family Engagement
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Commitment
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UCI Health
Challenge 16: Optimizing Person and Family Engagement
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Organization Address:
101 The City Drive
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and Family Engagement
Commitment Name:
Challenge 16: Optimizing Person and Family Engagement
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
A new Experience Director is being recruited to focus organizational efforts for both staff and patient engagement and satisfaction. Simultaneously, efforts are underway through the Quality and Safety Oversight Committee to include community patient member(s) who will serve as a voice for the patient's perspective for this committee.
Commitment Timeline
Improvements for this challenge will be implemented during calendar year 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Overall mortality calculation is included in APSS #1.
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Nasogastric Feeding and Drainage Tube Placement and Verification
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Commitment
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Parrish Medical Center
Nasogastric Feeding and Drainage Tube Placement and Verification
Contact Info
Name: Edwin Loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: Senior Vice President - Integrated and Acute Care Services/CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32780 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric Feeding and Drainage Tube Placement and Verification
Commitment Name:
Nasogastric Feeding and Drainage Tube Placement and Verification
Commitment Start Date:09/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Nasogastric/Orogastric (NG/OG) tube placement is commonly used as an intervention in clinical practice for decompression of the stomach or for administration of enteral nutrition, fluid and medications. Misplacement of NG/OGs can lead to significant morbidity and even, death. Commitment Description & Detail:
NG/OG placement is confirmed by testing the pH of gastric aspirate which should be in the desired range of 1.0 to 5.0. Fluid retrieved from the NG tube is the only acceptable specimen. In order to meet the National Patient Safety Goal of zero harm, gastric pH testing for the confirmation of NG/OG tube placement must be implemented Action Plan:
Patients that have an NG/OG tube placed at Parrish Medical Center will be included. Fluid retrieved from the NG/OG tube will have the pH checked prior to use of tube. Nasogastric tube placement is confirmed by testing the pH of Gastric aspirate which should be in the desired range of 1.0 to 5.0. Prevent the harm caused by the misplacement of nasogastric feeding tubes. Commitment Timeline:
PMC has been working on this commitment since May 2018 and expects to have fully implemented by September 2018 to include all documentation, orders, testing, training and education.
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Parrish Medical Center |
FL |
US |
Pediatric Adverse Drug Events
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Commitment
×
Parrish Medical Center
Pediatric Adverse Drug Events
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: SVP Integrated and Acute Care Services / CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric Adverse Drug Events
Commitment Name:
Pediatric Adverse Drug Events
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Increase our standing order sets and protocols for each admitting diagnosis; continue to monitor and report CPOE/DSS; Pharmacists will continue to participate in daily Multidisciplinary rounds, use of BCMP and double checks prior to dispensing; enhance and improve compliance with handover communication process for all levels of transition; continued maintenance of smart drug infusion pumps/libraries that include peds drug concentrations related to all weight ranges; maintain individual pharmacist practice for ensuring correct concentration/infusion rate and pump capabilities are assessed. Will continue to use a collaborative approach for educating and training on the prescription, preparation, dispensing and administration of medications to children.
Commitment Timeline
Monitor data/reports daily, monthly and quarterly based on which team this data is being discussed/reported.
Impact Details Lives Lost in Last Calendar Year: 1 How many lives do you expect to spare from harm in the next calendar year 1 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
Lives = (pADE baseline - pADE Rate measurement) X Doses||Patient Days baseline
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Parrish Medical Center |
FL |
US |
Hand Hygiene
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Commitment
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Parrish Medical Center
Hand Hygiene
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: SVP Integrated and Acute Care Services / CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Hand Hygiene
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Implement WHO 5 moments of hand hygiene, train observers on hand hygiene observations, provide unit feedback, Safe Care Pledge from all leaders, perform assessment of location of alcohol based hand rub
Commitment Timeline
Start January 2018, monitor daily/report monthly, complete by Jan 2019
Impact Details Lives Lost in Last Calendar Year: 1 How many lives do you expect to spare from harm in the next calendar year 1 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
World Health Organization (WHO) 5 Moments of Hand Hygiene
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Parrish Medical Center |
FL |
US |
Medication Errors
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Commitment
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Parrish Medical Center
Medication Errors
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: SVP Integrated and Acute Care Services / CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication Errors
Commitment Name:
Medication Errors
Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
- Review results
- Prioritize actionable recommendations
- Implement recommendations
- Monitor for effectiveness
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 1 How many lives do you expect to spare from harm in the next calendar year 1 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
Lives = (ADE Rate baseline 2016 - ADE Rate measurement 2017 ) X Doses 2017 ￨￨ Patient Days baseline 2016 (32,159)
Control Rate Calculation:
Numerator: Number of ALL reported errors and adverse drug reactions (including harm and NOT causing harm or “near misses”)
Denominator: Number of doses administered over time period
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Parrish Medical Center |
FL |
US |
Sustaining a Culture of Safety
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Commitment
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Parrish Medical Center
Sustaining a Culture of Safety
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Fl 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Sustaining a Culture of Safety
Commitment Start Date 05/21/2002 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The Mission, Vision and Values of PMC drive our Culture of Safety. Safety for patients, care partners (employees, providers, volunteers) and community.
Mission- "Healing Experiences for Everyone all the Time".
Vision- "Healing Families, Healing Communities".
Values - Safety, Loyalty, Integrity, Compassion, Excellence, Stewardship.
Our safety culture began and continues with these drivers along with our commitment to our Strategic Plan- The Game Plan, that includes over 75 unique measures of process or outcomes. By using Lean/Sigma our journey of High Reliability continues.
Every care partner is empowered to be transparent and to hold each other accountable for safety. This is evidenced by our commitment to evidence based practices and commitment to zero.
Commitment Timeline
Ongoing process with monthly measures.
Impact Details Lives Lost in Last Calendar Year: 00 How many lives do you expect to spare from harm in the next calendar year 00 How many lives do you expect to save in the next calendar year 00 Methodology for Determining Lives Saved:
Lives saved from all other APPS
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Sustaining a Culture of Safety – Update – 01.30.18
View Update
Commitment Update
×
Parrish Medical Center
Sustaining a Culture of Safety – Update – 01.30.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 05/21/2002 How many hospitals are represented in this commitment?
Action Plan:
The Mission, Vision and Values of PMC drive our Culture of Safety. Safety for patients, care partners (employees, providers, volunteers) and community.
Mission- "Healing Experiences for Everyone all the Time".
Vision- "Healing Families, Healing Communities".
Values - Safety, Loyalty, Integrity, Compassion, Excellence, Stewardship.
Our safety culture began and continues with these drivers along with our commitment to our Strategic Plan- The Game Plan, that includes over 75 unique measures of process or outcomes. By using Lean/Sigma our journey of High Reliability continues.
Every care partner is empowered to be transparent and to hold each other accountable for safety. This is evidenced by our commitment to evidence based practices and commitment to zero.
Commitment Update:
PMC’s Board of Directors have used the Joint Commission tool Oro 2.0 to evaluate the effectiveness of our Culture of Choice and Culture of Safety. In addition PMC has implemented seven specific culture teams to conduct performance improvement work on items such as: safety, recruitment, retention, ideas for change, and effective rounding.
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
• Person and Family Engagement APSS
• Zero harm Board philosophy
• PFAC- Patient and Family Advisory Committee
• Lean/Sigma
• Transparent reporting
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
00 |
Lives Lost
00 |
Lives Lost:
38 |
Lives Spared Harm Target
00 |
Actual Lives Spared Harm in last 12 months
38 |
Lives Spared Harm Target for following calendar year
45 |
Lives Saved Target
00 |
Actual Lives Saved in last 12 months (might differ from initial target)
38 |
Projected Target of Lives Saved for following calendar to try to finish commitment
45 |
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New Lives Lost (lives lost – actual lives saved)
38 |
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Parrish Medical Center |
FL |
US |
Transitions in Caring
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Commitment
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Parrish Medical Center
Transitions in Caring
Contact Info
Name: Edwin Loftin
Phone: 3212686120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Fl 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
Transitions in Caring
Commitment Start Date 08/03/2010 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Hand Of Communication is a corners stone of our focus on Person and Family Centered Care. PMC uses several evidence based principles and techniques assuring high quality and effective hand off communication:
1-Face to face report shift to shift, ED to Floor and all acute transitions
2- Care Team Rounding- Interdisciplinary team rounding at bedside every day with a focus on person centered self-management
3-SBAR format
Commitment Timeline
This began in detail in 2010 and continues today. Next focal points are integrated hand off between organizations as a person moves within a system (PCP, acute care, SNF, HH)
Impact Details How many lives do you expect to spare from harm in the next calendar year 6000 Methodology for Determining Lives Saved:
By implementing safe and harm free hand off communications for every person leaving our organization we will move towards zero harm in transitions of care
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Transitions in Caring - Update - 01.30.18
View Update
Commitment Update
×
Parrish Medical Center
Transitions in Caring – Update – 01.30.18
Contact Info
Name: Edwin Loftin
Phone: 3212686120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 08/03/2010 How many hospitals are represented in this commitment?
Action Plan:
Hand Of Communication is a corners stone of our focus on Person and Family Centered Care. PMC uses several evidence based principles and techniques assuring high quality and effective hand off communication:
1-Face to face report shift to shift, ED to Floor and all acute transitions
2- Care Team Rounding- Interdisciplinary team rounding at bedside every day with a focus on person centered self-management
3-SBAR format
Commitment Update:
- Established HOC core team
- Reviewed current and PSMF HOC checklists
- Provided education for all those involved in HOC
- Evaluated plan for support utilization
Your commitment aligns with APSS
Challenge 6 - Hand-off Communications Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
SBAR form
Recently accepted to the Patient Safety Movement “ED to Med/Surg Safe Hand-off Checklist”
Safe Discharge Checklist (Code Salmon sheet)
Nurse documentation within the EMR, “Transfer: Handoff Report PRN”
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
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Lives Lost:
0 |
Lives Spared Harm Target
6000 |
Actual Lives Spared Harm in last 12 months
5 |
Lives Spared Harm Target for following calendar year
5 |
Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
5 |
Projected Target of Lives Saved for following calendar to try to finish commitment
5 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Parrish Medical Center |
FL |
US |
Venous Thromboembolism (VTE)
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Commitment
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Parrish Medical Center
Venous Thromboembolism (VTE)
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12 - Embolic Events
Commitment Name:
Venous Thromboembolism (VTE)
Commitment Start Date 03/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
* Venous Thromboembolism (VTE) Risk Assessment completed upon admission and daily in EHR. - Use the VTE risk assessment to triage patients into low-, moderate-, or high-risk categories. - EHR prompt for providers to order VTE prophylaxis when completing admission orders - VTE risk assessment into admission order sets *Nursing Assessment and Intervention - Promote highest level of patient mobility and advance as tolerated. - Assess for symptoms/presence of acute DVT and provide intervention, if appropriate. *Early Ambulation PI to address maximize patient mobility whenever possible and take measures to reduce the amount of time the patient is immobile. *Monitor appropriate use of prophylaxis for VTE in patients at risk thereby use of clinically appropriate evidence-based methods of thromboprophylaxis
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
VTE rate for PMC versus national average applying both to our inpatient volume of 6500. The difference will be lives saved/year
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Venous Thromboembolism (VTE) – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Venous Thromboembolism (VTE) – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 03/01/2015 How many hospitals are represented in this commitment?
Action Plan:
* Venous Thromboembolism (VTE) Risk Assessment completed upon admission and daily in EHR. - Use the VTE risk assessment to triage patients into low-, moderate-, or high-risk categories. - EHR prompt for providers to order VTE prophylaxis when completing admission orders - VTE risk assessment into admission order sets *Nursing Assessment and Intervention - Promote highest level of patient mobility and advance as tolerated. - Assess for symptoms/presence of acute DVT and provide intervention, if appropriate. *Early Ambulation PI to address maximize patient mobility whenever possible and take measures to reduce the amount of time the patient is immobile. *Monitor appropriate use of prophylaxis for VTE in patients at risk thereby use of clinically appropriate evidence-based methods of thromboprophylaxis
Commitment Update:
- Establish interdisciplinary team
- Establish concurrent chart review process / procedures
- Establish appropriate chart review tool
- Establish appropriate tool to be used for RCA of outliers
Your commitment aligns with APSS
Challenge 12 - Embolic Events Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- VTE Risk assessment completed on all patients at admission and daily
- All patients triaged into low, medium, and high risk categories
- EHR prompts for providers to order VTE prophylaxis
- VTE risk assessment incorporated into nursing admission order sets/intervention
- Encouraging highest level of patient mobility as tolerated
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-1 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
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New Lives Lost (lives lost – actual lives saved)
-1 |
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Parrish Medical Center |
FL |
US |
Access To Acute Psychiatric Beds
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Commitment
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Parrish Medical Center
Access To Acute Psychiatric Beds
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13 - Mental Health
Commitment Name:
Access To Acute Psychiatric Beds
Commitment Start Date 03/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The strategy focuses on enabling people with mental health problems and illnesses to recover a meaningful life with less reliance on acute care, and with less risk of developing complex and expensive social problems. This means strengthening services, treatments and supports in the community and access to primary care providers. Focus areas include: * Tools to recognizing and identify hazards that may increase the chance of patient suicide or self-harm. (EHR) *Improving Patient Flow and Reducing Emergency Department Crowding through implementation of Mission Control, a centralized bed placement within the hospital to expedite bed assignment *Partnering with Florida Information Technology to assist in developing a behavioral health program in the Patient Centered Mental Home. * Ongoing relationship with The Community Health Partnership (CHP) members. CHP is a consortium of medical providers and social service agencies that evaluate the needs assessments of the community and work together to implement solutions. * A trained social worker, the 2-1-1 navigator provides assistance to Brevard County residents to access social programs that can help improve health; find transportation to medical appointments; find resources for prescriptions; and search for access to health insurance and mental health programs * Ongoing monitoring to maintain system in order to adhere to current standards and protocols.
Commitment Timeline
Ongoing
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Medical care evaluation studies are conducted as part of the Performance Improvement process. Review current data include length of stay, ancillary cost/charges, benchmark data, avoidable day trends, and medical necessity for performance of ancillary testing. The data utilized in performance improvement process is obtained through All Scripts, and the patient’s medical record. (S.Hillman is pulling baseline report) * OP-20 Door to Doc Diagnostic Evaluation by a Qualified Medical Professional
○ This measure can be utilized to look at the median time from ED arrival to provider contact for ED patients. This measure could be adapted to compare patients with a primary Mental Health
diagnosis vs. Medical diagnosis and reduce disparities in treatment efficiency and access. (Not currently collected based on mental health profession) * # of Baker Acts/Marchman # are collected with place of transfer if applicable- data collected from EHR
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Access To Acute Psychiatric Beds – Update – 01.29.18
View Update
Commitment Update
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Parrish Medical Center
Access To Acute Psychiatric Beds – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 03/01/2016 How many hospitals are represented in this commitment?
Action Plan:
The strategy focuses on enabling people with mental health problems and illnesses to recover a meaningful life with less reliance on acute care, and with less risk of developing complex and expensive social problems. This means strengthening services, treatments and supports in the community and access to primary care providers. Focus areas include: * Tools to recognizing and identify hazards that may increase the chance of patient suicide or self-harm. (EHR) *Improving Patient Flow and Reducing Emergency Department Crowding through implementation of Mission Control, a centralized bed placement within the hospital to expedite bed assignment *Partnering with Florida Information Technology to assist in developing a behavioral health program in the Patient Centered Mental Home. * Ongoing relationship with The Community Health Partnership (CHP) members. CHP is a consortium of medical providers and social service agencies that evaluate the needs assessments of the community and work together to implement solutions. * A trained social worker, the 2-1-1 navigator provides assistance to Brevard County residents to access social programs that can help improve health; find transportation to medical appointments; find resources for prescriptions; and search for access to health insurance and mental health programs * Ongoing monitoring to maintain system in order to adhere to current standards and protocols.
Commitment Update:
We have changed our commitment to include the evaluation of current technology solutions to include web-based and mobile application psychiatric bed registry that serves as a platform for inpatient hospital bed openings. We will collaborate with key stake-holders in the community/county for interest, feasibility, implementation and support of a shared registry tool.
Your commitment aligns with APSS
Challenge 13 - Mental Health Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Utilization of internal centralized bed placement system.
- Established a communication/command center called, “Mission Control” centrally monitoring patient placement.
- Providing 1:1 patient care sitters with all Baker Acts within the ED and inpatient setting.
- Accessing a trained social work, the 2-1-1 navigator who provides assistance to Brevard County residents to access supportive programs and resources.
-Continued community collaboration and planning for access to supportive resources to meet the increased psych patient population needs.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Parrish Medical Center |
FL |
US |
Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy
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Commitment
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Parrish Medical Center
Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11 - Optimizing Obstetric Safety
Commitment Name:
Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy
Commitment Start Date 07/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• Review literature to include AWHONN and AGOG standards
• Review and update current policies and procedures for management of Preeclampsia and Magnesium Sulfate administration, as well as pharmaceutical management of hypertension in pregnancy
• Begin data collection and chart reviews for all Hypertensive disorders in pregnancy
Commitment Timeline
Currently reviewing order sets, policies and procedures
Jan 2017 Begin collecting data
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
National statistics report that 10% pregnant women will have some type of hypertensive disorder in pregnancy. Here at Parrish Medical Center approximately 7% of our mothers who deliver have a reported hypertensive disorder. The actual impact is probably much larger because we did not include the high risk mothers that were transferred to a tertiary medical center before delivery.
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Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 07/01/2016 How many hospitals are represented in this commitment?
Action Plan:
• Review literature to include AWHONN and AGOG standards
• Review and update current policies and procedures for management of Preeclampsia and Magnesium Sulfate administration, as well as pharmaceutical management of hypertension in pregnancy
• Begin data collection and chart reviews for all Hypertensive disorders in pregnancy
Commitment Update:
- Completed review of literature: AWHONN and AGOG standards
- Continuing to review policies and procedures
- Collaborating with physicians to provide a standardized treatment plan for patients presenting with risk factors or indications suggesting hypertensive disorders in pregnancy
- Educating staff to recognize risk factors and indications suggesting hypertensive disorders in pregnancy
Your commitment aligns with APSS
Challenge 11 - Optimizing Obstetric Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Following best practices we are looking at changing practice and following protocols for the early detection and management of hypertensive disorders in pregnancy. Our biggest challenge has been buy in from all physicians. We currently have a group of 6 physicians in our Parrish Obstetrics group with different backgrounds and experiences and 6 different ways of treating hypertensive disorders in pregnancy so standardizing practice is going to be our main focus. We will address this at our next OB/GYN Department meeting.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
2 |
Lives Spared Harm Target for following calendar year
2 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
2 |
Projected Target of Lives Saved for following calendar to try to finish commitment
2 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Parrish Medical Center |
FL |
US |
Neonatal Oxygen Targeting
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Commitment
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Parrish Medical Center
Neonatal Oxygen Targeting
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7 - Neonatal Safety
Commitment Name:
Neonatal Oxygen Targeting
Commitment Start Date 10/01/2011 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• New education with updated NRP guidelines has already started and will continue
• Update policies and protocols for optimal neonatal oxygen including targets and alarm settings for both term and pre-term newborns to be reviewed and updated as needed
• Budget for new and improved pulse oximeters with Signal Extraction Technology (SET) and heated and humidified oxygen all in the delivery rooms
• Begin data collection and monitoring of all resuscitations and oxygen administration
Commitment Timeline
Quarterly
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
National Statistics report 10% of all babies will need some sort of resuscitative measures including some oxygen, and only 1% require a more extensive resuscitation. Here at Parrish Medical Center in our low risk L&D and level 1 nursery we find that approximately 6% of our newborns require resuscitation or require some type of flow or oxygen therapy.
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Neonatal Oxygen Targeting – Update – 01.29.18
View Update
Commitment Update
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Parrish Medical Center
Neonatal Oxygen Targeting – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 10/01/2011 How many hospitals are represented in this commitment?
Action Plan:
• New education with updated NRP guidelines has already started and will continue
• Update policies and protocols for optimal neonatal oxygen including targets and alarm settings for both term and pre-term newborns to be reviewed and updated as needed
• Budget for new and improved pulse oximeters with Signal Extraction Technology (SET) and heated and humidified oxygen all in the delivery rooms
• Begin data collection and monitoring of all resuscitations and oxygen administration
Commitment Update:
- Process has been identified and researched
- Procedure was revised in March 2017
- Staff has been educated
- Continuation of data collection
Your commitment aligns with APSS
Challenge 7 - Neonatal Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Following the best practices of using heated humidified oxygen via an oxygen blender, and setting alarm parameters, and using pulse oximetry to guide the optimal and safe use of oxygen to reduce complications such as ROP is our constant focus.
The biggest lesson learned is involving physicians in the implementation and changing of protocols. (One of our Pediatricians tends to order oxygen based on symptoms instead of using pulse ox to guide the need for increased oxygen.) We will take this to our next Pediatrics Department Meeting.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Anemia and Blood Transfusions
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Commitment
×
Parrish Medical Center
Anemia and Blood Transfusions
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Participants:
-
Matt Graybill,Exec Director Surgical and Diagnostic services
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient Blood Management
Commitment Name:
Anemia and Blood Transfusions
Commitment Start Date 05/26/2011 How Many Hospitals Will This Commitment Represent? 1
Action Plan
See Above
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Reduction per 1000 patients times the occurrence of significant adverse reactions to blood products
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Anemia and Blood Transfusions – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Anemia and Blood Transfusions – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 05/26/2011 How many hospitals are represented in this commitment?
Action Plan:
See Above
Commitment Update:
Action items by Blood Management Committee include:
- Transfusion not meeting criteria review
- Single unit transfusions
- Implement blood conservation modalities
- Reduction and frequency of blood draws including discard of or hold volumes
- Preoperative management of platelet inhibitors and other anticoagulants
- Red cell recovery in the operating room
Your commitment aligns with APSS
Challenge 5 - Patient Blood Management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Cellsaver in OR where/when applicable. Monitoring Single versus Two Unit orders/transfusions. Patient Blood Transfusion Committee in place. Blood order sets in place, with thresholds for when to give or reasoning is needed. Follow-up letters for inappropriate orders for blood sent to ordering MD’s. Ongoing education.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION
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Commitment
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Parrish Medical Center
FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
titusville, fl 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for Opioid-induced Respiratory Depression
Commitment Name:
FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION
Commitment Start Date 10/01/2012 How Many Hospitals Will This Commitment Represent? 1
Action Plan
See above
Commitment Timeline
2017- Complete equipment and EMR integration
2018- Repeat FMEA to assess for additional opportunities
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Number of patients requiring reversal for opioids
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FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 10/01/2012 How many hospitals are represented in this commitment?
Action Plan:
See above
Commitment Update:
- Repeat FMEA to assess for additional opportunities
- Perform Performance Improvement plan using the DMAIC process
Your commitment aligns with APSS
Challenge 4 - Monitoring for Opioid-induced Respiratory Depression Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. CPOE
a. Order strings with preset doses
b. Dosage checks/alerts
2. Nursing assessment
a. PASERO assessment prior to and after administration
3. Monitoring of Naloxone use for opioid reversal
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
12 |
Lives Spared Harm Target for following calendar year
12 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
12 |
Projected Target of Lives Saved for following calendar to try to finish commitment
12 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Airway Safety
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Commitment
×
Parrish Medical Center
Airway Safety
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
titusville, fl 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8 - Airway Safety
Commitment Name:
Airway Safety
Commitment Start Date 10/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Develop Failed Airway protocol and comprehensive, standardized airway cart and equipment system, hardwire and maintain EBP critical practices, and initiate team competency for protocol, equipment and critical practices.
Commitment Timeline
Start November 2016, monitor daily and report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
HIIN data
|
Airway Safety – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Airway Safety – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 10/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Develop Failed Airway protocol and comprehensive, standardized airway cart and equipment system, hardwire and maintain EBP critical practices, and initiate team competency for protocol, equipment and critical practices.
Commitment Update:
- Continue to modify and develop Failed Airway protocol, airway cart/box and equipment system, hardwire and maintain EBP critical practices
- Continue to educate team with competencies for protocol, equipment and critical practices
Your commitment aligns with APSS
Challenge 8 - Airway Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Assess airway security every shift by both Respiratory and Nurses
- Team communication and collaboration with plan
- Pre-oxygenation with every intubation
- Waveform Capnography – Immediately following all intubations
- System for appropriate sedation and patient restraints to decrease risk of unplanned extubation (UE)
- Implement best practice guidelines for weaning & planned extubation
- RL Systems for tracking and analyzing QA, adverse, and near miss events for airway management (airway registry beyond hospital safety reporting system) for all unplanned extubations
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
2 |
Lives Spared Harm Target for following calendar year
2 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
2 |
Projected Target of Lives Saved for following calendar to try to finish commitment
2 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Resuscitation Optimization
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Commitment
×
Parrish Medical Center
Resuscitation Optimization
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, Florida 32796 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest
Commitment Name:
Resuscitation Optimization
Commitment Start Date 10/01/2010 How Many Hospitals Will This Commitment Represent? 1
Action Plan
see above
Commitment Timeline
This process began in 2010 and continues today.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
reduction of 2-3% of all cause mortality rate
|
Resuscitation Optimization – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Resuscitation Optimization – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 10/01/2010 How many hospitals are represented in this commitment?
Action Plan:
see above
Commitment Update:
- Uses existing Code Blue Committee as steering committee for assess opportunities, identifying and implementing solutions and gathering/reporting of data pertaining to this APSS.
- Code Blue cases and Rapid Response calls are monitored weekly and any variances are entered into RL solutions.
Your commitment aligns with APSS
Challenge 10 - Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Code blue committee in place.
- Rapid Response Team (aka Critical Access Team).
- Post code conferences.
- ACLS training. BCLS training.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
25 |
Lives Spared Harm Target for following calendar year
25 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
25 |
Projected Target of Lives Saved for following calendar to try to finish commitment
25 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers
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Commitment
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Parrish Medical Center
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Jacqueline Wiseman,WOCN Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers
Commitment Start Date 08/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
This is a nurse driven initiative which allows the staff to quickly provide intervention for patients with PU or who are at a high risk for development of PU. Quarterly prevalence surveys are completed and the date reported to NDNQI in addition to random surveillance of documentation for accuracy and compliance. Weekly check-in meetings with senior staff are used to review risk and identify deficiencies for early intervention.
Commitment Timeline
Begin 8/1/16 and complete by 8/1/18
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
We do a yearly IPUP (International Pressure Ulcer Prevalence) study sponsored by Hill-Rom. The national bench mark for pressure ulcer prevalence by census size is 7.8% for a facility size of 1-199. This does not break in into Stage III and IV pressure ulcer although our facility results do. We have zero PU Stage III or IV for the last 5 years.
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Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 08/01/2016 How many hospitals are represented in this commitment?
Action Plan:
This is a nurse driven initiative which allows the staff to quickly provide intervention for patients with PU or who are at a high risk for development of PU. Quarterly prevalence surveys are completed and the date reported to NDNQI in addition to random surveillance of documentation for accuracy and compliance. Weekly check-in meetings with senior staff are used to review risk and identify deficiencies for early intervention.
Commitment Update:
- PMC maintains a supply of pressure reduction mattress replacements on site
- Evaluation of new hospital beds and support surfaces has been completed
- Addition members added to PUP team
- Improvements to EMR continue to be monitored to enhance nurse compliance and ease of charting
Your commitment aligns with APSS
Other Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Skin Risk Assessment every shift using Braden scores to identify risk for skin breakdown
- Individualized Care Plans
- Nutritional support
- Specialty Support surfaces
- Turning and repositioning at least q 2 hours.
- Individual treatment plan appropriate to the wound and severity.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
4 |
Lives Spared Harm Target for following calendar year
4 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
4 |
Projected Target of Lives Saved for following calendar to try to finish commitment
4 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Zero Falls with injury for our patients
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Commitment
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Parrish Medical Center
Zero Falls with injury for our patients
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, Fl 32796 US
Participants:
-
Jacqueline Wiseman,WOCN Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Zero Falls with injury for our patients
Commitment Start Date 08/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The development of an all or nothing approach for patients at risk was established and a fall bundle created. Each patient at risk will be visually identified using yellow non-skid socks, door magnets, and wristbands in addition to bed alarms and chair alarms. A new computer based learning module was created for both clinical and non-clinical staff with an accountability statement. This involved a 'hands on or within interventional range' for out of bed activity. Support for additional initiatives such as care team rounds, early ambulation and hourly rounds which can have a direct impact on patient safety and Zero Falls.
Commitment Timeline
Start date is 8/1/2016 complete by 8/1/18
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NDNQI Methodology
|
Zero Falls with injury for our patients – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Zero Falls with injury for our patients – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 08/01/2016 How many hospitals are represented in this commitment?
Action Plan:
The development of an all or nothing approach for patients at risk was established and a fall bundle created. Each patient at risk will be visually identified using yellow non-skid socks, door magnets, and wristbands in addition to bed alarms and chair alarms. A new computer based learning module was created for both clinical and non-clinical staff with an accountability statement. This involved a 'hands on or within interventional range' for out of bed activity. Support for additional initiatives such as care team rounds, early ambulation and hourly rounds which can have a direct impact on patient safety and Zero Falls.
Commitment Update:
- Frequent observation and hourly rounding on the fall risk patient
- Review of clinical equipment for function and efficacy as well as development of new process for patient safety when out of bed for fall risk patients
- Ancillary staff such as EVS and Dietary have been enlisted for alarms awareness and response to alarms
Your commitment aligns with APSS
Challenge 14 - Falls and Fall Prevention Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- The development of an all or nothing approach for patients at risk was established and a fall
bundle created.
- Each patient at risk will be visually identified using yellow non-skid socks, door magnets, and wristbands in addition to bed alarms and chair alarms.
- Hands on or within interventional range' for out Of bed activity.
- A new computer based learning module was created for both clinical and non-clinical staff with an accountability statement
- Support for additional initiatives such as care team rounds, early ambulation, hourly rounding
Interdisciplinary post fall conference at bedside.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
16 |
Lives Spared Harm Target for following calendar year
16 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
16 |
Projected Target of Lives Saved for following calendar to try to finish commitment
16 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Critical Congenital Heart Disease Screening in Newborns
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Commitment
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Parrish Medical Center
Critical Congenital Heart Disease Screening in Newborns
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Melinda Hodges,Manager, Women's Services
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7 - Neonatal Safety
Commitment Name:
Critical Congenital Heart Disease Screening in Newborns
Commitment Start Date 09/01/2012 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Pre and Post-ductal pulse oximetry readings are collected and analyzed according to the American Academy of Pediatrics algorythm. Results are entered into the EMR and reported to the responsible physician for follow-up.
Commitment Timeline
1 - Process identified and researched June/July 2012.
2 - Nursery Procedure completed with input from Department of Pediatrics.
3 - Screening program began September 2012, and continues today for all newborns delivered at Parrish Medical Center.
4 - Florida legislation passed mandating CCHD screening for all newborns - SB-124 - July 2013.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Early detection provides the ability to provide early intervention.
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Critical Congenital Heart Disease Screening in Newborns – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Critical Congenital Heart Disease Screening in Newborns – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 09/01/2012 How many hospitals are represented in this commitment?
Action Plan:
Pre and Post-ductal pulse oximetry readings are collected and analyzed according to the American Academy of Pediatrics algorythm. Results are entered into the EMR and reported to the responsible physician for follow-up.
Commitment Update:
- Screening program continues for all newborns delivered at Parrish Medical Center
- New query to be added to CCHD intervention to streamline data collection
Your commitment aligns with APSS
Challenge 7 - Neonatal Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We continue to screen all newborns and follow the CCHD algorithm from the American Academy of Pediatrics, and notify pediatricians of all positive screens for further treatment. (We were doing this before it was required by the state, as we previously discussed, we are often early adopters of patient safety initiatives.)
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
2 |
Lives Spared Harm Target for following calendar year
2 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
2 |
Projected Target of Lives Saved for following calendar to try to finish commitment
2 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
VAE/IVAC - Ventilator Associated Event w/infection
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Commitment
×
Parrish Medical Center
VAE/IVAC – Ventilator Associated Event w/infection
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Nancy Bakewell,Executive Director, Critical Care Services
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-Associated Pneumonia (VAP)
Commitment Name:
VAE/IVAC – Ventilator Associated Event w/infection
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Continue monitoring sputum cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Timeline
Start January 2015, monitor daily/report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NHSN methodology.
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VAE/IVAC – Ventilator Associated Event w/infection - Update - 01.29.18
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Commitment Update
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Parrish Medical Center
VAE/IVAC – Ventilator Associated Event w/infection – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Continue monitoring sputum cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Update:
- Continue monitoring of PEEP/Fi02 for events
Your commitment aligns with APSS
Challenge 2D - Ventilator-Associated Pneumonia (VAP) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Daily oral care and daily check-list.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
6 |
Lives Spared Harm Target for following calendar year
6 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
6 |
Projected Target of Lives Saved for following calendar to try to finish commitment
6 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Distribution of "Baby Boxes" to decrease the incidence of co-bedding and SIDs deaths
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Commitment
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Parrish Medical Center
Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Melinda Hodges,Manager, Women's Services
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths
Commitment Start Date 05/23/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1 - The Healthy Start Coalition of Brevard County has purchased the supplies and 500 Baby Boxes, which have been shipped to Parrish Medical Center in early May 2016.
2 - Parrish Medical Center has partnered with an area Boy Scout Troop to assemble and stock baby boxes - 250 completed by 6/18/16.
3 - Baby Boxes have been given to every delivery - starting with discharges on May 23, 2016.
4 - An additional assembly day will be scheduled in October 2016 to assemble the remaining Baby Boxes.
5 - Additional funding sources are being sought for future purchases of the Baby Boxes and supplies.
6 - County wide stats will be monitored for effect on SID's deaths.
Commitment Timeline
In collaboration with the Healthy Start Coalition, Parrish Medical Center is committed to distributing Baby Boxes and educating ALL families delivering babies at our facility through our current supplies.
Will explore and seek additional funding sources to expand this program beyond the initial supply of 500.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Rate of SID per 1,000 newborns.
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Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 01.29.18
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Commitment Update
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Parrish Medical Center
Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 05/23/2016 How many hospitals are represented in this commitment?
Action Plan:
1 - The Healthy Start Coalition of Brevard County has purchased the supplies and 500 Baby Boxes, which have been shipped to Parrish Medical Center in early May 2016.
2 - Parrish Medical Center has partnered with an area Boy Scout Troop to assemble and stock baby boxes - 250 completed by 6/18/16.
3 - Baby Boxes have been given to every delivery - starting with discharges on May 23, 2016.
4 - An additional assembly day will be scheduled in October 2016 to assemble the remaining Baby Boxes.
5 - Additional funding sources are being sought for future purchases of the Baby Boxes and supplies.
6 - County wide stats will be monitored for effect on SID's deaths.
Commitment Update:
- 800 new Baby Boxes have been donated by the Jess Parrish Foundation for distribution in 2017 & 2018
- Investigation continues for additional funding sources for future purchases of Baby Boxes and supplies
- County wide statistics continue to be monitored for effect on SIDS deaths
Your commitment aligns with APSS
Other Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We will continue distributing baby boxes to all families who deliver at Parrish Medical Center because it is the right thing to do to provide a safe place for all babies to sleep. However as always the main focus is always on education, educating families about safe sleep and the avoidance of co-bedding, the major contributor for SIDS death, is even more important than the boxes alone.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
4.28 |
Lives Spared Harm Target for following calendar year
4.28 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
4.28 |
Projected Target of Lives Saved for following calendar to try to finish commitment
4.28 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
SSI - Surgical Site Infection for COLO and HYST procedures
View Commitment
Commitment
×
Parrish Medical Center
SSI – Surgical Site Infection for COLO and HYST procedures
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Matt Graybill,Executive Director - Perioperative/Diagnostic Services
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical Site Infections (SSI)
Commitment Name:
SSI – Surgical Site Infection for COLO and HYST procedures
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Continue monitoring site cultures, site assessments and post d/c surveillance for events, maintain EBP bundles.
Commitment Timeline
Start January 2015, monitor daily/report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NHSN methodology.
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SSI – Surgical Site Infection for COLO and HYST procedures – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
SSI – Surgical Site Infection for COLO and HYST procedures – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Continue monitoring site cultures, site assessments and post d/c surveillance for events, maintain EBP bundles.
Commitment Update:
- Continue surveillance for: ED visits, Readmissions within 30 days of procedure, radiologic exam positive for infection/abscess and/or positive wound cultures at the surgical site
- Verify use of ASHP guidelines for pre-operative antibiotics
- Perform assessments of OR pressures and OR traffic
Your commitment aligns with APSS
Challenge 2C - Surgical Site Infections (SSI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Use of CHG for skin prep in OR, hair clipping, postoperative normothermia, adequate glucose control, VTE prophylaxis. Minimize traffic in/out of rooms while being set up and in progress, monitor temperature, humidity, and pressures, minimize IUSS.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
2 |
Lives Spared Harm Target for following calendar year
2 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
2 |
Projected Target of Lives Saved for following calendar to try to finish commitment
2 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Sepsis
View Commitment
Commitment
×
Parrish Medical Center
Sepsis
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Nancy Bakewell,Executive Director, Critical Care Services
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Sepsis
Commitment Start Date 08/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Develop multidisciplinary team to evaluate evidence based practice of Sepsis bundle.
Commitment Timeline
January 31, 2017
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Date # Discharges # Obs Mortality Obs Mortality Rate Norm Mortality Rate
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Sepsis – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
Sepsis – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 08/01/2016 How many hospitals are represented in this commitment?
Action Plan:
Develop multidisciplinary team to evaluate evidence based practice of Sepsis bundle.
Commitment Update:
- Sepsis committee assesses opportunities, identifies and implements solutions and gathers/reports data pertaining to this APSS
- Conducts weekly safety meetings to discuss variances in the sepsis protocol
- Sepsis committee meets monthly to fulfill the obligations to the sepsis population
Your commitment aligns with APSS
Challenge 9 - Early Detection and Treatment Of Sepsis Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Board level involvement in the sepsis program
- Established Interdisciplinary Sepsis Committee
- Sepsis Dashboard in place
- Critical Assessment Team in place for sepsis patients
- Sepsis screening tool incorporated into EHR / pulls automated screening information
- Alerts in place for “high” screening
- Separate sepsis profile for continuous monitoring and early detection based on changes in patient’s clinical status
- Workflow specific to level of alert
- Sepsis order sets in place/ monitoring for compliance in their use
- Peer review process in place for outliers
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
19 |
Lives Spared Harm Target for following calendar year
19 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
19 |
Projected Target of Lives Saved for following calendar to try to finish commitment
19 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
Antimicrobial Stewardship
View Commitment
Commitment
×
Parrish Medical Center
Antimicrobial Stewardship
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
David Ruta,Pharmacy Director
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial Stewardship – The Role of Pharmacy & the Microbiology Lab in Patient Safety
Commitment Name:
Antimicrobial Stewardship
Commitment Start Date 07/19/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The Antimicrobial Stewardship Program utilizes the following interventions and strategies:
Formulary Restrictions and Pre-authorization Requirements.
Educate and promote ASP strategies and prescribing criteria.
Antimicrobial Order Forms or Order Sets.
Dose Optimization
IV to PO Conversion
Commitment Timeline
Start July 19, 2016, P&T meets monthly, complete by January 1, 2017.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Right patient, right drug for the condition, goal to prevent resistance, overuse of antibiotics. Potential metrics: Hospital onset C-Diff due to antibiotics (broad spectrum) -->Cdiff per AA, adverse events from antibiotics, resistance rates of VRE, MRSA, ESBL, carbapenem resistance, etc.
|
Antimicrobial Stewardship – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
Antimicrobial Stewardship – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 07/19/2016 How many hospitals are represented in this commitment?
Action Plan:
The Antimicrobial Stewardship Program utilizes the following interventions and strategies:
Formulary Restrictions and Pre-authorization Requirements.
Educate and promote ASP strategies and prescribing criteria.
Antimicrobial Order Forms or Order Sets.
Dose Optimization
IV to PO Conversion
Commitment Update:
- 48 hour antibiotic timeout
Your commitment aligns with APSS
Challenge 3B - Antimicrobial Stewardship – The Role of Pharmacy & the Microbiology Lab in Patient Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Multidisciplinary Team
a. Medicine including ID, Pharmacy including ID, Clinical Laboratory, Nursing, IT
2. CPOE w CDS
3. Order sets/Protocols
4. Pharmacy
a. All orders reviewed
b. Interventions: 48hr time out, IV/PO, Dose optimization, Dose adjustments, Automatic stop orders
5. Microbiology
a. Antibiogram twice yearly
b. Rapid Diagnostics
i. PCR, Molecular DNA Testing
c. Procalcitonin
d. Selective reporting of susceptibilities of antimicrobials
6. Multifaceted Implementation Strategy
a. Restrictive, Prospective audit, Concurrent monitoring
7. Education
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection
View Commitment
Commitment
×
Parrish Medical Center
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Dawn Page,Infection Prevention Professional
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium Difficile Infection (CDI)
Commitment Name:
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Continue monitoring lab ID events, maintain EBP bundles.
Commitment Timeline
Start January 2015, monitor daily/report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NHSN methodology.
|
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Continue monitoring lab ID events, maintain EBP bundles.
Commitment Update:
- Educate family members on infections
- Educate on appropriate testing
- Develop and implement a testing algorithm
Your commitment aligns with APSS
Challenge 2E - Clostridium Difficile Infection (CDI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Implementation of antimicrobial stewardship program, institution of empiric precautions of placing patients on Contact Precautions at onset of diarrhea, education and re-education of cleaning and disinfection of patient care equipment, Education of timely collection of loose stool, lab rejection of formed stool, and weekly report outs of hospital acquired infections.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1.9 |
Lives Spared Harm Target for following calendar year
1.9 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1.9 |
Projected Target of Lives Saved for following calendar to try to finish commitment
01.9 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
CLABSI-Central Line Associated Bloodstream Infection
View Commitment
Commitment
×
Parrish Medical Center
CLABSI-Central Line Associated Bloodstream Infection
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Dawn Page,Infection Prevention Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
CLABSI-Central Line Associated Bloodstream Infection
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Continue monitoring blood cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Timeline
Start January 2015, monitor daily/report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NHSN methodology.
|
CLABSI-Central Line Associated Bloodstream Infection – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
CLABSI-Central Line Associated Bloodstream Infection – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Continue monitoring blood cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Update:
- Eliminate unnecessary blood draws from lines.
- Perform RCS on all CLABSI's
- Add insertion checklist to EMR
- Document tubing changes
Your commitment aligns with APSS
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Education for physicians, nurses, and other licensed practitioners, implementing blood draws from line by physician order only, complete and document an insertion checklist.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
FL |
US |
CAUTI-Indwelling Catheter Associated Urinary Tract Infection
View Commitment
Commitment
×
Parrish Medical Center
CAUTI-Indwelling Catheter Associated Urinary Tract Infection
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N. Washington Avenue
Titusville, FL 32796 US
Participants:
-
Dawn Page,Infection Prevention Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
CAUTI-Indwelling Catheter Associated Urinary Tract Infection
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Continue monitoring urine cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Timeline
Start January 2015, monitor daily/report monthly, complete by January 2018.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NHSN methodology.
|
CAUTI-Indwelling Catheter Associated Urinary Tract Infection – Update – 01.29.18
View Update
Commitment Update
×
Parrish Medical Center
CAUTI-Indwelling Catheter Associated Urinary Tract Infection – Update – 01.29.18
Contact Info
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: VP Acute Care/ CNO
Organization Name: Parrish Medical Center
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Action Plan:
Continue monitoring urine cultures for events, maintain EBP bundles, perform daily needs assessment for devices.
Commitment Update:
Implemented:
- Nurse driven protocol
- Assessment/education on alternatives to indwelling urinary catheters
Your commitment aligns with APSS
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
CAUTI Best practices learned: Best practices currently in place include inserting catheters only for appropriate indications, only properly trained persons insert and maintain catheters, and performing aseptic insertion. We learned that implementing a nurse driven protocol for removal of indwelling foley catheters will be beneficial.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
University of Pittsburgh Medical Center |
PA |
US |
Getting to Zero-Eliminating Catheter-Associated Urinary Tract Infections
View Commitment
Commitment
×
University of Pittsburgh Medical Center
Getting to Zero-Eliminating Catheter-Associated Urinary Tract Infections
Contact Info
Name: Colleen Tanner, MSN, RN
Phone: 412-864-1872
Email: tannerca@upmc.edu
Position: Senior Quality Manager, Complication and Infection Prevention
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Blvd , Suite 230
Pittsburgh, PA 15213 US
Participants:
-
Graham Snyder, MD, SM,Medical Director, Infection Prevention and Hospital Epidemiology
-
Elise Martin, MD, MS,Associate Medical Director, Infection Prevention and Hospital Epidemiology
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
Getting to Zero-Eliminating Catheter-Associated Urinary Tract Infections
Commitment Start Date:04/09/2018 How Many Hospitals Will This Commitment Represent? 30 Commitment Summary:
Reduction of our system-wide CAUTI rate 10% by the end of calendar year 2019. Commitment Description & Detail:
The CAUTI best practice guide was recently developed to help managers focus on the bedside practices of urinary catheter insertion, removal, care and specimen collection. It provides managers with the tools needed to educate and promote ongoing best practice at the bedside. This guide was developed using evidence-based resources. The guide includes skills checklists and videos for several key areas of care at the bedside level which can be used when orienting new staff or ongoing competency for current staff. The guide, tools, and videos have been posted on the UPMC Infonet for anyone to access. A System-wide Webinar on Best Practices to Reduce Catheter-Associated Urinary Tract Infections was conducted on June 19, 2018. The webinar and the content presented was made available through our system quality education department. Urine Reflex to Culture workgroup who meets biweekly to address best practices in urine specimen collection and testing. Action Plan:
Action Plan:
1. Increase awareness of the risk of indwelling catheters and move toward a goal of eliminating catheter associated urinary tract infections. This will be accomplished through best practice guide education, introduction of tools that may be utilized to review events, development of technology- assisted education, and electronic health record opportunities.
2. Promote standardized practice using the best practice guide, competencies, and supply evaluation.
3. Identify opportunities to improve current practices through audit and root cause analysis (RCA) tools.
4. Creation of System-wide monthly meeting of CAUTI Champions.
5. Urine Reflex to Culture workgroup who meets biweekly to address best practices in urine specimen collection and testing
Commitment Timeline:
The CAUTI Reduction Project Began with a System-wide Best Practice Guide being posted and shared on the UPMC Infonet the week of April 9, 2018. A System-wide Webinar on Best Practices to Reduce Catheter-Associated Urinary Tract Infections was conducted on June 19, 2018. System-wide monthly meeting of CAUTI Champions: beginning September 2018; and Ongoing. Urine Reflex to Culture workgroup: Ongoing. EMR meetings to address opportunities for urinary catheter and urine culturing reduction: Ongoing
Impact Details
Lives Saved
Lives Saved predicted:
0.5588999999999996 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
|
|
|
University of Pittsburgh Medical Center |
PA |
US |
Getting to Zero-Eliminating Clostridium difficile (C. diff) Infections for the Adult Population
View Commitment
Commitment
×
University of Pittsburgh Medical Center
Getting to Zero-Eliminating Clostridium difficile (C. diff) Infections for the Adult Population
Contact Info
Name: Colleen Tanner
Phone: 412-864-1872
Email: tannerca@upmc.edu
Position: Senior Quality Manager, Complication and Infection Prevention
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Blvd , Suite 230
Pittsburgh, PA 15213 US
Participants:
-
Graham Snyder, MD, SM,Medical Director, Infection Prevention and Hospital Epidemiology
-
Elise Martin, MD, MS,Associate Medical Director, Infection Prevention and Hospital Epidemiology
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium Difficile Infection (CDI)
Commitment Name:
Getting to Zero-Eliminating Clostridium difficile (C. diff) Infections for the Adult Population
Commitment Start Date:04/09/2018 How Many Hospitals Will This Commitment Represent? 30 Commitment Summary:
CDC: Clostridium difficile (C. difficile) is an important cause of infectious disease death in the United States. C. difficile was estimated to cause almost half a million infections in the United States in 2011. Approximately 83,000 of the patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis.
Poor prescribing practices put patients at risk for C. difficile infections. More than half of all hospitalized patients will get an antibiotic at some point during their hospital stay, but studies have shown that 30-50% of antibiotics prescribed in hospitals are unnecessary or incorrect.
C. difficile infections can be prevented by using infection control recommendations and more careful antibiotic use.
Improper or delayed ordering and specimen collection lead to delays in diagnosis and treatment.
Dubberke, E.R., MD, et al: Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update, Infection Control and Hospital Epidemiology, June 2014, Vol. 35, No. S2,
pp S48-S65.
“Attributable costs of inpatient CDI in 2008 dollars have been estimated to be $3,006-$ 15,397 per episode.28 US hospital costs for CDI management have been estimated to be $1.0-4.9 billion per year.28 Costs of CDI in the outpatient and non-acute care settings have not been assessed.”
Reduce our system-wide C.diff rate by 10% by the end of calendar Commitment Description & Detail:
The C. diff best practice guide was recently developed to help managers focus on the bedside practices of specimen ordering, specimen collection, proper infection prevention techniques, and patient/family education. It provides managers with the tools needed to educate and promote ongoing best practice at the bedside. This guide was developed using evidence-based resources. The guide includes fact sheets and pocket cards (which includes appropriate UV light disinfectant) for several key areas of care which can be utilized to educate all staff. It also provides an observational audit tool to provide real-time feedback, identify barriers, or areas of concern. It also provides a root cause analysis tool which may be utilized to identify opportunities for improvement. The guide and tools are to be been posted on the UPMC Infonet for anyone to access. Additionally, EMR functionality has been utilized to assist provider’s in appropriate ordering of C.diff specimens. Action Plan:
1. Increase awareness of the risk of C. diff infections. This will be accomplished through best practice guide education, introduction of tools that may be utilized to review events, development of technology- assisted education, and electronic health record opportunities.
2. Promote standardized practice using the best practice guide, educational resources, and tools.
3. Identify opportunities to improve current practices through audit and root cause analysis (RCA) tools.
4. Creation of System-wide monthly meeting of C. diff Champions, including our Antimicrobial stewardship representatives. Commitment Timeline:
The C. diff reduction program began with a system-wide change in provider ordering of C. diff specimens with collaboration of our eQuality/EMR team in the fall of 2017 and is ongoing. A System-wide Best Practice Guide is to be posted and shared on the UPMC Infonet in Sept. 2018. System-wide monthly meeting of C. diff Champions is to begin Sept. 2018 and ongoing.
Impact Details
Lives Saved
Lives Saved predicted:
5.404499999999996 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
6
|
|
|
University of Pittsburgh Medical Center |
PA |
US |
Perfect Hand Hygiene - Every Time
View Commitment
Commitment
×
University of Pittsburgh Medical Center
Perfect Hand Hygiene – Every Time
Contact Info
Name: Bonnie Colaianne, MSN, RN, CNL, CIC, FAPIC
Phone: 412-647-5675
Email: colaiannebv2@upmc.edu
Position: Improvement Specialist
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Blvd , Suite 245
Pittsburgh, PA 15213 US
Participants:
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Graham Snyder, MD, SM,Medical Director, Infection Prevention and Hospital Epidemiology
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Elise Martin, MD, MS,Associate Medical Director, Infection Prevention and Hospital Epidemiology
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Perfect Hand Hygiene – Every Time
Commitment Start Date:05/01/2012 How Many Hospitals Will This Commitment Represent? 30 Commitment Summary:
Hand hygiene is the single most effective way to prevent the spread of infection. At UPMC, we want hand hygiene to be a focus for everyone within the entire health system, from physicians and nurses to maintenance people, dietary staff, transportation workers, patients and visitors. Commitment Description & Detail:
UPMC implemented the World Health Organization’s hand hygiene program called Five Moments of Care. This program trains staff to stop and think about more opportunities for hand washing.
To further increase compliance, UPMC instituted a top-down initiative. After performing a system-wide survey of 8,000 respondents, we uncovered important information on barriers to hand washing, and have developed strategies to increase compliance.
Action Plan:
Increase hand hygiene compliance to 90% or greater.
Action Plan:
1. Affirm the local hand hygiene task force infrastructure
2. Maintain an environment that supports hand hygiene
3. Promote hand hygiene campaign awareness
4. Provide hand hygiene education
5. Establish hand hygiene as a patient safety priority
6. Institute a Just Culture environment for hand hygiene compliance
7. Design hand hygiene data management tools
Commitment Timeline:
The current hand hygiene campaign kicked off in May 2012 with all action plan items completed by January 2013. Within this timeframe UPMC increased compliance from 63% to 80%.
Develop an Infection Prevention Education Working Group (to include hand hygiene) - August 28, 2018
Review and update current action plan
Review UPMC hand hygiene app
Review technology options for hand hygiene observations
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University of Pittsburgh Medical Center |
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Getting to Zero-Eliminating Preventable Death from VTE
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Commitment
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University of Pittsburgh Medical Center
Getting to Zero-Eliminating Preventable Death from VTE
Contact Info
Name: Amy Lukanski
Phone: 412-802-8065
Email: lukanskia@upmc.edu
Position: Improvement Specialist
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Blvd, Suite 212
Pittsburgh, PA 15017 US
Participants:
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Josh Levenson,Physician-Heart Vascular Institute
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MD
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous Thromboembolism (VTE)
Commitment Name:
Getting to Zero-Eliminating Preventable Death from VTE
Commitment Start Date 05/05/2017 How Many Hospitals Will This Commitment Represent? 24
Action Plan
UPMC plans to reach our goal of eliminating preventable VTE deaths by the following:
1. Implementing a VTE Risk Assessment in the electronic medical record to guide providers to order appropriate prophylaxis based on the patient’s VTE risk factors.
2. Develop VTE Power Plans within the electronic medical record to guide care providers to appropriately order VTE prophylaxis
3. Develop a VTE Prevention Toolkit to guide nurses in completing VTE Preventative Interventions.
4. To have an effect on the awareness of the UPMC physicians, nurses, physical therapists, pharmacists, and other healthcare professionals to prevent VTE events.
5. To have an effect on the awareness of the patients and families that we care for at UPMC on the prevention of VTE.
Commitment Timeline
Timeline
The VTE Reduction Project officially began on May 5, 2017.
VTE Risk Assessment integration into EMR projected completion: June 2018
VTE Power Plan projected completion: June 2018
VTE Prevention Nursing Toolkit completion: August 2017
VTE Awareness Campaign: Ongoing
Impact Details
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University of Pittsburgh Medical Center |
PA |
US |
Reduce the mortality rate of our patients with Sepsis and Septic Shock
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Commitment
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University of Pittsburgh Medical Center
Reduce the mortality rate of our patients with Sepsis and Septic Shock
Contact Info
Name: Phoebe Haupert
Phone: 570 321 2212
Email: phaupert@susquehannahealth.org
Position: Director of Performance Improvement
Organization Name: University of Pittsburgh Medical Center
Organization Address:
700 High Street
Williamsport, PA 17701 US
Participants:
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Dr. Daniel Glunk,V.P. and Chief Quality Officer
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Reduce the mortality rate of our patients with Sepsis and Septic Shock
Commitment Start Date 10/01/2015 How Many Hospitals Will This Commitment Represent? 3
Action Plan
See Commitment Description and Details
Commitment Timeline
Baseline Data Analysis 2015/2015.
Implementation of order bundles Sept 2015
Intentional education efforts and concurrent reviews started Oct 2015
Efforts will be ongoing with no targeted completion date.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Data is analyzed using Crimson Continuum of Care. The ICD 9 and ICD 10 codes for Sepsis, Severe Sepsis with Shock and Severe Sepsis without Shock are used to analyze the mortality rates.
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University of Pittsburgh Medical Center |
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Getting to Zero – Eliminating Surgical Site Infections
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Commitment
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University of Pittsburgh Medical Center
Getting to Zero – Eliminating Surgical Site Infections
Contact Info
Name: Bonnie Colaianne, MSN, RN, CNL, CIC
Phone: (412) 647-5675
Email: colaiannebv2@upmc.edu
Position: Corporate Infection Prevention Coordinator
Organization Name: University of Pittsburgh Medical Center
Organization Address:
Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC , 4601 Baum Boulevard, Suite 212
Pittsburgh, PA 15213 US
Participants:
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UPMC System Infection Control Committee members and multidisciplinary representatives from each UPMC facility.
Commitment Details
Commitment Name:
Getting to Zero – Eliminating Surgical Site Infections
Action Plan
Our top six areas of focus in the prevention of SSIs include, but are not limited to:
• Standardization of Preoperative bathing instructions - revising the CHG patient bathing instruction sheet, sending the document to the printer for system-wide hospital and surgeon office use.
• Proper skin preparation - Skin antisepsis with CHG immediately prior to surgery, evidenced based practice as the standard of care in the prevention of SSIs.
• Postoperative wound and incisional care - System-wide postoperative wound and incisional care is being investigated for evidence base practice to standardize the surgical site dressing care and maintenance including incisional care following discharge.
• Discharge instructions.
• OR traffic/and attire - OR traffic- predetermine staff breaks and traffic are kept at a minimum. Attire to reduce environmental contamination intra-operatively.
• Flash sterilization- Flash sterilization is not intended to be used for either reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. Limit the number of flash instrumentation units in OR suites and standardizing accountability and practice when flash sterilization has been utilized.
Impact Details
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Getting to Zero – Eliminating Surgical Site Infections - Update - 08.23.18
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Commitment Update
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University of Pittsburgh Medical Center
Getting to Zero – Eliminating Surgical Site Infections – Update – 08.23.18
Contact Info
Name: Bonnie Colaianne
Phone: (412) 647-5675
Email: colaiannebv2@upmc.edu
Position: Corporate Infection Prevention Coordinator
Organization Name: University of Pittsburgh Medical Center
Commitment Details Commitment Start Date: 03/13/2014 How many hospitals are represented in this commitment?
Action Plan:
Surgical site infections (SSI) represent a national problem, accounting for 31% of all nosocomial infections in hospitalized patients (1). National Healthcare Safety Network data show an overall SSI rate of 1.9% (2), although rates vary widely by clinical population, type of procedure, and size of hospital, among other factors. Despite widespread infection control efforts,
SSIs continue to present a substantial public health risk and are correlated with increased treatment intensity, prolonged hospital stays, increased costs, and a greater possibility of death. These infections are linked with a mortality rate of 3%, and 75% of SSI-associated deaths are directly attributable to the SSI (3). When safe practices are aligned with current evidence-based practices and implemented during the perioperative period, SSIs can be prevented.
References:
1. Magill, S.S., et al., Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. InfectControl Hosp Epidemiol, 2012. 33(3): p. 283-91.
2. Mu, Y., et al., Improving risk-adjusted measures of surgical site infection for the national healthcare safety network. Infect Control Hosp Epidemiol, 2011. 32(10): p. 970-86.
3. Awad, S.S., Adherence to surgical care improvement project measures and post-operative surgical site infections. Surg Infect (Larchmt), 2012. 13(4): p. 234-7.
Commitment Update:
Our top six areas of focus in the prevention of SSIs included:
• Standardization of Preoperative bathing instructions - revising the CHG patient bathing instruction sheet, sending the document to the printer for system-wide hospital and surgeon office use.
Update - the use of CHG patient bathing has increased throughout UPMC but is not universally prescribed to all pre-operative patients. The use of CHG clothes in the pre-operative holding areas has increased and varies depending on surgeon preference and procedure.
• Proper skin preparation - Skin antisepsis with CHG immediately prior to surgery, evidenced based practice as the standard of care in the prevention of SSIs.
Update - CHG is the primary skin antisepsis but not completely universal dependent on surgeon preference and procedure location.
• Postoperative wound and incisional care - System-wide postoperative wound and incisional care is being investigated for evidence base practice to standardize the surgical site dressing care and maintenance including incisional care following discharge
Update - this continues to be a challenge as no one specific set of instructions is appropriate for all post op care.
• Discharge instructions
Update - none
• OR traffic/and attire - OR traffic- predetermine staff breaks and traffic are kept at a minimum. Attire to reduce environmental contamination intra-operatively.
Update - OR traffic is monitored. The OR dress code policy has been enhanced to specify appropriate attire per AORN guidelines.
• Flash sterilization- Flash sterilization is not intended to be used for either reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. Limit the number of flash instrumentation units in OR suites and standardizing accountability and practice when flash sterilization has been utilized.
Update - Many facilities have greatly reduced or eliminated this practice. Purchases of additional equipment and restructuring of OR scheduling has helped to reduce usage.
Your commitment aligns with APSS
Challenge 2C - Surgical Site Infections (SSI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
OR Traffic evaluation has offered several opportunities to improve process. Restructuring staffing needs and rearranging of supplies has helped reduce the traffic in and out of the OR suites.
Limiting and/or reducing Flash Sterilization required commitment from facilities through purchasing of equipment and supplies.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
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Lives Lost:
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Lives Spared Harm Target
60 |
Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
2 |
Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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University of Pittsburgh Medical Center |
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Getting to Zero – Eliminating Central Line Associated Blood Stream Infections
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Commitment
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University of Pittsburgh Medical Center
Getting to Zero – Eliminating Central Line Associated Blood Stream Infections
Contact Info
Name: Audrey Paul
Phone: (412) 802-8081
Email: paulal@upmc.edu
Position: Improvement Specialist, Clinical Improvement Department
Organization Name: University of Pittsburgh Medical Center
Organization Address:
Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC , 4601 Baum Boulevard, Suite 230
Pittsburgh, PA 15213 US
Participants:
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Bonnie Colaianne, RN, MSN, CNL, CIC,Corporate Infection Prevention Coordinator
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Infusion Best Practice Team (multidisciplinary representatives from each UPMC facility)
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Getting to Zero – Eliminating Central Line Associated Blood Stream Infections
How Many Hospitals Will This Commitment Represent? 16
Action Plan
1. Increase awareness of the risk of central line infections and move toward a culture in which zero is
possible, through talking points, posters, screensavers, educational materials, and videos.
2. Promote standardized practice through the use of bundles, guidelines for daily practice, and
competencies.
3. Audit protocol measures to ensure compliance.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Getting to Zero – Eliminating Central Line Associated Blood Stream Infections - Update - 08.17.18
View Update
Commitment Update
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University of Pittsburgh Medical Center (UPMC)
Getting to Zero – Eliminating Central Line Associated Blood Stream Infections – Update – 08.17.18
Contact Info
Name: Audrey Paul
Phone: (412) 802-8081
Email: paulal@upmc.edu
Position: Improvement Specialist, Clinical Improvement Department
Organization Name: University of Pittsburgh Medical Center (UPMC)
Commitment Details Commitment Start Date: 08/15/2018 How many hospitals are represented in this commitment?
Last Report
16 |
Current
30 |
Action Plan:
Commitment Summary: Reduce our system wide CLABSI rate from 0.87 to 0.77 by the end of calendar year 2019. UPMC has a system wide infusion group that meets and reviews practices on a monthly basis. The CLABSI best practice guide was recently developed to help managers focus on the bedside practices of central line care and maintenance and will provide managers with the tools needed to educate and promote ongoing best practice at the bedside. This guide was developed using the central line toolkit that had been developed using evidence-based resources for care and maintenance and available for several years. The guide includes skills checklists and education slides for several key areas of care and maintenance at the bedside level which can be used when orienting new staff or ongoing competency for current staff.
Action Plan:
1. Increase awareness of the risk of central line infections and move toward a goal of eliminating central line infections. This will be accomplished through best practice guide education, introduction of tools to review events, video development, and electronic health record opportunities.
2. Promote standardized practice using the best practice guide, competencies, and supply evaluation.
3. Identify opportunities to improve current practices through audit and root cause analysis (RCA) tools
Commitment Update:
Commitment Update
1. The CLABSI best practice guide has been developed and is at the final stages of completion before becoming available to the UPMC staff.
Your commitment aligns with APSS
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Collaboration between quality, educators, infusion nurses, and infection prevention teams will align plans and goals related to central line infection prevention.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
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Lives Lost:
0 |
Lives Spared Harm Target
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Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
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Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
0 |
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University of Pittsburgh Medical Center |
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Reducing Failed Transitions
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Commitment
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University of Pittsburgh Medical Center
Reducing Failed Transitions
Contact Info
Name: Tami Minnier
Phone: (412) 647-1602
Email: minnierte@upmc.edu
Position: Chief Quality Officer
Organization Name: University of Pittsburgh Medical Center
Organization Address:
200 Lothrop Street , 11086 Forbes Tower
Pittsburgh, PA 15213 US
Participants:
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John Beuerlein,MD, MMM, FAAP, SFHM, CMIO, UPMC St. Margaret and UPMC East
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Deborah Brodine,President, UPMC Community Provider Services
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Anne Docimo,MD, Senior Medical Director, UPMC Hospitals, and Chief Medical Officer, UPMC Health Plan
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Todd Pollock,Improvement Specialist, Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation at UPMC
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Sandy Rader,DNP, MSA, RN, NEA-BC, Chief Nursing Officer and Vice President, Patient Care Services, UPMC Shadyside •Margaret Reidy, MD, Senior Vice President of Medical Affairs, UPMC Presbyterian Shadyside
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Neil Resnick,MD, Chief, UPMC Division of Geriatric Medicine
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Karen Shaffer-Platt,Vice President UPMC Revenue Cycle and Patient Concierge Services
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Francis Solano,MD, FACP, President, Community Medicine, Inc. and Vice-President, UPMC Physician Services Division
Commitment Details
Commitment Name:
Reducing Failed Transitions
Action Plan
UPMC’s Failed Transition Action Bundle:
Readmission Risk Assessment Performed to Provide High Risk Patients with:
1. Discharge follow-up phone calls
2. Enhanced medication reconciliation
3. Improved handoffs to the next level of care
4. Discharge follow-up appointment scheduling
The following is a high level overview of the implementation plan for high-risk readmission patients:
• Implement a standard readmission risk calculator for use in the UPMC electronic medical record.
• Spread automated phone calls and patient alert follow-up phone calls to all UPMC patients discharged to home.
• Pilot sustainable system-wide strategies to improve medication education and reconciliation at the time of discharge.
• Refine clinical information needed for handoff of discharges to home or to extended care facilities.
• Provide patients with assistance in setting up follow-up provider appointments within 7 days after discharge.
Impact Details
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Reducing Failed Transitions - Update - 2015
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Commitment Update
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University of Pittsburgh Medical Center
Reducing Failed Transitions – Update – 2015
Contact Info
Name: Tami Minnier
Phone: (412) 647-1602
Email: minnierte@upmc.edu
Position: Chief Quality Officer
Organization Name: University of Pittsburgh Medical Center
Commitment Details Commitment Start Date: 03/13/2014 How many hospitals are represented in this commitment?
Action Plan:
Commitment Update:
Readmission Risk Score Implementation: A readmission risk score is automatically calculated for all patients in UPMC hospitals. Individual hospitals are using this information to prevent hospital readmissions.
Discharge Phone Calls: A post discharge call pilot at one of UPMC's hospitals has shown promise of reducing 7 and 30 day readmissions for moderate risk patients. There has been a 4.61% reduction in 7 day readmissions and 7.67% reduction in 30 day readmissions during the pilot. Additional data is being analyzed to determine if the pilot should be spread to another hospital.
Handoffs to Next Level of Care: Two UPMC hospitals are piloting an improved handoff to local Short Term Nursing Facilities.
Your commitment aligns with APSS
Challenge 6 - Hand-off Communications Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
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Lives Lost:
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Lives Spared Harm Target
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Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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The Patient Blood Management Program of UPMC (PBM) - Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare
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Commitment
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University of Pittsburgh Medical Center
The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare
Contact Info
Name: Mary Kay Wisniewski
Phone: (412) 802-8066
Email: wisniewskimk@upmc.edu
Position: Coordinator, Patient Blood Management Program of UPMC
Organization Name: University of Pittsburgh Medical Center
Organization Address:
Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC , 4601 Baum Boulevard, Suite 212
Pittsburgh, PA 15213 US
Participants:
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Jonathan H. Waters,MD, PBM Medical Director, Chief of Anesthesiology, Magee-Womens Hospital of UPMC
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Louis Alarcon,PBM Co-Medical Director, Chief of Trauma Surgery, UPMC Presbyterian
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Darrell Triulzi,MD, Director of the Division of Transfusion Medicine UPMC
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Tami Minnier,RN, MSN, FACHE, Chief Quality Officer, UPMC
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Steven D. Shapiro,MD, Chief Medical and Scientific Officer, UPMC
Commitment Details
Commitment Name:
The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare
Commitment Start Date 03/13/2014
Action Plan
Our PBM 2014 program milestones are:
1. Reduction in blood product procurement and utilization.
2. Reduction in non-evidence based transfusion use.
3. Reduction in wasted blood products as a result of improper storage and handling when the product is stored out of the blood bank.
4. Reduction of transfusions and thereby reducing HAI incidence.
5. Revising the computer physician order entry (CPOE) process to embed real-time transfusion variance notifications for clinicians at the point of order entry.
Impact Details
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The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare - Update - 2015
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Commitment Update
×
University of Pittsburgh Medical Center
The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare – Update – 2015
Contact Info
Name: Mary Kay Wisniewski
Phone: (412) 802-8066
Email: wisniewskimk@upmc.edu
Position: UPMC Patient Blood Management Program Coordinator
Organization Name: University of Pittsburgh Medical Center
Commitment Details Commitment Start Date: 03/13/2014 How many hospitals are represented in this commitment?
Action Plan:
Commitment Update:
2015 PBM program outcomes are directly related to multidisciplinary collaboration and commitment.
-Reduced non-evidence based transfusions by 12% (exceeding milestone goal of 10%)
-Reduced blood product waste, 1) decreased red blood cell units wasted by 41% and 2) decreased platelet wasted units by 67%. The blood waste prevention initiative has resulted in a $183K cost avoidance.
-Reduced volume of purchased products, 1) RBC 7% decrease, 2) plasma 2.7% decrease, and 3) platelets 8.0% decreased. This reduction in purchased blood products has resulted in a $1.5M cost avoidance.
Your commitment aligns with APSS
Challenge 5 - Patient Blood Management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
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Lives Lost:
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Lives Spared Harm Target
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Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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University of Pittsburgh Medical Center |
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Preventing neonate/infant mortality by the reduction or elimination of elective deliveries greater than or equal to 37 but less than 39 weeks gestational age unless medically indicated for the health and safety of the mother or fetus.
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Commitment
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University of Pittsburgh Medical Center
Preventing neonate/infant mortality by the reduction or elimination of elective deliveries greater than or equal to 37 but less than 39 weeks gestational age unless medically indicated for the health and safety of the mother or fetus.
Contact Info
Name: Linda Harvey
Phone: (412) 802-6890
Email: harveyls@upmc.edu
Position: Director, P4P/Quality Oversight, Wolff Center at UPMC
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Blvd , 2nd floor
Pittsburgh, PA 15213 US
Participants:
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Maribeth McLaughlin,CNO and VP of Patient Care Services Magee-Womens Hospital of UPMC
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Robert Edwards,Professor and Chair of Obstetrics and Gynecology University of Pittsburgh School of Medicine
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Hy Simhan,Professor and Executive Vice Chair of Obstetrics and Gynecology University of Pittsburgh School of Medicine
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11 - Optimizing Obstetric Safety
Commitment Name:
Preventing neonate/infant mortality by the reduction or elimination of elective deliveries greater than or equal to 37 but less than 39 weeks gestational age unless medically indicated for the health and safety of the mother or fetus.
How Many Hospitals Will This Commitment Represent? 7
Action Plan
Will utilize the EHR and coding data, appropriate documentation, and event reporting information to ensure mother and baby have received safe quality care based on current recommended standards and according to
policy.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Estimate of Lives Potentially Saved
Neonate/Infant: With the focus of eliminating elective deliveries greater than or equal to 37 but less than 39 weeks, and the relative risk of mortality for neonates as high as 2.3 per 1,000 live births, we would potentially save 2 lives and avert the potential numerous adverse events and potential lifelong effects.
The American College of Obstetricians and Gynecologists (ACOG) has noted the relative risk of mortality and the mortality rate (see Commitment Background). Will first take the number of patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed over total deliveries for an overall rate of elective deliveries. Will then take the number of neonate/infant mortalities of elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation over the overall number of elective deliveries for actual mortality rate.
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University of Pittsburgh Medical Center |
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Emergency Physician Airway Management Training and Standardization of Guidelines
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Commitment
×
University of Pittsburgh Medical Center
Emergency Physician Airway Management Training and Standardization of Guidelines
Contact Info
Name: Paul Phrampus
Phone: (412) 648-6073
Email: phrampuspe@upmc.edu
Position: Medical Director, Patient Safety, Director at WISER
Organization Name: University of Pittsburgh Medical Center
Organization Address:
4601 Baum Boulevard
Pittsburgh, PA 15236 US
Participants:
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Paul Phrampus, MD,Medical Director, Patient Safety UPMC Health System, Director, Winter Institute for Simulation, Education, and Research (WISER), Vice Chair, Quality and Patient Safety, Department of Emergency Medicine
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Donald Yealy, MD,Professor and Chair of Emergency Medicine, University of Pittsburgh / University of Pittsburgh Physicians
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Richard Wadas, MD, FACEP,President and Chief Medical Officer, Emergency Resource Management, Inc., Clinical Associate Professor of Emergency Medicine, University of Pittsburgh
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
Commitment Name:
Emergency Physician Airway Management Training and Standardization of Guidelines
How Many Hospitals Will This Commitment Represent? 14
Action Plan
Refine existing curricular materials
Refine existing airway management guidelines through a consensus of evidence and best practice experts in emergency medicine at UPMC
Create web-based education modules
Create appropriate simulation-based scenarios and course design
Create instructor training faculty guidelines
Create course evaluation and feedback materials
Deploy training program to all emergency physicians across the UPMC health system
Commitment Timeline
Q1 2016 - Curriculum material refinement and course creation complete by
Q2 2016 - Begin offering training program at various simulation facilities located throughout the health system
Q4 2017 - Goal of training completed by all attending emergency physicians and completion of the project
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Estimate 2500 emergency department endotracheal intubations per year across the UPMC Health system
Estimates as high as 20% difficult airways in the emergency department setting
Up to 1% (blended rate medical and trauma) will likely require emergent cricothyrotomy = 25
Estimate 25 lives saved per year
Walls RM, Brown CA, Bair AE, and Pallin DJ: Emergency Airway Management: A Multi-center Report of 8937
Emergency Department Intubations. J Emerg Med 2011; 41: pp. 347-354
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University of Pittsburgh Medical Center |
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US |
Best Code Airway Management
View Commitment
Commitment
×
University of Pittsburgh Medical Center
Best Code Airway Management
Contact Info
Name: James Snyder
Phone: (412) 973-5522
Email: snyderjv@upmc.edu
Position: Professor Emeritus Critical Care Medicine
Organization Name: University of Pittsburgh Medical Center
Organization Address:
110 Grandview Drive
Verona, PA 15147 US
Participants:
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Steven Orebaugh, MD,Professor of Anesthesiology, UPMC
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8 - Airway Safety
Commitment Name:
Best Code Airway Management
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Publish articles to initiate interest:
1.chapter in a book (done);
2. letter to editor (draft completed);
3. communicate with leaders in the field regarding optimal course
4. develop website to present ideas and invite exchange;
5. publish concepts and practices individually or in small groups via e-books to develop a well-critiqued
summary;
6. publish more complete texts to convey the program.
7.Use performance data and critiqued texts to interest simulation development.
Commitment Timeline
1 done
2 mid-january
3 mid-January
4 end of February
5. April 2016
6. December 2016
7. Ongoing
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Every study of airway management in codes (emergent care) shows a high level of morbidity and mortality. Our airway-novice trainees report performance (97% success in emergent cases), which suggests that morbidity at our facility is already sharply reduced. Estimated # codes = 1000/year, reduction in morbidity may be 80% (pure guess), impact in house may be 100/year. Impact depends on application in other training centers, which requires development of simulators followed by dispersion of practices through graduating trainees.
Available data relates only to intubation; improved non-invasive management is likely to have a greater but less documentable impact.
Estimates are factitious, but 100,000 is probably low.
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Hospital Español |
Mexico City |
MX |
Hand Hygiene Improvement
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Commitment
×
Hospital Español
Hand Hygiene Improvement
Contact Info
Name: Raquel Martínez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 col. Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. José Donis Hernández,Head of Infectious Disease
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Dr. Luis Torres Torija,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Hand Hygiene Improvement
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Infections related to health care have a considerable economic effect on patients and on health systems. Hygiene of the hands is the most important measure to avoid infections and health care, since it has been demonstrated that the hands of the health personnel are the transmission routes of most of the cross infections and of some outbreaks epidemic.
The simple task of cleaning hands at the right times and in the right way can save lives. Although hand hygiene is a simple action, the lack of compliance among health professionals continues to be a problem worldwide.
The improvement in hand hygiene can be achieved through the application of multiple measures to address different obstacles as well as behavioral barriers, which result in non-compliance with hand washing.
Commitment Description & Detail:
The improvement in effective and sustained hand hygiene is achieved through the application of multiple measures to address different obstacles as well as behavioral barriers, which result in non-compliance with hand hygiene.
The effectiveness of the hand hygiene program involves a series of components that together allow for improvement in the process like: infraestructure, education programs, culture improvement and evaluation and feedback Action Plan:
1. Hand hygiene program and plans for monitoring and sustenance.
2. Evaluation of the infrastructure for hand hygiene (Availability of soap, paper towels and alcohol base solution), placement of sinks at the entrance of the rooms starting on the fourth and sixth floors.
3. Education training on the importance of hand hygiene to new clinical and non-clinical hospital staff.
4. Patients and family education through videos, brochures, posters and direct capacitation.
5. “Chorrito time”strategy every 2 hours as a reminder of the importance of hand hygiene to all the hospital personnel.
5. Periodic audits with results report to the areas and services of the hospital.
6. Visit of the areas by the staff of the Epidemiological Surveillance Unit to give training and feedback to the clinical staff.
7. Analysis of the results in the Infection Control Committee.
Commitment Timeline:
The timeline for improving hand hygiene rate will be from September 1, 2018 –September 1, 2019
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Hospital Español |
Mexico City |
MX |
Development of a incident reporting system for notification and analysis of adverse events associated with medical care.
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Commitment
×
Hospital Español
Development of a incident reporting system for notification and analysis of adverse events associated with medical care.
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 col Granada
México, Ciudad de México 11520 MX
Participants:
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Dr. Rafael Puppo Castro,Quality Coordinator
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Dr. Luis Torres Torija Arguelles,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Development of a incident reporting system for notification and analysis of adverse events associated with medical care.
How Many Hospitals Will This Commitment Represent? 1
Action Plan
1.- Implement a mechanism for electronic notification of adverse events to facilitate access and timeliness in notification for staff.
2.- Develop a methodology for the analysis and management of adverse events, including the analysis of patterns and trends as well as root cause analysis for sentinel events.
3.-Establish feedback mechanisms to staff about the results of the program.
4.-Develop a working group for the analysis of serious events composed of quality leaders, nurses, doctors, representatives of the ethics committee, among others.
5.-Establish a communication mechanism with senior management and hospital leaders for the analysis and management of the results of the program in their area of influence.
6.- Include in the strategic objectives of the Organization the development and implementation of a "Just Culture".
7.- Align to the operative objectives of the organization, the importance of the notification of the adverse events.
Commitment Timeline
The timeline to implement the strategies related to the culture of safety go from January 2018 - January 2019
Impact Details Lives Lost in Last Calendar Year: 2 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Número de eventos centinela/ Total de días paciente
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Hospital Español |
Mexico City |
MX |
Fall Risk Prevention in Hospitalized Patients
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Commitment
×
Hospital Español
Fall Risk Prevention in Hospitalized Patients
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejercito Nacional 613 col. Granada Delegación Miguel Hidalgo
Mexico City, Mexico City 11520 MX
Participants:
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Dr. Luis Torres Torija,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
Fall Risk Prevention in Hospitalized Patients
How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. Establish an assessment tool that allows identifying patients with a high risk of falling and adding an injury classification depending of the consequence of the fall.
2. Define a prevention program for the hospital-level categories that includes the initial evaluation, the periodic evaluations, as well as the necessary prevention measures according to the identified risk.
3. Implement the program in the organization through training strategies, dissemination, awareness, etc.
4. Involvement of nursing coordinators using Kaizen methodology to identify areas of opportunity in the process.
5. Follow up the program through a composite indicator.
Commitment Timeline
The timeline for reducing the fall rate will be from July 1, 2018 –January 1, 2019
Impact Details Lives Lost in Last Calendar Year: 3 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
El indicador de caídas es un indicador compuesto que mide la efectividad del programa de caídas a nivel institucional, este indicador esta integrado por sub- indicadores.
Sub indicadores:
1.- Criterios de Infraestructura. 20%
2.-Criterios de Proceso (valoración y revaloración). 20%
3.-Aspectos de educación al paciente y su familia. 30 %
4.-Competencias del personal involucrado.30%
Para la organización es importante contar con información que nos permita analizar los factores que intervienen en las caídas de los pacientes , sobre todo los relacionados con los factores intrínsecos que favorecen una caída, ya que es ahí donde podemos hacer intervenciones de mejora.
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Hospital Español |
Mexico City |
MX |
Person and Family Engagement
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Commitment
×
Hospital Español
Person and Family Engagement
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 col. Granada
Mexico City, Mexico City 11520 MX
Participants:
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Mtra. Juana Vargas Robles,Chief Nursing Officer
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Dr. Luis Torres Torija,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and Family Engagement
Commitment Name:
Person and Family Engagement
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
The education provided to the patient and his family helps to improve their participation in care and informed decisions. This education is planned, provided and documented by health professionals of the organization, from admission to discharge of the patient. Commitment Description & Detail:
The Hospital Español constantly seeks continuous improvement in the services it offers and with the purpose of improving the quality of life of patients , the hospital develops the Patient and Family Education Plan, in this plan the clinical and non-clinical personnel promote prevention, recovery and healthy behaviors. Action Plan:
1. Training of a multidisciplinary team involved in patient care, responsible for the management of the patient and family's education plan.
2. Evaluation of the learning barriers as well as the individual education needs of the patient, which will be provided during the hospital stay by health personnel.
3. Participation of people within the board of directors and quality and patient safety committee assuming the role of patient or family that allows greater knowledge about their respective needs.
4. Information to patients of services and procedures offered by the hospital through technological platforms such as email and the hospital website.
5. Monitoring of patient and family education programs through process and results metrics.
6. Application of satisfaction surveys electronically.
7. Strengthen education strategies and patient involvement on the main pathologies that are presented in the hospital.
Commitment Timeline:
The timeline for improving person and family engagement will be from October 8, 2018 – October 8, 2019
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Hospital Español |
Mexico City |
MX |
Improving Hand-off Communications
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Commitment
×
Hospital Español
Improving Hand-off Communications
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 col. Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. Luis Torres Torija Arguelles,Quality Coordinator
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Dr. Rafael Puppo Castro,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
Improving Hand-off Communications
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
It has been observed that a large part of adverse events in hospitals were derived due to erroneous delivery or lack of information regarding patient care.
The interruption of the communication was the main cause of the sentinel events reported to the Joint Commission, presenting 65% as the first cause of a sentinel event.
Commitment Description & Detail:
The efficient and timely communication of the patient's status within a hospital is fundamental, since the accuracy of the patient's information allows a reduction in the risks associated with medical care.
Ensure the transfer of complete and standardized information of the patient's condition, allows the continuity of their care and avoids the omission of vital activities for their treatment. Action Plan:
1.- Adopt and adapt the tool of the 5P's, in the Hospital Español we have two structured mechanisms of the 5P´s, one for the medical staff and the other for the nursing personnel.
2.- Develop competency in 5P´s through practice and simulation during the induction course of the clinical staff to the organization and in the course of quality and patient safety aimed to doctors in training.
3.- Use of the tool 5P´s for the transfer of patient information during transitions in time (change of guard and shift links) and when place transitions occur as is the case of the patient's change to another area or service.
4.- Training will be provided on a regular basis to the clinical staff.
5.- Use ok Kaizen methodology to identify areas of opportunity in the communication process between different hospital services.
6.- Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented.
Commitment Timeline:
The timeline for improving hand-off communications will be from July 1, 2018 – June 1, 2019
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Hospital Español |
Mexico City |
MX |
Prevention of Ventilator Associated Pneumonia
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Commitment
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Hospital Español
Prevention of Ventilator Associated Pneumonia
Contact Info
Name: Raquel Martínez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 col. Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. Ricardo Martinez Zubieta,Director of Intensive Care Unit
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Dr. Luis Torres Torija,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-Associated Pneumonia (VAP)
Commitment Name:
Prevention of Ventilator Associated Pneumonia
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Ventilator associated pneumonia (VAP) is the most common nosocomial infection in patients receiving mechanical ventilation, and it accounts for about half of all antibiotics given in the intensive care unit (ICU).VAP is associated with increased intensive care unit stay, patient ventilator days, and mortality. Commitment Description & Detail:
To prevent the risk of VPA the hospital involved all healthcare workers and included a multidisciplinary task force, educational sessions, technical improvements, and use of several evidence-based strategies intended to minimize the VPA. Action Plan:
1. Evidence-based bundles for the prevention of ventilator-associated pneumonia .
2. Daily assessment of interruption or decreased sedation.
3. Continuous training for physicians on the intubation procedure.
4. Taking and monitoring tracheal aspirate cultures in patients with suspected infection.
5. Conduct spontaneous breathing trails and evaluation of extubation as soon as possible.
6. Continuous control of tracheal cuff pressure and subglottic secretion suctioning protocol.
7. Reinforcement of follow-up protocol regarding subglottic secretion suctioning.
8. Prophylaxis of peptic ulcer disease.
9. Education plan for doctors and nurses pertaining to the prevention of VAP.
10. Analysis of the results of the audits in the Infection Detection and Control Committee.
Commitment Timeline:
The timeline for reducing the ventilator associated pneumonia will be from September 25, 2018 – September 25, 2019
Impact Details
Lives Saved
Lives Saved predicted:
0.23039999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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Hospital Español |
Mexico City |
MX |
Prevention of Venous Thromboembolism in Hospitalized Patients
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Commitment
×
Hospital Español
Prevention of Venous Thromboembolism in Hospitalized Patients
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av. Ejercito Nacional 613 Col Granada Ciudad de México
Ciudad de México, México 11530 MX
Participants:
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Dr. Ricardo Martínez Zubieta,Director of Intensive Care Unit
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Dr. Luis Torres Torija,Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous Thromboembolism (VTE)
Commitment Name:
Prevention of Venous Thromboembolism in Hospitalized Patients
Commitment Start Date 07/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. Define institutional guide that includes risk assessment mechanism for all hospitalized patients and the evaluation of the implemented measures thromboprophylaxis according to the best evidence and the mechanism of communication with the physician responsible for the patient.
1.1 All Spanish Hospital hospitalized adult patients will be evaluated to identify the risk of thrombosis during hospitalization and within 72 hours of hospitalization.
1.2 When detecting a patient at high risk of venous thromboembolic disease that does not have the necessary prophylactic measures, communication with the treating physician will be set to notify the risk and inform the relevant recommendations.
Commitment Timeline
July 2016 Definition of an institutional guide with the participation of a multidisciplinary team.
August-October 2016 Implementation of a risk assessment scale; training personnel involved, piloting the instrument.
November 2016 to February 2017 Measurement of attachment to the guide
March 2017 Analysis of information for improvement
April 2017 Implementation of relevant changes
May to December 2017 Evaluation of results with patients
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Patients benefit from this commitment is calculated according to the number of discharges in a year.
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PREVENTION OF VENOUS THROMBOEMBOLISM IN HOSPITALIZED PATIENTS – Update – 01.31.18
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Commitment Update
×
Hospital Español
PREVENTION OF VENOUS THROMBOEMBOLISM IN HOSPITALIZED PATIENTS – Update – 01.31.18
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Director of Quality
Organization Name: Hospital Español
Commitment Details Commitment Start Date: 07/01/2016 How many hospitals are represented in this commitment?
Action Plan:
1. Define institutional guide that includes risk assessment mechanism for all hospitalized patients and the evaluation of the implemented measures thromboprophylaxis according to the best evidence and the mechanism of communication with the physician responsible for the patient.
1.1 All Spanish Hospital hospitalized adult patients will be evaluated to identify the risk of thrombosis during hospitalization and within 48 hours of hospitalization.
1.2 When detecting a patient at high risk of venous thromboembolic disease that does not have the necessary prophylactic measures, communication with the treating physician will be set to notify the risk and inform the relevant recommendations.
Commitment Update:
The Hospital Español has developed in the year 2017 the institutional guide for the evaluation of the risk of venous thromboembolism (ETV) in hospitalized adult patients, the critical points of the process were measured as:
a. initial evaluation
b. reevaluation on the second day of internment (48 hours)
c. communication with the treating doctor
d. pharmacological intervention if there´s no contraindication in patients detected with high risk.
A multidisciplinary committee is created where the results of the process are evaluated. The action plan for the year 2018 is to review with the committee of experts the results of the metrics related to ETV and to establish different strategies like the improvement of the education program to the patient and his family.
Your commitment aligns with APSS
Challenge 12 - Embolic Events Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
The Hospital Español as a good practice incorporates the reevaluation of the risk of thrombosis within 48 hours of hospitalization , as a challenge the adoption of a valid scale was identified to assess the risk according to our patient population..
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
6 |
Lives Lost
0 |
Lives Lost:
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Lives Spared Harm Target
42 |
Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
10000 |
Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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Secretaría de Salud |
Hidalgo |
MX |
Planificación de atención colaborativa
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Commitment
×
Secretaría de Salud
Planificación de atención colaborativa
Contact Info
Name: FRANCISCO GODINEZ RIOS
Phone: 5566133673
Email: fgodinezg92@gmail.com
Position: Epidemiologia
Organization Name: Secretaría de Salud
Organization Address:
Carretera Mexico Pachuca Km 62.5
Tolcayuca, Hidalgo 43870 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13 - Mental Health
Commitment Name:
Planificación de atención colaborativa
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Identificación y análisis de causas ( Identificar el porque).
Medición de indicadores (Cuando un indicador se ha medido en varias ocasiones, es posible identificar patrones y tendencias ).
Formar grupos de trabajo interno formado por personal multidisciplinario que coadyuven a la calidad ( identificar condiciones inseguras y defensa del paciente).
Documentar con experiencias exitosas el trabajo con el modelo colaborativo para la atención de la salud mental con el fin de tratar la depresión y la ansiedad (Establecer un vínculo entre el psiquiatra y primer nivel de atención, así como mejorar la comunicación con el paciente y sus familiares).
Fortalecimiento de liderazgo entre la Junta Directiva para desarrollar una cultura de seguridad.
Commitment Timeline
Enero
Dar a conocer en COCASEP la APP Soluciones accionables de seguridad del paciente (APSS).
Febrero
Difusión al personal operativo de la APP Soluciones accionables de seguridad del paciente (APSS).
Marzo
Documentación de experiencias exitosas sobre el modelo colaborativo para la atención de la salud mental con el fin de tratar la depresión y la ansiedad.
Abril
Medición de indicadores ya establecidos y proponer nuevos indicadores que apliquen en la Unidad Medica.
Mayo
Integración de grupos de trabajo en todos los turnos
Junio
Capacitación y talleres sobre liderazgo dirigido a Jefes de servicio.
Impact Details Lives Lost in Last Calendar Year: 117 How many lives do you expect to spare from harm in the next calendar year 35 How many lives do you expect to save in the next calendar year 70 Methodology for Determining Lives Saved:
Porcentaje 30%
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Secretaría de Salud |
Hidalgo |
MX |
The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform.
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Commitment
×
Secretaría de Salud
The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform.
Contact Info
Name: José María Busto Villarreal
Phone: +5217717121422
Email: jose.busto@ssh.gob.mx
Position: Head of the Second Level of Healthcare Attention
Organization Name: Secretaría de Salud
Organization Address:
Blvd. Nuevo Hidalgo No. 102, Col. El Venado
Mineral de la Reforma, Hidalgo 42083 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform.
Commitment Start Date 01/10/2018 How Many Hospitals Will This Commitment Represent? 16
Action Plan
Patient safety is defined as the reduction of the unnecessary risk of harm related to health care to an acceptable minimum, which refers to the collective notions of current knowledge, the resources available and the context in which the attention was provided. The Mexican Federal Government, supporting patient safety initiatives promoted by the World Health Organization since 2007, has recognized patient safety as a fundamental component of the improvement of quality in health services, established in the National Development Plan 2013-2018 and in the Sectoral Health Program of the same period.
For this reason, in the different hospitals of the state, considering the different levels of complexity of each one, several elements oriented to patient safety are put into practice, in such a way that the users of the health system are increasing their knowledge about this topic and ask for better conditions to improve quality in the processes implemented from the perspective of patient safety.
The Knowledge Management Process (GC) covers the entire way of generating, storing, distributing and using knowledge. This process involves the treatment of large volumes of data generated in the various health information systems, making it necessary to use information technologies to achieve efficiency in their analysis and application. With the aim of promoting growth, development, communication and the preservation of knowledge within hospitals as organizations, the GC enables health professionals to achieve quick and assertive responses related to the decisions they need to make in the field of healthcare, based on the leadership that is generated in the Patient Quality and Safety Committee (COCASEP).
The aim is to disseminate and share the tacit and explicit knowledge with the members of the hospital teams and with other health professionals. In this way, each hospital has greater capacity to decide on the actions that should be generated from their own data, focusing on the need to understand each other as organizations that work with knowledge to develop new products, new processes and new ways or more flexible organizational arrangements for greater safety and quality of care.
As part of the strengthening of technological tools to impact on better patient safety conditions, the Automated Health Incident Registry System (SIRAIS) is created, whose objective is to contribute to the progress of the patient safety culture, privileging the report of clinical processes and procedures, medication and falls, establishing improvement measures, strengthening skills in worker’s performance and promoting the culture of registration.
The main objective of this commitment is not only the implementation and consolidation of the reporting culture using the SIRAIS platform as a tool, but also the use of technology as a way of continuous improvements.
STEPS TO FOLLOW
a) Promote: Train the management staff of each Hospital about the SIRAIS Platform (website navigation, benefits and use). Train the personnel that will carry out the capture in the electronic platform (password and user) for each hospital unit. Train the multidisciplinary team that has direct and indirect contact with the user (patient) who participates in the care processes. Carry out a diffusion campaign of simultaneous way on "Culture of Safety" in the different hospitals.
b) Explore in the SIRAIS platform the adverse events reported for the intelligent recovery of relevant data in patient safety. There are no institutional policies to organize and manage the created knowledge. So then, the analysis is not conducted and put into bibliographic or databases; so, the first thing is to identify this information.
i. Identify the causes associated with adverse events reported in the SIRAIS platform.
c) Define priority lines in patient safety (According to SIRAIS platform classification).
i. Medication
ii. Documents of the medical records
iii. Infection associated with medical care
iv. Blood products
v. Medical devices and equipment
vi. Surgical or medical procedures
vii. Falls
viii. Pathologies / Clinical laboratory / Imaging
ix. Others
d) Define key performance indicators in patient safety and measure them. As part of this prioritization process we must explore the intervention alternatives, since it does not make sense to address a problem if no solution is available. Therefore, in addition to the importance of the problem, we must consider the effectiveness of the intervention (demonstrated ability to produce the desired effect) and the feasibility of the intervention (legal, ethical, political, economic, sociocultural and organizational), considering the population to which it is addressed and the level of prevention it affects.
i. Essential Actions for patient safety
ii. Clinical Practice Guidelines and Algorithms
iii. Guidelines and Nursing Care Plans.
iv. Methodology of the use of the SIRAIS platform for the control of risk.
v. Identification of threats and the vulnerability of risks and their prioritization.
vi. Implementation of systems for the prevention, reduction and control of adverse events related to medical care.
e) Develop a control panel to follow up on reported adverse events: There are no permanent programs related to the development of scientific information search and retrieval skills; critical analysis of the bibliography and better management of the scientific evidence. Perform analysis of the events reported by any hospital unit and follow up on clinical sessions where the event was presented (unified format).
i. Information management
ii. Information life cycle
iii. Information systems, management and consultation
iv. Search protocol
v. Analysis and critical reading of literature
vi. Safeguarding information
vii. Document management
f) Review, redesign and organize documents, manuals, protocols and routines related to activities associated with patient safety (related to adverse events) through a multidisciplinary committee on patient safety and root cause analysis. Semi-annual evaluation of the predominant adverse events (in all the state).
g) Development of Knowledge Management (GC) systems in healthcare equally focused on promoting honesty and cooperation in the reporting and mitigation of adverse events in patients; also promote that personnel recognize risk in conditions and practices.
i. Evaluate the Knowledge Management (GC) system from the comparison with other organizations.
h) Share knowledge, through practice communities and manuals and use them into practice through practice based on evidence.
i) Follow up the SIRAIS platform and use it as a tool to generate statistics for carrying out improvement projects in the different processes of each hospital unit.
Commitment Timeline
We divide the process into: look at the approach, implantation, measurement and continuous improvement.
We aim to look at the approach during January (step A, B and E), February (step C and D) and march (step E), on this transition we will start with the implantation through step F during March to June and step G through June to August, with a implantation check on December with step F.
Having a measurement stage from March to October by the step D and a measurement of step C from November to December.
We endeavor to have a continuous improvement stage from august to December, focusing on steps H and I.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
For the first stage, unfortunately there is no information available to have a baseline and to project the impact of the commitment; for the next year there will be information to recognize the impact and to compare information
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Secretaría de Salud |
Hidalgo |
MX |
Avoiding maternal morbi-mortality.
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Commitment
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Secretaría de Salud
Avoiding maternal morbi-mortality.
Contact Info
Name: José María Busto Villarreal
Phone: +5217717121422
Email: jose.busto@ssh.gob.mx
Position: Head of Second Level of Healthcare Attention
Organization Name: Secretaría de Salud
Organization Address:
Blvd. Nuevo Hidalgo No. 102, Col. El Venado
Mineral de la Reforma, Hidalgo 42083 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11 - Optimizing Obstetric Safety
Commitment Name:
Avoiding maternal morbi-mortality.
Commitment Start Date 01/10/2018 How Many Hospitals Will This Commitment Represent? 15
Action Plan
Maternal mortality is one of the most sensitive indicators for a nation's development, it shows inequity, lack of access and poor quality of obstetric care. In Mexico, this problem persists and constitutes a challenge for the Public Health System.
The general trend of the country is towards the reduction of maternal mortality, in 1990 there was a death rate (deaths per 100,000 inhabitants) of 89, for 2014 there was a ratio of 38.0, it is required to reach a maternal death ratio lower than 30.0 by 2018, in compliance with the Sustainable Development Goals (ODS).
The main objective is to avoid the severe maternal morbility.
Objectives to follow to reach the goal:
1. Promotion of the Pre-Gestational Consultation.
2. Efficient pregnancy, delivery and puerperium care, with a risk approach.
3. Systematization of triage, mater code and immediate obstetric reaction equipment.
4. To make efficient the promotion of family planning methods in women of childbearing age with risk factors and to make efficient Post-Event Contraception.
5. Efficient Reference System - Counter-reference.
6. Continuous medical update based on clinical practice guidelines.
Strategies:
1. Implement Preconceptional and multidisciplinary Consultation.
2. Supervise prenatal care compliance to pregnant women with an opportunity for prenatal observation in the first, second and third trimesters.
3. Supervise the attention of Triage, Mater Code and Immediate Obstetric Reaction, evaluation according to the stablished indicators.
4. Notify to the first level of care (health centers) of patients who are not attending their prenatal checkup.
5. Supervise the implementation of the use of reactive strip (labstix) to all patients in consultation.
6. Send evidence of obstetric emergency drills in different shifts (at least 2 per month). (Video-tapes, analysis and feedback) to the Second Level of care.
7. Supervise the active management of the third period of labor.
8. Supervise the immediate puerperium surveillance according to the Official Mexican Standard NOM-SSA2-007-2016.
9. Train on the different methods of quantification of bleeding due to hemorrhage; recognition and treatment of shock grades.
10. Supervise the obstetric boxes pink (hemorrhage) and red (hypertensive diseases).
11. Identify the available human resources for each shift: Gynecologist or Surgeon with experience in staggered desarterialization, hypogastric ligation and compression techniques.
12. Supervise the delivery of obstetric patients into the Toco-surgical unit, recovery and intensive adult care, especially those with severe morbidity.
13. Hold meetings for the local Maternal Death Committee to discuss real cases of emergency and obstetric death.
14. Apply the available supervision cards which are according to Clinical Practice Guidelines.
15. Send documentary evidence of continuous training to the pregnant women to reinforce the safety plan.
16. Evaluate the user satisfaction through Health Quality Indicators (INDICAS).
Evaluation and control method
• Analysis of applied supervision card which focuses on the quality of obstetric care according to the Clinical Practice Guideline (GPC) "Prenatal care with patient-centered care", "Prevention, diagnosis and treatment of preeclampsia in the second and third levels of care", "Diagnosis and treatment of obstetric hemorrhage in the second half of pregnancy and immediate puerperium"
• Creation and implementation of the check in Card for the abatement of C- sections
• Minutes of the Hospital Committee for the Prevention, Study and Monitoring of Morbidity and Maternal and Perinatal Mortality, with analysis of severe morbidity.
• Documents to support obstetric emergency drills.
• Census (name, age, address, telephone, diagnosis, and important background) of high-risk pregnant women based on the risk assessment table of prenatal care that had been identified in emergencies and consultation areas. This census will be daily reported inside the hospital areas through a technology tool which allow the areas connectivity.
• Analysis of triage, Mater Code and immediate obstetric reaction.
• Evaluation of clinical competences and techniques of health personnel during mater codes.
• Application of satisfaction surveys to patients and relatives.
• Implementation of satisfaction surveys of the work environment on the staff.
Commitment Timeline
As this challenge must be continuously reviewed, the distribution of activities will be as follow:
During the first months (January and February):
1. Implement Preconceptional and multidisciplinary Consultation.
9. Train on the different methods of quantification of bleeding due to hemorrhage; recognition and treatment of shock grades.
11. Identify the available human resources for each shift: Gynecologist or Surgeon with experience in staggered desarterialization, hypogastric ligation and compression techniques.
However to have a correct follow up:
Weekly activities:
4. Notify to the first level of care (health centers) of patients who are not attending their prenatal checkup.
Monthly activities:
2. Supervise prenatal care compliance to pregnant women with an opportunity for prenatal observation in the first, second and third trimesters.
3. Supervise the attention of Triage, Mater Code and Immediate Obstetric Reaction, evaluation according to the stablished indicators.
5. Supervise the implementation of the use of reactive strip (labstix) to all patients in consultation.
6. Send evidence of obstetric emergency drills in different shifts (at least 2 per month). (Video-tapes, analysis and feedback) to the Second Level of care.
7. Supervise the active management of the third period of labor.
8. Supervise the immediate puerperium surveillance according to the Official Mexican Standard NOM-SSA2-007-2016.
10. Supervise the obstetric boxes pink (hemorrhage) and red (hypertensive diseases).
12. Supervise the delivery of obstetric patients into the Toco-surgical unit, recovery and intensive adult care, especially those with severe morbidity.
13. Hold meetings for the local Maternal Death Committee to discuss real cases of emergency and obstetric death.
14. Apply the available supervision cards which are according to Clinical Practice Guidelines.
15. Send documentary evidence of continuous training to the pregnant women to reinforce the safety plan.
16. Evaluate the user satisfaction through Health Quality Indicators (INDICAS).
Impact Details Lives Lost in Last Calendar Year: 19 How many lives do you expect to spare from harm in the next calendar year 2072 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Since this is a morbidity measure, the lives saved calculation is not applicable.
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Secretaría de Salud |
Hidalgo |
MX |
Reducción de Infecciones Asociadas a Falta de Lavado de Manos
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Commitment
×
Secretaría de Salud
Reducción de Infecciones Asociadas a Falta de Lavado de Manos
Contact Info
Name: Victor Manuel Vargas Aguilar
Phone: 2464643409
Email: hospitaldelamujertlaxcalteca@hotmail.com
Position: Direccion
Organization Name: Secretaría de Salud
Organization Address:
20 de Noviembre, San Matias Tepetomatitlan, Apetatitlan de Antonio Carvajal
Tlaxcala , Tlaxcala 90606 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Reducción de Infecciones Asociadas a Falta de Lavado de Manos
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Capacitación al personal relacionado en atención a la salud para el adecuado lavado de manos
Supervisión del cumplimiento mediante estudios de sombra
Commitment Timeline
Cursos de capacitación durante el primer semestre del 2018
Supervisar las acciones mediante estudios de sombra el segundo semestre del año
Determinar el impacto en la reducción de mortalidad e infecciones asociadas al inadecuado lavado de manos
Impact Details Lives Lost in Last Calendar Year: 8 How many lives do you expect to spare from harm in the next calendar year 2 How many lives do you expect to save in the next calendar year 2 Methodology for Determining Lives Saved:
Estimación por numero de casos detectados
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Secretaría de Salud |
Hidalgo |
MX |
CIRUGIA SEGURA
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Commitment
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Secretaría de Salud
CIRUGIA SEGURA
Contact Info
Name: NOE RODRIGUEZ FIGUEROA
Phone: 3171074205
Email: calidad.regionautlan@gmail.com
Position: Director del Hospital Comunitario El Grullo
Organization Name: Secretaría de Salud
Organization Address:
Avenida Hidalgo No. 540.
El Grullo, Jalisco 48740 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
CIRUGIA SEGURA
Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
APLICACIÓN DEL LISTA DE COTEJO A TODO PACIENTE QUE SE SOMETA A UN PROCEDIMIENTO QUIRÚRGICO EN EL HOSPITAL DE PRIMER CONTACTO EL GRULLO. SE REALIZARA REVISIÓN MENSUAL DE LOS EXPEDIENTES VERIFICANDO QUE CONTENGA EL LISTADO DE CIRUGÍA SEGURA DEBIDAMENTE REQUISITADO EN TIEMPO Y FORMA.
Commitment Timeline
LA PRIMER SEMANA DE CADA MES SE REALIZARA REVISIÓN DE LOS EXPEDIENTES DE PACIENTES SOMETIDOS A PROCEDIMIENTOS QUIRÚRGICOS Y SE ELABORARA UN REPORTE QUE PERMITIRÁ MEDIR EL INDICADOR Y SUS RESULTADOS.
Impact Details Lives Lost in Last Calendar Year: 2 How many lives do you expect to spare from harm in the next calendar year 10 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
NUMERO DE EVENTOS QUIRÚRGICOS REALIZADOS/NUMERO DE LISTAS DE COTEJO APLICADAS X 100
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Secretaría de Salud |
Hidalgo |
MX |
Hospital-acquired Pneumonia Prevention Initiative (HAPPI): Prevention of non-ventilator Pneumonia
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Commitment
×
Secretaría de Salud
Hospital-acquired Pneumonia Prevention Initiative (HAPPI): Prevention of non-ventilator Pneumonia
Contact Info
Name: RAUL LOPEZ
Phone: 05554379041
Email: ek2balam@yahoo.com.mx
Position: RESPONSABLE ESTATAL DE CALIDAD
Organization Name: Secretaría de Salud
Organization Address:
ALTADENA 23
CIUDAD DE MÉXICO, CIUDAD DE MÉXICO 03810 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-Associated Pneumonia (VAP)
Commitment Name:
Hospital-acquired Pneumonia Prevention Initiative (HAPPI): Prevention of non-ventilator Pneumonia
Commitment Start Date 01/02/2017 How Many Hospitals Will This Commitment Represent? 4
Action Plan
Action Plan:
1. Establish a research protocol to study incident of ventilator related hospital-acquired pneumonia.
2. Establish a multidisciplinary team.
3. Reduce ventilator related hospital-acquired pneumonia by 35% in the hospital
4. Standardize preventive care processes for ventilator-associated pneumonia
5. Application of ventilator care bundle:
• Hand washing
• Assessment of interruption of daily sedation in intubated patients.
• Semifowler position: head-of-bed elevation between 30 to 45 degrees.
• Intubation of patient by competent personnel.
6. Continue dissemination and a call to action for all health care professional to measure and monitor related hospital-acquired pneumonia.
Commitment Timeline
JANUARY: training all personal.
FEBRUARY: Strategy implementation.
MARCH: Standardize preventive care processes for ventilator-associated pneumonia
APRIL to NOVEMBER: monitoring and evaluation of the results
DECEMBER: Study findings.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
1. Documentation of nursing practices and doctors performed for all ventilator related hospital-acquired pneumonia.
2. Tracking the number of ventilator related hospital-acquired pneumonia cases by month and determining the breakthrough causality.
3. Computation of the percent of hand washing: (Number of washing hands properly / performed Opportunity Handwashing X 100).
4. Computation of the percent of Daily interruption of sedation: (Number of patients with ventilator, with daily documentation of the consideration of interruption of sedation and early assessment / Number of patients with ventilator weaning).
5. Computation of the percent of Position intubated patient semifowler: Number of patients with head in semifowler / Number of patients with ventilator.
6. Computation of the percent of ventilator related hospital-acquired pneumonia cases (total discharges during same period) and odds ratios of ventilator related hospital-acquired pneumonia during the intervention period using the baseline NV-HAP incidence
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Secretaría de Salud |
Hidalgo |
MX |
El Médico en tu Casa: Home health care in vulnerable population
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Commitment
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Secretaría de Salud
El Médico en tu Casa: Home health care in vulnerable population
Contact Info
Name: César Alexis Solís Romero
Phone: 50381700 ext 1060
Email: medicoentucasadf@gmail.com
Position: Medical Director of Heath Care
Organization Name: Secretaría de Salud
Organization Address:
Altadena 23 Street, Napoles Colony, C.P. 03810, Delegation Benito Juárez. Mexico City
México, Distrito Federal 03810 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
El Médico en tu Casa: Home health care in vulnerable population
Action Plan
From the first attention level, physicians, nurses, clinic psychologist, nutritionists, physical therapist, social workers and health promoters, visits patient’s homes looking for bring attention to the most vulnerable people off our city.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Primary Care in heath method and Local Health systems
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Changhua Christian Hospital |
Changhua |
TW |
Failure to detect critical congenital heart disease (CCHD)
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Commitment
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Changhua Christian Hospital
Failure to detect critical congenital heart disease (CCHD)
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
135 Nanxiao St.,
Changhua, Changhua 500 TW
Participants:
-
Rei-Cheng Yang,superintendent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7B - Failure to Detect Critical Congenital Heart Disease (CCHD) in Newborns
Commitment Name:
Failure to detect critical congenital heart disease (CCHD)
Commitment Start Date 10/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
● Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices,including awareness, accountability, and action.
● Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system.
● Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap
● Set a goal date to implement the plan to address the gap with measurable quality indicators.
● Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders.
● Clinical/safety leadership endorse the plan and drive implementation across all providers and systems.
● Conduct data collection and analysis to be used for implementation and assessment of outcomes
Commitment Timeline
Failure to detect critical congenital heart disease (CCHD): Oct. 1st, 2017 ~ Sept. 30th, 2018
Impact Details Lives Lost in Last Calendar Year: 48 How many lives do you expect to spare from harm in the next calendar year 4 How many lives do you expect to save in the next calendar year 4 Methodology for Determining Lives Saved:
Based on Actionable Patient Safety Solution (APSS) for #7B: FAILURE TO DETECT CRITICAL CONGENITAL HEART DISEASE (CCHD) IN NEWBORNS
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Failure to detect critical congenital heart disease (CCHD) - Update - 09.02.18
View Update
Commitment Update
×
Changhua Christian Hospital
Failure to detect critical congenital heart disease (CCHD) – Update – 09.02.18
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment Details Commitment Start Date: 10/01/2017 How many hospitals are represented in this commitment?
Action Plan:
● Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices,including awareness, accountability, and action.
● Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system.
● Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap
● Set a goal date to implement the plan to address the gap with measurable quality indicators.
● Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders.
● Clinical/safety leadership endorse the plan and drive implementation across all providers and systems.
● Conduct data collection and analysis to be used for implementation and assessment of outcomes
Commitment Update:
In the “Failure to Detect CCHD” program, we have established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents. In addition, education and training for physicians and nursing staff in the baby room have been established. Everyone is familiar with this screening activity. Hence this screening has already started in mid-August.
Your commitment aligns with APSS
Challenge 7B - Failure to Detect Critical Congenital Heart Disease (CCHD) in Newborns Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) for #7B:FAILURE TO DETECT CRITICAL CONGENITAL HEART DISEASE (CCHD) IN NEWBORNS. The valuable lessons is established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
48 |
Lives Lost
48 |
Lives Lost:
45 |
Lives Spared Harm Target
4 |
Actual Lives Spared Harm in last 12 months
3 |
Lives Spared Harm Target for following calendar year
4 |
Lives Saved Target
4 |
Actual Lives Saved in last 12 months (might differ from initial target)
3 |
Projected Target of Lives Saved for following calendar to try to finish commitment
4 |
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New Lives Lost (lives lost – actual lives saved)
45 |
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Changhua Christian Hospital |
Changhua |
TW |
Airway Safety
View Commitment
Commitment
×
Changhua Christian Hospital
Airway Safety
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
135 Nanxiao St.,
Changhua, Changhua 500 TW
Participants:
-
Maw-Soan Soon,vice superintendent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
Commitment Name:
Airway Safety
Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Improve Airway Safety
(1)Difficult Intubation Assessment; This will be assessed according to criteria related to throat, neck trauma, infection, surgery, obesity, or assessing history of difficult intubation.
(2)OSCE Training Program and Outcome, also known as Rapid Sequence intubation training and emergency cricothyrotomy
(3)Mobile Intubation Car with all Requirements for Difficult
(4)Intubation and Resuscitation Services; Anesthesia physicians will support difficult intubation and ENTs, thoracic surgery physicians will support emergency cricothyrotomy.
Commitment Timeline
Improve Airway Safety- July 1st, 2017 ~ June 30th, 2018
Impact Details Lives Lost in Last Calendar Year: 2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Airway Safety - Update - 09.02.18
View Update
Commitment Update
×
Changhua Christian Hospital
Airway Safety – Update – 09.02.18
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment Details Commitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Improve Airway Safety
(1)Difficult Intubation Assessment; This will be assessed according to criteria related to throat, neck trauma, infection, surgery, obesity, or assessing history of difficult intubation.
(2)OSCE Training Program and Outcome, also known as Rapid Sequence intubation training and emergency cricothyrotomy
(3)Mobile Intubation Car with all Requirements for Difficult
(4)Intubation and Resuscitation Services; Anesthesia physicians will support difficult intubation and ENTs, thoracic surgery physicians will support emergency cricothyrotomy.
Commitment Update:
We organize OSCE committee to implement training program and audit operation process. Physician, intern and registered nurse include training program are above 90% certified rate. The successful rate of cricothyrotomy within 2 times improve from 79% to 87%.
Following airway safety guideline, keep patient more safety and efficiency.
Your commitment aligns with APSS
Challenge 8A - Safer Airway Management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) #8A:SAFER AIRWAY MANAGEMENT. The valuable lessons is we organize OSCE committee to implement training program and audit operation process.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2319 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
81 |
Lives Spared Harm Target for following calendar year
90 |
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
81 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2319 |
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Changhua Christian Hospital |
Changhua |
TW |
Healthcare-associated Infections (HAIs)
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Commitment
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Changhua Christian Hospital
Healthcare-associated Infections (HAIs)
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
135 Nanxiao St.,
Changhua, Changhua 500 TW
Participants:
-
Maw-Soan Soon,Vice superintendent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2 - Healthcare-associated Infections (HAIs)
Commitment Name:
Healthcare-associated Infections (HAIs)
Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Reduce Healthcare-associated Infections (HAIs):
(1) Health care–associated infection risks, rates, and trends are tracked quarterly by the infection committee.
(2)Processes are redesigned based on risk, rate, and trend data and information.
(3)Assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program.
Commitment Timeline
Reduce Healthcare-associated Infections (HAIs)- July 1st, 2017 ~ June 30th, 2018
Impact Details Lives Lost in Last Calendar Year: 2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Healthcare-associated Infections (HAIs) - Update - 09.02.18
View Update
Commitment Update
×
Changhua Christian Hospital
Healthcare-associated Infections (HAIs) – Update – 09.02.18
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment Details Commitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Reduce Healthcare-associated Infections (HAIs):
(1) Health care–associated infection risks, rates, and trends are tracked quarterly by the infection committee.
(2)Processes are redesigned based on risk, rate, and trend data and information.
(3)Assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program.
Commitment Update:
As urinary tract infection (UTI), we refer evidence to alter Foley size from 16 Fr. To 14Fr. for general drain urine condition to mitigate harm for urine tract. We also introduce bladder scan to detect urine volume in bladder and help physician to assess whether or not remove Foley. The UTI rate improves from 0.72% to 0.48%
Your commitment aligns with APSS
Challenge 2 - Healthcare-associated Infections (HAIs) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Sunnybrook Health Sciences Centre, Medical Directive for Early Removal of Urinary Catheter’s in Medical Ward Patients. 2015. We introduce some medical device to improve UTI.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2306 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
94 |
Lives Spared Harm Target for following calendar year
95 |
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
94 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2306 |
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Changhua Christian Hospital |
Changhua |
TW |
Creating a Culture of Safety
View Commitment
Commitment
×
Changhua Christian Hospital
Creating a Culture of Safety
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
135 Nanxiao St.,
Changhua, Changhua 500 TH
Participants:
-
Maw-Soan Soon,Changhua Christian Hospital
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Creating a Culture of Safety
Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Create a Culture of Safety:
(1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations
(2)Individuals are able to report errors or near misses without fear of reprimand or punishment;
(3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
(4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.
Commitment Timeline
Create a Culture of Safety- July 1st, 2017 ~ June 30th, 2018
Impact Details Lives Lost in Last Calendar Year: 2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Creating a Culture of Safety - Update - 09.02.18
View Update
Commitment Update
×
Changhua Christian Hospital
Creating a Culture of Safety – Update – 09.02.18
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment Details Commitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Create a Culture of Safety:
(1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations
(2)Individuals are able to report errors or near misses without fear of reprimand or punishment;
(3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
(4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.
Commitment Update:
We refer evidence Patient Safety Culture Improvement Tool to implement the following activity
1.Team Work – Collaborative disciplines
2.Patient Safety Leader Education and Training
3. Patient Safety Leader Performance Evaluation
4.Workload Management
5.Fatigue Management
6.Incident Sharing and Leaning
7.Incident Disclosure
8.Safety Risk Analysis System
We conduct patient safety culture survey and improve from 67.9% to 74.1%.
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from the Actionable Patient Safety Solution (APSS) #1:CULTURE OF SAFETY. We conduct patient safety culture survey and improve from 67.9% to 74.1%.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2308 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
92 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
92 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2308 |
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Changhua Christian Hospital |
Changhua |
TW |
Hand-off Communications
View Commitment
Commitment
×
Changhua Christian Hospital
Hand-off Communications
Contact Info
Name: Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
135 Nanxiao St.,
Changhua, Changhua 500 TW
Participants:
-
Maw-Soan Soon,Vice superintedent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
Hand-off Communications
Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Promote Hand-off Communications
(1) Standardized critical content is communicated between health care practitioners during handovers of patient care.
(2) Standardized forms, tools, or methods support a consistent and complete handover process
(3) Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented.
Commitment Timeline
Promote Hand-off Communications- July 1st, 2017 ~ June 30th, 2018
Impact Details Lives Lost in Last Calendar Year: 2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000
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Sharp HealthCare |
CA |
US |
Hand Hygiene
View Commitment
Commitment
×
Sharp HealthCare
Hand Hygiene
Contact Info
Name: Patricia Atkins
Phone: 858-499-3525
Email: patricia.atkins@sharp.com
Position: VP Quality
Organization Name: Sharp HealthCare
Organization Address:
8695 Spectrum Center Blvd , Clinical Effectiveness
San Diego, CA 92123 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Hand Hygiene
Commitment Start Date:07/31/2014 How Many Hospitals Will This Commitment Represent? 7 Commitment Summary:
We use TJC Targeted Solutions Tool across the organization and have achieved >90% compliance with hand hygiene Commitment Description & Detail:
We followed TJC project framework. Action Plan:
Secret observers were trained. Barriers were identified and addressed. Physicians made their own videos. A patient engagement video "It's OKay to Ask" was made and is taught during new employee orientation. Commitment Timeline:
Annual
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Sharp HealthCare |
CA |
US |
Reducing Medication Errors
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Commitment
×
Sharp HealthCare
Reducing Medication Errors
Contact Info
Name: Patricia Atkins
Phone: 858-499-3525
Email: patty.atkins@sharp.com
Position: VP Quality
Organization Name: Sharp HealthCare
Organization Address:
8695 Spectrum Center Blvd
San Diego, CA 92123 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication Errors
Commitment Name:
Reducing Medication Errors
How Many Hospitals Will This Commitment Represent? 7
Action Plan
1) Achieve 98% compliance with Barcoding Medication Processes.
2) Sustain gains in Always Events for Patient Identification, Line Reconciliation and use of Alaris IV Pump Guardrails Compliance
3) Implement standardized medication reconciliation measurement methodology and engage pharmacists, nurses and physicians in improvement strategies where opportunities are discovered.
Commitment Timeline
2014 Launch of Always Events
2015 Launch of Medication Barcoding
2017 Launch Med Rec Measurement and PI Projects
Impact Details Lives Lost in Last Calendar Year: 7 How many lives do you expect to spare from harm in the next calendar year 50 How many lives do you expect to save in the next calendar year 5 Methodology for Determining Lives Saved:
Serious Safety Event Rate per Healthcare Performance Improvement (HPI) methodology.
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Reducing Medication Errors - Update - 07.31.18
View Update
Commitment Update
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Sharp HealthCare
Reducing Medication Errors – Update – 07.31.18
Contact Info
Name: Patricia Atkins
Phone: 858-499-3525
Email: patty.atkins@sharp.com
Position: VP Quality
Organization Name: Sharp HealthCare
Commitment Details Commitment Start Date: 07/31/2018 How many hospitals are represented in this commitment?
Action Plan:
1) Achieve 98% compliance with Barcoding Medication Processes.
2) Sustain gains in Always Events for Patient Identification, Line Reconciliation and use of Alaris IV Pump Guardrails Compliance
3) Implement standardized medication reconciliation measurement methodology and engage pharmacists, nurses and physicians in improvement strategies where opportunities are discovered.
Commitment Update:
System-wide Medication Reconciliation Project began, 2018
Your commitment aligns with APSS
Challenge 3A - Medication Errors Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Med rec on admission is well facilitated by a pharm tech in the ED.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
7 |
Lives Lost
7 |
Lives Lost:
2 |
Lives Spared Harm Target
50 |
Actual Lives Spared Harm in last 12 months
50 |
Lives Spared Harm Target for following calendar year
50 |
Lives Saved Target
5 |
Actual Lives Saved in last 12 months (might differ from initial target)
5 |
Projected Target of Lives Saved for following calendar to try to finish commitment
5 |
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New Lives Lost (lives lost – actual lives saved)
2 |
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Sharp HealthCare |
CA |
US |
Zero Suicides: Inpatient and within 72 hours of Discharge
View Commitment
Commitment
×
Sharp HealthCare
Zero Suicides: Inpatient and within 72 hours of Discharge
Contact Info
Name: Patricia Atkins
Phone: 858-499-3525
Email: patty.atkins@sharp.com
Position: VP Quality and Patient Saftey
Organization Name: Sharp HealthCare
Organization Address:
8695 Spectrum Center Blvd
San Diego, CA 92123 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13 - Mental Health
Commitment Name:
Zero Suicides: Inpatient and within 72 hours of Discharge
Action Plan
All action plans fully deployed throughout Sharp HealthCare by May, 2017
Commitment Timeline
Completed by May, 2017
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Based on the number of inpatient and suicides within 24 hours of discharge over the past four years
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Zero Suicides: Inpatient and within 72 hours of Discharge - Update - 07.31.18
View Update
Commitment Update
×
Sharp HealthCare
Zero Suicides: Inpatient and within 72 hours of Discharge – Update – 07.31.18
Contact Info
Name: Patricia Atkins
Phone: 858-499-3525
Email: patty.atkins@sharp.com
Position: VP Quality and Patient Saftey
Organization Name: Sharp HealthCare
Commitment Details Commitment Start Date: 07/31/2018 How many hospitals are represented in this commitment?
Action Plan:
All action plans fully deployed throughout Sharp HealthCare by May, 2017
Commitment Update:
Suicide screening process updated in EHR and widespread education.
Your commitment aligns with APSS
Challenge 13 - Mental Health Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Documentation by all team members is key and making the documentation easily accessible to all.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
1 |
Lives Lost
0 |
Lives Lost:
-1 |
Lives Spared Harm Target
1 |
Actual Lives Spared Harm in last 12 months
1 |
Lives Spared Harm Target for following calendar year
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Lives Saved Target
1 |
Actual Lives Saved in last 12 months (might differ from initial target)
1 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1 |
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New Lives Lost (lives lost – actual lives saved)
-1 |
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Sharp HealthCare |
CA |
US |
Culture of Safety; Eliminate wrong patient, side and site surgery and procedures
View Commitment
Commitment
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Sharp HealthCare
Culture of Safety; Eliminate wrong patient, side and site surgery and procedures
Contact Info
Name: Patricia Atkins
Phone: (858) 499-3525
Email: patty.atkins@sharp.com
Position: VP, Quality and Patient Safety
Organization Name: Sharp HealthCare
Organization Address:
8695 Spectrum Center Blvd , Clinical Effectiveness
San Diego, CA 92123 US
Participants:
-
Cheryl Dailey,Director, Patient Safety, Sharp HealthCare
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Culture of Safety; Eliminate wrong patient, side and site surgery and procedures
How Many Hospitals Will This Commitment Represent? 7
Action Plan
1. Adopt Safety as a new core value for Sharp HealthCare.
2. Formulate a committee to explore and implement high reliability principles and commit to becoming a HRO.
3. Standardize and mandate safety training from Board to Bedside.
4. Implement team training for key physicians.
5. Add specific safety section to Sharp's annual performance targets - including hand-washing, AHRQ Culture of Safety Survey scores, employee injuries, and eliminating overlap registrations - in addition to the quality measures of mortality, readmissions and complications.
Commitment Timeline
2017
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Culture of Safety; Eliminate wrong patient, side and site surgery and procedures - Update - 07.31.18
View Update
Commitment Update
×
Sharp HealthCare
Culture of Safety; Eliminate wrong patient, side and site surgery and procedures – Update – 07.31.18
Contact Info
Name: Patricia Atkins
Phone: (858) 499-3525
Email: patty.atkins@sharp.com
Position: VP, Quality and Patient Safety
Organization Name: Sharp HealthCare
Commitment Details Commitment Start Date: 07/31/2012 How many hospitals are represented in this commitment?
Action Plan:
1. Adopt Safety as a new core value for Sharp HealthCare.
2. Formulate a committee to explore and implement high reliability principles and commit to becoming a HRO.
3. Standardize and mandate safety training from Board to Bedside.
4. Implement team training for key physicians.
5. Add specific safety section to Sharp's annual performance targets - including hand-washing, AHRQ Culture of Safety Survey scores, employee injuries, and eliminating overlap registrations - in addition to the quality measures of mortality, readmissions and complications.
Commitment Update:
We conduct an annual sustainment session and are adding retained foreign object and specimen management to the safe surgery and procedural experience initiative.
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Executive commitment is key
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
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Lives Spared Harm Target
2 |
Actual Lives Spared Harm in last 12 months
2 |
Lives Spared Harm Target for following calendar year
2 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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University of Vermont Medical Center |
VT |
US |
2E-HAI-Clostridium Difficile
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Commitment
×
University of Vermont Medical Center
2E-HAI-Clostridium Difficile
Contact Info
Name: Lori Notowitz
Phone: 802-847-5619
Email: Lori.Notowitz@UVMHealth.org
Position: Director Patient Safety & Advocacy
Organization Name: University of Vermont Medical Center
Organization Address:
111 Colchester Ave.
Burlington, VT 05401 US
Participants:
-
Carolyn Terhune,Manager Infection Prevention
-
Beth Paquin,Quality Improvement Consultant
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium Difficile Infection (CDI)
Commitment Name:
2E-HAI-Clostridium Difficile
Commitment Start Date 01/31/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
• Perform analysis to compare practices/ processes used within our health care organization with suggested best practices, outlined by the Patient Safety Movement.
• Determine gaps between our practices/processes and suggested best practices, and select any suggested best practices for implementation.
• Multidisciplinary approach: involvement from Infection Prevention, Quality Improvement, Pharmacy, Infectious Disease physicians, etc.
• Evaluation of patient care equipment cleaning processes.
Commitment Timeline
By end of calendar year 2017.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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University of Vermont Medical Center |
VT |
US |
Targeting Zero: Eliminating/Reducing Central Line Associated Blood Stream Infections
View Commitment
Commitment
×
University of Vermont Medical Center
Targeting Zero: Eliminating/Reducing Central Line Associated Blood Stream Infections
Contact Info
Name: Rachael Raynes
Phone: 802-881-8762
Email: rachael.raynes@uvmhealth.org
Position: Senior Contract Specialist, Supply Chain Services
Organization Name: University of Vermont Medical Center
Organization Address:
111 Colchester Ave.
Burlington, VT 05401 US
Participants:
-
Anna Noonan,Vice President, Quality
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Targeting Zero: Eliminating/Reducing Central Line Associated Blood Stream Infections
Commitment Start Date 01/21/2016
Action Plan
Through the use of multi-disciplinary teams project managed by a performance improvement expert, UVMMC implemented the following clinical interventions and practice changes:
- Standardized the central line insertion kit. This was done at the inception of UVMMC’s focus on CLABSI reduction/elimination in 2009.
- Simulation lab training was developed and built into CME structure.
- Built an insertion checklist in our electronic medical record.
- Began to utilize ultrasound guided placement.
- Daily chlorhexidine gluconate (CHG) bathing.
- Conduct daily assessment of need for central line.
- Conduct weekly rounds.
- Began to report data to team and leadership on a monthly basis.
- Enhanced nursing education – care and maintenance bundle.
These clinical interventions and practice changes are based on guidelines set by the Centers for Disease Control and Prevention (CDC), the Joint Commission, Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control and Epidemiology and Association for Vascular Access.
Commitment Timeline
This one-year study will conclude on December 31, 2016.
Although we aim to reduce our CLABSI rates to 0.85 or less by the end of 2016, our efforts to achieve zero infections will be ongoing.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
UVMMC's baseline rate is 1.13 infections per 1000 central line days. Our goal is to reduce the rate to 0.85 infections per 1000 central line days. As of August, 2016, we are on target to meet our goal.
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University of Vermont Medical Center |
VT |
US |
Culture of Safety
View Commitment
Commitment
×
University of Vermont Medical Center
Culture of Safety
Contact Info
Name: Lori Notowitz
Phone: (802) 847-5619
Email: Lori.Notowitz@UVMHealth.org
Position: Director of Patient Safety & Advocacy
Organization Name: University of Vermont Medical Center
Organization Address:
111 Colchester Ave
Burlington, VT 05401 US
Participants:
-
Anna Noonan,Vice President, Jeffords Institute for Quality
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Culture of Safety
Action Plan
The University of Vermont employs a multi-pronged approach to improving and maintaining a highly positive safety culture. Elements of this approach include the following:
• Leadership/Governance:
o Patient safety and quality is a strategic priority for the organization and is the foundation for all we do.
o Safety culture is recognized throughout the organization as a critical element of a high performing team and advances the quality of care.
o Provide and support infrastructure focused on patient safety and quality
• Infrastructure:
o Centralized patient safety and quality programs, with content expert leadership specific to each team.
o Online electronic event reporting system available throughout the organization, with the ability to report anonymously.
• Procedures:
o Implementation of patient safety plans/policies that stress a blame free but accountable culture
o Implement a non-retaliation policy
o Regular planned and structured communication between risk management, quality, patient safety, nursing, regulatory, patient and family advocacy, and medical staff quality leadership to identify issues, complaints, and/or event reports that indicate systems and process failures, and initiate improvements.
o Use of an objective structured event review and analysis process, such as root cause analysis, to identify process and systems issues, and avoid blame and focus on individual performance issues.
o Event review/analysis facilitated by trained experts in process failure, human factor analysis, and systems design
o Ensure performance improvement plans are systems focused, with individuals assigned to each action item, and timelines for implementation
o Use data to analyze the effectiveness of the performance improvement plans at regular intervals
o Ensure analysis and improvement data is reported through structured committees up to and including the Board of Directors in the organization
o Educate hospital staff, including Residents and Medical staff on the importance of identification and reporting events and on the use of the reporting tool.
o Provide a feedback mechanism for front line reporters
o Educate management on the non-punitive nature of the event reporting and how to recognize performance issues as opposed to systems failures.
o Conduct FMEAs to proactively evaluate the risk potential in our systems and use redesign principles to optimize performance.
• Assess the Culture of Safety:
o Regularly measure the culture of safety
o Share safety culture results throughout the organization
o Focus on areas of concern to affect change in those areas
o Celebrate the positive culture throughout the organization
Commitment Timeline
Ongoing
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Unavailable at this time
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University of Vermont Medical Center |
VT |
US |
Hand-off Communication Improvement
View Commitment
Commitment
×
University of Vermont Medical Center
Hand-off Communication Improvement
Contact Info
Name: Amy Cohen
Phone: (802) 847-4777
Email: Amy.Cohen@uvmhealth.org
Position: Patient- and Family-Centered Care Program Manager
Organization Name: University of Vermont Medical Center
Organization Address:
111 Colchester Ave
Burlington, VT 05401 US
Participants:
-
Elise Everett,MD
-
Mark Levine,MD
-
Jason Minor,Director of Continuous Systems Improvement
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
Hand-off Communication Improvement
Action Plan
1. Using materials and collaboration from the I-PASS consulting/training team, all providers will be trained in the I-PASS methodology.
2. Opportunities will be provided for residents to develop competency in I-PASS through practice and simulation.
3. Additional training will be provided for some providers who will be selected to act as observers and assessors of I-PASS competency
4. Techniques for remediation will be implemented with those requiring additional practice and support.
5. Residents will be assessed to assured competency and formerly acknowledge when that competency has been met.
6. Implement mandated use of I-PASS.
Commitment Timeline
Pilot phrase completed over 6 months, will full GME implementation over the next year.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Data provided by the I-PASS Institute & American Journal of Medical Quality, p1-7, DOI:10.1177 indicates that 1.5 adverse events per 100 hospital admissions per year are prevented by I-pass implementation.
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University of Vermont Medical Center |
VT |
US |
Alignment of Supply Chain and Information Systems Contracting and Supplier Management Processes to Ensure Interoperability of Medical Devices and Clinical Software
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Commitment
×
University of Vermont Medical Center
Alignment of Supply Chain and Information Systems Contracting and Supplier Management Processes to Ensure Interoperability of Medical Devices and Clinical Software
Contact Info
Name: Charlie Miceli
Phone: (802) 847-0033
Email: charles.miceli@vtmednet.org
Position: Vice President Supply Chain and Information Systems
Organization Name: University of Vermont Medical Center
Organization Address:
111 Colchester Avenue
Burlington, VT 05401 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Alignment of Supply Chain and Information Systems Contracting and Supplier Management Processes to Ensure Interoperability of Medical Devices and Clinical Software
How Many Hospitals Will This Commitment Represent? 5
Action Plan
1. Architecture and Steering Committee questionnaire will be modified to include interrogatories regarding interoperability capabilities of the software and/or medical device being vetted in the acquisition process.
2. Standard terms and conditions of purchase will be modified to include compliance language for suppliers to clearly articulate capabilities and commitment to interoperability of their respective software with other software systems and applicable medical devices
3. Strategic supplier management processes will include discussion, commitment and governance processes to pursue interoperability between software systems and applicable medical devices
4. Request that all contracted suppliers make the pledge to the Patient Safety Movement to pursue interoperability with their respective software and/or medical devices.
5. All work done in this arena will be presented to industry colleagues, product suppliers and service providers
Commitment Timeline
Action Plan 1 December 2013
Action Plan 2 January 2014
Action Plan 3 December 2013
Action Plan 4 June 2014
Action Plan 4 Continuous
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA |
MEXICO |
MX |
CAMINANDO POR LA CULTURA DE LA SEGURIDAD EN EL PACIENTE
View Commitment
Commitment
×
H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
CAMINANDO POR LA CULTURA DE LA SEGURIDAD EN EL PACIENTE
Contact Info
Name: NANCY TERESA
Phone: 0445512465760
Email: calidadhgn2@gmail.com
Position: DIRECTORA
Organization Name: H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
Organization Address:
AV. FERROCARRIL ACAMBARO S/ N ESQUINA 1 DE MAYO. COL. SAN ANDRES ATOTO
MEXICO, MEXICO 53500 MX
Participants:
-
DR. SEVERO LEAL UTRERA,JEFE DE GINECO OBSTETRICIA
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LIC. LILIANA SALGADO MARTINEZ,COORDINADORA DE LA UVEH
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MTRA. LEONOR MARTINEZ CAMPOS,GESTORA DE CALIDAD DE ENFERMERIA
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NORMA RAQUEL GUERRERO RAMIREZ,JEFE DE ENFERMERAS
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DR. ROBERTO GONZALEZ HIDALGO,ENCARGADO DE LA SUBDIRECCIÓN MÉDICA
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MTRA. LETICIA SÁNCHEZ RAMOS,GESTOR DE CALIDAD DEL HOSPITAL
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AURORA PATRICIA CASTAÑEDA PEÑA,JEFE DE LA DIVISION DE ENSEÑANZA
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
CAMINANDO POR LA CULTURA DE LA SEGURIDAD EN EL PACIENTE
Commitment Start Date 06/22/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
DIFUSION DE LAS ACCIONES ESENCIALES DE SEGURIDAD DEL PACIENTE
DIFUSION DEL PROCESO DE REPORTE DE EVENTOS ADVERSOS
DIFUSION DEL FORMATO DE EVENTOS ADVERSOS
MEDICION DE LA CULTURA DE SEGURIDAD DEL PACIENTE
IDENTIFICACION DE PROCESOS CLAVES QUE AFECTAN LA SEGURIDAD DEL PACIENTE
Commitment Timeline
ELABORACION DE PROYECTO JUNIO
DAR A CONOCER EL PROYECTO JULIO
ESTABLECER ESTRATEGIAS AGOSTO SEPTIEMBRE DICIEMBRE
SEGUIMIENTO DE ESTRATEGIAS NOVIEMBRE DICIEMBRE ENERO
ANALISIS DE RESULTADOS FEBRERO MARZO
MEJORASABRIL MAYO
CONCLUSIONES CONCLUSIONES
Impact Details Lives Lost in Last Calendar Year: 1 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
NUMERO DE EVENTOS CENTINELA / NUMERO DE EGRESOS DE PACIENTES X 100
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H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA |
MEXICO |
MX |
PAQUETE DE MEDIDAS PARA DISMINUIRLAS INFECCIONES DEL TRACTO URINARIO ASOCIADA AL CATETER VESICAL
View Commitment
Commitment
×
H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
PAQUETE DE MEDIDAS PARA DISMINUIRLAS INFECCIONES DEL TRACTO URINARIO ASOCIADA AL CATETER VESICAL
Contact Info
Name: ROBERTO GONZALEZ HIDALGO
Phone: 0445532322826
Email: robertogh2565@gmail.com
Position: ENCARGADO DE LA SUBDIRECCION MEDICA
Organization Name: H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
Organization Address:
AVENIDA FERROCARRIL A ACAMBARO S7 ESQUINA AVENIDA 1 DE MAYO COLONIA SAN ANDRES ATOTO NAUCALPAN
MEXICO, MEXICO 53510 MX
Participants:
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NORMA RAQUEL GERRERO RAMIREZ,JEFE DE ENFERMERAS
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LEONOR MARTINEZ CAMPOS,GESTORA DE CALIDAD DE ENFERMERIA
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LILIANA SALGADO MARTINEZ,COORDINADORA DE LA UVEH
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AURORA PATRICIA CASTAÑEDA PEÑA,JEFE DE LA DIVISIÓN DE ENSEÑANZA
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LETICIA SANCHEZ RAMOS,GESTOR DE CALIDAD DEL HOSPITAL
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SEVERO LEAL UTRETA,JEFE DE LA DIVISIÓN DE GINECO
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NANCY TERESA JORDAN GONZALEZ,DIRECTOR DEL HOSPITAL
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
PAQUETE DE MEDIDAS PARA DISMINUIRLAS INFECCIONES DEL TRACTO URINARIO ASOCIADA AL CATETER VESICAL
Commitment Start Date 06/22/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
ABORDAREMOS EL DESAFIO ESTANDARIZANDO EL CUIDADO DEL PACIENTE CON SONDA VESICAL MEDIANTE LA IMPLEMENTACION USO Y LA DURACIÓN INNECESARIA UN PAQUETE DE MEDIDAS QUE PERMITA SUBSANAR LOS PUNTOS EN EL CUIDADO DEL PACIENTE DURANTE LA INSTALACIÓN, MANTENIMIENTO Y RETIRO DE LA SONDA VESICAL A GRAVES DE BUENAS PRACTICAS COMO SON:
REDUCIR EL USO Y LA DURACIÓN INNECESARIA DEL CATÉTER URINARIO
IDENTIFICAR LOS PUNTOS CRÍTICOS EN EL CUIDADO DEL PACIENTE CON SONDA VESICAL DURANTE LA INSTALACIÓN, MANTENIMIENTO Y RETIRO
REALIZAR UN PROCESO ESTANDARIZADO PARA LA INSTALACIÓN, MANTENIMIENTO Y RETIRO PARA EL PACIENTE CON SONDA VESICAL CON APOYO DE UN LISTADO DE VERIFICACIÓN DE INSTALACIÓN DE SONDA VESICAL Y HOJA DE SEGUIMIENTO LO QUE PERMITIRÁ REALIZAR UN CESO SOBRE LAS SONDAS INSTALADAS ASÍ COMO INCLUIR UN KIT DE INSTALACIÓN
DIFUNDIR EL PROCESO AL PERSONAL ADSCRITO, BECARIO Y DE NUEVO INGRESO E INCLUIRLO EN LOS MANUALES DE PROCEDIMIENTOS
DAR SEGUIMIENTO DEL CUMPLIMIENTO DEL PROCESO
MEDICIÓN DEL APEGO AL PROCESO
IMPLEMENTAN DE MEJORAS DEL PROCESO
Commitment Timeline
ELABORACION DE PROYECTO JUNIO
DAR A CONOCER EL PROYECTO JULIO
ESTABLECER ESTRATEGIAS AGOSTO, SEPTIEMBRE OCTUBRE
SEGUMIENTO DE ESTRATEGIAS NOVIEMBRE DICIEMBRE ENERO
ANALISIS DE RESULTADOS FEBRERO MARZO
MEJORAS ABRIL Y MAYO
CONCLUSIONES JUNIO 2019
Impact Details Lives Lost in Last Calendar Year: 1 How many lives do you expect to spare from harm in the next calendar year 1 How many lives do you expect to save in the next calendar year 0.023 Methodology for Determining Lives Saved:
tasa de IVU-CU=# de casos x # días de uso de sonda vesical /100
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H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA |
MEXICO |
MX |
MEJORANDO LA ATENCIÓN EN PACIENTES ´PRECLAMPTICAS
View Commitment
Commitment
×
H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
MEJORANDO LA ATENCIÓN EN PACIENTES ´PRECLAMPTICAS
Contact Info
Name: SEVERO LEAL UTRERA
Phone: 04455 50 68 24 16
Email: seveleal@yahoo.com.mx Foto del perfil de seveleal@yahoo.com.mx
Position: JEFE DE LA DIVISIÓN DE GINECO OBSTETRICIA
Organization Name: H.G. DR. MAXIMILIANO RUIZ CASTAÑEDA
Organization Address:
AVENIDA FERROCARRIL A ACAMBARO S/N AVENIDA 1 DE MAYO COLONIA SAN ANDRES ATOTO
MEXICO, MEXICO 53510 MX
Participants:
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ROBERTO GONZALEZ HIDALGO,ENCARGADO DE LA SUBDIRECCION MEDICA
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NORMA RAQUEL GUERRERO RAMIREZ,JEFE DE ENFERMERAS
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AURORA PATRICIA CASTAÑEDA PEÑA,JEFE DE LA DIVISION DE ENSEÑANZA
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LILIANA SALGADO MARTINEZ,COORDINADORA DE LA UVEH
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LEONOR MARTINEZ CAMPOS,GESTOR DE CALIDAD DE ENFERMERIA
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LETICIA SANCHEZ RAMOS,GESTOR DE CALIDAD DEL HOSPITAL
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11B - Severe Hypertension in Pregnancy and Postpartum
Commitment Name:
MEJORANDO LA ATENCIÓN EN PACIENTES ´PRECLAMPTICAS
Commitment Start Date 06/18/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
FORTALECER LA APLICACIÓN DE LA GUÍA DE PRACTICA CLÍNICA
LINEAMIENTO DE MANEJO DE PRECLAMPSIA
CAPACITACIÓN A LOS MÉDICOS ADSCRITOS Y BECARIOS
APLICACIÓN DE LISTA DE COTEJO
USO CORRECTO DE MAGNESIO
SEGUIMIENTO ADECUADO DE LA RUTA CRITICA DE EMERGENCIA POR PRECLAMPSIA CON DATOS DE SEVERIDAD
Commitment Timeline
ELABORACIÓN DE PROYECTO JUNIO
DAR A CONOCER EL PROYECTO JULIO
ESTABLECER ESTRATEGIAS AGOSTO SEPTIEMBRE OCTUBRE
SEGUIMIENTO DE ESTRATEGIAS NOVIEMBRE DICIEMBRE ENERO
ANÁLISIS DE RESULTADOS FEBRERO MARZO
MEJORAS ABRIL MAYO
CONCLUSIONES JUNIO
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
NUMERO DE PACIENTES FALLECIDAS POR PRECLAMPSIA / NUMERO DE PACIENTES ATENDIDAS DE PRECLAPMSIA X 100
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Scottish Patient Safety Programme (SPSP) |
Scotland |
GB |
The Scottish Patient Safety Programme (SPSP): Mental Health
View Commitment
Commitment
×
Scottish Patient Safety Programme (SPSP)
The Scottish Patient Safety Programme (SPSP): Mental Health
Contact Info
Name: Joanne Matthews
Phone: (013) 162-3472
Email: joanne.matthews1@nhs.net
Position: Head of the Scottish Patient Safety Programme
Organization Name: Scottish Patient Safety Programme (SPSP)
Organization Address:
1 Gyle Square , Gyle Crescent
Edinburgh, Scotland EH12 9EB GB
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13 - Mental Health
Commitment Name:
The Scottish Patient Safety Programme (SPSP): Mental Health
Commitment Start Date 09/17/2015
Action Plan
SPSP is led and co-ordinated nationally, supporting implementation within NHS boards through local teams within hospitals, GP practices, mental health inpatients units and, community pharmacies.
The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model, using national learning sessions to bring NHS boards together to share and learn from each other interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement, to bring about improvements in care provision.
Commitment Timeline
Whilst SPSP does not have a target figure for number of lives saved there are aspirational aims, which are:
Further improve the safety of people in acute care by ensuring 95% of people are free from harm in the following areas; cardiac arrest, CAUTI, pressure ulcers and falls
Reduce Hospital Associated Mortality Reduce (HSMR) by 20%.
Other areas of work have set goals; for example the overall aims of the Maternity Care strand are to:
• increase the percentage of women satisfied with their experience of maternity care to > 95% by the end of 2015, and
• reduce the incidence of avoidable harm in women and babies by 30% by the end of 2015. Avoidable harm is defined by the further sub aims to:
• reduce stillbirths and neonatal mortality by 15% • reduce severe post-partum haemorrhage (PPH) by 30%
• reduce the incidence of non-medically indicated elective deliveries prior to 39 weeks gestation by 30%
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The Scottish Government is committed to the Scottish Patient Safety Programme and new phases of work continue to come on stream, therefore there are no completion dates, although specific areas of work do have set goals and set dates.
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Scottish Patient Safety Programme (SPSP) |
Scotland |
GB |
The Scottish Patient Safety Programme (SPSP): Medicines
View Commitment
Commitment
×
Scottish Patient Safety Programme (SPSP)
The Scottish Patient Safety Programme (SPSP): Medicines
Contact Info
Name: Joanne Matthews
Phone: (013) 162-3472
Email: joanne.matthews1@nhs.net
Position: Head of the Scottish Patient Safety Programme
Organization Name: Scottish Patient Safety Programme (SPSP)
Organization Address:
1 Gyle Square , Gyle Crescent
Edinburgh, Scotland EH12 9EB GB
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3 - Medication Safety
Commitment Name:
The Scottish Patient Safety Programme (SPSP): Medicines
Commitment Start Date 09/17/2015
Action Plan
SPSP is led and co-ordinated nationally, supporting implementation within NHS boards through local teams within hospitals, GP practices, mental health inpatients units and, community pharmacies.
The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model, using national learning sessions to bring NHS boards together to share and learn from each other interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement, to bring about improvements in care provision.
Commitment Timeline
Whilst SPSP does not have a target figure for number of lives saved there are aspirational aims, which are:
Further improve the safety of people in acute care by ensuring 95% of people are free from harm in the following areas; cardiac arrest, CAUTI, pressure ulcers and falls
Reduce Hospital Associated Mortality Reduce (HSMR) by 20%.
Other areas of work have set goals; for example the overall aims of the Maternity Care strand are to:
• increase the percentage of women satisfied with their experience of maternity care to > 95% by the end of 2015, and
• reduce the incidence of avoidable harm in women and babies by 30% by the end of 2015. Avoidable harm is defined by the further sub aims to:
• reduce stillbirths and neonatal mortality by 15% • reduce severe post-partum haemorrhage (PPH) by 30%
• reduce the incidence of non-medically indicated elective deliveries prior to 39 weeks gestation by 30%
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The Scottish Government is committed to the Scottish Patient Safety Programme and new phases of work continue to come on stream, therefore there are no completion dates, although specific areas of work do have set goals and set dates.
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Scottish Patient Safety Programme (SPSP) |
Scotland |
GB |
The Scottish Patient Safety Programme (SPSP): Maternity and Children
View Commitment
Commitment
×
Scottish Patient Safety Programme (SPSP)
The Scottish Patient Safety Programme (SPSP): Maternity and Children
Contact Info
Name: Joanne Matthews
Phone: (013) 162-3472
Email: joanne.matthews1@nhs.net
Position: Head of the Scottish Patient Safety Programme
Organization Name: Scottish Patient Safety Programme (SPSP)
Organization Address:
1 Gyle Square , Gyle Crescent
Edinburgh, Scotland EH12 9EB GB
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11 - Optimizing Obstetric Safety
Commitment Name:
The Scottish Patient Safety Programme (SPSP): Maternity and Children
Commitment Start Date 09/17/2015
Action Plan
SPSP is led and co-ordinated nationally, supporting implementation within NHS boards through local teams within hospitals, GP practices, mental health inpatients units and, community pharmacies.
The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model, using national learning sessions to bring NHS boards together to share and learn from each other interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement, to bring about improvements in care provision.
Commitment Timeline
Whilst SPSP does not have a target figure for number of lives saved there are aspirational aims, which are:
Further improve the safety of people in acute care by ensuring 95% of people are free from harm in the following areas; cardiac arrest, CAUTI, pressure ulcers and falls
Reduce Hospital Associated Mortality Reduce (HSMR) by 20%.
Other areas of work have set goals; for example the overall aims of the Maternity Care strand are to:
• increase the percentage of women satisfied with their experience of maternity care to > 95% by the end of 2015, and
• reduce the incidence of avoidable harm in women and babies by 30% by the end of 2015. Avoidable harm is defined by the further sub aims to:
• reduce stillbirths and neonatal mortality by 15% • reduce severe post-partum haemorrhage (PPH) by 30%
• reduce the incidence of non-medically indicated elective deliveries prior to 39 weeks gestation by 30%
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The Scottish Government is committed to the Scottish Patient Safety Programme and new phases of work continue to come on stream, therefore there are no completion dates, although specific areas of work do have set goals and set dates.
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Scottish Patient Safety Programme (SPSP) |
Scotland |
GB |
The Scottish Patient Safety Programme (SPSP): Healthcare-acquired Infections
View Commitment
Commitment
×
Scottish Patient Safety Programme (SPSP)
The Scottish Patient Safety Programme (SPSP): Healthcare-acquired Infections
Contact Info
Name: Joanne Matthews
Phone: (013) 162-3472
Email: joanne.matthews1@nhs.net
Position: Head of the Scottish Patient Safety Programme
Organization Name: Scottish Patient Safety Programme (SPSP)
Organization Address:
1 Gyle Square , Gyle Crescent
Edinburgh, Scotland EH12 9EB GB
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2 - Healthcare-associated Infections (HAIs)
Commitment Name:
The Scottish Patient Safety Programme (SPSP): Healthcare-acquired Infections
Commitment Start Date 09/17/2015
Action Plan
SPSP is led and co-ordinated nationally, supporting implementation within NHS boards through local teams within hospitals, GP practices, mental health inpatients units and, community pharmacies.
The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model, using national learning sessions to bring NHS boards together to share and learn from each other interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement, to bring about improvements in care provision.
Commitment Timeline
Whilst SPSP does not have a target figure for number of lives saved there are aspirational aims, which are:
Further improve the safety of people in acute care by ensuring 95% of people are free from harm in the following areas; cardiac arrest, CAUTI, pressure ulcers and falls
Reduce Hospital Associated Mortality Reduce (HSMR) by 20%.
Other areas of work have set goals; for example the overall aims of the Maternity Care strand are to:
• increase the percentage of women satisfied with their experience of maternity care to > 95% by the end of 2015, and
• reduce the incidence of avoidable harm in women and babies by 30% by the end of 2015. Avoidable harm is defined by the further sub aims to:
• reduce stillbirths and neonatal mortality by 15% • reduce severe post-partum haemorrhage (PPH) by 30%
• reduce the incidence of non-medically indicated elective deliveries prior to 39 weeks gestation by 30%
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The Scottish Government is committed to the Scottish Patient Safety Programme and new phases of work continue to come on stream, therefore there are no completion dates, although specific areas of work do have set goals and set dates.
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Scottish Patient Safety Programme (SPSP) |
Scotland |
GB |
The Scottish Patient Safety Programme (SPSP) is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered.
View Commitment
Commitment
×
Scottish Patient Safety Programme (SPSP)
The Scottish Patient Safety Programme (SPSP) is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered.
Contact Info
Name: Joanne Matthews
Phone: (013) 162-3472
Email: joanne.matthews1@nhs.net
Position: Head of the Scottish Patient Safety Programme
Organization Name: Scottish Patient Safety Programme (SPSP)
Organization Address:
1 Gyle Square , Gyle Crescent
Edinburgh, Scotland EH12 9EB GB
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
The Scottish Patient Safety Programme (SPSP) is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered.
How Many Hospitals Will This Commitment Represent? 300
Action Plan
SPSP is led and co-ordinated nationally, supporting implementation within NHS boards through local teams within hospitals, GP practices, mental health inpatients units and, community pharmacies.
The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model, using national learning sessions to bring NHS boards together to share and learn from each other interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement, to bring about improvements in care provision.
Commitment Timeline
Whilst SPSP does not have a target figure for number of lives saved there are aspirational aims, which are:
Further improve the safety of people in acute care by ensuring 95% of people are free from harm in the following areas; cardiac arrest, CAUTI, pressure ulcers and falls
Reduce Hospital Associated Mortality Reduce (HSMR) by 20%.
Other areas of work have set goals; for example the overall aims of the Maternity Care strand are to:
• increase the percentage of women satisfied with their experience of maternity care to > 95% by the end of 2015, and
• reduce the incidence of avoidable harm in women and babies by 30% by the end of 2015. Avoidable harm is defined by the further sub aims to:
• reduce stillbirths and neonatal mortality by 15% • reduce severe post-partum haemorrhage (PPH) by 30%
• reduce the incidence of non-medically indicated elective deliveries prior to 39 weeks gestation by 30%
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The Scottish Government is committed to the Scottish Patient Safety Programme and new phases of work continue to come on stream, therefore there are no completion dates, although specific areas of work do have set goals and set dates.
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Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez |
Ciudad de México |
MX |
Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease
View Commitment
Commitment
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease
Contact Info
Name: Roberto Galán
Phone: (55) 56063822 ext. 1012
Email: rgalan@innn.edu.mx
Position: Deputy Director of Diagnostic and Treatment Auxiliary Services, Medical Surgeon
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Organization Address:
Insurgentes Sur 3877, Colonia La Fama, Tlalpan
Ciudad de México, Ciudad de México 14269 MX
Participants:
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Dra. Teresita Corona Vazquez,Directora General
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Dr. Miguel Angel Celis Lopez,Director Medico
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease
Commitment Start Date 01/01/1970 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Provide two briefings to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Publish 200 posters and 2000 brochures to publicize the project.
Raise an informative draft of the dissemination of the project to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Schedule two weekly educational sessions in order to reinforce and develop the moments of handwashing to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Prepare a checklist to evaluate handwashing moments to check the impact of educational actions.
Carry out the shadow study of handwashing moments in all areas of the INNN.
Keep alcohol gel in 100% of INNN areas.
Improve information sessions based on assessment results and hat study.
Establish four campaigns in the months of March, June, September and November to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Establish indicators to measure impact and generate improvement actions.
Establish an evaluation methodology that allows for a clinical audit.
Commitment Timeline
BIMESTRES
1 2 3 4 5 6
STRATEGY 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Provide two briefings to 100% of the staff of the medical and paramedical branch assigned to the INNN x x
Publish 200 posters and 2000 brochures that reveal the project X x x x x x
Raise an informative draft of the dissemination of the project to 100% of the staff of the medical and paramedical branch assigned to the INNN. X x
Schedule two weekly educational sessions in order to reinforce and develop the moments of handwashing to 100% of the staff of the medical and paramedical branch assigned to the INNN. X x x x x x x x x x x x x x x x x x x x x x x x x x
Prepare a checklist to evaluate handwashing moments to check the impact of educational actions. X x
Carry out the shadow study of handwashing moments in all areas of the INNN. X x x x x x x x x x x x x x x x x x x x x
Keep alcohol gel in 100% of INNN areas. X x x x x x x x x x x x x x x x x x x x x
Improve information sessions based on assessment results and hat study. X x x x
Establish four campaigns in the months of March, June, September and November to 100% of the staff of the medical and paramedical branch assigned to the INNN. X x x x
Establish indicators to measure impact and generate improvement actions. X x
Establish an evaluation methodology that allows for a clinical audit x x x x
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Establish improvement actions in each of the sessions. Documentar each of the actions Number of cases with saved infections.
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Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease – Update – 01.29.18
View Update
Commitment Update
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease – Update – 01.29.18
Contact Info
Name: Roberto Galán
Phone: (55) 56063822 ext. 1012
Email: rgalan@innn.edu.mx
Position: Deputy Director of Diagnostic and Treatment Auxiliary Services, Medical Surgeon
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Commitment Details Commitment Start Date: 01/01/1970 How many hospitals are represented in this commitment?
Action Plan:
Provide two briefings to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Publish 200 posters and 2000 brochures to publicize the project.
Raise an informative draft of the dissemination of the project to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Schedule two weekly educational sessions in order to reinforce and develop the moments of handwashing to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Prepare a checklist to evaluate handwashing moments to check the impact of educational actions.
Carry out the shadow study of handwashing moments in all areas of the INNN.
Keep alcohol gel in 100% of INNN areas.
Improve information sessions based on assessment results and hat study.
Establish four campaigns in the months of March, June, September and November to 100% of the staff of the medical and paramedical branch assigned to the INNN.
Establish indicators to measure impact and generate improvement actions.
Establish an evaluation methodology that allows for a clinical audit.
Commitment Update:
Durante el año 2017, el INNN, se enfocó a eliminar las muertes anuales prevenibles implementando programas de acciones de seguridad, promoviendo la calidad y seguridad de la atención y protegiendo la dignidad del paciente. Las acciones llevadas a cabo fueron por los Comites de Prevención y Control de Infecciones; Consultoría en Enfermería; Comité de Calidad y Seguridad del Paciente; Comité del Expediente Clínico y Comité de Morbi- mortalidad.
Se otorgaron dos sesiones informativas al 100% del personal de la rama médica y paramédica. Se publicaron 100 carteles y 1000 trípticos, se realizaron 4 sesiones educativas mensuales con el fin de reforzar y desarrollar los momentos del lavado de manos al 100% del personal de la rama médica y paramédica del INNN. Se implemento el estudio de sombrero, con un apego del 97.1% del personal observado realiza algún método para lavar- higienizar las manos.
Dentro de la técnica de lavado, el cumplimiento de la higiene de manos en el personal observado es superior al 50% en todos los momentos.
Por lo anterior, la tasa de infecciones asociada a la atención a la salud se mantiene por debajo de 15 casos por 100 egresos.
Your commitment aligns with APSS
Challenge 2A - Hand Hygiene Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Dentro de los valores adquiridos durante el año 2017, fue lograr la comunicación eficiente con los integrantes de los diversos comités a fin de dirigirlos al logro de las metas planteadas dentro de este compromiso; así como estandarizar la metodología de lavado de manos
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
3114 |
Lives Spared Harm Target for following calendar year
3021 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
73 |
Projected Target of Lives Saved for following calendar to try to finish commitment
3091 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez |
Ciudad de México |
MX |
Consultoría en Enfermería
View Commitment
Commitment
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Consultoría en Enfermería
Contact Info
Name: MRN. Rocío Valdez Labastida
Phone: (55) 56063822 ext 1062, 1098
Email: rvaldez@innn.edu.mx
Position: Subdirectora de Enfermería, Maestra en Rehabilitación Neurológica y con Licenciatura en Enferemría
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Organization Address:
Insurgentes Sur 3877, Colonia La Fama, Tlalpan
Ciudad de México, Ciudad de México 14269 MX
Participants:
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Ernestina Patricia Zamora Ruiz,Coordinadora Clínica Enfermería
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Silvia Alajandro Escobar,Coordinadora de Enseñanza Enfermería
Commitment Details
Commitment Name:
Consultoría en Enfermería
Commitment Start Date 01/01/1970
Action Plan
Formar y capacitar profesionales de enfermería como consultoras
Implementar el modelo de Consultoría en Enfermería
Difundir el modelo de Consultoría en Enfermería
Desarrollar e implementar indicadores que permitan medir el impacto y generar acciones de mejora
Establecer una metodología de evaluación
Commitment Timeline
Formar y capacitar profesionales de enfermería como consultoras un cuatrimestre
Implementar el modelo de Consultoría en Enfermería dos cuatrimestres
Difundir el modelo de Consultoría en Enfermería seis cuatrimestre
Desarrollar e implementar indicadores que permitan medir el impacto y generar acciones de mejora dos cuatrimestres seis cuatrimestres
Establecer una metodología de evaluación seis cuatrimestres
Impact Details Methodology for Determining Lives Saved:
Se atenderán a los pacientes que de acuerdo a los criterios establecidos por el programa principal para la consultoría sean enviados por los servicios de hospitalización y consulta externa.
Los pacientes deben tener alguna enfermedad crónica degenerativa, pacientes crónicos, adulto mayor que requieran cuidados especializados en el hogar y apego a los diferentes tratamientos instituidos en su hospitalización, que beneficien el autocuidado de cada enfermo a través de la educación y así favorecer la calidad de vida de cada persona.
Contar con mayor número de consultorios para enfermería, donde se de orientación y capacitación a los enfermos y sus familias.
Para la orientación y capacitación de los enfermos y sus familiares se hará uso de simuladores y maniquís que favorezcan a través de la práctica en un escenario real, un mejor aprendizaje en el cuidado especializado.
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Consultoría en Enfermería – Update – 01.29.18
View Update
Commitment Update
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Consultoría en Enfermería – Update – 01.29.18
Contact Info
Name: MRN. Rocío Valdez Labastida
Phone: (55) 56063822 ext 1062, 1098
Email: rvaldez@innn.edu.mx
Position: Subdirectora de Enfermería, Maestra en Rehabilitación Neurológica y con Licenciatura en Enferemría
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Commitment Details Commitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Formar y capacitar profesionales de enfermería como consultoras
Implementar el modelo de Consultoría en Enfermería
Difundir el modelo de Consultoría en Enfermería
Desarrollar e implementar indicadores que permitan medir el impacto y generar acciones de mejora
Establecer una metodología de evaluación
Commitment Update:
El Instituto, continuo con el modelo de Consultoría en Enfermería Neurológica, en cuidados paliativos y en heridas y estomas cumplió en reducir el número de ingresos hospitalarios por complicaciones por mal cuidado en el hogar, prolongó la vida y su calidad, impactando en el proceso de atención y en la planificación del egreso del paciente neurológico a su domicilio. El resultado fue otorgar 688 atenciones a pacientes que acudieron al INNN, lo que representó un aumento 171 atenciones que, en el 2016, lo que evito sus reingresos. Durante el año 2017, se recibió la donación de simuladores anatómicos adulto y geriátrico, monitor de signos vitales, aditamentos de exploración neurológica, espacio físico para crear el Centro de Instrucción de Enfermería Especializada (CIEE). Dio inicio a la evaluación del impacto de la consultoría en enfermaría, con el fin de realizar acciones de mejora que repercuta en el cuidado del paciente neurológico.
Your commitment aligns with APSS
Consultoria en Enfermería Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
El desarrollo de habilidades y destrezas del cuidador principal, el apoyo moral, económico por parte de la comunidad hospitalaria al compromiso adicional realizado por cada uno de los integrantes de la familia. Por último, la integración del paciente a que sea productivo y del autocuidado al reintegrarse a la sociedad.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
|
Lives Lost:
0 |
Lives Spared Harm Target
|
Actual Lives Spared Harm in last 12 months
688 |
Lives Spared Harm Target for following calendar year
690 |
Lives Saved Target
|
Actual Lives Saved in last 12 months (might differ from initial target)
15 |
Projected Target of Lives Saved for following calendar to try to finish commitment
20 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
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|
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Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez |
Ciudad de México |
MX |
Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018
View Commitment
Commitment
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018
Contact Info
Name: Roberto Galán
Phone: (55) 56063822 ext. 1012
Email: rgalan@innn.edu.mx
Position: Subdirector de Servicios Auxiliares de Diagnóstico y Tratamiento, Medico Cirujano
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Organization Address:
Insurgentes Sur 3877, Colonia La Fama, Tlalpan
Ciudad de México, Ciudad de México 14269 MX
Participants:
-
Dra. Teresita Corona Vazquez,Directora General
-
Dr. Miguel Angel Celis Lopez,Director Medico
Commitment Details
Commitment Name:
Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018
Commitment Start Date 01/01/1970
Action Plan
Elaborar el plan para la presentación del modelo de seguridad y calidad para difundirlo a todo el personal de la rama médica y paramédica adscrito al Instituto.
Generar carteles, trípticos, videos que den a conocer el modelo a todo el personal de la rama médica y paramédica adscrito al Instituto.
Sesiones educativas de coaching quincenales con el fin de reforzar y desarrollar el modelo de seguridad y calidad en el paciente a todo el personal adscrito al Instituto.
Realizar rastreos mensuales en todos los departamentos del instituto para evaluar la aplicación del modelo se seguridad y calidad.
Generar las sesiones informativas basada en los resultados de los rastreos y avances alcanzados en las diferentes áreas del instituto.
Establecer indicadores que permitan medir el impacto y permitan generar acciones de mejora.
Commitment Timeline
Elaborar el plan para la presentación del modelo de seguridad y calidad para difundirlo a todo el personal de la rama médica y paramédica adscrito al Instituto.
2 meses
Generar carteles, trípticos, videos que den a conocer el modelo a todo el personal de la rama médica y paramédica adscrito al Instituto.
1 mes
Sesiones educativas de coaching quincenales con el fin de reforzar y desarrollar el modelo de seguridad y calidad en el paciente a todo el personal adscrito al Instituto.
48 sesiones en 24 meses
Realizar rastreos mensuales en todos los departamentos del instituto para evaluar la aplicación del modelo se seguridad y calidad.
24 rastreos
Generar las sesiones informativas basada en los resultados de los rastreos y avances alcanzados en las diferentes áreas del instituto.
48 sesiones en 24 meses
Impact Details Methodology for Determining Lives Saved:
Uso de Guía de Práctica Clínica o Protocolo de Atención con el propósito de estandarizar un proceso de atención en el que se observan problemas de variabilidad.
Indicadores de Mejora de la Calidad de acuerdo con los estándares para la certificación de hospitales del CSG, se diseñaron indicadores con enfoque clínico y de gestión para abordar e ir resolviendo gradualmente la problemática y riesgos detectados.
Reporte y Aprendizaje de Eventos Centinela, Adversos y Cuasifallas para el diseño de un mecanismo de reporte y aprendizaje de los incidentes en seguridad del paciente, se investigaron los diferentes eventos no deseados.
Herramienta proactiva en el INNyN se decidió adoptar como herramienta proactiva el Análisis de Modo y Efecto de Falla (AMEF) con el propósito de analizar uno de los riesgos más importantes y rediseñarlo para hacerlo más seguro
Identificar riesgos y problemas en el instituto realizando una priorización que considerara tres criterios
Criterios Calificación
1 2 3
Frecuencia No ocurre u ocurre esporádicamente Pasa en la mitad de los casos Siempre o casi siempre ocurre
Impacto Cuasifalla o no afecta al personal Evento adverso o accidente del personal Evento centinela o accidente incapacitante en el personal
Factibilidad El abordaje y solución depende de alguna instancia externa La solución implica la participación de otras organizaciones con las que se tiene convenio de colaboración Depende del personal del INNyN
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Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018 – Update – 01.29.18
View Update
Commitment Update
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018 – Update – 01.29.18
Contact Info
Name: Roberto Galán
Phone: (55) 56063822 ext. 1012
Email: rgalan@innn.edu.mx
Position: Subdirector de Servicios Auxiliares de Diagnóstico y Tratamiento, Medico Cirujano
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Commitment Details Commitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Elaborar el plan para la presentación del modelo de seguridad y calidad para difundirlo a todo el personal de la rama médica y paramédica adscrito al Instituto.
Generar carteles, trípticos, videos que den a conocer el modelo a todo el personal de la rama médica y paramédica adscrito al Instituto.
Sesiones educativas de coaching quincenales con el fin de reforzar y desarrollar el modelo de seguridad y calidad en el paciente a todo el personal adscrito al Instituto.
Realizar rastreos mensuales en todos los departamentos del instituto para evaluar la aplicación del modelo se seguridad y calidad.
Generar las sesiones informativas basada en los resultados de los rastreos y avances alcanzados en las diferentes áreas del instituto.
Establecer indicadores que permitan medir el impacto y permitan generar acciones de mejora.
Commitment Update:
Durante el año del 2017, se desarrolló el Plan de Modelo de Cultura de la Seguridad y Calidad, que permitió establecer políticas con un enfoque proactivo, sistemático y multidisciplinario. Como resultado se cuenta con un expediente clínico electrónico (ECE) apegado a las normas mexicanas, cuidando la privacidad y confidencialidad del paciente, en donde los profesionales de la salud** tienen acceso seguro al ECE, lo que permite la trazabilidad del paciente y usuario del ECE.
Dentro del ECE, se registra y validar cada una de las notas médicas con su firma electrónica, permite aplicar las metas internacionales, el registro de alergias del paciente, continuidad de la atención del paciente, identificar la dieta y medicamentos prescritos por el médico tratante bajo en unidosis, registro de la lista de verificación de cirugía segura, consentimientos informados por procedimiento invasivo, entre otros. Se ha observado incremento en la cultura del reporte de eventos adversos, se dio inicio al análisis Causa- raíz de eventos centinelas,
**Profesionales de la salud: médicos, enfermeras y personal técnico (radiológico, inhalo terapista, rehabilitación, químico laboratorista, entre otros).
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
El Programa de Análisis de Cuasifallas, Eventos Adversos y Eventos Centinela ha permitido fomentar la cultura del reporte de los mismos y el análisis proactivo con miras a reducir la recurrencia y las complicaciones. El análisis Causa- Raíz ha permitido aprender de los errores y verlos como una oportunidad
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
|
Lives Lost:
0 |
Lives Spared Harm Target
|
Actual Lives Spared Harm in last 12 months
3114 |
Lives Spared Harm Target for following calendar year
3091 |
Lives Saved Target
|
Actual Lives Saved in last 12 months (might differ from initial target)
73 |
Projected Target of Lives Saved for following calendar to try to finish commitment
70 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
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|
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Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez |
Ciudad de México |
MX |
Disminuir las infecciones asociadas al cuidado de la salud en pacientes con padecimientos del sistema nervioso en el INNN a través del lavado de manos en el año 2017
View Commitment
Commitment
×
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Disminuir las infecciones asociadas al cuidado de la salud en pacientes con padecimientos del sistema nervioso en el INNN a través del lavado de manos en el año 2017
Contact Info
Name: Roberto Galán
Phone: 5556063822
Email: rgalan@innn.edu.mx
Position: Subdirector de Servicios Auxiliares de Diagnóstico y Tratamiento, Médico Cirujano
Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez
Organization Address:
Insurgentes Sur 3877, Colonia La Fama, Tlalpan
Ciudad de México, Ciudad de México 14269 MX
Participants:
-
Dra. Teresita Corona Vazquez,Directora General
-
Dr. Miguel Ángel Celis López,Director Médico
Commitment Details
Commitment Name:
Disminuir las infecciones asociadas al cuidado de la salud en pacientes con padecimientos del sistema nervioso en el INNN a través del lavado de manos en el año 2017
Commitment Start Date 01/01/1970
Action Plan
Otorgar dos sesiones informativas al 100% del personal de la rama médica y paramédica adscrito al INNN.
Publicar 200 carteles y 2000 trípticos que den a conocer el proyecto.
Levantar una minuta informativa de la difusión del proyecto al 100% del personal de la rama médica y paramédica adscrito al INNN.
Calendarizar dos sesiones educativas semanales con el fin de reforzar y desarrollar los momentos del lavado de manos al 100% del personal de la rama médica y paramédica adscrito al INNN.
Elaborar una lista de cotejo para evaluar los momentos de lavado de manos mediante para comprobar el impacto de las acciones educativas.
Realizar el estudio de sombra de los momentos de lavado de manos en todas las áreas del INNN.
Mantener alcohol gel en el 100% de las áreas del INNN.
Mejorar las sesiones informativas basada en los resultados de las evaluaciones y estudio de sombrero.
Establecer cuatro campañas en los meses de marzo, junio, septiembre y noviembre al 100% del personal de la rama médica y paramédica adscrito al INNN.
Establecer indicadores que permitan medir el impacto y permitan generar acciones de mejora.
Establecer una metodología de evaluación que permita realizar una auditoria clínica.
Commitment Timeline
BIMESTRES
1 2 3 4 5 6
ESTRATEGIA 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Otorgar dos sesiones informativas al 100% del personal de la rama médica y paramédica adscrito al INNN x x
Publicar 200 carteles y 2000 trípticos que den a conocer el proyecto X x x x x x
Levantar una minuta informativa de la difusión del proyecto al 100% del personal de la rama médica y paramédica adscrito al INNN. x x
Calendarizar dos sesiones educativas semanales con el fin de reforzar y desarrollar los momentos del lavado de manos al 100% del personal de la rama médica y paramédica adscrito al INNN. x x x x x x x x x x x x x x x x x x x x x x x x
Elaborar una lista de cotejo para evaluar los momentos de lavado de manos mediante para comprobar el impacto de las acciones educativas. x x
Realizar el estudio de sombra de los momentos de lavado de manos en todas las áreas del INNN. x x x x x x x x x x x x x x x x x x x x
Mantener alcohol gel en el 100% de las áreas del INNN. x x x x x x x x x x x x x x x x x x x x
Mejorar las sesiones informativas basada en los resultados de las evaluaciones y estudio de sombrero. x x x x
Establecer cuatro campañas en los meses de marzo, junio, septiembre y noviembre al 100% del personal de la rama médica y paramédica adscrito al INNN. x x x x
Establecer indicadores que permitan medir el impacto y permitan generar acciones de mejora. x x
Establecer una metodología de evaluación que permita realizar una auditoria clínica x x x x
Impact Details Methodology for Determining Lives Saved:
Identificación de casos con infecciones nosocomiales
Tasa de incidencia de infecciones nosocomiales
Control de colocación de instrumentos invasivos
Realizar cuatro sesiones informativas de avances
Establecer acciones de mejora en cada una de las sesiones
Documentar cada una de las acciones
Numero de cosos con infecciones salvadas
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Tri-City Medical Center |
California |
US |
3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culure of Safety scores compared to the 2016 survey data.
View Commitment
Commitment
×
Tri-City Medical Center
3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culure of Safety scores compared to the 2016 survey data.
Contact Info
Name: Kevin McQueen, MHA, RRT, CM
Phone: 760-940-3076
Email: mcqueenkm@tcmc.com
Position: Director, Patient Safety Officer
Organization Name: Tri-City Medical Center
Organization Address:
4002 Vista Way
Oceanside, California 92056 US
Participants:
-
Marcia Cavanaugh,Sr. Director of Risk/Quality
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MSN,Director of Regulatory Compliance/Quality
-
RN,Clinical Risk Management Quality Specialist
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MBA
-
CPHRM
-
NEA-BC
-
Jami Piearson
-
BSN
-
RN
-
MBA
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culure of Safety scores compared to the 2016 survey data.
Commitment Start Date 10/07/2016
Action Plan
3. C-Suite leaders to work with area directors and managers to focus efforts aimed at improving AHRQ Culture of Patient Safety scores that are not achieving AHRQ benchmark data levels.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Tri-City Medical Center |
California |
US |
2. Reducing falls on the inpatient nursing units at Tri-City Medical Center
View Commitment
Commitment
×
Tri-City Medical Center
2. Reducing falls on the inpatient nursing units at Tri-City Medical Center
Contact Info
Name: Kevin McQueen, MHA, RRT, CM
Phone: 760-940-3076
Email: mcqueenkm@tcmc.com
Position: Director, Patient Safety Officer
Organization Name: Tri-City Medical Center
Organization Address:
4002 Vista Way
Oceanside, California 92056 US
Participants:
-
Marcia Cavanaugh,Sr. Director of Risk/Quality
-
MSN,Director of Regulatory Compliance/Quality
-
RN,Clinical Risk Management Quality Specialist
-
MBA
-
CPHRM
-
NEA-BC
-
Jami Piearson
-
BSN
-
RN
-
MBA
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
2. Reducing falls on the inpatient nursing units at Tri-City Medical Center
Commitment Start Date 10/07/2016
Action Plan
2. Continue to implement evidence-based TJC Center for Transforming Healthcare’s TST tools across inpatient nursing care units in an effort to reduce inpatient falls by 20% compared to FY2016.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Tri-City Medical Center |
California |
US |
1. To maintain our Neonatal Intensive Care Unit (NICU) free of any Central Line Associated Bloodstream Infections (CLABSI). 2. To reduce falls on our inpatient care units (1 North, Pavilion, Telemetry and ICU) by 20% compared to FY16 data. 3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety scores compared to the 2016 survey data.
View Commitment
Commitment
×
Tri-City Medical Center
1. To maintain our Neonatal Intensive Care Unit (NICU) free of any Central Line Associated Bloodstream Infections (CLABSI). 2. To reduce falls on our inpatient care units (1 North, Pavilion, Telemetry and ICU) by 20% compared to FY16 data. 3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety scores compared to the 2016 survey data.
Contact Info
Name: Kevin McQueen, MHA, RRT, CM
Phone: 760-940-3076
Email: mcqueenkm@tcmc.com
Position: Director, Patient Safety Officer
Organization Name: Tri-City Medical Center
Organization Address:
4002 Vista Way
Oceanside, California 92056 US
Participants:
-
Marcia Cavanaugh, MSN, RN, MBA, CPHRM, NEA-BC,Sr. Director of Risk/Quality
-
Jami Piearson, BSN, RN, MBA,Director of Regulatory Compliance/Quality
-
Michelle Hardin, BSN,Clinical Risk Management Quality Specialist
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
1. To maintain our Neonatal Intensive Care Unit (NICU) free of any Central Line Associated Bloodstream Infections (CLABSI). 2. To reduce falls on our inpatient care units (1 North, Pavilion, Telemetry and ICU) by 20% compared to FY16 data. 3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety scores compared to the 2016 survey data.
Commitment Start Date 07/01/2010
Action Plan
1. The commitment to remain CLABSI-free is ongoing and continues to be a top priority. Continue to use evidence-based CLABSI prevention practices to maintain the NICU as CLABSI-free.
2. Continue to implement evidence-based TJC Center for Transforming Healthcare’s TST tools across inpatient nursing care units in an effort to reduce inpatient falls by 20% compared to FY2016.
3. C-Suite leaders to work with area directors and managers to focus efforts aimed at improving AHRQ Culture of Patient Safety scores that are not achieving AHRQ benchmark data levels.
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - Obstetrical Adverse Events
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Obstetrical Adverse Events
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11 - Optimizing Obstetric Safety
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Obstetrical Adverse Events
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - Readmissions
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Readmissions
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Readmissions
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - Falls
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Falls
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Falls
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - VAP
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – VAP
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-Associated Pneumonia (VAP)
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – VAP
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - Pressure Ulcers
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Pressure Ulcers
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Pressure Ulcers
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - CLABSI
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CLABSI
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – CLABSI
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - SSI
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – SSI
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical Site Infections (SSI)
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – SSI
Commitment Start Date 12/03/2016
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals - CAUTI
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CAUTI
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – CAUTI
Commitment Start Date 12/03/2016 How Many Hospitals Will This Commitment Represent? 96
Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics
Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Children's Hospitals' Solutions for Patient Safety |
OH |
US |
Eliminating Serious Harm in Children's Hospitals
View Commitment
Commitment
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals
Contact Info
Name: Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children's Hospitals' Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , MLC 7014
Cincinnati, OH 45229 US
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric Adverse Drug Events
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals
Commitment Summary:
The Children’s Hospitals’ Solutions for Patient Safety National Children’s Network represents the most herculean effort to date by the country’s children’s hospitals to create a universally safe and healing environment for all children who are in our care. We are working together to eliminate serious harm across children's hospitals in the United States. Commitment Description & Detail:
With the creation of the SPS National Children’s Network – funded in part by the federal Partnership for Patients initiative and the Cardinal Health Foundation - leaders from 81 children’s hospitals across the United States have stepped forward and committed to clear, shared network goals of harm reduction by December 31, 2014.
40 percent reduction in hospital-acquired conditions (HACs)
20 percent reduction in readmissions
25 percent reduction in serious safety events (SSEs)
A Journey Toward Zero Harm
The 80+ Children’s Hospitals’ Solutions for Patient Safety (SPS) Network hospitals are driven by the
shared goal to urgently reduce and then eliminate serious harm for the children being cared for in our
facilities. To guide this work, SPS network hospitals have come together around the following tenants.
Leadership Matters
Executive leadership is a critical aspect of successful improvement in pediatric patient safety. The
network has designed efforts to inspire and continuously develop the safety leadership skills of the
executives who lead our network hospitals.
Our mission motivates all that we do
We must act with urgency and discipline, focusing on outcomes through a combination of high-reliability concepts and quality improvement science methods. We learn through testing and partnering with families and front-line staff.
Network hospitals must commit to building a “culture of safety". Hospitals within the network are employing the cultural transformation strategies of other high reliability industries to significantly reduce harm in their institutions. This emphasis on creating a culture of safety within pediatric institutions is a unique aspect of SPS’s approach.
Network hospitals will NOT compete on safety
Instead, the SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone.
“All Teach, All Learn”
SPS network hospitals must humbly share and gratefully learn from others. Accomplishing our goals requires focus on the detailed processes and cultural elements that lead to safer hospitals, guidance and support for hospital teams as they build the capacity for change and facilitating relationships within the network to broaden and accelerate learning. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline:
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
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Eliminating Serious Harm in Children’s Hospitals - CAUTI - Update - 12.03.16
View Update
Commitment Update
×
Children's Hospitals' Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CAUTI – Update – 12.03.16
Contact Info
Name: Anne Lyren, MD, MSc, Associate Professor of Pediatrics and Bioethics, Strategic Advisor of Quality and Safety
Phone: 216-844-3669
Email: Anne.Lyren@UHhospitals.org
Position: Clinical Director, Children's Hospitals' Solutions for Patient Safety, Associate Professor of Pediatrics & Bioethics, Case Western Reserve University School of Medicine, Strategic Advisor of Quality and Safety, UH Rainbow Babies & Children's Hospital
Organization Name: Children's Hospitals' Solutions for Patient Safety
Commitment Details Commitment Update:
As of August 2016, the Solutions for Patient Safety has decreased hospital-acquired harm in all areas the network has tackled, including a 79% reduction in serious falls, 63% reduction in adverse drug events, 47% reduction in catheter-associated urinary tract infections, and a 31% reduction in surgical site infections. SPS estimates that the network has prevented harm to over 6800 children and saved over $120,000,000 in healthcare costs.At the same time, the network has grown from the original 8 Ohio children's hospitals to over 110 children's hospitals across the United States and Canada, all of whom are teaching and learning together.
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Mayo Clinic, Florida |
FL |
US |
The Blue Angel Standard
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Commitment
×
Mayo Clinic, Florida
The Blue Angel Standard
Contact Info
Name: Perry Bechtle
Phone: 904-472-8898
Email: bechtle.perry@mayo.edu
Position: Consultant in Anesthesiology, Assistant Professor of Anesthesiology
Organization Name: Mayo Clinic, Florida
Organization Address:
4500 San Pablo Rd
Jacksonville, FL 32082 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
The Blue Angel Standard
Commitment Start Date 11/20/2013 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The use of systematic personal and group strategies to ensure the proper configuration and functioning software equipment, processes and care teams has lagged far behind the explosion of high-consequence devices, procedures, and complexity at the bedside. Despite the increasing use of time-outs, checklists, briefing and debriefing to achieve reliability, as they did in the aviation industry, we just don't see the same results in medicine, not even close.
As a former officer and Flight Surgeon for the US Navy Blue Angels, my life and the lives of others on the team and on the ground depended on using personal strategies, structured communication tools and teamwork strategies to achieve the highest degree of reliability and safety in one of the most hazardous and unforgiving environments in the world: low-level, near supersonic formation aerobatics over and in front of hundreds of thousands of spectators. Now, as a private pilot and a neuroanesthesiologist at Mayo Clinic in Florida, I use these same strategies to keep my family safe and my personal flying and my patients safe during high-consequence and highly complex neurological procedures, respectively. My commitment is to use this unique experience to produce media and print, specifically meant for front-line healthcare workers of all disciplines and levels, that describes the essential individual behaviors, essential team members, and the variety of communication tools that can be employed by anyone interested in achieving "Blue Angel" levels of habitual individual excellence and team member trust. Both of these factors: habitual individual excellence and team member trust are critical in achieving safety and reliability. Proper configuration and functioning of software, equipment, processes and care teams is merely a byproduct of these two behaviors when combined with an understanding and consistent use of communication tools such as time-outs, checklists, briefing, debriefing, and Standard Operating Procedures.
My action plan:
1. Produce the manuscript outline and manuscript
2. Select great examples from medicine that concretely illustrate the above concepts
3. Produce the interviews and media for the target audience of front line workers (I already have an in-house audio and video media production capability)
4. Post-production work including exploring partnerships to ensure widespread availability to front-line healthcare workers
Commitment Timeline
Completion of Manuscript by May 2014
Media production complete by August 2014
Post-production complete by November 2014
Roll-out December 2014
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Mayo Clinic, Florida |
FL |
US |
Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery.
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Commitment
×
Mayo Clinic, Florida
Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery.
Contact Info
Name: Klaus Torp
Phone: (904) 956-3328
Email: torp.klaus@mayo.edu
Position: Assitant Professor of Anesthesiology
Organization Name: Mayo Clinic, Florida
Organization Address:
4500 San Pablo Rd
Jacksonville, FL 32224 US
Participants:
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Mary O'Connor,MD, Chair and Professor of Orthopedic Surgery
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient Blood Management
Commitment Name:
Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery.
How Many Hospitals Will This Commitment Represent? 1
Action Plan
At the time of the surgery interview, the patient will have a spot check Hgb. If the value is acceptable the patient will be scheduled for surgery. If the value is not acceptable, the surgery will be deferred and the patient will be referred to an anemia management program.
Commitment Timeline
1 year, single institution.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery - Update
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Commitment Update
×
Mayo Clinic Florida
Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery – Update
Contact Info
Name: Klaus Torp
Phone: 904-956-3328
Email: torp.klaus@mayo.edu
Position: Assistant Professor of Anesthesiology
Organization Name: Mayo Clinic Florida
Commitment Details Commitment Start Date: 01/03/2014 How many hospitals are represented in this commitment?
Action Plan:
Pre-operative anemia is a major risk factor for perioperative blood transfusion. Often the patient's hemoglobin is not known until the patient is scheduled for surgery and goes through the pre-operative workup, which may occur too close to the surgical date to correct anemia effectively. Knowing the Hgb value at the time of the surgical office visit would help in directing the patient to either the regular preoperative pathway or to an anemia management program.
Commitment Update:
A Hgb screening tool has been identified and approved by the laboratory director. An electronic interface has been created to report the Hgb values into the medical record. Training of the personnel in the correct use of the Hgb spot check device has been completed. An laboratory test algorithm in case of low Hgb spot check values has been created. An anemia management program, using EPO injections for those patients with anemia of chronic disease has been created and approved for a pilot project.
Your commitment aligns with APSS
Challenge 5 - Patient Blood Management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Meeting with the appropriate stakeholders is important like the laboratory, hematology, surgical service, ambulatory infusion center and billing department in order not to miss important details of the project.
Nothing is ever simple. The biggest issue is to assemble the right people with the right knowledge and motivation who are ready to make a change. Everyone has part of the answer, but putting it all together is time consuming for people who have additional clinical responsibilities. This project involved two components: 1) Identification of
anemic patients early, before they are scheduled for surgery and 2) Create an anemia management program that would work for most patients using existing resources.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
60 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Mayo Clinic, Florida |
FL |
US |
Sepsis and Shock Response Team (SSRT): A Multidisciplinary Approach to Bundle Adherence and Patient Safety
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Commitment
×
Mayo Clinic, Florida
Sepsis and Shock Response Team (SSRT): A Multidisciplinary Approach to Bundle Adherence and Patient Safety
Contact Info
Name: Sandra Booth
Phone: (904) 953-2515
Email: booth.sandra@mayo.edu
Position: Quality Improvement Advisor
Organization Name: Mayo Clinic, Florida
Organization Address:
4500 San Pablo Road , Stabile S 180A
Jacksonville, FL 32224 US
Participants:
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Pablo Moreno Franco,Consultant Transplant Critical Care
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Ami Grek,ARNP Transplant Critical Care
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Torp Klaus,Consultant Anesthesia
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Sepsis and Shock Response Team (SSRT): A Multidisciplinary Approach to Bundle Adherence and Patient Safety
How Many Hospitals Will This Commitment Represent? 1
Action Plan
A baseline retrospective chart review of 25 consecutive patients discharged with the diagnosis of sepsis (ICD 995.91), severe sepsis (ICD 995.92), or septic shock (ICD 785.52) to Mayo Clinic’s ED in Jacksonville, FL from December 2011 to March 2012 was initially completed. Compliance data was recorded for each of the seven elements and an all-or-none calculation was completed. Prospective data collection for compliance with the same seven element bundle occurred for one year from the start of implementation for all 116 patients identified in the ED with severe sepsis/ septic shock activation triggers. Monthly hospital sepsis mortality rates were extracted from institutional discharge data from the University HealthSystem Consortium (UHC) from September 2011 through August 2013. To adjust for possible changes in severity, mortality rates were adjusted using UHC’s patient-specific expected mortality. In addition, CLABSI rates were obtained from our hospital’s infection control for 2013-2014.
At the project start, key stakeholders were identified and a multidisciplinary QI team was assembled. A number of QI tools were used throughout the Define-Measure-Analyze-Improve-Control project life cycle. The project team began constructing a Supplier-Input-Process-Outcome-Customers-Requirements (SIPOC+R) diagram in the define phase in order to understand the high level process flow . The SIPOC+R was particularly useful in identifying the requirements based on the Surviving Sepsis Campaign Care Bundle, which eventually led to the use of a critical to quality tree and failure mode and effects analysis (FMEA) tool. During the analyze phase, the team divided the sepsis resuscitation process steps into three primary drivers for the effective treatment of sepsis: 1. identify severe sepsis and septic shock, 2. standardize quantitative resuscitation, and 3. triage decision. Those primary drivers were then further broken down into ten secondary drivers, which ultimately populated the FMEA as process steps and sub-process steps. This organization allowed the QI team to be divided into subgroups that were then responsible to act as focused process and sub-process experts. These focused expert groups were then responsible for identifying the potential failure modes and possible causes. Each failure mode was assessed for frequency of occurrence, severity, and presence of potential detection system in place; these characteristics were rated in scale from 0 to 10. Using the individual scores, we calculated risk priority numbers (RPNs) consisting of frequency score x severity score x detection system score; the results obtained ranged from 4 – 700. Interventions were designed and deployed addressing the highest RPNs first.
Commitment Timeline
September 2013-September 2014
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Post intervention: n=401, observed deaths = 52, expected deaths based on severity = 79, pre-implementation O/E = 0.884, Saved lives = (0.884 X 79) – 52 = 18 or 18/401 = 4.5 per 100 discharges
Based on 3260 patients with sepsis sniffer activation seen in Mayo Clinic Florida Emergency Department ( From September 2013 to September 2014).
This represents 146.7 lives saved per year
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Hospital Quality Institute (HQI) |
CA |
US |
Reduce death from sepsis
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Reduce death from sepsis
Contact Info
Name: Julianne Morath
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
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State and national collaborative,sepsis champion physicians
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professional physician and academic partners,emergency medicine, professional associations
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Health Services Advisory Group,the California Innovation Network (QIN)
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Reduce death from sepsis
Action Plan
1. Provide peer-to-peer learning through learning opportunities/activities and mentor hospitals
2. Distribute evidence- based guidelines and playbooks
3. Provide ongoing performance feedback
4. Provide sepsis simulation trainings
5. Support and work with Process Improvement team
Commitment Timeline
1. Mobilize plan in Jan 2015
2. Realize results over 2 years
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Reduce death from sepsis – Update – 01.25.18
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Commitment Update
×
Hospital Quality Institute (HQI)
Reduce death from sepsis – Update – 01.25.18
Contact Info
Name: Julianne Morath
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Last Report
400 |
Current
400 |
Action Plan:
1. Provide peer-to-peer learning through learning opportunities/activities and mentor hospitals
2. Distribute evidence- based guidelines and playbooks
3. Provide ongoing performance feedback
4. Provide sepsis simulation trainings
5. Support and work with Process Improvement team
Commitment Update:
1. 2017 peer-peer sepsis learning opportunities:
a. Three in-person peer-peer learning events hosting 150 attendees representing 100 hospitals
b. Access to five national sepsis expert webinars
c. HQI annual conference sepsis focused breakout sessions and posters : Over 400 attendees from 200+ hospitals
2. Sepsis Clinical Field Guide disseminated via HSAG HIIN, HQI Sepsis Infographic distributed via websites and mailing lists
3. Unblinded hospital variation data provided to Regional Association Boards
4. Ongoing individualized support to hospitals
5. Roundtable held and proceedings to be published 1Q2018.
Your commitment aligns with APSS
Challenge 9 - Early Detection and Treatment Of Sepsis Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
With the 2004 original SSC campaign, Hospital X focused on intensive care (ICU) response to sepsis with high usage of protocols. Early mortality rates dropped from 40% to 28% as a result. To obtain further gains, the leadership recognized it was important to convey that sepsis was not an ICU problem but a hospital problem. Existing protocols were split into high, medium, and low intensity to match levels of care on the nursing units so that patients on all nursing units received recognition of sepsis, initial treatment, and were transferred to higher acuity as needed. In addition, Hospital X added a dedicated sepsis nurse and triage in the ED to recognize patients early and begin treatment. Resulting in $7,000 cost per case and 14 percent savings overall, even after accounting for additional FTE for the dedicated sepsis nurse. The value of the sepsis nurse eliminated grey area of patients waiting in the ED for an available ICU bed. This positively impacted ED flow and ICU availability, in addition to the patient benefit from prompt treatment. The nurse coverage started with 12 hours daily and then expanded to 24-hour coverage. The nurse also followed patients for 24-36 hours to relieve ICUs.
Initially the sepsis nurse’s role was to be an extra hand in ICUs with a high census. It evolved to be a dedicated sepsis responsibility. Health System X has adopted some variation of the dedicated nurse in all hospitals. For training, the sepsis nurses are drawn from those who have a minimum of two years’ experience in critical care and rapid response (RRT). Initially, the sepsis nurse was used as a flexible resource to bolster lean staffing in critical care or other areas. At Hospital X, after recognizing the positive value of the resource, the sepsis nurses can no longer be pulled. From all efforts, Hospital X’s sepsis mortality dropped from 25 percent in 2002 to 5-6 percent today.
The sepsis nurses across Health System X are currently working to create standardized performance among all hospitals. This work involves reducing from 33 separate order sets to two order sets, containing exact workflow. At Hospital Y, the sepsis nurse completes sepsis consults with staff, evaluates sepsis screens, and consults with other nurses. The sepsis nurse sees on average 200-230 patients per month but some see well over 300 monthly. Hospital Y is staffed with one sepsis nurse plus one RRT nurse.
For hospitals employing this resource, Health System X has tried multiple phases and found an evolutionary process that works by building the sepsis nurse into the RRT team at first and then separating the resource as demand and value builds. The organization’s guide to determine how sepsis nurses are deployed is based on the volume of annual sepsis cases. For a hospital with 1500 cases, a dedicated sepsis nurse utilized covering day and some eve/weekend shifts. The number of cases is measured initially by examining DRG cases. Ultimately, the sepsis nurse case volume is recommended to be measured by how many times the protocol is activated because that is where the work is. The order set must be activated to signal the need for the sepsis nurse. No activation, no nurse.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
4064 |
Projected Target of Lives Saved for following calendar to try to finish commitment
4259 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Hospital Quality Institute (HQI) |
CA |
US |
Eliminate preventable mortality and morbidity in maternity care
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Eliminate preventable mortality and morbidity in maternity care
Contact Info
Name: Julianne Morath
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
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Hospital Quality Institute (HQI),California Maternal Quality Care Collaborative (CMQCC)
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American Congress of Obstetricians and Gynecologists (ACOG),and collaborative staff throughout the State of California
Commitment Details
Commitment Name:
Eliminate preventable mortality and morbidity in maternity care
Action Plan
1. Recruit hospitals with maternity services to CMQCC and PSF
2. Increase data reporting to CMQCC database: California Maternal Data Center (CMDC)
3. Develop method of data capturing at state level
4. Distribute evidence- based guidelines and playbooks
5. Provide ongoing performance feedback
6. Conduct collaboratives to support hospital and medical staff in change management
7. Develop mentors for hospitals and medical staff
Commitment Timeline
Calendar year 2015 and be renewed each year.
Impact Details
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Eliminate preventable mortality and morbidity in maternity care – Update – 01.25.18
View Update
Commitment Update
×
Hospital Quality Institute (HQI)
Eliminate preventable mortality and morbidity in maternity care – Update – 01.25.18
Contact Info
Name: Julianne Morath
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Last Report
243 |
Current
242 |
Action Plan:
1. Recruit hospitals with maternity services to CMQCC
2. Increase data reporting to CMQCC database: California Maternal Data Center (CMDC)
3. Develop method of data capturing at state level
4. Distribute evidence- based guidelines and playbooks
5. Provide ongoing performance feedback
6. Conduct collaboratives to support hospital and medical staff in change management
7. Develop mentors for hospitals and medical staff
Commitment Update:
Evidence-Based Medicine (EBM) maternal care guidelines and bundles were developed and distributed
• April 2016: Deployed Supporting Vaginal Births Toolkit to 243 birthing hospitals and CHPSO’s national network (including OB Hemorrhage, Preeclampsia, EED)
• August 2017: Deployed Promoting Optimal NTSV Delivery Rates (PONDR) report to 243 birthing hospitals
• Distributed CMQCC toolkits to 243 maternity hospitals
• Made SmartCare Award Announcements
• Released CalHospital Compare maternal outcome data to hospitals
• Continued HQI-CMQCC programming
Collaboratives are established and meeting to accelerate maternal improvement.
• Participate in monthly maternity collaborative calls with CHCF, CMQCC, IHA, DHCS, PBGH
• Member, CMQCC Executive Committee
• CMQCC Collaborative – recruiting hospitals for third phase
• ACOG Speakers’ Bureau – recruiting hospitals for inaugural year
Mentors are available through the ACOG Speakers’ Bureau.
Early Elected Deliveries (EED) are continuing to be reduced at an accelerated rate.
• There was a 46% reduction in EED seen in HEN 2.0 hospitals (n=124) encompassed the period from October 2015-September 2016. During roughly that same period the Hospital Compare data show a reduction of 51.1% (n=105) vs. CY 2014.
Your commitment aligns with APSS
Challenge 11 - Optimizing Obstetric Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
HQI’s emphasis on patient safety is rooted in the Institute of Medicine’s landmark report, To Err is Human. We continually draw our foundational research from organizations such as the American College of Obstetricians and Gynecologists (ACOG) and The Joint Commission Patient Safety Journal and releases from PSMF. The learnings from these organizations such as these are used in our research, such as the PONDR report, and shared with hospitals through venues such as the CHPSO Patient Safety Organization safe table or webinars. One of the challenges we have overcome is building a rapport with hospital contacts. Relationships with hospital teams require time and we often find there is turnover. HQI continues to maintain its commitment to disseminating resources with hospitals from within and from our stakeholders, alerting hospitals of communications from external organizations before they become public, and sustaining open lines of communication.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
|
Lives Lost:
0 |
Lives Spared Harm Target
|
Actual Lives Spared Harm in last 12 months
14311 |
Lives Spared Harm Target for following calendar year
14392 |
Lives Saved Target
|
Actual Lives Saved in last 12 months (might differ from initial target)
9 |
Projected Target of Lives Saved for following calendar to try to finish commitment
9 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
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Hospital Quality Institute (HQI) |
CA |
US |
Aim is to eliminate preventable harm to hospitalized patients (Pressure Ulcers)
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Aim is to eliminate preventable harm to hospitalized patients (Pressure Ulcers)
Contact Info
Name: Julianne Morath, RN, MS, CPPS
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
-
Health Services Advisory Group,the California Innovation Network (QIN)
-
Hospital Acquired- Infections (HAI) groups),Patient Safety First (PSF)
-
state and national collaboratives
Commitment Details What Patient Safety Challenge does your Commitment address?
Pressure Ulcers
Commitment Name:
Aim is to eliminate preventable harm to hospitalized patients (Pressure Ulcers)
How Many Hospitals Will This Commitment Represent? 400
Action Plan
1. Continue to support successes and sustain gains
2. Stratify hospitals with greatest opportunities
3. Recruit virtual collaboratives
4. Encourage reporting and provide ongoing feedback
5. Engage senior leadership
6. Provide evidence- based practices
7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals
Commitment Timeline
1. Fiscal Year of 2015
2. Recalibrate goals for subsequent year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hospital Quality Institute (HQI) |
CA |
US |
Aim is to eliminate preventable harm to hospitalized patients (VTE)
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Aim is to eliminate preventable harm to hospitalized patients (VTE)
Contact Info
Name: Julianne Morath, RN, MS, CPPS
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
-
Health Services Advisory Group,the California Innovation Network (QIN)
-
Hospital Acquired- Infections (HAI) groups),Patient Safety First (PSF)
-
state and national collaboratives
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous Thromboembolism (VTE)
Commitment Name:
Aim is to eliminate preventable harm to hospitalized patients (VTE)
How Many Hospitals Will This Commitment Represent? 400
Action Plan
1. Continue to support successes and sustain gains
2. Stratify hospitals with greatest opportunities
3. Recruit virtual collaboratives
4. Encourage reporting and provide ongoing feedback
5. Engage senior leadership
6. Provide evidence- based practices
7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals
Commitment Timeline
1. Fiscal Year of 2015
2. Recalibrate goals for subsequent year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hospital Quality Institute (HQI) |
CA |
US |
Aim is to eliminate preventable harm to hospitalized patients (CAUTI)
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Aim is to eliminate preventable harm to hospitalized patients (CAUTI)
Contact Info
Name: Julianne Morath, RN, MS, CPPS
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
-
Health Services Advisory Group,the California Innovation Network (QIN)
-
Hospital Acquired- Infections (HAI) groups),Patient Safety First (PSF)
-
state and national collaboratives
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
Aim is to eliminate preventable harm to hospitalized patients (CAUTI)
How Many Hospitals Will This Commitment Represent? 400
Action Plan
1. Continue to support successes and sustain gains
2. Stratify hospitals with greatest opportunities
3. Recruit virtual collaboratives
4. Encourage reporting and provide ongoing feedback
5. Engage senior leadership
6. Provide evidence- based practices
7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals
Commitment Timeline
1. Fiscal Year of 2015
2. Recalibrate goals for subsequent year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hospital Quality Institute (HQI) |
CA |
US |
Aim is to eliminate preventable harm to hospitalized patients (CLABSI)
View Commitment
Commitment
×
Hospital Quality Institute (HQI)
Aim is to eliminate preventable harm to hospitalized patients (CLABSI)
Contact Info
Name: Julianne Morath, RN, MS, CPPS
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Organization Address:
1215 K Street , Suite 800
Sacramento, CA 95814 US
Participants:
-
Health Services Advisory Group,the California Innovation Network (QIN)
-
Hospital Acquired- Infections (HAI) groups),Patient Safety First (PSF)
-
state and national collaboratives
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Aim is to eliminate preventable harm to hospitalized patients (CLABSI)
How Many Hospitals Will This Commitment Represent? 400
Action Plan
1. Continue to support successes and sustain gains
2. Stratify hospitals with greatest opportunities
3. Recruit virtual collaboratives
4. Encourage reporting and provide ongoing feedback
5. Engage senior leadership
6. Provide evidence- based practices
7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals
Commitment Timeline
1. Fiscal Year of 2015
2. Recalibrate goals for subsequent year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Aim is to eliminate preventable harm to hospitalized patients – Update – 01.25.18
View Update
Commitment Update
×
Hospital Quality Institute (HQI)
Aim is to eliminate preventable harm to hospitalized patients – Update – 01.25.18
Contact Info
Name: Julianne Morath, RN, MS, CPPS
Phone: (916) 552-7600
Email: info@hqinstitute.org
Position: President/CEO
Organization Name: Hospital Quality Institute (HQI)
Commitment Details Commitment Start Date: 01/01/2015 How many hospitals are represented in this commitment?
Last Report
400 |
Current
400 |
Action Plan:
1. Continue to support successes and sustain gains
2. Stratify hospitals with greatest opportunities
3. Recruit virtual collaboratives
4. Encourage reporting and provide ongoing feedback
5. Engage senior leadership
6. Provide evidence- based practices
7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals
Commitment Update:
1. Continued to support successes and sustain gains
2. Stratified hospitals with greatest opportunities and assigned mentor
3. Continued conducting virtual collaboratives
4. Encouraged reporting and provided ongoing feedback through HQI improvement forums
5. Engaged senior leadership through HIIN, CMQCC, and quarterly CEO reports
6. Evidence-based practices deployed through website, Clinical Improvement Advisors, studies, and reports
7. Continued peer-to-peer learning through learning opportunities/activities and mentor hospitals, subject matter experts, and patient/family engagement
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Subject matter experts identified to support improvement teams
2. Developed Khan Academy style High Reliability Modules on Foundations and Clinical Topics of harm available on any web-enabled device by subscription
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
|
Lives Lost:
0 |
Lives Spared Harm Target
|
Actual Lives Spared Harm in last 12 months
5113 |
Lives Spared Harm Target for following calendar year
5369 |
Lives Saved Target
|
Actual Lives Saved in last 12 months (might differ from initial target)
1614 |
Projected Target of Lives Saved for following calendar to try to finish commitment
1695 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
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Baylor Scott & White Health Care System |
Texas |
US |
High Risk Surgery Initiative
View Commitment
Commitment
×
Baylor Scott & White Health Care System
High Risk Surgery Initiative
Contact Info
Name: Jan Compton
Phone: 214-265-3622
Email: jan.compton@bswhealth.org
Position: Chief Patient Safety Officer
Organization Name: Baylor Scott & White Health Care System
Organization Address:
8080 N. Central Expressway , Suite 500
Dallas, Texas 75206 US
Participants:
-
Robert A. Probe MD,FAAOS,Chief Medical Officer Baylor Scott and White Health
-
David J. Ballard, MD, MSPH, PhD, FACP,Chief Quality Officer Baylor Scott and White Health and President STEEEP Global Institute
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
High Risk Surgery Initiative
How Many Hospitals Will This Commitment Represent? 23
Action Plan
All final recommendations are approved through the The Baylor Scott and White Health STEEEP Governance Council. After approval of each procedure, a notification letter is sent to senior leaders and physician providers with recommended hospital volumes and required program elements.
For surgeons wishing to continue to provide these services within the Baylor Scott & White System, we are encouraging application for privileges at one of the hospitals meeting minimum volume requirements.
Commitment Timeline
This high risk surgery work began in fall of 2015. The expected implementation date is June 30, 2017 which includes the initial 11 procedures. BSWH plans to evaluate other procedures that may benefit from this process. For this reason, we entered a completion date for the initial 11 procedures, but not for the ongoing evaluation of additional procedures.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The estimated number of lives saved for High Risk Surgeries for calendar year 2017 is 12, and 20 for calendar year 2018. This was calculated using mortality estimates reported in literature along with procedure volumes in identified low volume BSWH facilities.
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Baylor Scott & White Health Care System |
Texas |
US |
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk.
View Commitment
Commitment
×
Baylor Scott & White Health Care System
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk.
Contact Info
Name: Don Kennerly MD, PhD
Phone: (214) 265-3621
Email: donaldk@baylorhealth.edu
Position: Chief Patient Safety Officer
Organization Name: Baylor Scott & White Health Care System
Organization Address:
3500 Gaston Avenue
Dallas, TX 75246 US
Participants:
-
Joel Allison,President and CEO Baylor Scott & White Health Care System
-
Don Kennerly,MD, PhD, Chief Patient Safety Officer. Baylor Scott & White Health Care System
-
David Ballard,MD, PhD, Chief Quality Officer, Baylor Scott & White Health Care System
-
Jan Compton,RN, BSN, Chief Patient Safety Officer, Baylor Scott & White Health Care System North
-
Michael Ramsay,MD, FRCA Chairman Department of Anesthesiology, Baylor University Medical Center
-
The Breathe Team,Baylor University Medical Center
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk.
How Many Hospitals Will This Commitment Represent? 46
Action Plan
The plan is already in place but is being updated regularly and enhanced. Milestones Completed:
39.5% reduction in Hospital Standardized Mortality Rate in 5 years (year on year = 9.6% / yr). 360 fewer
deaths in last 2.5 years
45% reduction in preventable hospital acquired adverse events in last 4 years
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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MedStar Health |
MD |
US |
Serious Safety Events
View Commitment
Commitment
×
MedStar Health
Serious Safety Events
Contact Info
Name: David Mayer
Phone: 410-772-6547
Email: david.b.mayer@medstar.net
Position: VP Quality and Safety
Organization Name: MedStar Health
Organization Address:
5565 Sterrett
Columbia, MD 21044 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Serious Safety Events
Commitment Start Date 07/01/2015
Action Plan
See above
Commitment Timeline
One fiscal year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Annual deaths from seroius safety events
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Serious Safety Events – Update – 08.22.18
View Update
Commitment Update
×
MedStar Health
Serious Safety Events – Update – 08.22.18
Contact Info
Name: David Mayer
Phone: 410-772-6547
Email: david.b.mayer@medstar.net
Position: VP Quality and Safety
Organization Name: MedStar Health
Commitment Details Commitment Start Date: 07/01/2015 How many hospitals are represented in this commitment?
Action Plan:
See above
Commitment Update:
By implementing the CANDOR program and the 7 pillars of open and honest communication Beta Healthcare gives Medstar a 5% reduction on their medical malpractice claims. Medstar has seen their medical malpractice claims go from 82.8 million to 48.8 million while increase the # of lives in their system. When Medstar first started their “JUST” culture they had 110 reportable events. The real number was probably around 200 because many events went unreported due to lack of a safe reporting process. Once the “Just” culture was implemented the system saw their reportable even go down to 40 and a solid feeling this represents a true number.
Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Dilaudid Free program
EHR hard stops and alerts
System wide telemetry project (initiation and discontinuation)
The Candor approach to serious safety events was adopted as a best practice. The goal is to notify the patient/family immediately following an unanticipated event, meet their immediate needs, support the providers, and begin an event review. This is the best way to ensure transparency and also provides an opportunity to learn and discover where the systems and or processes may have gaps. As time passes we lose those opportunities. We are now capturing the time from when the incident occurred to the time it was reported and working to drive those numbers down.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-4 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
10 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
4 |
Projected Target of Lives Saved for following calendar to try to finish commitment
0 |
|
|
New Lives Lost (lives lost – actual lives saved)
-4 |
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MedStar Health |
MD |
US |
Sepsis
View Commitment
Commitment
×
MedStar Health
Sepsis
Contact Info
Name: David Mayer
Phone: 410-772-6547
Email: david.b.mayer@medstar.net
Position: VP Quality and Safety
Organization Name: MedStar Health
Organization Address:
5565 Sterrett
Columbia, MD 21044 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Sepsis
Commitment Start Date 07/31/2015
Action Plan
1. Standard work across system
2. Adopt newer best practices (e.g. nurse activated protocol)
3. Full implementation of EHR sepsis tools acorss sytem
Commitment Timeline
One fiscal year
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Numbers of lives lost annually to sepsis across our system
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Sepsis – Update – 08.01.18
View Update
Commitment Update
×
MedStar Health
Sepsis – Update – 08.01.18
Contact Info
Name: David Mayer
Phone: 410-772-6547
Email: david.b.mayer@medstar.net
Position: VP Quality and Safety
Organization Name: MedStar Health
Commitment Details Commitment Start Date: 07/31/2015 How many hospitals are represented in this commitment?
Action Plan:
1. Standard work across system
2. Adopt newer best practices (e.g. nurse activated protocol)
3. Full implementation of EHR sepsis tools acorss sytem
Commitment Update:
Medstar has implemented the “Score at the Door” toolkit to identify sepsis early. They
have also included a person and family engagement questionnaire to rule out sepsis as soon as
possible. Medstar has seen a 10% reduction in all-cause mortality.
Your commitment aligns with APSS
Challenge 9 - Early Detection and Treatment Of Sepsis Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
3 and 6 hour bundles
Sepsis EHR alerts
Nurse activated protocols
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-85 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
100 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
85 |
Projected Target of Lives Saved for following calendar to try to finish commitment
0 |
|
|
New Lives Lost (lives lost – actual lives saved)
-85 |
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The American College of Obstetricians and Gynecologists |
Florida |
US |
Creating a Culture of Safety
View Commitment
Commitment
×
The American College of Obstetricians and Gynecologists
Creating a Culture of Safety
Contact Info
Name: Darren Salinger
Phone: 3054692727
Email: dsalinger@yahoo.com
Position: Physician
Organization Name: The American College of Obstetricians and Gynecologists
Organization Address:
8201 SW 189 Terrace
Cutler Bay, Florida 33157 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Creating a Culture of Safety
Commitment Start Date 05/25/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
A culture of safety is important at all levels of healthcare delivery. Everyone involved from the first person a patient makes contact with to the last person the patient makes contact with should be mindful of the importance of working in a culture of safety. This is a constant process that can always be improved and our journey starts now.
Commitment Timeline
This commitment will be rolled out with communication involving one on one discussions, group discussions, brain-storming sessions, listening tours with patients and patient representatives, as well as everyone interested in patient safety.
Impact Details Lives Lost in Last Calendar Year: 5 How many lives do you expect to spare from harm in the next calendar year 1 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
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The American College of Obstetricians and Gynecologists |
Florida |
US |
AIM (The Alliance for Innovation in Maternal Health) to reduce severe maternal morbidity and mortality
View Commitment
Commitment
×
The American College of Obstetricians and Gynecologists
AIM (The Alliance for Innovation in Maternal Health) to reduce severe maternal morbidity and mortality
Contact Info
Name: Barbara Levy
Phone: 202-863-2503
Email: blevy@acog.org
Position: Vice President for Health Policy
Organization Name: The American College of Obstetricians and Gynecologists
Organization Address:
409 12th St. SW
Washington, DC 20024 US
Commitment Details
Commitment Name:
AIM (The Alliance for Innovation in Maternal Health) to reduce severe maternal morbidity and mortality
Commitment Start Date 09/01/2014
Action Plan
Engage states, public health, hospitals and multidisciplinary care teams to implement protocols and simulations to eliminate the remediable causes of severe maternal morbidity and mortality
Commitment Timeline
4 years
Impact Details Methodology for Determining Lives Saved:
Institute for Healthcare Improvement strategies for bundles of care
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AIM (The Alliance for Innovation in Maternal Health) to reduce severe maternal morbidity and mortality - Update - 01.04.18
View Update
Commitment Update
×
The American College of Obstetricians and Gynecologists
AIM (The Alliance for Innovation in Maternal Health) to reduce severe maternal morbidity and mortality – Update – 01.04.18
Contact Info
Name: Barbara Levy
Phone: 202-863-2503
Email: blevy@acog.org
Position: Vice President for Health Policy
Organization Name: The American College of Obstetricians and Gynecologists
Commitment Details Commitment Start Date: 09/01/2014 How many hospitals are represented in this commitment?
Last Report
0 |
Current
2500 |
Action Plan:
Engage states, public health, hospitals and multidisciplinary care teams to implement protocols and simulations to eliminate the remediable causes of severe maternal morbidity and mortality
Commitment Update:
AIM has now enrolled 15 states with 20 more interested. We have achieved a 20% reduction in severe maternal morbidity overall in the reporting states. AIM has added bundles to address disparities and management of opioid users during and after pregnancy.
Your commitment aligns with APSS
Challenge 11 - Optimizing Obstetric Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
It is a long process to generate culture change. We have found that collaboration between public health, provider organizations (hospitals and provider groups), along with patients and families is critical for sustainable improvement in the systems necessary to reduce disparities in maternal outcomes. Preparation for and early recognition of uncommon events is essential for improvement. This requires dedication of administration and staff as well as streamlined processes to respond rapidly to the events.
In 2018 and beyond we are seeking funding to expand AIM to all 50 states and to bring the lessons learned to a broader stakeholder community.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
|
Lives Lost:
|
Lives Spared Harm Target
|
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
|
Actual Lives Saved in last 12 months (might differ from initial target)
|
Projected Target of Lives Saved for following calendar to try to finish commitment
|
|
|
New Lives Lost (lives lost – actual lives saved)
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Chi Mei Medical Center, Yungkang, Tainan, Taiwan |
Tainan |
TW |
Creating a Culture of Safety
View Commitment
Commitment
×
Chi Mei Medical Center, Yungkang, Tainan, Taiwan
Creating a Culture of Safety
Contact Info
Name: Che-Kim Tan
Phone: +886-6-2812811 ext 52955
Email: chekim.tan@gmail.com
Position: Deputy Director, Center for Quality Management
Organization Name: Chi Mei Medical Center, Yungkang, Tainan, Taiwan
Organization Address:
901, Chunghua Rd
Tainan, Tainan 710 TW
Participants:
-
Hung-Jung Lin,Vice Superintendent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Creating a Culture of Safety
How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. Continuously implementation of Team Resource Management
2. Care for the care providers and care for the patients campaign
3. Cultivate a positive attitude towards patient safety
4. Hospital-wide implementation of Shared Decision Making
5. Encourage hospital staff to participate in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan, goal of participation rate 80% of the staff.
Commitment Timeline
Dec 2017 Increase of 5-points in the Patient Safety domain in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan.
Dec 2018 Increase of another 5-points in the Patient Safety domain in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan.
Impact Details Lives Lost in Last Calendar Year: 1400 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
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Chi Mei Medical Center, Yungkang, Tainan, Taiwan |
Tainan |
TW |
Hand-off Communications
View Commitment
Commitment
×
Chi Mei Medical Center, Yungkang, Tainan, Taiwan
Hand-off Communications
Contact Info
Name: Che-Kim Tan
Phone: +886-6-2812811 ext 52955
Email: chekim.tan@gmail.com
Position: Deputy Director
Organization Name: Chi Mei Medical Center, Yungkang, Tainan, Taiwan
Organization Address:
901, Chunghua Rd
Tainan, Tainan 71004 TW
Participants:
-
Hung-Jung Lin,Vice Superintendent
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
Hand-off Communications
How Many Hospitals Will This Commitment Represent? 1
Action Plan
We have established several computerized hand-off systems for physicians among wards, ER and ICU. We have have different hand-off systems for different healthcare professionals.
We tried to integrated all the different hand-off systems into a "multidisciplinary communication platform"
Commitment Timeline
June 2017 - complete the "multidisciplinary communication platform" and fine tuning the platform from the feedback of users.
Dec 2017 - establish a complete hand-off system between OR and ward/ICU, between examination room and ward/ICU/ER
Impact Details Lives Lost in Last Calendar Year: 1400 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
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Instituto Nacional de Cardiología Ignacio Chávez |
MX |
MX |
Medication Errors
View Commitment
Commitment
×
Instituto Nacional de Cardiología Ignacio Chávez
Medication Errors
Contact Info
Name: Marco Antonio Martínez Ríos
Phone: 52-55-55732911
Email: dirgral2@cardiologia.org.mx
Position: Managing Director
Organization Name: Instituto Nacional de Cardiología Ignacio Chávez
Organization Address:
Juan Badiano No. 1, Colonia Seccion XVI, Tlalpan
CDMX, MX 14080 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3 - Medication Safety
Commitment Name:
Medication Errors
Commitment Start Date 08/28/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Consolidate the culture of Report, Follow-up and Prevention of Adverse Events related to the medication process, identify failures in the system and implement safety actions to reduce the impact or prevent the rate of incidents.
a. Empowering the Subcommittee on Reporting, Follow-up and Prevention of Adverse Events to improve effectiveness in the implementation of security actions.
b. To sensitize the Institute's staff in the relevance of the process of reporting and monitoring adverse events related to the medication process, for improve patient safety.
c. Free access to operational definitions of medication errors in the staff to facilitate the identification and reporting of medication errors.
Commitment Timeline
24 month time period
Impact Details Methodology for Determining Lives Saved:
For the determination of the number of lives saved, we suggested an indicator for each Actionable Patient Safety Solutions (APSS)
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Instituto Nacional de Cardiología Ignacio Chávez |
MX |
MX |
Patient Safety Culture
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Commitment
×
Instituto Nacional de Cardiología Ignacio Chávez
Patient Safety Culture
Contact Info
Name: Marco Antonio Martínez Ríos
Phone: 52-55-55732911
Email: dirgral2@cardiologia.org.mx
Position: Managing Director
Organization Name: Instituto Nacional de Cardiología Ignacio Chávez
Organization Address:
Juan Badiano No. 1, Colonia Seccion XVI, Tlalpan
CDMX, MX 14080 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Patient Safety Culture
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Develop and implement a culture of health care with quality and safety, based on the Institutional Quality Model, which allows the recognition of different national certifying entities.
a. Reinforce the involvement of middle managers and managers in the development of a culture of quality and safety.
b. Carry out awareness campaigns of quality and safety to patients, families, hospital staff, suppliers and visitors in general.
c. Participate in committees or subcommittees of quality and safety.
d. Implement a program of active participation of all hospital staff in quality and
safety.
Commitment Timeline
A 24 month period
Impact Details Methodology for Determining Lives Saved:
For the determination of the number of lives saved, we suggested an indicator for each Actionable Patient Safety Solutions (APSS) .
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Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán |
Mexico City |
MX |
Control of Nosocomial Infections
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Commitment
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Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán
Control of Nosocomial Infections
Contact Info
Name: Jose Sifuentes-Osornio, MD
Phone: (52-55) 56559068
Email: sifuentesosornio@gmail.com
Position: Director of Medicine
Organization Name: Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán
Organization Address:
Vasco de Quiroga 15, Colonia Belisario Dominguez Seccion XVI
Delegación Tlalpan, Mexico City 14080 MX
Participants:
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Raul Rivera-Moscoso,Planning and Quality Improvement Director
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MD
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2 - Healthcare-associated Infections (HAIs)
Commitment Name:
Control of Nosocomial Infections
Commitment Start Date 01/03/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
2) For the second purpose we propose:
a. Maintain ongoing activities of the infection control committee
b. Continue the strict surveillance program on infections associated with intravenous therapy in the intensive care unit in conjunction with the medical and nursing staff in this area.
c. Continue the active surveillance program in conjunction with the Medical and Nursing Divisions, the Infectious Diseases Department and the Laboratory of Clinical Microbiology.
Commitment Timeline
2) Second objective, we propose 36 months.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The estimate of the potential number of lives that can be saved will be realized during the first year based on the historical data from one to three previous years and with the results obtained during the monitoring of the first year.
We will measure the impact with the number of lives saved by comparing the data obtained from the baseline period with the data obtained during the commitment period from March 2017 to October 2021.
The data will be available for partial analysis by the second semester of each year since 2018 and the global data by the second half of 2021.
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Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán |
Mexico City |
MX |
Patient Safety Culture and Control of Nosocomial Infections
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Commitment
×
Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán
Patient Safety Culture and Control of Nosocomial Infections
Contact Info
Name: Jose Sifuentes-Osornio, MD
Phone: (52-55) 56559068
Email: sifuentesosornio@gmail.com
Position: Director of Medicine
Organization Name: Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán
Organization Address:
Vasco de Quiroga 15, Colonia Belisario Dominguez Seccion XVI
Delegación Tlalpan, Mexico City 14080 MX
Participants:
-
Raul Rivera-Moscoso, MD,Planning and Quality Improvement Director
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Patient Safety Culture and Control of Nosocomial Infections
Commitment Start Date 01/03/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1) For the first objective we propose:
a. Develop review and motivation workshops for medical, nursing and other personnel with contact with patients.
b. Establish monitoring mechanisms through appropriate committees, as well as with the support of the specific medical treatment groups determine the progress and improvement of processes to increase the quality of medical care.
c. Evaluate the improvement of the management of the high-risk drugs through the pharmacovigilance committee.
d. Evaluate the development of the programs through clinical audits.
2) For the second purpose we propose:
a. Maintain ongoing activities of the infection control committee
b. Continue the strict surveillance program on infections associated with intravenous therapy in the intensive care unit in conjunction with the medical and nursing staff in this area.
c. Continue the active surveillance program in conjunction with the Medical and Nursing Divisions, the Infectious Diseases Department and the Laboratory of Clinical Microbiology.
Commitment Timeline
1) First objective, we propose 24 months.
2) Second objective, we propose 36 months.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The estimate of the potential number of lives that can be saved will be realized during the first year based on the historical data from one to three previous years and with the results obtained during the monitoring of the first year.
We will measure the impact with the number of lives saved by comparing the data obtained from the baseline period with the data obtained during the commitment period from March 2017 to October 2021.
The data will be available for partial analysis by the second semester of each year since 2018 and the global data by the second half of 2021.
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Hospital Vera Cruz |
São Paulo |
BR |
Comissão de Risco
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Commitment
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Hospital Vera Cruz
Comissão de Risco
Contact Info
Name: CLAUDIA MATIAS
Phone: 55 19 37343018
Email: qualidade@hospitalveracruz.com.br
Position: Quality Manager
Organization Name: Hospital Vera Cruz
Organization Address:
Avenida Andrade Neves 402 Centro
Campinas, São Paulo 13013900 BR
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Comissão de Risco
How Many Hospitals Will This Commitment Represent? 1
Action Plan
We would like to improve a safety mindset in our organization. Our main goal is to secure the focus on patient care and in your needs.
We would like to create a task force formed by a multidisciplinary team, which primary responsibilities is to create a safety patient environment.
The methodology that we choose to work are: meetings, lectures, reporting never events and adverse events, monitoring results, dashboards.
Commitment Timeline
Step 1: Create a team work, and define atibutes and responsabilities of each other.
When? February 2018
Step 2: Scenario analysis. Define what indicators who will make up the dashboard, start data coletting and first analysis and conclusions.
When? March/april 2018
Step 3: Patient Safety Course
When? May 2018
How: Leadership training
Step 4: Safety Culture program research
When June 2018
Step 5:Action Implementation, in relation to the scenario describe.
When: July/August/September
Step 6:Data Analysis and continuous monitoring.
When: Oct/November
Impact Details Lives Lost in Last Calendar Year: 305 How many lives do you expect to spare from harm in the next calendar year 3 How many lives do you expect to save in the next calendar year 3 Methodology for Determining Lives Saved:
We don't have any methodology yet. We would like support to understand your methodolgy.
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AACD |
SP |
BR |
Criar uma Cultura de Segurança
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Commitment
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AACD
Criar uma Cultura de Segurança
Contact Info
Name: Alessandra Fatima de Sousa
Phone: +55(11)5576-0434
Email: afsousa@aacd.org.br
Position: Gerente da qualidade
Organization Name: AACD
Organization Address:
Professor Ascendino Reis, 724
São Paulo , SP 04027000 BR
Participants:
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Leonardo Hiroki Kawasaki ,Diretoria Medica Hospitalar
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-
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Criar uma Cultura de Segurança
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Nosso compromisso visa melhorar o resultado na pesquisa de Cultura de Segurança até o próximo ciclo de 2019. As oportunidades de melhoria relacionam-se as seguintes dimensões:
Percepções gerais da segurança do paciente ( nota de segurança)
Resposta não punitiva ao erro
Commitment Description & Detail:
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade
Action Plan:
Nosso compromisso visa melhorar o resultado na pesquisa de Cultura de Segurança até o próximo ciclo de 2019. As oportunidades de melhoria relacionam-se as seguintes dimensões:
Percepções gerais da segurança do paciente ( nota de segurança)
Resposta não punitiva ao erro
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade Commitment Timeline:
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade
Impact Details
Lives Saved
Predicted Lives Spared Harm:
0.08 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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Pingtung Christian Hospital |
Ping Tung |
TW |
Using Patient Safety Culture Improvement Tool to Create a Safety Culture
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Commitment
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Pingtung Christian Hospital
Using Patient Safety Culture Improvement Tool to Create a Safety Culture
Contact Info
Name: Yu, Kwong-Leung
Phone: 886-8-7368686 Ext.1650
Email: 02825@ptch.org.tw
Position: Superintendent
Organization Name: Pingtung Christian Hospital
Organization Address:
No.60, Da-Lian Road,
Ping Tung , Ping Tung 900 TW
Participants:
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Sheu, Hwang-Tzer,Senior Specialist
-
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Using Patient Safety Culture Improvement Tool to Create a Safety Culture
Commitment Start Date 11/01/2017 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Currently, patient safety culture is commonly assessed via self-completion questionnaires. This process typically involves mailing questionnaires to all staff , then collecting and calculating means responses to items or factors. Safety culture surveys provide much information about employee attitudes, but it is difficult to use the results to identify practical actions to improve the culture. The PSCIT was developed to enable healthcare organizations to assess the maturity of the systems currently in place to promote a positive patient safety culture. Improvement actions are identified by comparing current systems with the practices associated with the next level of maturity.
For the best results, the PSCIT should be completed by a multidisciplinary team, consisting of those with expertise in the operation of current patient safety systems, those with budgetary authority and healthcare providers. The PSCIT can be used at the organizational or departmental level. The appropriate level of analysis depends on the organizational structure; the important issues are budgetary authority and the ability to implement new systems.
Incident reporting system (either paper or electronic) is in place. Training on how to use the system is provided to all staff. Learning from reported incidents is used in patient safety training. Reports have the option for individuals to identify themselves so that additional information about the incident can be obtained.
1.Incident reporting system (either paper or electronic) is in place.
2.Training on how to use the system is provided to all staff.
3.Learning from reported incidents is used in patient safety training.
4.Reports have the option for individuals to identify themselves so that additional information about the incident can be obtained.
Commitment Timeline
We started and advocated this commitment since November 1st, 2017, and launched the project from 01/01/2018 to 12/31/2018 with reinforcement on "patient safety leader education and training" and related activities. Finally the data will be reviewed and evaluated at the end of 2018. Then we will disseminate the results in the early 2019.
Impact Details Lives Lost in Last Calendar Year: 50 How many lives do you expect to spare from harm in the next calendar year 35 How many lives do you expect to save in the next calendar year 1 Methodology for Determining Lives Saved:
We use our hospital Patients Safety Reporting System to calculate the number of people classified in SAC (Severity Assessment Code) first level :Serious.
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Taipei Hospital, Ministry of Health and Welfare, Taiwan |
TAIWAN(R.O.C.) |
TW |
Challenge 1-Creating a Culture of Safety
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Commitment
×
Taipei Hospital, Ministry of Health and Welfare, Taiwan
Challenge 1-Creating a Culture of Safety
Contact Info
Name: Suying HUNG
Phone: 886-2-22765566
Email: sdm@tph.mohw.gov.tw
Position: Supervisor
Organization Name: Taipei Hospital, Ministry of Health and Welfare, Taiwan
Organization Address:
NO.127, SU-YUAN ROAD, HSIN-CHUANG DISTRICT
NEW TAIPEI CITY , TAIWAN(R.O.C.) 242-13 TW
Participants:
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Jiin-Chryr HSU,Superintendent
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Challenge 1-Creating a Culture of Safety
Commitment Start Date 04/01/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
Five ways of Taipei Hospital to create trustworthy patient safety culture:
1.Creating mutual trust in the organization
a.Care for patients: to create a safe medical environment;
b.Care for employees: to build SOP for safety patient care;
c.Integrity: employees responsible for automatically reporting incidents and identifying strategies to promote patient safety.
Through the way mentioned above to create mutual trust between patients and medical staffs, and safe patient care, consequently.
2.Establishment of accountability
a.Promotion for patient safety aggressively
b.Establishment of patient safety and medical quality committee, supervised by the superintendent. The committee is held regularly.
3.Identification of insecurity condition for patients Encourage reporting of patient safety events. Update the concept of team resource management. Establish mechanism to educate and train medical team members to ensure safe patient care by quality control center. Set key performance indicators for patient safety and follow up every month.
4.Updating patient safety reporting process and system Focus on the principles of security, confidentiality, motivation and convenience.
5.Regular Evaluation and continual improvement of organizational patient safety culture Set department sub-vision for patient safety and regularly discuss the safety events and through SAC status determination, sentinel events investigation to improve patient safety. The meeting to trace performance is held every month.
Commitment Timeline
Commitment Start Date:1, April, 2018 Commitment End Date:31, December, 2019
Impact Details Lives Lost in Last Calendar Year: 25 How many lives do you expect to spare from harm in the next calendar year 20 How many lives do you expect to save in the next calendar year 20 Methodology for Determining Lives Saved:
We use our hospital Patients Safety Reporting System to calculate the number of people classified in SAC (Severity Assessment Code) first level.
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Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation |
Taiwan (R.O.C.) |
TW |
Patient Safety Culture in order to Raise Healthcare Quality
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Commitment
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Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
Patient Safety Culture in order to Raise Healthcare Quality
Contact Info
Name: Chang Hsin Yi
Phone: 886436060666#3641
Email: tc1420501@tzuchi.com.tw
Position: Vice Director
Organization Name: Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
Organization Address:
No.88, Sec. 1, Fengxing Rd.
Tanzi Dist., Taichung City, Taiwan (R.O.C.) 42743 TW
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Patient Safety Culture in order to Raise Healthcare Quality
Commitment Start Date 03/12/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. "Patients' safety culture" is our hospital's top priority. 2. The leader of our hospital need to make promises. 3. Activating the functions of “Patient Safety Committee”: The superintendent will lead and invite attending physicians of all disciplines to join the committee to implement healthcare quality and patient safety plans. 4. Forming a “multidisciplinary healthcare team”: Physicians of all disciplines, nurses, patients and their relatives are invited to join the team to promote shared decision making while actively supplying information concerning patient safety. 5. Calls to “mobilize all hospital employees on patient safety issues”: Each employee is required to attend patient safety on job training and related activities on annual basis in order to integrate the knowledge, skills and attitudes into daily routine. In the meantime, offering psychological assistance and emtional support to staff members who are involved in medical malpractice thereby cultivating positive patient safety culture.
Commitment Timeline
Launch all five strategies from 01/01/2018 2018/06/01 reinforce on "multidisciplinary healthcare team" 2018/10/01 establish "Patient Safety Week" and related activities Review and evaluate the results in the end of 2018
Impact Details Lives Lost in Last Calendar Year: 35 How many lives do you expect to spare from harm in the next calendar year 35 How many lives do you expect to save in the next calendar year 20 Methodology for Determining Lives Saved:
We use our hospital Patients Safety Reporting System to calculate the number of people classified in SAC (Severity Assessment Code) first level.
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (CAUTI)
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Commitment
×
Hoag Memorial Hospital Presbyterian
Avoidable Harm (CAUTI)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)
Commitment Name:
Avoidable Harm (CAUTI)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (CLABSI)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (CLABSI)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated Blood Stream Infections (CLABSI)
Commitment Name:
Avoidable Harm (CLABSI)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (C diff)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (C diff)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium Difficile Infection (CDI)
Commitment Name:
Avoidable Harm (C diff)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (Falls)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (Falls)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Avoidable Harm (Falls)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (Sepsis)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (Sepsis)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details
Commitment Name:
Avoidable Harm (Sepsis)
Commitment Start Date 11/13/2013
Action Plan
Impact Details
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (MRSA)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (MRSA)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Avoidable Harm (MRSA)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm (Medication Harm)
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Commitment
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Hoag Memorial Hospital Presbyterian
Avoidable Harm (Medication Harm)
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3 - Medication Safety
Commitment Name:
Avoidable Harm (Medication Harm)
Commitment Start Date 11/13/2013
Action Plan
Commitment Timeline
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Decrease Sepsis Mortality
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Commitment
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Hoag Memorial Hospital Presbyterian
Decrease Sepsis Mortality
Contact Info
Name: Marilyn Lang
Phone: 949-764-6790
Email: marilyn.lang@hoag.org
Position: DIrector of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
One Hoag Drive
Newport Beach, CA 92368 US
Participants:
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Allyson Brooks, MD,Chief Quality Officer
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Andre Vovan, MD,Executive Medical Director Clinical Effectiveness
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Robyn Myran, RN,Director of Sepsis Program
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Decrease Sepsis Mortality
Commitment Start Date 01/01/2015 How Many Hospitals Will This Commitment Represent? 4
Action Plan
1. Streamline order sets to make it easier to follow evidence based treatment goals by segmenting the sepsis population based on low, medium, and high risk classifications to decrease variation and increase compliance.
2. Focus on early recognition by a robust screening process, especially for the ED.
3. Establish a 24/7 sepsis nurse function to ensure protocol is consistently followed.
Monitor and analyze outcomes and implement a performance improvement process to ensure sepsis care is continually refined.
Commitment Timeline
Work on sepsis has been ongoing for a number of years. Clinicians and healthcare executives know we will never eradicate sepsis, but we can significantly reduce it's impact. We will continue to work on this goal to ensure sustained compliance through the Patient Safety Movement end goal of achieving zero preventable harm by 2020.
Impact Details Lives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
[Will be provided in an update]
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Hoag Memorial Hospital Presbyterian |
CA |
US |
Avoidable Harm
View Commitment
Commitment
×
Hoag Memorial Hospital Presbyterian
Avoidable Harm
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Organization Address:
Newport Beach, CA US
Commitment Details
Commitment Name:
Avoidable Harm
Action Plan
Impact Details
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Avoidable Harm - Update
View Update
Commitment Update
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Hoag Memorial Hospital Presbyterian
Avoidable Harm – Update
Contact Info
Name: Marilyn Lang
Phone: (949) 764-6790
Email: marilyn.lang@hoag.org
Position: Director of Patient Safety and Regulatory Compliance
Organization Name: Hoag Memorial Hospital Presbyterian
Commitment Details Commitment Update:
Hoag continues to use designated multidisciplinary teams to continuously develop, test, adjust , and implement focused action plans to address each area of avoidable harm.
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Taitung Hospital |
台灣 |
TW |
Creating a Culture of Safety
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Commitment
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Taitung Hospital
Creating a Culture of Safety
Contact Info
Name: Liao Yi Sheng
Phone: +886 089 324112#1300
Email: neuro0168@gmail.com
Position: Associate Dean
Organization Name: Taitung Hospital
Organization Address:
No.1, Wuquan Street, Taitung City
Taitung , 台灣 95043 TW
Participants:
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Creating a Culture of Safety
Commitment Start Date 04/03/2018 How Many Hospitals Will This Commitment Represent? 1
Action Plan
(1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations
(2)Individuals are able to report errors or near misses without fear of reprimand or punishment;
(3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
(4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.
Commitment Timeline
3/15/2018-12/31/2018
Impact Details Lives Lost in Last Calendar Year: 60 How many lives do you expect to spare from harm in the next calendar year 10 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
Building a safer health system
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Penghu Hospital, Ministry of Health and Welfare |
Taiwan (R.O.C.) |
TW |
Creating a culture of safety in Penghu hospital
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Commitment
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Penghu Hospital, Ministry of Health and Welfare
Creating a culture of safety in Penghu hospital
Contact Info
Name: Tai-Hung, Kuo
Phone: +886 6-9261151 #50501
Email: dire@pngh.mohw.gov.tw
Position: superintendent
Organization Name: Penghu Hospital, Ministry of Health and Welfare
Organization Address:
No.10, Zhongzheng Rd., Magong City, Penghu County 880, Taiwan (R.O.C.)
Magong City, Taiwan (R.O.C.) 880 TW
Participants:
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Chang, Tsun TZU,Head nurse
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Creating a Culture of Safety
Commitment Name:
Creating a culture of safety in Penghu hospital
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Five ways of Penghu Hospital to create trustworthy patient safety culture:
□ Creating mutual trust in the organization to promote care and integrity is the core value of Penghu Hospital:
1. Creating a safe medical environment.
2. Building SOP for safety patient care.
3. Employees are responsible for automatically reporting incidents and identifying strategies to promote patient safety.
In conclusion, establishing mutual trust between patients and medical staff and perfecting patient care are our goals.
□Establishment of accountability:
1. Promoting patient safety aggressively.
The superintendent of Penghu Hospital is responsible for medical quality management and actively participates in promoting patient safety.
2. The establishment of the medical quality and patient safety committee. The committee is held regularly.
□Encourage reporting of patient safety events.
1. Reward reporting of patient safety events.
2. Establish mechanism to educate and train medical team members.
3. Participate in TPR notification software system to learn from one defect per month.
□Creating patient safety culture：
1. Use Team Resource Management(TRM) to strengthen the effective communication and teamwork between medical teams
2. Promote the sharing of medical decision-making (Shared Decision Making, SDM): constitute the SDM team, provide related information actively, and promote SDM.
3. Participate patient safety culture survey, perform post-test, and analyze the data.
□Regular Evaluation and continual improvement of organizational patient safety culture.
The meeting to trace performance is held every 3 months. Regularly discuss the safety events and through IDT analyses, SAC status determination, sentinel events investigation to improve patient safety.
Commitment Timeline
We started this commitment since on January 1st, 2017.
Impact Details Lives Lost in Last Calendar Year: 120 How many lives do you expect to spare from harm in the nex |
